Sharon Care Center

Based on observation, interview and record review, the facility failed to ensure residents received meals that met their assessed nutritional needs and prescribed Kosher diet requirements for three of three meal trays reviewed for therapeutic diets. Kosher diet (Kosher foods meet the regulations established by Jewish dietary law and include requirements related to the preparation and serving of foods, including separation of meat and dairy products.) and protein (an essential nutrient necessary for growth, tissue repair, immune function, and maintenance of muscle mass) requirements were not followed when: 1. Two Kosher diet trays were served pureed green beans, pureed potato, and pureed bread without a protein source. 2. One Kosher diet was served pureed lasagna prepared with beef and dairy products in the same meal, which was not consistent with Kosher dietary requirements. These deficient practices had the potential to result in inadequate nutritional intake, failure to meet therapeutic dietary needs, and resident dissatisfaction with meals. Findings: During an observation of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen when: 1.Bulk food (sugar, flour, breadcrumbs) were stored in bins lined with trash bags that were not food grade (refers to materials that are safe for direct contact with food, free from harmful substances, and designed to prevent contamination).2.The temperature of bottled juice and a gallon of milk used for lunch service was kept out at room temperature, not at safe temperatures (refrigerated). 3. Food brought to residents from outside of the facility, including leftovers were stored in the resident food refrigerator located in the facility's utility room with no label or received date. These deficient practices had the potential to result in harmful bacteria growth and cross contamination of food (transfer of harmful bacteria and chemicals from one place to another) that could lead to food borne illness in 81 out of 84 residents who received food from the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection control practices for three of five sampled residents (Resident 17, 19 and 28) by failing to: 1. Ensure Resident 17, who was re-admitted to the facility with a Peripherally Inserted Central Catheter (PICC-a long, thin flexible tube inserted through a vein in the upper arm, extending to the supervisor vena cava [a large valve in the heart] near the heart) and surgical wound, was placed in enhanced barrier precautions (EBP-infection control strategy for nursing home, requiring gowns and gloves to be used during high-contact care for residents with or at high risk for multidrug-resistant organisms [MDRO: bacteria, often called superbugs, that have evolved to resist the antibiotics designed to kill them]). 2. Ensure Certified Nursing Assistant 10 (CNA 10) wore proper personal protective equipment (PPE-wearable gear-like gloves, mask, goggles, gowns-designed to protect person from injuries, illness or hazardous materials)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 renew an antidepressant medication (drugs that balance chemicals in the brain) informed consent (a process during which residents or caregivers are educated regarding the potential risks and benefits of medication therapy) for one of five sampled residents (Resident 78) by failing to: -Ensure to renew Resident 78's Mirtazapine (a medication used to treat depression [a mood disorder marked by varying degrees of sadness]) informed consent from 11/15/2024 from Resident 78's responsible party (a person delegated to make medical decisions for the resident in the event they are unable to do so). This failure had the potential for Resident 78's responsible party to be denied the opportunity to give informed consent.Findings:During a review of Resident 78's admission Record, the admission Record indicated the facility admitted Resident 78 on 4/22/2023 with diagnoses that included adult failure to thrive(a syndrome in older adults 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.

Based on observation, interview, and record review the facility failed to answer the call light (a device used by a resident to signal his or her need for assistance) for one of one sampled resident (Resident 103) as soon as possible, but no later than five minutes as indicated in the facility's policy. This failure had the potential not to meet Resident 103's needs timely.Findings:During a review of Resident 103's admission Record, the admission record indicated the facility admitted Resident 103 on 4/24/2026 with diagnoses that included history of falling, acute on chronic diastolic congestive heart failure (a person with long-term, stiff-heart disease suddenly experiences a severe, dangerous spike in symptoms, usually due to fluid overload, requiring urgent medical care), malignant neoplasm of stomach (stomach cancer), muscle weakness, essential hypertension (high blood pressure when blood pushes too hard against artery walls without a known, specific medical cause), syncope and collapse (fainting or passing out, which occurs when a temporary drop in blood flow causes a brief…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2 of 4 sampled residents (Resident 43 and 78) had documentation in the active medical record showing the residents and/or resident representatives were provided an Advanced Directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) Acknowledgement Forms (a signed acknowledgment indicating the resident and/or resident representative were provided with information regarding creating an Advanced Directive. By failing to: Ensure Resident 43's Advanced Directed Acknowledgement Form dated 2/28/2026 was completed in its entirety. Ensure Resident 78 had a documented Advanced Directive Acknowledgement Form documented in the resident's medical record. These deficient practices violated the residents' rights and/or representative's right to be fully informed of the option to request or refuse medical care and treatment. Findings:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect private health information by leaving confidential medical information easily accessible for two of two sampled residents (Resident 9 and Resident 40).This deficient practice had the potential to result in violation of Resident 9 and Resident 40's right to personal privacy and confidentiality of their medical records. Findings: 1.During a review of Resident 9's admission Record, the admission Record indicated the facility admitted the resident on 3/21/2026, with diagnoses that included Atherosclerotic Heart Disease (a chronic condition caused by plaque buildup inside artery walls, causing them to narrow and harden), dementia (a progressive state of decline in mental abilities), and hypertension (high blood pressure). During a review of Resident 9's Minimum Data Set (MDS, a resident assessment tool), dated 3/30/2026, the MDS indicated the resident was severely cognitively impaired (significant difficulty with memory, orientation,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews and record reviews the facility failed to submit the required complete information contained in the Minimum Data Set (MDS- standardized data collection tool used to assess cognitive and functional status, and care needs) for one of one sampled residents (Resident 84) within 14 days after discharge date (2/14/2026) to the Centers for Medicare & Medicaid Services (CMS: a federal agency within the United States Department of Health and Human Services) System. This deficient practice had the potential to deny Resident 84 proper healthcare monitoring to ensure all the necessary care and services were provided and had the potential for residents to be improperly billed for services not provided.Findings: During a review of Resident 84's admission Record, the admission Record indicated the facility admitted the resident on 1/4/2025 and readmitted on [DATE] with diagnoses including encephalopathy (a change in how the brain functions) unspecified, chronic kidney disease (a condition in which the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to accurately code the Minimum Data Set (MDS - a resident assessment tool) for two out of five sampled residents (Resident 10 and Resident 43) by failing to: 1. Document Resident 10's peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs) wounds 2. Document Resident 43's tobacco use. These failures had the potential to result in a delay in the necessary care and treatment for Resident 10 and Resident 43.Findings: 1.During a review of Resident 10's admission Record, the admission Record indicated the facility originally admitted Resident 10 on 11/10/2021 and readmitted Resident 10 on 6/28/2023 with diagnoses that included multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), bilateral primary osteoarthritis of knee (a degenerative, age-related condition where protective cartilage breaks down in both knees at the same time without a specific…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 update and revise 1 of 3 sampled residents (Resident 78's) care plan titled The resident is at risk for fall dated 7/9/2025, after a physician's order for a low bed with bilateral floor mats for safety was received on 8/24/2024. This deficient practice had the potential to result in a delay of nursing care.Findings:During a review of Resident 78's admission Record, the admission Record indicated the facility admitted the resident on 4/22/2026 with diagnoses that included right and left contracture (a permanent tightening or shortening of muscles, tendons, skin, or nearby soft tissues that causes joints to become stiff and rigid), Anemia (a common blood condition where you have a lower-than-normal amount of red blood cells or hemoglobin), and calculus ( hard, solid deposits made of minerals and salts (such as calcium or uric acid) that form inside the kidneys). During a review of Resident 78's Minimum Data Set (MDS: standardized assessment tool) dated 3/5/2026, the MDS indicated Resident 78 sometimes made…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an activity assessment was completed for one of one sampled resident (Resident 99) to evaluate the resident's preferences for activities. This failure had the potential for Resident 99 to feel bored and to affect Resident 99's quality of life.Findings: During a review of Resident 99's admission Record, the admission Record indicated the facility admitted the resident on 4/22/2026 with diagnoses that indicated hydrocephalus (a condition characterized by the abnormal buildup of cerebrospinal fluid (CSF) within the brain), hyperlipidemia (high levels of cholesterol in the blood), hypertension (high blood pressure), and muscle weakness. During a review of Resident 99's History and Physical (H&P) dated 4/23/2026, the H&P indicated the resident was alert and oriented times two (A&Ox2, when a resident is awake and aware of their surroundings, specifically knowing their own name and where they are). During a concurrent interview and record review on 4/27/2026 at 10:42 AM, in Resident 99's room, Resident 99 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 provide skin and pressure ulcer (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) prevention care consistent with professional standards of practice and per physician's orders for two of four sampled residents (Resident 2 and Resident 8) on Low Air Loss Mattresses (LALM - a pressure-relieving mattress used to prevent and treat pressure injuries). By failing to: 1. Ensure Resident 2's low air loss mattress (LAL-a mattress designed to prevent and treat pressure wounds) was at a proper setting per manufacturer's guideline.2. Ensure Resident 8's LAL mattress was working properly. This deficient practice had the potential to delay healing, placed Resident 2 and Resident 8 at risk for developing new pressure injuries, worsening of existing ones, and complications resulting from untreated or improperly treated pressure injuries which could result in systemic infections that could lead 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 observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 3) reviewed for urinary indwelling catheter (a hollow tube that is inserted into the bladder to drain or collect urine) received the necessary urinary catheter care by failing to: -Monitor Resident 3's urinary indwelling catheter for signs and symptoms of infection This failure had the potential for Resident 3 to develop an infection that was not timely identified or treated.Findings:During a review of Resident 3's admission Record, the admission Record indicated the facility admitted the resident on 9/30/2025 with diagnoses that included urinary tract infection (UTI, an infection in the bladder/urinary tract), benign prostatic hyperplasia (enlargement of the prostate gland), and obstructive uropathy (a blockage in the urinary tract that prevents normal urine flow). During a review of Resident 3's Order Summary Report, the Order Summary Report indicated the resident had a physician order dated 1/21/2026 to monitor the resident for signs and symptoms of infection 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 observation, interview, and record review the facility failed to label with a date on the oxygen tubing and humidifier (a small plastic bottle filled with water that attaches to an oxygen concentrator [medical device that gives you extra oxygen] or tank that allows the oxygen to pass through the water to add moisture to the oxygen before it reaches the resident's nose to prevent dryness) for one out of one sampled resident (Resident 46). This failure had the potential for Resident 46 to experience respiratory infections (infection of the parts of the body involved in breathing) associated with using an unsanitary (dirty, unhealthy, or unclean way that could endanger health) oxygen tubing or humidifier.Findings: During a review of Resident 46's admission Record, the admission Record indicated the facility originally admitted Resident 46 on 11/8/2018 and readmitted Resident 46 on 1/13/2022 with diagnoses that included amyotrophic lateral sclerosis (also known as Lou Gehrigsdisease that destroys nerve cells in the brain and spinal cord) that worsens over time), morbid obesity…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 obtain updated hemodialysis (HD, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) access site (a surgically created site used to remove and return blood during HD) monitoring orders for one of two sampled residents (Resident 40) reviewed for dialysis by failing to: -Ensure to address Resident 40's right arm arteriovenous (AV) fistula/shunt (a surgically created connection linking an artery [a type of blood vessel that carries oxygen-rich blood the entire body] directly to a vein [a type of blood vessel that collected oxygen-poor blood and returns it to the heart]). This failure had the potential to damage Resident 40's (AV) fistula/shunt and compromised the HD access site.Findings:During a review of Resident 40's admission Record, the admission Record indicated the facility readmitted the resident on 6/13/2025, with diagnoses that included end stage renal disease (ESRD, irreversible kidney failure), epilepsy (a brain disorder that…

