Temple Park Convalescent Hospital

Based on observation, interview, and record review, the facility failed to ensure that dental services were provided to one of two sampled residents (Resident 24) reviewed for dental services by failing to: -Ensure to schedule Resident 24's dental consultation and treatment in accordance with the facility's policy and procedure titled Dental, Vision, and Hearing Evaluations. This failure had the potential to negatively affect Resident 24's oral health and ability to chew food.Findings:During review of Resident 24's admission Record , the admission Record indicated the facility originally admitted Resident 24 on 10/5/2024 and readmitted the resident on 3/9/2026 with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), type 2 diabetes mellitus (disorder characterized by difficulty in blood sugar control and poor wound healing), anemia (a condition where the body does not have enough healthy red blood cells), and dysphagia (difficulty swallowing). During a review of Resident 24's Onsite Mobile Dental form…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a significant change in condition was promptly reported to licensed nursing staff for one of three residents reviewed (Resident 2), when Certified Nursing Assistant 1 (CNA) did not report a resident's cough on 4/11/2026 for approximately four (4) days.This failure had the potential to delay assessment, diagnosis, and treatment, placing Resident 2 at risk for worsening condition.During a review of Resident 2's admission Record, indicated Resident 2 was admitted to the facility on [DATE] with diagnosis of acute bronchitis (the temporary inflammation of the airways in the lungs, typically caused by viruses), and Chronic Obstructive Pulmonary Disorder (COPD -lung disease causing restricted airflow and breathing problems).During a review of Resident 2's Minimum Data Set (MDS- resident assessment tool), dated 2/5/2026, indicated, Resident 2 had intact cognitive skills for daily decision making. The MDS indicated Resident 2 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 ensure one of three sampled residents (Resident 2) had a comprehensive care plan that was timely revised, consistently documented, and readily accessible to staff following a significant change in condition requiring hospitalization on 1/27/2026.This failure resulted in Resident 2 lacking a Care Plan listing goals and interventions to address her diagnosis of acute bronchitis (the temporary inflammation of the airways in the lungs, typically caused by viruses) on 1/27/2026 and had the potential to impact the coordination of care and Resident 2's health outcomes.During a review of Resident 2's admission Record, indicated Resident 2 was admitted to the facility on [DATE] with diagnosis of acute bronchitis (the temporary inflammation of the airways in the lungs, typically caused by viruses).During a review of Resident 2's Minimum Data Set (MDS- resident assessment tool), dated 2/5/2026, indicated, Resident 2 had intact cognitive skills for daily decision…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administration of medication was documented for one of three sampled residents (Resident 1). For Resident 1, the facility failed to document when Resident 1 was given Benadryl (medication used to relieve symptoms of allergies) 25 milligrams (mg., metric unit of measurement, used for medication dosage and/or amount) orally on 9/18/25.This deficient practice had the potential for medication error and medication duplication to Resident 1. During a review of the admission Record, indicated the facility admitted Resident 1 on 1/31/25 and re-admitted on [DATE] with diagnoses including generalized muscle weakness, hypertension (high blood pressure) and dementia (a group of thinking and social symptoms that interferes with daily functioning).During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 9/14/25, the MDS indicated Resident 1 had intact cognition (participant has sufficient judgement, planning organization,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a physician order before administering a medication to one of three sampled residents (Resident 1). For Resident 1 the facility failed to:1. Obtain a physician order prior to the administration of Benadryl tablet (medication used to relieve symptoms of allergies) 25 milligrams (mg., metric unit of measurement, used for medication dosage and/or amount) orally.2. Ensure the Benadryl 25 mg. tablet was not left at Resident 1's bedside table unattended.These deficient practices had the potential to result in harm to Resident 1 and other residents from inappropriate and unsafe medication administration.During a review of the admission Record, indicated the facility admitted Resident 1 on 1/31/25 and re-admitted on [DATE] with diagnoses including generalized muscle weakness, hypertension (high blood pressure) and dementia (a group of thinking and social symptoms that interferes with daily functioning).During a review of Resident 1's…

