Solheim Senior Community

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately monitor the fluid intake for one of one sampled resident (Resident 33) under hydration care area. This deficient practice had the potential to cause fluid overload (when the body has too much water, causing fluid to build up in blood vessels and tissues, leading to swelling, high blood pressure, shortness of breath, and increased strain on the heart and kidneys) and/or increase edema ( swelling caused by excess fluid trapped in the body's tissues and shortness of breath). Findings: During a review of Resident 33's admission Record, the admission Record indicated Resident 33 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 33's diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (brain damage, affecting left side of the body [arm, leg, face] due to blocked blood flow, depriving brain cells of oxygen and causing cell death), chronic obstructive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interventions to prevent accidents (any unexpected or unintentional incident, which results or may result in injury or illness) such as for aspiration (happens when food, liquid, or other material enters a person's airway and eventually the lungs by accident) and/ or choking (when food or another object gets stuck in your airway) for one (1) of seven sampled residents (Resident 39) from the accidents care area by failing to ensure Resident 39's head of the bed (HOB) was upright or elevated to 90-degree angle (a unit for measuring angles, where a full circle is 360 ) and properly positioned during mealtimes. This deficient practice placed Residents 39 at risk for aspiration and choking which had the potential to result in serious consequences like aspiration pneumonia (is a type of lung infection that is due to a relatively large amount of material from the stomach or mouth entering the lungs), hospitalization, 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 maintain an accurate and complete record for one (1) of 20 sampled residents (Resident 30) as indicated in the facility's policy and procedure. This deficient practice had the potential to result in miscommunication, improper delivery of care and inaccurate information of the care provided to the Resident, which could negatively affect the overall wellbeing of Resident 30.Findings:During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was admitted to the facility on [DATE] and re-admitted on [DATE], Resident 30's diagnoses included osteomyelitis (inflammation or swelling that occurs in the bone) of the right ankle/ foot, congestive heart failure (is a long-term condition in which your heart cannot pump blood well enough to meet your body needs), chronic obstructive pulmonary disease (COPD, is a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and dementia (a progressive state of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility failed to develop and implement a comprehensive person-centered care plan (a document that outlines the facility's plan to provide personalized care to a resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs) for one of two sampled residents (Resident 1) to address resident's poor mobility and balance per facility policy. This deficient practice resulted in Resident 1 sustaining a fall in the shower room on 11/2/2025 at around 10 AM while sitting in a shower chair. Resident 1 sustained laceration (a deep cut or tear in the skin) to forehead and was sent to the General Acute Care Hospital (GACH) on 11/2/2025 at 10:40 AM, where Resident 1 was diagnosed with acute nondisplaced fracture (a break in the bone that has not moved out of position, is recent) of first cervical vertebra (C1, the topmost bone that connects the skull to the spine) right posterior (back) arch, midline forehead hematoma…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide pharmaceutical services for two of four sampled residents (Residents 16 and 53) by failing to: 1. Administer Resident 16's diltiazem (medication for high blood pressure and angina [chest pain]) as ordered by the physician. 2. Ensure no expired medication was kept in the medication cart and medication storage room. On 10/19/2024, observed 1 expired bottle of diltiazem (Resident 16's medication), 2 bottles of buspirone (a medication that treats anxiety) and 3 bottle of Blood Sugar Check Machine Control solution (test strips used to check that the meter used to check blood sugar is working properly and is reflecting accurate results). 3. Administer Resident 53's Valproic Acid (medication given to treat Bipolar disorder which is a mental illness that causes extreme mood swings or shifts between mania and depression) as ordered by the physician. These deficient practices placed Resident 16 and Resident 53 at increased risk for being…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication error (any preventable event that may cause or lead to inappropriate medication use or resident harm while the medication is in the control of the health care professional, patient) rate during medication pass observation on 10/9/2024 was not above (5) percent (%). The outcome was two (2) medication errors out of twenty-eight (28) opportunities for errors, which resulted in a Medication Administration Error Rate of 7.1%. Findings: 1. During a review of Resident 16's Face Sheet, , the Face Sheet indicated Resident 16 was originally admitted at the facility on 1/13/2021 and readmitted on [DATE] with diagnoses that included but not limited to chronic diastolic congestive heart failure (a condition where the heart's left ventricle [chamber in heart that receives blood] stiffens and can't relax normally), paroxysmal atrial fibrillation (a type of irregular heartbeat that occurs in brief episodes), hypertensive heart…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with its policy and procedure by failing to: 1. Label food items in the kitchen. 