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

Based on interview and record review, the facility failed to respond to the pharmacist's recommendation from February 2026 to remove heart rate hold parameters (clinical conditions that would require a medication to not be given) from amlodipine (a medication used to treat high blood pressure) in one of five residents sampled for unnecessary medications (Resident 4). The deficient practice of failing to respond to the pharmacist's recommendation to remove heart rate monitoring parameters for amlodipine increased the risk that Resident 4 may not have received his amlodipine regularly, possibly leading to an increase in blood pressure and an increased risk of heart attacks and strokes.Findings: During a review of Resident 4's admission Record (a record containing diagnostic and demographic resident information) dated 4/29/2026, the admission Record indicated the facility admitted Resident 4 on 3/2/2021 and readmitted the resident on 8/26/2024 with diagnosis including essential hypertension (high blood pressure not caused by another medical condition.) During a review of Resident 4's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of five sampled residents (Resident 1 and 94) were free from unnecessary drugs (a medication that may be doing more harm than good or isn't needed for the resident's current condition) by failing to: 1. Limit the duration of treatment for Resident 1's metoclopramide (a medication used to treat nausea and vomiting) to 12 weeks or less as per Resident 1's care plan (a document containing a resident-specific plan of care for a resident's concerns or problems) for GERD, dated 2/8/26.2. Ensure Resident 94's blood pressure (BP-the force of your blood pushing against the walls of your arteries as the heart pumps it around the body) was monitored and documented prior to administering Resident 94's Midodrine (a medication used to treat hypotension [low blood pressure]) 5 mg by mouth in the morning every Monday, Wednesday and Friday for hypotension before dialysis and hold if systolic blood pressure (SBP: measures the maximum pressure in the arteries…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 remove one expired fluticasone/salmeterol (a medication used to treat breathing problems) inhaler from the medication cart affecting Resident 6 in one of two inspected medication carts (Medication Cart 3.) The deficient practice of failing to remove expired products from the medication cart increased the risk that Resident 6 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization or death.Findings:During a concurrent observation and interview on [DATE] at 11:48 AM of Medication Cart 3 with Licensed Vocational Nurse 2 (LVN 2), 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:One open fluticasone/salmeterol inhaler for Resident 6 labeled with an open date of…

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

Based on observation, interview and record review, the facility failed to ensure the minced and moist texture green bean was prepared according to the International Dysphagia Diet Standardization Initiative (IDDSI: standardized framework (0-7 levels) that uses consistent terminology, colors, and testing methods to define texture-modified foods and thickened liquids for people with swallowing difficulties [dysphagia] Level Five minced and moist foods - (All foods prepared for this diet must be soft, moist with all excess fluid drained, and minced to size no larger than 4mm fits through the gaps of fork prongs). This deficient practice had the potential to result in meal dissatisfaction, decreased nutritional intake and increase choking risk for residents receiving a minced and moist diet due to food textures not prepared in accordance with IDDSI Level 5 requirements. Findings: During an observation in the kitchen on 4/27/2026 at 12:00PM, a meal tray preparation for a minced and moist diet was observed, cook 1 removed a portion of the lasagna and chopped the lasagna into small and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide food that accommodated resident preferences for two of four sampled residents (Resident 68 and Resident 72) by failing to: -Provide Resident 68 with food that did not contain beef. -Review and update Resident 72's food preferences quarterly (three-monthly).-Provide Resident 72 with a vegetarian diet (excludes meat, poultry, and fish, often focusing on plant-based foods like vegetables, fruits, whole grains, beans, and nuts). These failures resulted in Resident 68 and 72 not having their food preferences honored by the facility, which had the potential for Resident 68 and Resident 72 to experience weight loss due to not liking or eating the food provided by the facility.Findings: 1.During a review of Resident 68's admission Record, the admission Record indicated the facility originally admitted Resident 68 on 6/21/2023 and readmitted Resident 68 on 11/6/2023 with diagnoses that included other seizures (a sudden, uncontrolled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain accurate and complete medical records for one of five sampled residents (Resident 94) by failing to ensure the electronic medication administration record (MAR) for Resident 94's midodrine (a medication used to treat hypotension [low blood pressure]) indicated if the medication was administered or held on 2/13/2026 and 2/25/2026. This deficient practice placed Resident 94 at risk of not receiving appropriate care due to inaccurate medical care information and the potential to result in confusion in the care and services provided to Resident 94. Findings: During a review of Resident 94's admission Record, the admission Record indicated the facility originally admitted Resident 94 on 11/8/2025 and was re-admitted on [DATE] with diagnoses including right hip wound, end stage renal failure (ESRD-a medical condition in which a person's kidney [organ in the body that filters waste and excess fluid from the blood] stop functioning on a permanent…

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

Based on interview and record review, the facility failed to implement and maintain an effective infection prevention and control program for one of eight residents (Resident 76) sampled for immunizations, by failing to: 1. Ensure Resident 76 was assessed for and offered the influenza (Flu-common viral infection that can be deadly, especially in high-risk groups) vaccine, including documentation of administration and/or refusal, in accordance with facility policy and procedures (P&P) titled Influenza Vaccine reviewed by the facility on 12/18/2025 and current standards of practice. 2.Ensure Resident 76 was assessed for and offered the pneumococcal (Pneumonia [PNA]-infection that inflames air sacs in one or both lungs which may fill with fluid) vaccine, including documentation of administration and/or refusal, in accordance with facility policy and procedures (P&P) titled Pneumococcal Vaccine reviewed by the facility on 12/18/2025 and current standards of practice. These deficient practices placed Resident 76 at a higher risk of acquiring and transmitting vaccine-preventable…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accessible and adequate private closet space for one of one residents (Resident 88) reviewed for dignity and resident rights. By failing to ensure facility staff did not store pillows in Resident 88's assigned closet space. This deficient practice prevented Resident 88 from storing personal belongings in the closet and had the potential to cause Resident 88 emotional distress, loss of dignity, and compromised privacy.Findings: During a review of Resident's 88 admission Record, the admission Record indicated the facility readmitted the resident on 2/9/2026, with diagnoses that included cerebral infarction (stroke, loss of blood flow to a part of the brain), epilepsy (brain disorder that causes recurring seizures), and dysphagia (difficulty swallowing). During a review of Resident 88's Minimum Data Set (MDS, a standardized assessment tool), dated 3/27/2026, the MDS indicated the resident was dependent on facility staff to complete activities of daily living (ADLs, activities a person performs daily such…

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

Based on observation, interview, and record review the facility failed to ensure the call light (a device used by a resident to signal his or her need for assistance) was within reach for one of four sampled residents (Resident 51). This failure resulted in Resident 51's call light resting on the floor, out of Resident 51's reach and had the potential to result in staff delay in meeting Resident 23's needs.Findings:During a review of Resident 51's admission Record, the admission Record indicated the facility admitted Resident 51 on 7/6/2022 with diagnoses that included benign neoplasm of meninges, unspecified (a slow-growing, typically noncancerous tumor arising from the protective membranes covering the brain and spinal cord), altered mental status unspecified (a person is not acting like their normal self mentally, but the specific cause isn't yet known), generalized muscle weakness, difficulty walking, lack of coordination, and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition,…