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

Based on interview and record review the facility failed to administer medication as ordered by the physician for one of four sampled residents (Resident 1). For Resident 1, the facility failed to administer the metronidazole (antibiotic that treats infection) 500 milligrams (mg., metric unit of measurement, used for medication dosage and/or amount) as ordered by the physician. This deficient practice resulted in Resident 1 not given one dose of the metronidazole 500 mg. and had the potential for Resident 1's infection to worsen.During a review of the admission Record indicated the facility admitted Resident 1 on 1/30/25 with diagnoses including diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) and pressure ulcer (wounds that occur from prolonged pressure on the skin) of the sacral region (lower back). During a review of Resident 1's Care Plan initiated on 2/26/25 indicated Resident 1 was on enhanced barrier precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications were kept secure in accordance with professional standards of practice for one of four sample residents (Resident 2). During medication pass observation on 7/22/25 at 9 a.m., the facility failed to ensure Resident 2's medications were not left on top of the medication cart while the medication cart was left unattended. This deficient practice had the potential for other residents and other individuals to easily access the medications on top of the cart for their own. use. During a review of the admission Record indicated the facility admitted Resident 2 on 8/2/23 and readmitted on [DATE] with diagnoses including pneumonia (an infection/inflammation in the lungs) and generalized muscle weakness. During a review of the Minimum Data Set (MDS, resident assessment tool) dated 7/10/25 indicated Resident 2 was cognitively intact. Resident 2 needed substantial assistance (helper does more than half the effort) with toileting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement the care plan for one of three sampled residents (Resident 1). For Resident 1, the facility failed to assess and document weekly Resident 1 ' s moisture associated skin damage (MASD, moisture associated skin damage caused from prolonged exposure to moisture) to the buttocks area as indicated in Resident 1 ' s care plan. This deficient practice resulted in not being able to determine if Resident 1 ' s MASD had healed before Resident 1 was discharged from the facility on 4/11/25. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 4/2/25 with diagnoses including diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), difficulty in walking and dementia (a progressive state of decline in mental abilities). During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 4/6/25 indicated Resident 1 had severed cognitive impairment.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 environment is free of hazard for one of three sampled residents (Resident 3). During observation on 5/13/25, the facility hall was lined with linen carts, dirty linen hampers, trash hampers and showers chairs on both sides of the hall. Residents 3 stated it was difficult for him to self-propel his wheelchair due to the clutter in the hallway. This deficient practice had the potential for accidents to occur for Resident 3 and other residents. Findings: During a review of the admission Record indicated the facility admitted Resident 3 on 3/21/24 with diagnoses including diabetes mellitus (DM, disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness and abnormalities of gait and mobility. During a review of Resident 3 ' s Minimum Data Set (MDS, a resident assessment tool) dated 3/4/25 indicated Resident 3 was cognitively intact. The MDS indicated Resident 3 was independent with activities of daily living (ADLs) and used the walker and wheelchair as mobility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 19) had an advance directive (a legal document indicating resident preference on end-of-life treatment decisions). This failure violated Resident 19 and/or representative's rights to be fully informed of the option to formulate an advanced directive and had the potential not to follow Resident 19's wishes. Findings: During a review of Resident 19's admission Information, the admission Information indicated the facility admitted Resident 19 on 9/30/2024 and readmitted Resident 19 on 3/6/2025 with diagnoses including metabolic encephalopathy (brain dysfunction caused by problems with the body's metabolism), cerebral infarction (a condition where brain tissue dies due to a lack of blood flow and oxygen) and moderate intellectual disabilities (observable developmental delays, which may be accompanied by physical impairments). During a review of Resident 19's Resident Care Conference Review dated 10/11/2024, the Resident Care Conference Review indicated Resident 19 was under 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 notify the State Long Term Care Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) when the facility transferred one of two sampled residents (Resident 53) to the General Acute Care Hospital (GACH). This failure had the potential for Resident 53 not to have a representative. Findings: During a review of Resident 53's admission Record, the admission Record indicated the facility admitted the resident on 11/8/2024 with diagnoses that included metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), dementia (a progressive state of decline in mental abilities), human immunodeficiency virus (HIV, a virus that attacks the body's immune system), chronic respiratory failure (a condition when the lungs cannot release enough oxygen into the blood), congestive heart failure (CHF, a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and dysphagia (difficulty swallowing). 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, interview, and record review the facility failed to ensure to implement the care plan for one of 19 sampled resident (Resident 92) for the use of a hand mitten (used to help protect residents who are prone to disrupting medical treatment). This failure had the potential to cause a lack of monitoring for Resident 93's skin integrity and circulation. Findings: During a review of Resident 92's admission Record, the admission Record indicated the facility admitted Resident 92 on 1/9/2025 with diagnoses including cerebral infarction (a serious condition where blood flow to the brain is blocked, leading to tissue damage and death), legal blindness, and need for assistance with personal care. During a review of Resident 92's Minimum Data Set (MDS, a resident assessment tool) dated 1/13/2025, the MDS indicated the resident was not oriented to the day, month, or year. The MDS indicated Resident 92 had poor recall. During an observation on 4/7/2025 at 10:29 AM in Resident 92's room, Resident 92 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 provide care and services to maintain good hygiene for one of one sampled residents (Resident 68). This failure had the potential to expose Resident 68 to skin irritation, skin breakdown, and possible infection. Findings: During a review of Resident 68's admission Record), the admission Record indicated the facility admitted Resident 68 on 1/24/2025 with diagnoses that included muscle weakness, need for assistance with personal care (bathing, dressing, eating, toileting, and transferring - moving from one place to another), hemiplegia (the loss of the ability to move, feel, or otherwise control muscles on one side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting left non-dominant (the side that is not your preferred side of the body for performing tasks) side. During a review of Resident 68's Minimum Data Set (MDS, a resident assessment tool)…