2. Discard expired food in the kitchen. 3. Discard dented soda can found in storage room. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization. Findings: During a concurrent observation and interview on 10/8/2024 at 8:17 AM with kitchen staff (KS) 1, a tray of breaded fish was observed on a rack. The tray was not labeled with a preparation date or an expiration date. KS 1 stated the food item was breaded fish and it was not labeled. It should have been labeled with a preparation date and expiration date when it was prepared.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow its infection control policy for four (4) of 18 sampled residents (Resident 19, 60, 9 and 53) by failing to ensure: 1. 2. and 3. Staff were using a gown while providing wound care treatment to Residents 19, 60 and 9, who were on enhanced barrier precaution (EBP, an infection control practice that involves wearing gowns and gloves during high-contact activities with residents in nursing homes). 4. Staff was using a gown while administering medication via gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for residents with swallowing problems) tube to Resident 53 who was on enhanced barrier precaution. This deficient practice had the potential to result in Resident 19, 60, 9 and 53 developing an infection and spread of infection among staff and residents. Findings: 1. During a review of Resident 19's Face Sheet (front page of the chart that contains a summary 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 develop a comprehensive, resident-centered care plan (a document that outlines a resident's care goals and the activities that will be performed to achieve those goals) for resident's actual fall on 6/13/2024 and implement the care plan interventions for one of two sampled residents (Resident 44). 1. On 6/13/2024, Resident 44 was left unattended by facility staff during shower to dispose soiled clothes. 2. On 10/8/2024, Resident 44 was observed Resident 44 got up from his bed by himself, and walked to the restroom and was wearing non-skid sock (slip resistant socks designed to reduce the risk of slipping and falling on wet or slippery surfaces) on left foot and no non- skid sock on the right foot. 3. Resident 44's Actual Fall care plan initiated on 6/13/2024, did not indicate the resident needs assistance during bathing. These deficient practices resulted in Resident 44 from falling on 6/13/2024 and resident sustained left hand fifth digit…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 address a significant unplanned weight loss of greater than five (5) % within 30 days from 9/6/2024 to 10/9/2024 for one (1) of 1 sampled Residents (Resident 62) in accordance with the facility policy. This deficient practice had the potential to cause Resident 62 to experience further weight loss and complications such as skin breakdown, malnutrition (faulty nutrition due to inadequate or unbalanced intake of nutrients), and weakness affecting the resident's over all well-being. Findings: During a review of Resident 62's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), and severe obesity (when a person's weight is more than 80 to 100 pounds above their ideal body weight). During a review of Resident 62's History and Physical (H&P) dated 9/6/2024, the H&P…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administer the correct oxygen level for one (1) of 1 sampled resident (Resident 16) in accordance with physician's order. These deficient practices had the potential to cause Resident 16 to experience shortness of breath (SOB) and desaturation (low oxygen level). Findings: During a review of Resident 16's Face Sheet, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included chronic congestive heart failure (CHF, a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) and sleep apnea (a sleep disorder that causes breathing to repeatedly stop or become shallow during sleep). During a review of Resident 16's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 7/11/2024, the MDS indicated the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident 53) was free from unnecessary use of psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility policy and procedure by failing to ensure Resident 53 has the specific target behavior and indication for the use and monitoring of quetiapine (Seroquel, to treat certain mental/mood disorders). This deficient practice had the potential to place Resident 53 at risk for significant adverse (harmful) consequences from the use of unnecessary psychotropic drug, which could result to impairment or decline in the residents' mental, physical condition, functional, and psychosocial status. Findings: During a review of Resident 53's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 53 was originally admitted to the facility on [DATE] and readmitted on [DATE].…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure: 1. Resident 53's medication bottle for sucralfate (to prevent ulcers [open sores]) was labeled in accordance with doctor's orders and included the appropriate cautionary instructions regarding administration route. This deficient practice had the potential to harm Resident 53 due to potential dispensing and administration errors (incorrect route) and can possibly lead to adverse side effects, aspiration, and/ or death. 