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

Base on observation, interview, and record review, the facility failed to implement its' infection control policy and procedures (P&P) for one of three residents (Resident 4) by failing to ensure Resident 4's Representative (RP) was provided a consent (give permission for something to happen) for Influenza (Inactivated or recombinant injection given to prevent influenza (flu) illness, Pneumonia (dangerous lung infections), and Covid (highly contagious respiratory illness which is airborne and transmitted through coughing or sneezing) vaccinations.This deficient practice deprived Resident 4 and RP of the right to make an informed decision and placing her (Resident 4) at a risk of contracting the Flu, Pneumonia, and or Covid illnesses.During a review Resident 4's admission record indicated the facility admitted Resident 4 on 7/6/2026, with diagnoses that included benign neoplasm of meninges (a non-cancerous (benign) tumor that develops in the protective membrane surrounding the brain and spinal cord), altered mental status (any sudden or gradual change in a person's baseline mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to update the fall risk care plan (instructions to provide person centered care and future plans) for one of two sampled residents (Resident 1).This failure resulted in Resident 1 sustaining an assisted fall (an unplanned, sudden descent to the floor where a staff member or caregiver is present and acts to ease the resident's fall).Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 3/27/2025 with diagnoses including muscle wasting and atrophy (thinning, loss of muscle tissue resulting in reduced strength and size), lack of coordination (clumsy, awkward movements caused by damage to nerve pathways), and end stage renal disease (irreversible, failure of the kidneys no longer function properly). During a review of Resident 1's Care Plan Report, dated 11/12/2025, the Care Plan Report indicated Resident 1 had a deficit in the activities of daily living for self-care. Interventions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Minimum Data Set (MDS - a resident assessment tool) for one of two sampled residents (Resident 5) reflected the diagnosis of depression (a serious mood disorder causing persistent sadness and loss of interest in activities, affecting how you feel, think, and handle daily life). This failure had the potential for Resident 5 not to have a proper assessment, management, and monitoring of the psychotropic medication (drugs that alter brain chemistry to treat mental health conditions).Findings:During a review of Resident 5's admission Record, the admission Record indicated the facility admitted the resident on 12/10/2025 with diagnoses of Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), muscle weakness, and difficulty walking. During a review of Resident 5's Order Summary Report dated 12/25/2025, the Order Summary Report indicated Resident 5 was prescribed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 to develop a care plan for one of one sampled resident (Resident 2) reviewed for diabetes mellitus (a medical condition characterized by the body's inability to regulate blood sugar levels).This failure had the potential to affect Resident 2's diabetes care.Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 3/23/2024 with diagnoses including type 2 DM, and myocardial infarction (MI-heart attack). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 12/31/2025, the MDS indicated Resident 2 was alert and oriented with good recall. The MDS indicated Resident 2 had an active diagnoses section of DM. During a concurrent interview and record review on 1/21/2026 at 1:21 PM with the Director of Nursing (DON) and the Minimum Data Set Nurse (MDSN), Resident 2's Care Plan Report was reviewed. The MDSN stated once the diagnosis was triggered in the MDS, a care plan would be triggered (in general). During the review of…

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

Based on observation, interviews and record review, the facility failed to follow their own Policy and Procedure (P&P) by failing to provide access for medical records within 24 hours of Resident Representative (RP) request for one of the three sampled residents (Resident 2).This failure resulted in Resident 2's RP being denied the right to access the requested documents.Findings: A review of Resident 2's admission record indicated the facility admitted the resident on 11/18/2015, with diagnoses that included rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), anemia (a condition where the body does not have enough healthy red blood cells), and hypertension (HTN-high blood pressure). During a review of Resident 2's history and physical (H&P) dated 12/12/2024 indicated, Resident 1 was able to make needs known but could not make medical decisions and that Resident 2's family member (FM) was the DPOA (durable power of attorney - legal authority to make Resident 2's decisions). The same H&P 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 Comprehensive Care Plan (a personalized document that outlines a resident's needs, goals, and the specific services required to achieve them, ensuring consistent and holistic care) for one of four sampled residents (Resident 3), to address Resident 3's left ear hearing loss.This failure resulted in the absence of individualized interventions and assessments to manage Resident 3's reported loss of hearing to his left ear. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnosis of epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures, which are sudden surges of abnormal electrical activity in the brain, causing temporary disruptions in behavior, movement, or awareness), femur fracture (a break in the thigh bone) and end stage renal disease (ESRD- Condition in which the kidneys cease functioning on a permanent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews, the facility failed to ensure one of three sampled residents (Resident 1) who was at risk for dehydration (lack of drinking sufficient fluids to meet the body's need) and malnutrition (food ingested [eaten]) does not provide enough nutrients or the right balance for optimal health) did experience unplanned severe weight (wt.) loss (a body weight loss of greater than 7.5 percent [% - unit of measure] in three months). By failing to: 1. Implement physician orders for a Restorative Nursing Aide (RNA: a certified nursing assistant who has completed additional training in rehabilitation who helps people regain and maintain their ability to do everyday things like walking, eating, and bathing) feeding program for breakfast and lunch dated 9/24/205. As a result, Resident 1 experienced a 9.4% weight loss in three months from 9/17/2025 (82.8lbs) to 12/4/2025 (75lbs). These failures had the potential for further decline and complications related to 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.

Based on interviews and record reviews, the facility failed to report to the Medical Doctor (MD) when there was a change in condition (COC) for one of the three sampled residents (Resident 1) who was refusing to eat more than 50% of her meals. This deficient practice resulted in Resident 1 being severely dehydrated and possible deterioration of her (Resident 1) sacral (a triangular bone in the lower back) pressure ulcer (PU- localized damage to the skin and/or underlying tissue usually over a bony prominence). As a result, Resident 1 was transferred to General Acute Care Hospital (GACH) where she was treated with intravenous (IV - tube inserted into a vein) fluids, antibiotics and was treated for acute kidney injury (AKI - a sudden decline in kidney function)A review of Resident 1's admission record indicated the facility admitted the resident on 11/18/2015, with diagnosis that included rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), anemia (a condition where the body does not have enough…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent the deterioration of pressure injuries and provided care and services consistent with professional standards of practice for one out of three sampled residents (Resident 1) by failing to:1. Change Resident 1's incontinence briefs when she was soiled.2. Follow the physician's order for intravenous (IV) fluids administration3. Implement the physician's order for registered dietician (RD) due to poor oral intake and weight loss.4. Report Resident 1's decreased oral intake upon identification on 10/29/2025 to the physician as well as Resident 1's healthcare proxy (a trusted person you legally appoint to make medical decisions for you if you become unable to communicate or decide for yourself, ensuring your healthcare wishes are followed even in an emergency or serious illness) FM 1. This deficient practice potentially caused Resident 1's sacrococcyx pressure ulcer (a type of pressure sore (bedsore) that forms on the tailbone or lower back due 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 observation, interview and record review, the facility failed to conduct an Interdisciplinary Team (IDT- brings together knowledge from different health care disciplines to help people receive the care they need) which included resident and or responsible party (RP) for one of the three sampled residents (Resident 1). This deficient resulted in a failure to address Resident 1's non-compliance for care such as eating, personal care, and ordered procedure (laboratory draws and supportive treatments). Refer to F580, F658, F686A review of Resident 1's admission record indicated the facility admitted the resident on 11/18/2015, with diagnosis that included rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), anemia (a condition where the body does not have enough healthy red blood cells), and hypertension (HTN-high blood pressure). The admission record indicated family member (FM) 1 as the healthcare proxy (a trusted person you legally appoint to make medical decisions for you if you become…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 meet professional standards of quality by failing to carry out the physician's order for one of the three sampled residents (Resident 1) who had orders to check laboratory (lab) for blood and urine as well as intravenous (IV) fluids for poor oral intake. This failure resulted in the physician having limited information to determine the extent of Resident 1's health status and potentially worsening of Resident 1's hydration status leading to altered mental status (AMS). As a result, Resident 1 was transferred to General Acute Care Hospital (GACH) for failure to thrive (FTT- a complex syndrome characterized by a state of decline that includes weight loss, decreased appetite, poor nutrition, and inactivity), AMS, and sacral wound. Refer to F580A review of Resident 1's admission record indicated the facility admitted the resident on 11/18/2015, with diagnosis that included rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to revise:The care plan for one of two sampled residents (Resident 1) after the resident had his urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) removed and reinserted (to put something back in).This deficient practice had the potential to place the resident at risk for urinary retention (inability to fully empty your bladder when urinating), infection (harmful germs such as bacteria, viruses, or fungi, enter your body, multiply, and cause harm), hospitalization and sepsis (a life-threatening blood infection).2. And update the comprehensive care plan for one of three sampled residents (Resident 2) who had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD- lung disease causing restricted airflow and breathing problems) who returned from the hospital on [DATE] following an episode of respiratory failure (a condition caused by inadequate supply of oxygen and/or the inability to remove carbon dioxide…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure licensed nurses disposed of used tube feeding formula and tubing, discarded remaining formula, and tubing per facility policy for one of three resident (Resident 3).This failure placed Resident 3 at risk for contamination of enteral formula, bacterial growth, aspiration (The accidental breathing in of food or fluid into the lungs, potentially causing pneumonia or other lung problems), gastrointestinal infection, sepsis (systemic infection), and compromised nutritional status.During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnosis of dysphagia (Difficulty or discomfort in swallowing), and gastrostomy (G-tube- tube inserted through the belly that brings nutrition directly to the stomach), COPD, and respiratory failure.During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool), dated 8/20/2025, indicated Resident 3 had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 manage pain in the left arm, back, and head for one of three sampled residents (Resident 2) by failing to:1. Notify a physician that Resident 2 continued to remain in pain after three to four hours of pian medication Oxycodone-Acetaminophen 10-325mg (a strong pain reliver to treat moderate to severe pain) administration. 2. Notify a physician that Resident 2 has been asking for the pain medication Hydromorphone-Acetaminophen 10-325 mg to be given every four hours instead of every six hours for better pain relief. These deficient practices have caused Resident 2 remined uncomfortable and kept waiting for the six hours mark on 11/12/2025 while in pain. Findings: A review of Resident 2's admission Record indicated, Resident 2 was admitted to the facility on [DATE] with a diagnosis of including unspecified fracture of lower end of left radius (broken arm bone), unspecified fall, heart failure (condition in which the heart muscle is unable to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assist and make transportation arrangements for recurring chemotherapy (treatment for cancer [A disease in which abnormal cells divide uncontrollably and destroy body tissue]) appointments for one of the three sampled residents (Resident 1). This deficient practice had the potential to result in Resident 1 missing the chemotherapy treatment. Findings: During a record review, the admission record for Resident 1 indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included non-Hodgkin lymphoma (a type of cancer that begins in lymphocytes, which are white blood cells that help fight infection), fracture (a break in a bone) of the left fibula (the smaller of the two long bones in the lower leg, running from the knee to the ankle), and falls (an event which results in a person coming to rest inadvertently on the ground or floor or other lower level). During a record review, the 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.