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

Based on interview and record review, the facility failed to administer insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) according to the facility's policy by failing to rotate the administration site when administering insulin to one of one sampled residents (Resident 4). This failure had the potential for Resident 4 to experience skin complications. Findings: During a review of Resident 4's admission Record, the admission Record indicated the facility re-admitted the resident on 1/26/2025 with diagnosis that included type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 4's Physician Orders dated 1/27/2025, the Physician Order indicated the resident was to receive Humulin R Insulin (a medication used to manage type 2 diabetes by lowering blood sugar levels) per sliding scale (varies the dose of insulin based on blood glucose level) subcutaneously (a method of administering medication by injecting it into the fatty layer 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 Treatment Nurse 1 (TN1) monitored the progression of the pressure ulcers (pressure injury, localized damage to the skin and/or underlying tissue usually over a bony prominence) for one of one sampled residents (Resident 53). This failure had the potential for Resident 53's pressure ulcers to worsen. Findings: During a review of Resident 53's admission Record, the admission Record indicated the facility re-admitted the resident on 2/1/2025 with diagnoses that included metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), dementia (a progressive state of decline in mental abilities), human immunodeficiency virus (HIV, a virus that attacks the body's immune system), chronic respiratory failure (a condition when the lungs cannot release enough oxygen into the blood), congestive heart failure (CHF, a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and dysphagia (difficulty swallowing). During a review of Resident 53's…

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

Based on observation, interview, and record review the facility failed to ensure not to leave a lighter unattended (left alone without supervision) and unsecured (unprotected) at a resident's bedside table for one of two sampled residents (Resident 55). This failure had the potential Resident 24 to sustain burns and/or cause a fire. Findings: During a review of Resident 55's admission Record dated 4/10/2025, the admission Record indicated the facility originally admitted Resident 55 on 4/30/2026 and readmitted Resident 55 on 10/28/2024 with the diagnoses of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and nicotine dependence (a person's body and brain become used to having nicotine, the addictive substance in tobacco products such as cigarettes), cigarettes, uncomplicated. During a review of Resident 55's Minimum Data Set (MDS - a resident assessment tool) dated 2/11/2025, indicated Resident 55 had the ability to make himself understood and had the ability to understand others. The MDS indicated Resident 55 was independent 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary respiratory care services for one of two sampled residents (Resident 78), by failing to ensure Resident 78 who was receiving oxygen through a nasal cannula tubing (device used to deliver supplemental oxygen or increased airflow to a person in need of respiratory help) was not wrapped around a trash can while Resident 78 used the nasal cannula. This failure had the potential for Resident 78 to experience respiratory infections (infections of parts of the body involved in breathing) associated with using an unsanitary (dirty, unhealthy, or unclean in a way that could endanger health) nasal cannula tubing. Findings: During a review of Resident 78's admission Record, the admission Record indicated the facility originally admitted Resident 78 on 4/23/2024 and readmitted [DATE] with diagnoses that included pneumonia (an infection/inflammation in the lungs), acute and chronic respirator failure (a sudden and gradual…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document and monitor for manifestations of behavior (how a person's personality or inner state is expressed through their outward actions and reactions) for one of five sampled residents (Resident 3) who was taking Aripiprazole (Abilify, a medication known as an antipsychotic medication used to treat and manage schizophrenia [a disorder that affects a person's ability to think, feel, and behave clearly]). This failure had the potential for Resident 3 to take unnecessary medication. Findings: During a review of Resident 3's admission Record, the admission Record indicated the facility admitted the resident on 11/22/2023 with diagnoses that included dementia (a progressive state of decline in mental abilities), schizophrenia, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool) dated 2/25/2025, the MDS indicated the resident was cognitively intact (had the ability to think,…