2. Resident 16's expired diltiazem (treats high blood pressure and prevents chest pain) was not stored in the facility's medication cart. This deficient practice had the potential for harm to Resident 16 due to the potential loss of strength of the drug, and for the residents to not receive the full effect of the medication. Findings: 1. During a review of Resident 53's Face Sheet, the Face Sheet indicated Resident 53 was originally admitted at the facility on 9/19/2022 and readmitted on [DATE] with diagnoses that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement treatment for the prevention of pressure ulcer (painful wound caused as a result of pressure or friction) by failing to ensure that the low air loss mattress (LAL, mattress used for residents who are at risk for developing sores or already have pressure sores designed to circulate a constant flow of air for the management of pressure sores) was on the correct settings for three (3) of 3 sampled residents (Residents 30, 36, and 38) in accordance with physician's order and facility policy. This deficient practice had the potential to place the residents at risk for skin integrity complications and pressure injury. Findings: a. A review of Resident 38's admission Record indicated Resident 38 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (describes abnormalities of water, electrolytes, vitamins, and other chemicals that adversely affect the brain function), muscle wasting and atrophy (muscle…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure they do not have a medication error rate of five percent (%) or greater as evidenced by eight (8) medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological; or accepted professional standards and principles which apply to professionals providing services) out of 26 opportunities (observed administered medications) for error and yielded a medication error rate of 30.77 percentage (%), for one of six sampled residents (Residents 64) observed during medication administration (Med Pass). These deficient practices of medication administration error rate of 30.77 % exceeded the five (5) percent threshold and placed Resident 64 at risk for not getting the full effect of the medications and/ or for adverse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the facility's policy and procedure on storage and disposal of medication for one of two medication storage rooms. There were three (3) unopened straight catheters (a soft, thin tube used to pass urine from the body) with expiration date of 2/1/2022, 3 boxes of insulin syringes (a medical instrument that is expressly designed to administer insulin [a hormone that lowers the level of glucose {a type of sugar} in the blood] into the body via injection) with expiration date of 11/8/2022, four (4) boxes of Brand 1 lancets (needle that is used to obtain blood for testing blood sugar) with expiration date of 5/31/2023, 3 boxes of brand 2 lancets with expiration date of 7/2023, one (1) bottle of Brand 1 blood sugar test strip (an easy way to test your blood sugar, strips work with glucose meters to read your blood sugar levels) with expiration date of 10/31/2020, two (2) boxes of Brand 2 blood sugar test strip with expiration 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: a. Label foods in the kitchen with item names, open date and/or receive date, and expiration date or use by date, and failed to discard expired foods from food storage and walk in refrigerator. b. Monitor and clean the ice machine. c. Ensure there was an air gap (an unobstructed vertical space between the water outlet and the flood level of a plumbing fixture) for a drainage pipe and not touching the kitchen floor. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization. Findings: a. During a concurrent observation and interview on 10/2/2023 at 9:38 AM in the Food Storage Room with the Director of Dining Services (DDS), the following 16 items were on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident was informed in advance, of the care to be furnished and the type of professional who will furnish care for one of seventeen residents (Resident 19) based on the facility policy. This deficient practice has resulted not honoring Resident 19's right to be informed and choose the option she prefers for her ancillary care. Findings: A review of Resident 19's admission Record indicated the resident was admitted to the facility on [DATE] and re- admitted on [DATE]. Resident 19's diagnoses included severe obesity (a condition marked by excess accumulation of body fat), atrial fibrillation (Afib, an irregular and often very rapid heartbeat) and respiratory failure (a serious condition that makes it difficult to breathe on your own). A review of Resident 19's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 9/12/2023, indicated Resident 19 has intact cognitive skills (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY b) A review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE] and re- admitted on [DATE]. The admission Record indicated, Resident 2's with diagnoses which included Diabetes Mellitus (DM, a condition that happens when your blood sugar [glucose] is too high), Functional quadriplegia (FQ, the complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord) and hypertension (HTN, high blood pressure) A review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 9/5/2023, indicated Resident 2 has intact cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. Resident 2 needs extensive assistance resident involved in activity, staff provide weight- bearing support) with one-person physical assist in bed mobility, transfer, locomotion, dressing, toilet use and personal hygiene. A review of Resident 2's Care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed notify the doctor for a severe weight loss and Registered Dietician (RD) recommendation on 9/22/2023 for one (1) of 3 sampled residents (Resident 5). This deficient practice placed Resident 5 at risk for further decline in nutritional status and continued weight loss. Findings: During a review of Resident 5's admission Record indicated Resident was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of unspecified lump in breast, dysphagia (difficulty swallowing), gastro-esophageal reflux disease (GERD - a digestive disease in which stomach acid or contents irritates the food pipe lining), and Alzheimer's disease (a brain disorder that destroys memory and other important mental functions). During a review of Resident 5's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 9/8/2023, indicated Resident 5 was not cognitively (mental action or process of acquiring knowledge and understanding)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a baseline care plan to reflect the use of oxygen one (1) of 17 sampled residents (Resident 221) in accordance with the facility policy and procedure. This deficient practice placed Resident 221 at risk for not having her needs met which had the potential to negatively affect resident's well-being. Findings: A review of Resident 221's admission Record indicated the resident was admitted to the facility on [DATE], with diagnosis that included heart failure (condition that develops when your heart doesn't pump enough blood for your body's needs), morbid obesity (weight more than 80 to 100 pounds above ideal body weight), and dysphagia (difficulty swallowing). A review of Resident 221's undated History and Physical Examination, indicated that Resident 221 had the capacity to understand and make decisions. A review of the Minimum Data Set (MDS - an assessment and care-screening tool), dated 10/4/2023, indicated Resident 221 has intact cognition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to revise the comprehensive care plan for one of one sampled residents (Resident 36) as indicated on the facility's policy. This deficient practice had the potential for Resident 36 to not receive specific interventions to prevent decline in functional ability. Findings: A review of Resident 36's admission Record indicated the resident was admitted to the facility on [DATE] and re- admitted on [DATE]. Resident 36's diagnoses included status post-surgical intervention for small bowel obstruction (a surgical emergency in which the obstruction of the small intestine hinders passage of intestinal contents), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) A review of Resident 36's Minimum Data Set (MDS, a standardized assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure four (4) out of 17 sampled residents (Resident 26, 7, 66 and 54) receive assistance with toileting on a timely manner. This deficient practice resulted in the residents feeling frustrated and embarrassed due to delay in receiving care and had the potential to lead to skin breakdown and urinary tract infection (UTI, an infection of the bladder and urinary system). Findings: During a review of Resident 26's admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of muscle wasting and atrophy (muscle shrinking), need for assistance with personal care, unsteadiness on feet, abnormalities of gait (a manner of walking or moving on foot) and mobility. During a review of Resident 26's History and Physical (H&P, the initial clinical evaluation and examination of the patient) dated 9/16/2023, indicated Resident 26 had the capacity to understand and make decisions. During a review of Resident 26's Minimum Data Set (MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and modify interventions, consistent with the resident's assessed needs, choices, and preferences to maintain acceptable parameters of nutritional status for two of three sampled residents (Resident 60 and Resident 5) a. The facility failed to implement interventions to prevent weight loss for Resident 5. The resident experienced a weight loss of 19 pounds (lbs., unit of measurement. Severe weight loss if there is loss greater than 5 % in one month) in one month. b. The facility failed to implement interventions for gradual weight loss such as to assist Resident 60 with hand feeding. Resident 60 was observed with untouched food tray on 10/4/2023. This deficient practice placed Resident 60 and Resident 5 at risk for further decline in nutritional status and continued weight loss. Findings: a. During a review of Resident 5's admission Record indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure for one of six sampled residents (Residents 64) was free from significant medication error (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturer's specifications [not recommendations] regarding the preparation and administration of the medication or biological; or accepted professional standards and principles) by failing to administer seven (7) medication due to be given at 9 AM in accordance with the physician's order. The following medications for Resident 64 were administered more than one (1) hour from the scheduled administration time: 1. Acetazolamid e (treats swelling caused by heart disease) 125 milligram (mg, unit of measurement) tablet daily, administer 1 tablet by mouth daily. For fluid retention, chronic kidney disease Stage 3 ([CKD] kidneys are damaged and can't filter blood the way they should), order date 7/5/2023.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: a. Follow infection control measures in the kitchen when a dirty white towel, dish sponge, spatula, and three containers were found on the floor and moldy tomatoes were found in the walk-in refrigerator. b. Follow infection control measures for oxygen administration by having the oxygen tubing laying on the floor while the Resident 19 is on oxygen therapy on 10/4/2023. These deficient practices resulted in contamination of kitchen items and placed the residents at risk for infection. In addition, these deficient practices resulted in potential for introducing bacteria that might cause respiratory tract infection (any infectious disease of the upper or lower respiratory tract) for Resident 19. Findings: a. During initial tour in the kitchen on 10/2/23 at 9:13 AM, observed a dirty white towel, blue sponge with debris (scattered pieces of waste or remains), a stained spatula, and a large black bin lying on the kitchen floor. During an…

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