Based on observation, interview, and record review, the facility failed to assess and ensure one of three sampled residents (Resident 11) had an order to self-administer a medication. This failure had a potential for Resident 11 to over or under medicate herself which could lead to complications. Findings: During a record review of Resident 11's admission Record, the admission Record indicated the facility admitted Resident 11 on 5/12/2023 with diagnosis including type 2 diabetes mellitus (a medical condition characterized by the body's inability to regulate blood sugar levels) hyperglycemia (too much sugar in the blood). During a review of Resident 11's Minimum data Set (MDS, a resident assessment tool), dated 2/10/2025, the MDS indicated Resident 11's cognition (thought process) was intact. The MDS indicated Resident 11 needed set up assistance with toilet hygiene and personal hygiene, partial moderate assistant (helper does less than half the effort) with shower bathe self, upper and lower body dressing. During an observation and interview on 4/12/2025 at 9am, the bedside of…

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

Based on observation, interview, and record review the facility failed to provide warm water for one of two sampled residents (Resident 2) to make tea during meals. This failure had the potential for Resident 2's preferences not to be honored and for Resident 2 to feel frustrated. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 3/4/2023 with diagnoses that included muscle weakness (a decrease in muscle strength and the ability to move the body, lack of coordination (a failure in the organization and communication of patient care activities across different healthcare providers and settings), and chronic kidney disease (a progressive, irreversible condition where kidney declines significantly over time). During a review of Resident 2's Food Preference Interview, dated 3/6/2023, the Food Preference Interview indicated Resident 2 preferred to drink tea for breakfast, lunch, and dinner. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 2/17/2025, 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.

Based on observation, interview, and record review the facility failed to ensure one of two sampled residents (Resident 2) had a homelike environment (creating a setting that feels more like a personal resident than a hospital-like institution) due to chip paint on the wall. This failure had the potential for Resident 2 not to have a comfortable homelike environment. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 3/4/2023 with diagnoses that included muscle weakness (a decrease in muscle strength and the ability to move the body, lack of coordination (a failure in the organization and communication of patient care activities across different healthcare providers and settings), and chronic kidney disease (a progressive, irreversible condition where kidney declines significantly over time). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 2/17/2025, the MDS indicated Resident 2's cognition (ability to learn, reason, remember, understand, and make decisions) was…

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

Based on observation, interview, and record review the facility failed to ensure one of six sampled residents (Resident 37) had a comprehensive care plan (a detail individualized document that outlines a patient's goals, needs, and the interventions needed to achieve them across various care settings) when the facility identified Resident 37 had a hard time hearing. This failure had the potential not to meet Resident 37's needs. Findings: During a review of Resident 37's admission Record, the admission Record indicated the facility admitted Resident 37 to the facility on 4/22/2023 with diagnoses of anxiety disorder (a mental health condition characterized by excessive and persistent worry and fear), major depressive disorder (a mental health condition characterized by a persistently low mood, loss of interest, or pleasure in activities), and atherosclerotic heart disease (a buildup of fats on the artery walls). During a review of Resident 37's History and Physical (H&P), dated 9/6/2024, the H&P indicated Resident 37 did not have the capacity to understand and make decisions. During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to provide necessary treatment and services to minimize the risk of development of pressure injuries (PIs, areas of damaged skin caused by staying in one position for too long) for three of four sampled residents (Resident 28, Resident 35, and Resident 71) by failing to: -Ensure to provide a properly functioning low air loss mattress (LALM, pressure relieving mattress that is filled with air) for Resident 28. -Ensure to set Resident 35 and Resident 71's LALM at the correct weight setting in accordance with the attending physician's (MD) order. These failures had the potential for Resident 28, Resident 35, and Resident 71 to develop PIs and skin wounds to worsen. Findings: a. During a review of Resident 28's admission Record, the admission Record indicated the facility admitted Resident 28 on 12/24/2018 with diagnoses of cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), and contractures (shortening and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a safe environment for two of two sampled residents (Resident 48 and Resident 11) by failing to ensure not to place an electrical extension cord in the residents' walk area. This failure had the potential for Resident 48 and Resident 11 to fall and sustain an injury. Findings: a. During a review of Resident 48's admission Record, the admission Record indicated the facility admitted Resident 48 on 4/1/2024 with diagnoses including acute kidney failure (rapid loss of the kidneys' ability to remove waste), chest pain, and muscle weakness. During a review of Resident 48's Minimum Data Set (MDS, a resident assessment tool) dated 2/28/2025, the MDS indicated Resident 48's cognitive skills (ability to think and reason) for daily decision-making was intact. The MDS indicated Resident 48 required set up or clean up assistance (helper provides verbal cues with and assistance) with shower/bathe self, lower body dressing, putting on /taking…

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

Based on observation, interview, and record review the facility failed to provide the necessary care and treatment for one of three sampled residents (Resident 51) who had an indwelling catheter (a medical device inserted into the bladder to drain urine continuously) by failing to notify the physician when there were sediment (the solid matter that settles to the bottom of a liquid, such as urine or blood) in the indwelling catheter's tubing. This failure placed Resident 51 at risk for urinary tract infection (UTI, an infection in any part of the urinary system). Findings: During a review of Resident 51's admission Record, the admission Record indicated the facility admitted Resident 51 on 11/25/2024 with diagnoses including osteomyelitis (a bone infection and inflammation caused by bacteria), diabetes mellitus (DM, a medical condition characterized by the body's inability to regulate blood sugar levels), and benign prostatic hyperplasia (a non-cancerous condition when the prostate gland grows larger than normal which can cause urinary problems). During a review of Resident 51's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure to label and date the feeding tube syringe (a specialized syringe used to administer liquid formula or medication directly into a feeding tube) for one of one sampled resident (Resident 35) who had a gastrostomy tube (G-tube, is a tube that is placed directly into the stomach). This failure placed Resident 35 at risk for infection and G-tube complications. Findings: During a review of Resident 35's admission Record, the admission Record indicated the facility initially admitted Resident 35 on 12/2/2022 and was readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease(COPD, a chronic lung disease causing difficulty in breathing), gastrotomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and dysphagia (difficulty swallowing). During a review of Resident 35's History and Physical (H&P), dated 6/23/2023, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two hemodialysis (HD, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) residents (Resident 125) received dialysis care and services based on professional standards. Resident 125 did not have equipment or supplies, including an emergency kit consisting of clean gauze, tourniquet (a device used to compress a limb to stop bleeding) and tape necessary to manage emergencies such as bleeding at the bedside. The deficient practices had the potential to result in not having the necessary supplies to stop bleeding from an arterial venous fistula shunt (AV shunt, an abnormal connection between an artery and a vein, provides an accessible pathway for blood removal and return during dialysis [a medical procedure that cleans your blood when your kidneys are not working]). Findings: During a review of Resident 125's admission Record, the admission Record 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.

Based on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant 4 (CNA4) and CNAs (in general) did not apply triamcinolone acetonide ointment 0.1 % (prescribed medication used to help relieve redness, itching, and swelling) to one of five sampled residents (Resident 11). This failure violated the facility's Administering Medications policy and procedure and had the potential for Resident 11 to use the medication inappropriately. Findings: During a record review of Resident 11's admission Record, the admission Record indicated the facility admitted Resident 11 on 5/12/2023 with diagnosis including type 2 diabetes mellitus (a medical condition characterized by the body's inability to regulate blood sugar levels) hyperglycemia (too much sugar in the blood). During a review of Resident 11's Minimum data Set (MDS, a resident assessment tool), dated 2/10/2025, the MDS indicated Resident 11's cognition (thought process) was intact. The MDS indicated Resident 11 needed set up assistance with toilet hygiene and personal hygiene, partial moderate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to properly store two of 20 sampled residents (Resident 62 and Resident 52) medications in accordance with the facility's Storage of Medications policy and procedure (P&P). This failure had the potential to cause Resident 62 and Resident 52 to use the medication improperly which could lead to harm. Findings: a. During a review of Resident 62's admission Record, the admission Record indicated the facility admitted Resident 62 on 1/25/2024 with diagnosis of cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area). During a review of Resident 62's Minimum Data Set (MDS, a resident assessment tool) dated 1/29/2025, the MDS indicated the resident had intact cognition (capable of remembering, learning new things, concentrating, or making decisions that affect everyday life) and required partial/moderate assistance (helper does less than half the effort) for toileting hygiene, showering, upper/lower body dressing,…

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

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety. In the refrigerator, there was no label or date on the sandwiches and the bin of expired butter cups were not discarded. These deficient practices had the potential to cause food-borne illnesses to the residents. -Ensure the low temperature dishwashing machine had the appropriate concentration of sanitizer. Findings: During an observation on 4/11/2025 at 6:36 PM, unlabeled sandwiches were observed in the facility's kitchen refrigerator. During a concurrent observation and interview on 4/11/2025 at 6:41 PM with [NAME] 1, unlabeled sandwiches were observed in the refrigerator. [NAME] 1 stated, There's no date on the sandwiches. If there's no date we don't know how old it is and someone can get sick if they eat an old sandwich. During an observation on 4/11/2025 at 6:58 PM, a bin of expired butter cups were observed in the facility's refrigerator. During a concurrent observation and interview on 4/11/2025 at 6:42 PM with Dishwasher 1,…

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

Based on observation, interview, and record review the facility failed to practice effective infection control for one of two sampled residents (Resident 23) in accordance with the facility's Infection Prevention and Control policy and procedure by failing to keep Resident 23's urinal (a device for males to urinate) away from his food. This failure had the potential for Resident 23 to eat contaminated food and placed Resident 23 at risk for infection. Findings: During a review of Resident 23's admission Record, the admission Record indicated the facility admitted Resident 23 on 1/12/2023 with diagnosis of unspecified mental disorder. During a review of Resident 23's History and Physical (H&P) dated 1/13/2023, the HP indicated Resident 23 did not have the capacity to understand and make decisions. During a review of Resident 23's Minimum Data Set (MDS, a resident assessment tool) dated 12/30/2024, the MDS indicated Resident 23 had moderately impaired cognition (capable of remembering, learning new things, concentrating, or making decisions that affect everyday life) and required…

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

Based on observation, interview, and record review the facility failed to ensure the call light (a device used by a resident to signal his or her need for assistance) for one of 20 sampled resident (Resident 2) functioned properly. This failure had the potential for Resident 2 not to be able to call for assistance. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 3/4/2023 with diagnoses that included muscle weakness (a decrease in muscle strength and the ability to move the body, lack of coordination (a failure in the organization and communication of patient care activities across different healthcare providers and settings), and chronic kidney disease (a progressive, irreversible condition where kidney declines significantly over time). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 2/17/2025, the MDS indicated Resident 2's cognition (ability to learn, reason, remember, understand, and make decisions) was able to usually understand. The MDS indicated Resident 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one sampled resident's (Resident 3) as needed (PRN) psychotropic medication (any drug that affects brain activities associated with mental processes and behavior) had a documented 14-day limit for administration. This failure caused an increased risk in Resident 3's mental and psychosocial well-being. Findings: A review of Resident 3's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and restlessness and agitation. A review of Resident 3's Medication Administration Record (MAR) dated 12/24/24 indicated the resident was prescribed Seroquel 25 milligrams (mg, unit of measurement) every 12 hours as needed without a 14-day stop. A review of the Scheduling Details dated 12/11/24 and 12/23/24, indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff properly assessed and document for one of three sampled residents (Resident 1) on Preadmission Screening and Resident Review, (PASARR- a federally required screening to help identify individuals with possible serious mental illnesses requiring a specialized follow up evaluation). The deficient practice resulted in Resident 1 not receiving a PASRR II (assessment that determines if resident's mental condition could be met in the nursing facility or if the individual requires specialized services) and subsequent follow up. Findings: During a review of the admission record for Resident 3 indicated Resident 3 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including metabolic encephalopathy (a brain dysfunction caused by underlying conditions affecting the body's metabolism, leading to impaired brain function and potentially symptoms like confusion, memory loss, or coma), schizophrenia (a mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify a physician after a significant change (COC- a sudden clinically important decline from a patient's baseline in physical, cognitive, behavioral, or functional abilities) in the mental or physical condition of a resident who has mental illness for one of the three sampled residents (Resident 1). This deficient practice resulted in Resident 1 ' s increased behavioral, psychiatric, and mood-related symptoms requiring General Acuate Care Hospital (GACH) admission on [DATE]. Cross reference F645and F656. Findings: During a review of the admission record for Resident 3 indicated Resident 3 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including metabolic encephalopathy (a brain dysfunction caused by underlying conditions affecting the body's metabolism, leading to impaired brain function and potentially symptoms like confusion, memory loss, or coma), schizophrenia (a mental illness that is characterized…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and record reviews, the facility failed to monitor one of the three sampled residents (Resident 1) by failing to: 1. Update Resident 1 ' s care plan for at risk for physical behavior towards others, after a Change of Condition (COC) on 1/14/2025 and 2/24/2025. 2. create an individualized and specific interventions for quetiapine fumarate (Seroquel- an antipsychotic medication that treats several kinds of mental health conditions including schizophrenia and bipolar disorder) and schizophrenia. This failure resulted in the escalation of behaviors requiring Resident 1 to be admitted to General Acute Care Hospital (GACH) on 3/6/2025. Findings: Cross reference F645. During a review of the admission record for Resident 3 indicated Resident 3 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including metabolic encephalopathy (a brain dysfunction caused by underlying conditions affecting the body's metabolism, leading to impaired brain function and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive care plan that meet the care/services based on the resident ' s individual assessed needs for one of five sampled resident (Resident 1) by failing to ensure a baseline care plan was initiated and implemented for Resident 1 ' s pain management and left lower leg fracture with splint. This deficient practice had the potential to result negative impact on Resident 1 ' s health and safety, as well as the quality of care and services received. Findings: A review of Resident 1's admission Record indicated that Resident 1 was admitted to the facility on [DATE] with diagnosis including fracture (broken bone) of left fibula (long, thin bone located in the lower leg) and osteoporosis (a condition in which bones become weak and brittle). A review of Resident 1's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 2/16/2025, MDS indicated Resident 1 has an intact cognition (mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure assessment and monitoring of the left lower leg splint to one of one sampled resident (Resident 1). This deficient practice has the potential for Resident 1 to develop complications such as skin breakdown and possibly compartment syndrome (excessive pressure builds up inside an enclosed muscle space in the body which slows the flow of blood, oxygen and nutrients to and from the affected tissue). Findings: A review of Resident 1's admission Record indicated that Resident 1 was admitted to the facility on [DATE] with diagnosis including fracture (broken bone) of left fibula (long, thin bone located in the lower leg) and osteoporosis (a condition in which bones become weak and brittle). A review of Resident 1's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 2/16/2025, MDS indicated Resident 1 has an intact cognition (mental action or process of acquiring knowledge and understanding) for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure sufficient nursing staff was available to provide nursing and related services to meet the resident ' s needs safely and in a manner that promotes each resident ' s rights, physical, mental, and psychosocial well-being for three of five sampled residents (Residents 1, 4 and 5) by failing to: 1. Ensure prompt assistance with basic care for Resident 1. 2. Ensure scheduled showers were provided to Residents 4 and 5. These deficient practices resulted in Residents 1 waiting for more than three hours for basic care, while Resident 4 and 5 not receiving the scheduled shower which has the potential to affect the quality of life for Residents 1, 4 and 5. Findings: 1. A review of Resident 1's admission Record indicated that Resident 1 was admitted to the facility on [DATE] with diagnosis including fracture (broken bone) of left fibula (long, thin bone located in the lower leg) and osteoporosis (a condition in which bones become weak and brittle). A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure: 1. Licensed nurses had the skills and knowledge to identify a change in condition for one of the three sampled residents (Resident 1) who had a critically low platelet count (PLT- a laboratory test that measures the number of platelets in the blood. Platelets are small, cell-like fragments that play a crucial role in blood clotting by forming a plug at the site of injury) level of 33,000 (normal PLT is between 150,000 and 400,000 platelets per microliter [µL]). 2. The physician was informed immediately when the critically low PLT count as soon as it was called in by the laboratory staff. This failure resulted in Resident 1 ' s delay in getting transferred to General Acute Care Hospital (GACH) for treatment and placing him at a risk for spontaneous bleeding which could result in death. Resident 1 died seven days later at GACH. Findings: During a review of the admission record for Resident 1 indicated Resident 1 was initially admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the dinnerware and food service equipment was clean and in good condition by failing to: 1. Ensure the residents had cups that were free from stains, residue, and cloudy dishwasher cleaning build-up and the blue coffee pots had lids that were not worn out. 2. Ensure the residents water pitchers were changed out in a timely manner by staff for washing. These deficient practices had the potential to result in cross contamination or drink safety issues. Findings: 1. During an observation with concurrent interview with Dietary Manager (DM) on 1/23/25 at 11:11 am, clear plastic glasses were drying on drying rack and some glasses were noted to be cloudy with wear from the dishwasher cleaning buildup, as well as coffee or tea-stained plastic mug. The DM stated the stained cups and cloudy glasses should have been replaced. During an interview with CNA 4, CNA 5 and CNA 6 on 1/29/25 at 2:34 pm, all three CNAs had concerns about the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to honor food preferences for two of five sample residents (Resident 2 and 3). This failure resulted in Resident 2 and 3 only having canned fruits to eat, instead of the fresh fruits preferred. Findings: During a review of Resident 2 ' s admission Record dated 1/24/25 indicated, Resident 2 was admitted to the facility on [DATE], with diagnoses including hypertension (high blood pressure), anemia (a condition where the body does not have enough healthy red blood cells), muscle weakness, and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 2 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 10/30/24, indicated Resident 2 had mild memory problems. During a review of Resident 2 ' s physicians orders date 1/24/25, indicated the resident was on a consistent carbohydrate diet (diabetic diet) with regular texture, no added salt, 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 three sampled residents (Resident 3) had a comprehensive care plan addressing Resident 3's bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs) and psychotropic medications (drugs that affect the brain and nervous system to treat mental illnesses). This deficiency had the potential for Resident 3 to have an adverse reaction that could go untreated. Findings: A review of Resident 3's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses including Type II diabetes mellitus (chronic disease that occurs when the body can't produce or use insulin properly), bipolar disorder, and cellulitis (a skin infection that causes swelling and redness). A review of the Physician's Order indicated Resident 3 was prescribed Risperidone for antipsychotic manifested by bipolar disorder mood swings. A review of Resident 3'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.

Based on interview and record review, the facility failed to ensure one Licensed Vocational Nurse (LVN 1) employee file contained a yearly performance evaluation. This deficient practice caused an increased risk in resident safety. Findings: A review of LVN 1's employee file indicated the date of hire was 9/22/22 and there was no performance evaluation (PE) completed since the date of hire. During an interview on 1/14/25 at 9:30 AM, the Director of Nursing (DON) stated PEs should be done 90 days after start of employment and then annually. The DON stated she could not explain why LVN 1 did not have a performance evaluation in the file. During a concurrent interview, the ADM stated she was unable to find LVN 1's performance evaluation. The DON and ADM both agreed and confirmed that a PE should have been performed once LVN 1 returned to work. The DON stated this created a risk to the residents safety. A review of the facility's policy and procedures titled, Performance Evaluations, dated 9/20, indicated a performance evaluation will be completed on employees at the conclusion of…

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

Based on interview and record review, the facility failed to ensure one of two sampled Certified Nurse Assistants (CNA 2) employee file contained a yearly skills competency checklist. This deficiency had the potential to have employees lacking safe, quality, and individualized care for the residents. Findings: A review of CNA 2's the employee file indicated the date of hire was 3/12/24 and there was no skills competency checklist in the file. During a concurrent interview, the Administrator (ADM) stated she was unable to find the skills competency checklist for CNA 2. During an interview on 1/14/25 at 9:30 AM, the Director of Nursing (DON) stated CNA 2's skills competency should have been completed upon hire and then annually. The DON stated, Check marks on a paper don't ensure that employees are competent. The DON stated agreed and confirmed that if documentation was not written then it was not done. The DON agreed and confirmed that the skills checklists were performed, reviewed, and documented to ensure employees know how to perform their job duties safely. The DON stated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one sampled resident (Resident 3) had a documented consent for psychotropic medications. This deficient practice caused an increased risk for Resident 3 to lack proper education regarding the medication. Findings: A review of Resident 3's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses including Type II diabetes mellitus (chronic disease that occurs when the body cannot produce or use insulin properly), bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs), and cellulitis (a skin infection that causes swelling and redness). A review of the Minimum Data Set (MDS - a resident assessment tool), dated 12/31/24, indicated Resident 3 was alert, oriented and had good recall. The MDS indicted Resident 3 felt down, depressed, or hopeless and had little interest or pleasure in doing things 7 days out of the week. The MDS indicated Resident 3 felt bad about…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 their abuse policy and procedures for two of 10 sampled residents (Residents 1 and 7). This deficient practice resulted in the resident-to-resident abuse incident was not reported to state licensing/certification office, police, and ombudsman, the incident was not investigated, and the residents were not separated (rooms changed) in a timely manner. Findings: During a review of Resident 1's admission Record, dated 11/21/24, indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breath), pneumonia (infection in the lungs), neoplasm of the prostate (tumor of the male gland in the rectum), muscle weakness, and abnormalities of gait and mobility. During a review of Resident 1's Minimum Data Set (MDS - resident assessment tool), dated 4/10/24, indicated, Resident 1 had mild cognitive issues (ability to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents are correctly identified for two of five sampled residents (Resident 1 and Resident 2). On 10/16/24, Resident 1 was for transfer to another skilled nursing facility (SNF) and Resident 2 had an appointment with the ophthalmologist (medical doctor with specialized training in medical and surgical eye care). The transportation company came and picked up Resident 2 and drove Resident 2 to the SNF instead of the ophthalmologist. This deficient practice resulted in Resident 2 stated that he felt mad and upset when the facility took him to the SNF resulting in Resident 2 missing his appointment with the eye specialist on 10/16/24. Findings: 1.During a review of the admission Record indicated the facility admitted Resident 1 on 10/15/24 with diagnoses including metabolic encephalopathy (alteration in consciousness caused by brain dysfunction) and generalized muscle weakness. During a review of the Minimum Data Set (MDS - a federally mandated…

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

Based on interview and record review the facility failed to provide care to the resident who had a fall in accordance with professional standards of practice for one of four sampled residents (Resident 1). For Resident 1 who had a fall on 10/16/24 during the night shift (11 p.m. to 6 p.m.), the facility failed to: 1.Assess Resident 1 immediately after the fall. 2.Notify Resident 1's physician and responsible party of the fall. These deficient practices resulted in Resident 1 not given immediate care after the fall. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 10/15/24 with diagnoses including metabolic encephalopathy (alteration in consciousness caused by brain dysfunction) and generalized muscle weakness. During a review of the Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 10/16/24, indicated Resident 1 had severe cognitive impairment. Resident 1 needed substantial assistance (helper does more than half of the effort) with eating, oral hygiene, toileting hygiene, shower/bathe, upper and lower 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 interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had pressure ulcers (also known as a pressure injury, a localized area of damaged skin or tissue caused by prolonged pressure on the skin), was assessed quarterly using the Braden scale assessment (a tool used to assess a patient's risk of developing pressure ulcers). This deficient practice caused an increased risk in assessing a significant change to Resident 1's skin integrity. Findings: A review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 4/15/2024 indicated the resident was at risk of developing pressure ulcers. A review of Resident 1's admission Record indicated the facility re-admitted the resident on 4/19/2024 with diagnoses including altered mental status, hemiplegia (severe or complete loss of strength or paralysis on one side of the body), hemiparesis (mild or partial weakness or loss of strength on one side of the body), muscle wasting and atrophy (the decrease in size or wasting away of a tissue, organ, or…

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

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had a severe risk for developing a pressure ulcer (also known as a pressure injury, a localized area of damaged skin or tissue caused by prolonged pressure on the skin), received necessary treatment and services to promote healing of pressure sore by: -Failing to develop a care plan for Resident 1's right lateral (side) leg vascular wound (develop due to problems with blood circulation, often caused by peripheral vascular disease [PVD, a circulatory condition that occurs when blood vessels outside of the heart and brain narrow, spasm, or become blocked]). -Failing to revise the care plan for Resident 1's sacral coccyx (tailbone area) pressure ulcer when it was re-classified from an unstageable pressure ulcer (when the stage of the pressure injury is not clear) to a Stage IV (characterized by full-thickness skin loss that extends through the fascia and into the muscle, bone, tendon, or joint) pressure ulcer. -Failing to indicate services that were to be provided to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the resident ' s right to be free from verbal abuse (a form of emotional or psychological harm that involves the use of words to demean, insult, or manipulate another person) for one of three sampled residents (Resident 1) when on 8/12/2024 at 5:30 AM, CNA 1 stated a derogatory word in Resident 1's room. This deficient practice resulted in Resident 1 being subjected to verbal abuse while under the care of the facility and had the potential to cause Resident 1 mental anguish. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 5/12/2023 with diagnoses including diabetes Type II (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly), spinal stenosis (a narrowing of one or more spaces within your spinal canal), personal history of transient ischemic attack (a stroke that last only a few minutes), and cerebral infarction…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sampled residents (Resident 1): 1. had and initial care plan developed for G-tube dislodgment and revised after the second dislodgement, to include new interventions. 2. had Interdisciplinary team meetings completed in a timely manner after G-tube dislodgement. This failure resulted in seven instances where Resident 1 ' s G-tube was dislodged and required replacement. Findings: 1. During a review of Resident 1's admission Record, dated 7/2/24, indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure), type two diabetes mellitus (a condition were your body has trouble controlling the level of sugar in the blood), heart failure (condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), muscle weakness, dysphagia (difficulty swallowing), and encephalopathy (disturbance in brain function). During a review of Resident 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 2), was not billed for a single room during the time another resident was on bed hold (bed at the facility is held for a resident during hospitalization up to seven days and paid for), in the same room as the resident. This failure resulted in the resident not receiving the single room they were paying for. Findings: During a review of Resident 2's admission Record, dated 7/2/24, indicated, Resident 2 was admitted to the facility on [DATE] with diagnoses including left artificial hip joint, muscle weakness, abnormal posture, abnormalities of gait and mobility, hypertension (high blood pressure) and type two diabetes mellitus (a condition were your body has trouble controlling the level of sugar in the blood). During a review of Resident 2 ' s Minimum Data Set (MDS, a standardized assessment and screening tool), dated 4/15/24, the MDS indicated, Resident 2 was independent in decision making, and required…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Registered Dietician (RD) recommendations made during the interdisciplinary team (IDT, different health care disciplines get together to review the plan of care of the resident) meeting to change the residents gastrostomy (G-tube, a tube inserted through the belly that brings nutrition directly to the stomach) feeding formula (nutrition) for one of five sampled residents (Resident 1). This failure resulted in recommendations for a change in Resident 1's G-tube formula to be delayed for 51 days and the resident losing six pounds (4% of their weight). Findings: During a review of Resident 1's admission Record dated 7/2/24, indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure), type two diabetes mellitus (a condition were your body has trouble controlling the level of sugar in the blood), heart failure (condition in which the heart muscle is unable to pump enough blood to meet the…

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

Based on interview and record review, the facility failed to perform staff competencies upon hire and/or annually for three of five sampled staff (Certified Nursing Assistant [CNA] 8, 10 and Licensed Vocational Nurse [LVN] 4). This deficient practice had the potential for residents to not receive the appropriate level of care needed affecting quality of care and potentially leading to resident harm. Findings: During a review on 6/6/2024 at 10:05 AM, employee files CNA 8, CNA 9, CNA 10, LVN 4, and Registered Nurse 2 (RN 2) were reviewed. CNA 8's employee file indicated the employee was hired on 11/30/2018. There were no competencies for the year 2023 available for review in CNA 8's employee file. CNA 10's employee file indicated the employee was hired on 6/6/2022. There were no competencies for the year 2023 available for review in CNA 9's employee file. LVN 4's employee file indicated the employee was hired on 2/14/2024. LVN 4's file indicated there was no employee competency completed upon hire. During an interview on 6/6/2024 at 10:34 AM, the Director of Staff Development (DSD)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nurses were rotating the insulin (a medication that regulates sugar in the blood) injection site for two of five sampled residents (Resident 21 and 75). This failure had the potential to result in bruising, pain, lipohypertrophy (a lump or accumulation of fatty tissue under skin), and/or localized cutaneous amyloidosis (-a condition caused by the buildup of abnormal proteins in the skin) to Residents 21 and 75. Findings: A review of Resident 21's medical records indicated the resident was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (a disease condition that affects the way the body produces and processes blood sugar), other diabetic kidney complications, long term use of insulin, and muscle wasting (a condition that causes a loss or thinning of muscle mass). A review of the Physician's Orders, dated 5/5/2024, indicated Resident 21 to receive 24 units of Humulin NPH (a type of intermediate-acting insulin) 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 interview and record review, the facility failed to ensure two of three sampled residents (Residents 11 and 55) were provided with the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN, a form issued in order to transfer financial liability to beneficiaries before the SNF provides an item or service that is usually paid for by Medicare, but may not be paid for in this particular instance because it is not medically reasonable and necessary, or is custodial in nature). This deficient practice had the potential to result in Resident 11 and Resident 55 not being given the information needed to make informed decisions about their care. Findings: a. A review of Resident 11's admission Record indicated the facility admitted the resident on 4/19/2024 with diagnoses that included an unspecified fall, urinary tract infection (an infection in any part of the urinary system), hypertension (high blood pressure), muscle weakness, anxiety, schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and major depressive…

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

Based on observation, interview, and record review, the facility failed to follow up on missing eyeglasses for one of six sampled residents (Resident 13), after the resident informed facility staff the eyeglasses were missing. This deficient practice had the potential to for Resident 13 to not have her missing items replaced. Findings: A review of the Resident 13's admission Record indicated the facility admitted the resident on 5/12/2023 with diagnoses that included Type II diabetes (a long term condition in which the body has trouble controlling blood sugar and using it for energy, causing high levels of sugar in the blood), arthritis (inflammation and swelling in one or more joints), spinal stenosis (when the spaces in the bones of the spine become too small), and hyperlipidemia (high cholesterol levels in the blood). A review of Resident 13's Inventory of Personal Effects dated 5/12/2023, indicated the resident had one pair of eyewear. A review of Resident 13's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 5/11/2024, indicated the resident…

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

Based on interview and record review, the facility failed to ensure a Notice of Transfer/Discharge Form was sent to the Office of the State Long-Term Care Ombudsman (representatives that assist the residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) for one of six sampled residents (Resident 8). This deficient practice had the potential to result in an unsafe discharge and/or denying the resident the right to appeal the discharge. Findings: A review of Resident 8's admission Record, indicated the facility re-admitted the resident on 1/11/2024 with diagnoses that included asthma (a condition in which your airways narrow and swell making breathing difficult), dysphagia (difficulty swallowing), dementia (impaired ability to remember, think, or make decisions that interferes with doing every day activities), muscle weakness, acute respiratory failure (a disease or injury that happened quickly without much warning and affects your breathing), and major depressive disorder (a mood disorder that causes a persistent…

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

Based on interview and record review, the facility failed to develop a person-centered care plan for Lexapro (a medication used to treat major depressive disorder [a mood disorder that causes a persistent feeling of sadness and loss of interest that can interfere with daily living]) for one of six sampled residents (Resident 27). This deficient practice had the potential for Resident 70 to not receive adequate and appropriate care. Findings: A review of the Resident 27's admission Record indicated the facility re-admitted the resident on 4/17/2024 with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and unspecified mental disorder (a diagnosis made when the healthcare provider doesn't specify a particular depressive disorder diagnosis). A review of Resident 27's Physician's Order dated 4/20/2024 indicated the resident was to receive Lexapro 5 milligrams (mg) by mouth one time a day for depression manifested by withdrawn behavior. A review of Resident 27'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.

Based on interview and record review, the facility failed to ensure two of six sampled residents (Resident 69 and Resident 80) received care and treatment in accordance with professional standards of practice by failing to: -Implement Physician's Orders in a timely manner for Resident 69's orthopedic consultation (a type of physician who treats conditions related to the musculoskeletal system). This failure resulted in the delay of physical therapy (PT-medical treatment used to restore standing, walking, and movement of different body parts) treatment for Resident 69. -Ensure staff followed up with the physician and obtain orders for Testosterone injections (treatment for individuals whose bodies do not make enough natural testosterone, a hormone that is responsible for many of the physical characteristics specific to adult males) for Resident 80. This deficient practice had the potential for Resident 80 to experience withdrawal (physical and mental symptoms that occur after stopping or reducing intake of a medication) symptoms of headache and nausea. Findings: a. A review of…

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

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 30) received care and services necessary to prevent accidents and falls by failing to provide a fall mat, per Resident 30's risk for fall care plan. This deficient practice placed the resident at increased risk for injury after a fall. Findings: A review of Resident 30's admission Record (face sheet) indicated the facility admitted the resident on 12/27/2023, with diagnoses including traumatic subdural hematoma (collection of blood between the covering of the brain and the surface of the brain due to an injury to the head), dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and hearing loss. A review of Resident 30's At Risk for Falls care plan, developed 1/15/2024, indicated the resident had cognitive loss, lack of safety awareness and impaired mobility. The care plan indicated the goal was for Resident 30 to have no falls with injury. The care plan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 68), who was experiencing unplanned severe weight loss (greater than five [5] percent [% - unit of measure] in one month), received the care and services necessary to prevent severe weight loss. Facility staff did not input into the electronic chart Resident 68's weekly weights, nor implement the care plan interventions of a frozen nutritional treat every day at lunch. These deficient practices placed Resident 68 at risk for continued nutritional decline and weight loss. Findings: A review of Resident 68's admission Record indicated the facility admitted the resident on 1/4/2024 with diagnoses including multiple sclerosis (MS, disabling disease of the brain and spinal cord that causes the nerves to deteriorate or become permanently damaged), adult failure to thrive (state of decline that may include weight loss, decreased appetite, poor nutrition, and inactivity) and schizophrenia (a serious…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 obtain informed consent for psychotropic medication (drugs that act on the brain to alter mood and behavior) use for two of three sampled residents (Resident 67 and Resident 290) when the following occurred: -Resident 67 gave verbal consent for a Quetiapine (a medication used for schizophrenia; a disorder that affects a person's ability to think, feel, and behave clearly), despite not having the mental capacity to make his own medical decisions. -There was no physician (MD) signature on the psychotropic medication administration disclosure form (form given to the resident with the risks and benefits for psychotropic medications) for Resident 67 and Resident 290. These failures had the potential to result in Resident 67 and Resident 290 not being educated on the risks and benefits of their prescribed psychotropic medications. Findings: A review of Resident 67's admission record indicated the facility admitted the resident on 2/27/2024 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 remove and replace expired medication in one of two Medication Storage Rooms. This deficient practice had the potential to result in a resident receiving expired or the wrong medication. Findings: On [DATE] at 11:32 AM, during an inspection of the Medication Room located at Nursing Station B with Registered Nurse 1 (RN 1), an intravenous piggyback (IVPB- a small volume of solution, through an established primary infusion line Meropenem (a medication used for the treatment of bacterial infections) 500 milligrams (mg) with expiration date of [DATE] was observed in the medication refrigerator. During a concurrent interview, RN 1 stated the medication was expired and was for a discharged resident. RN 1 sated the expired bag of Meropenem should have been discarded when the resident was discharged or when the medication became expired. RN 1 further stated by not discarding the medication, there was the potential for a resident to receive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sanitary food storage practices in the kitchen freezer area for one of two freezer floor areas located in the kitchen. The kitchen had trash littered on the floor where the frozen food was kept for resident consumption. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of bacteria from one object to another) that could lead to foodborne illness in 80 of 80 medically compromised residents who received food from the kitchen. Findings: During initial tour observation of the kitchen on 6/3/2024 at 7:18 a.m., the freezer area revealed an unsanitary floor area located in a small compartment inside a larger freezer area. During an interview on 6/3/2024 at 12:23 PM, the Dietary Manager (DM) stated the freezer area should be cleaned and sanitized, and the floor should not be dirty with trash littered on the floor where the food was stored. The DM stated that she would provide an immediate in service for the staff on cleaning and maintaining a safe and clean…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure necessary care was consistently provided for one of 23 sampled residents (Resident 38), who received hospice service (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill), by failing to maintain an integrated hospice binder that included: -Calendar of hospice staff visits. -Certification of Terminal Illness. -Ensure that hospice staff provided nursing/visitation notes to the facility. -Specific and resident centered end stage/hospice care plan. These deficient practices had the potential to lead to the resident not receiving the needed and necessary services timely. Findings: A review of the admission record indicated Resident 38 was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease, adult failure to thrive (state of decline that may include weight loss, decreased appetite, poor nutrition, and inactivity), moderate protein-calorie…

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

Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for one of six sampled residents (Resident 8). This deficient practice had the potential to result in the resident not being able to call nursing staff for assistance when needed. Findings: A review of Resident 8's admission Record, indicated the facility re-admitted the resident on 1/11/2024 with diagnoses that included asthma (a condition in which your airways narrow and swell making breathing difficult), Parkinson's disease (a brain disorder that causes unintended or uncontrolled movements such as shaking), Type II diabetes (a long term condition in which the body has trouble controlling blood sugar and using it for energy, causing high levels of sugar in the blood), dysphagia (difficulty swallowing), dementia (impaired ability to remember, think, or make decisions that interferes with doing every day activities), muscle weakness, acute respiratory failure (a disease or injury that happened quickly without much warning and affects your breathing), and major depressive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 out of six sampled residents (Resident 1) received treatment and care in accordance with professional standards of practice and physician's orders. By failing to apply bilateral (both sides) compression (a garment that applies gentle pressure to the limb to prevent fluid buildup in the tissues to manage swelling) sleeves for arms and stockings for legs for the management of lymphedema (swelling caused by a blockage of the lymphatic system [part of the body's immune system, made up of organs, tissues and vessels that protect the body from disease and infection] drainage). This failure had the potential to result in Resident 1's arms and legs to become swollen, painful, decrease blood flow, and tissue death. Findings: A review of Resident 1's admission Record dated 4/25/24, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including, type two diabetes (a condition were your body has trouble controlling the level 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 remove discontinued medication from the medication cart for one of six sampled residents (Resident 1). For Resident 1 who had a discontinued order for gabapentin 300 milligrams (mg, unit of measurement) for neuropathic pain (pain caused by disease or injury of the nervous system [includes the brain, spinal cord, and nerves) dated [DATE], the facility continued to store the discontinued gabapentin 300 mg. inside the medication cart. This deficient practice had the potential for medication error by giving the wrong dose of the gabapentin to Resident 1. Findings: A review of the admission Record indicated the facility admitted Resident 1 on [DATE] with diagnoses including diabetes mellitus (a disease in which the body does not control the amount of glucose (a type of sugar) in the blood) and muscle weakness. A review of the Minimum Data Set (MDS, standardized care and health screening tool) dated [DATE] indicated Resident 1 was cognitively…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to report to the local California Department of Public Health (CDPH) within two hours of the physical altercation that occurred on 2/27/2024 involving two residents (Resident 1 and 2). This deficient practice resulted in a delay of an onsite inspection by the California Department of Public Health (CDPH) to ensure circumstances were investigated and had the potential to place Resident 1 and 2 at further risk for injury and abuse. Findings: a. A review of Resident 1's admission record indicated the facility readmitted Resident 1 on 10/6/2023 with diagnoses including bipolar disorder (extreme mood swings that include mania [emotional highs] and depression which may lead to impaired functioning), anxiety disorder (a mental disorder characterized by feelings of excessive uneasiness and apprehension), and schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood). A review of the 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 interview and record review, the facility failed to ensure that COVID-19 (a viral infection, highly contagious, that easily transmits from person to person, causing respiratory problems and may cause death) vaccination was offered/ re-offered and/or administered for six of six sampled residents (Residents 1, 2, 3, 4, 5 and 6) per facility policy. This deficient practice resulted COVID-19 infection to Residents 1, 2, 3, 4, 5 and 6. Findings: 1. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), spinal stenosis (narrowing of the spaces within the spine, which can put pressure on the nerves that travel through the spine) and diabetes mellitus (DM-a chronic [ongoing] condition that affects the way the body processes blood sugar [glucose]). A review of Resident 1's Minimum…

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

Based on observation, interview and record review, the facility failed to maintain an infection control measure and prevention by failing to ensure three of 19 sampled facility staff (Cook [CK], Dietary Aid 2 [DA2], and Dietary Aid 3 [DA3]) were wearing a mask while working together at the kitchen. This deficient practice had the potential to result in the spread of COVID-19 (a viral infection, highly contagious, that easily transmits from person to person, causing respiratory problems and may cause death) infection to residents and staff. Findings: During a concurrent observation and interview with the Director of Nursing (DON) on 3/1/2024 at 12:54 p.m., CK, DA2 and DA3 was observed not wearing any face mask while working together inside the kitchen. DON stated and validated that all staff was supposed to wear a mask at all times due to high risk of infection. A review of facility ' s policy and procedures (P&P), titled, Personal Protective Equipment (PPE) Guide for Healthcare Personnel, revised on 12/2022, P&P indicated that when a center is experiencing an outbreak, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Influenza (Flu-common viral infection that can be deadly, especially in high-risk groups) vaccine was offered to two of six sampled residents (Resident 3 and 5) per facility policy. This deficient practice placed Resident 3 and 5 at a higher risk of acquiring and transmitting Flu infection to other residents and staff in the facility. Findings: 1. A review of Resident 3's admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and was re-admitted on [DATE], with diagnoses including congestive heart failure (CHF-a chronic condition in which the heart does not pump blood as well as it should), hypotension (low blood pressure reading) and chronic kidney disease (CKD-a longstanding disease of the kidneys leading to kidney failure). A review of Resident 3's Minimum Data Set (MDS-a standardized assessment and care-screening tool), dated 12/29/2023, indicated Resident 3's cognitive (mental action or process of acquiring…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 respond timely to resident's requests for one of four sampled residents (Resident 1). The facility failed to: 1. Assess Resident 1 when Resident 1 complained of headache on 11/7/2023 (unknown time) and administer acetaminophen (Tylenol, medication for pain) 650 milligrams (mg. unit of measurement) as needed (PRN) as ordered by the physician and based on the assessment, give the acetaminophen when indicated. 2. Licensed Vocational Nurse (LVN 1) went for her meal/rest break before administering the acetaminophen to Resident 1 on 11/7/2023. 3. Treat Resident 1 with respect when Resident 1 requested LVN 1 to lower her voice during the early morning hours. (Date unknown). LVN 1 did not lower her voice. These deficient practices resulted in Resident 1 stated she felt mad at LVN 1 and that LVN 1 was rude and disrespectful . Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 12/19/2022 with diagnoses including rotator cuff (group of muscles and tendons that hold the shoulder in place)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its policy to conduct a psychosocial (regarding how social factors influence the individuals mind or behavior) follow up for one of three sampled residents (Resident 1), after an alleged abuse incident report. This deficient practice had the potential to result in Resident 1 ' s care needs not being met. Findings: A review of Resident 1 ' s admission record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE], with diagnoses that included dementia (loss of cognitive functioning-thinking, remembering, and reasoning), diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]) and heart failure (CHF-a chronic condition in which the heart does not pump blood as well as it should). A review of Resident 1's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 8/4/2023, indicated the resident had impaired cognition (when a person…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 arrange for a home health visit for one of three sampled residents (Resident 3), after Resident 3 was discharge from the facility. This failure had the potential to result in rehospitalization or risk residents ' safety. Findings: A review of Resident 3 ' s admission Record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses that included encephalopathy (damage or disease that affects the brain), dementia (loss of cognitive functioning-thinking, remembering, and reasoning) and generalized muscle weakness (lack of physical or muscle strength). A review of Resident 3's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 9/21/2023, indicated Resident 3 had impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life) and required extensive assistance with bed mobility, transfer, dressing, eating, toilet use and personal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 conduct an interdisciplinary team meeting (IDT - a group of experts from several different fields) for one of three sampled residents (Resident 3), per the facility ' s policy. This deficient practice had the potential to result in Resident 3 ' s care needs not being met comprehensively when resident/resident ' s representative were not involved in developing a care plan and making decisions for Resident 3. Findings: A review of Resident 3 ' s admission record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses that included encephalopathy (damage or disease that affects the brain), dementia (loss of cognitive functioning-thinking, remembering, and reasoning) and generalized muscle weakness (lack of physical or muscle strength). A review of Resident 3's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 9/21/2023, indicated Resident 3 had impaired cognition (when a person has trouble remembering,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, for one of six sampled residents (Resident 1), the facility failed to revise Resident 1 ' s care plan to accurately reflect the correct Advance Directive (legal document that provide instructions for medical care when a person lose the ability to make their own decisions) status and the correct Physician Orders for Life-Sustaining Treatment (POLST, written medical order that helps give people with serious illness more control over their own care by specifying the types of medical treatment they want to receive during serious illness) status in accordance with the facility ' s policy and procedures titled, Person-Centered Care Plan, revised on 10/24/2022. This deficient practice resulted in failing to reflect Resident 1 ' s treatment options during medical emergencies and follow Resident 1 ' s wishes. Findings: During a review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 2/16/2022 with diagnoses including heart failure (the heart muscle cannot pump enough blood to meet the body ' s needs for blood and oxygen),…

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