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

Based on observation, interview, and record review the facility failed to ensure two opened insulin pens (a device used to administer insulin, a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) were discarded per facility's policy. This failure had the potential for the medication dispensing errors. Findings: During a concurrent observation and interview on 4/9/2025 at 2:23 PM, the facility's medication refrigerator was observed with Licensed Vocational Nurse (LVN) 1 in the facility's medication storage room. In the medication refrigerator the following were observed: 1. Novolog Flexpen (a type of insulin pen) labeled with an open date of 3/8/2025 and a discard date of 4/5/2025. 2. Lantus Solostart pen (a type of insulin pen) with an open date of 2/5/2025 and labeled discard. During a concurrent observation and interview on 4/9/2025 at 2:23 PM, LVN 1 stated that opened insulin pens should not be kept in the refrigerator and if the insulin pens were labeled discard they should be discarded and not left in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) for one of three residents (Resident 2's) right hand swelling noted on 1/5/25. This failure had the potential to negatively affect the delivery of care and services. Findings: During a review of Resident 2's admission Record dated 1/14/25, it was indicated that Resident 2 was admitted to the facility on [DATE], with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities), muscle weakness, hypertension (high blood pressure), dysphagia (difficulty swallowing), abnormal posture, and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). During a review of Resident 2's History and Physical (H&P), dated 7/19/24 indicated the patient did not have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three residents (Resident 2) was offered a substitute meal as required if the resident consumed less than 50% of the meal. This deficient practice had the potential to result in malnutrition, dehydration, and overall decline in health and medical condition. Findings: During a review of Resident 2's admission Record dated 1/14/25, it was indicated that Resident 2 was admitted to the facility on [DATE], with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities), muscle weakness, hypertension (high blood pressure), dysphagia (difficulty swallowing), abnormal posture, and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). During a review of Resident 2's History and Physical (H&P), dated 7/19/24 indicated the patient does not have the capacity (ability) to consent, the…

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

Based on observation, interview and record review, the facility failed to provide mouthcare regularly for one of three sampled residents (Resident 1). During observation on 12/30/24 at 10 a.m., Resident 1 was observed with creamy substance at the corner of the left mouth, tongue was coated with white crust and the lower lip was dry with crusts. This deficient practice had the potential for Resident 1 to suffer from pain and infection. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 7/18/24 with diagnoses including dementia (progressive sate of decline in mental abilities), Alzheimer's disease (progressive decline in mental abilities) and need for assistance with personal care. During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 10/21/24 indicated Resident 1 had severe cognitive impairment. Resident 1 needed substantial assistance (helper does more than half the effort) with toileting hygiene, shower/bathe self, lower body dressing, putting/taking off footwear, personal hygiene, and moderate assistance…

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

Based on interview and record review the facility failed to ensure the records for residents were complete and accurate for one of three sampled residents (Resident 1). For Resident 1, the facility failed to ensure the fluid and oral intake were accurately documented on 12/15/24,12/16/24, 12/17/24 and 12/29/24. This deficient practice resulted in failing to determine the oral and fluid intake of Resident 1. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 7/18/24 with diagnoses including dementia (progressive sate of decline in mental abilities), Alzheimer's disease (progressive decline in mental abilities) and need for assistance with personal care. During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 10/21/24 indicated Resident 1 had severe cognitive impairment. Resident 1 needed substantial assistance (helper does more than half the effort) with toileting hygiene, shower/bathe self, lower body dressing, putting/taking off footwear, personal hygiene, and moderate assistance (helper does less than half the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of Coronavirus - 19 (COVID-19, COVID, a virus that causes respiratory illness that can spread from person to person) as evidenced by: 1. Failing to ensure that one of the three sampled residents (Residents 1) was wearing a mask while the facility was in an active Covid 19 outbreak (a sudden increase in the number of cases of a disease or medical condition in a specific location or population over a given time period). 2. Failing to ensure that staff were fit tested for N95 respirators/masks (is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) 3. Failing to ensure that staff were appropriately screened before starting their shifts. These deficient practices had the potential to place both residents and staff at a risk for infection to COVID-19.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement abuse policy and procedure when the facility failed to report to the State Agency: 1. The alleged abuse between two residents (Residents 3 and 4). 2. The injury of unknown origin for Resident 5. This deficient practice resulted in Resident 3 and Resident 4 exposed to continuous verbal and mental abuse and for Resident 5 with a potential for contiuned physical abuse. Cross Reference: F726. Findings: 1. During a review of Resident 3's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses that included hepatic encephalopathy (a serious and potentially reversible condition that can affect individuals with advanced liver dysfunction), alcoholic cirrhosis of the liver (a condition that occurs when the liver is permanently damaged by alcohol, causing scar tissue to replace healthy tissue), and insomnia (a common sleep disorder that makes it difficult to fall asleep, stay asleep, or get quality sleep). 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 interviews, and record reviews the facility failed to implement abuse policy and procedure when the facility failed to report to the State Agency: the injury of unknown for 0ne of the three sampled residents (Resident 5). This deficient practice had the potential exposed to continuous verbal and mental abuse from Resident 3 causing mental anguish and emotional distress. Findings: During a review of Resident 5 ' s admission Record FS indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including metabolic encephalopathy (a neurological disorder that causes brain dysfunction due to a chemical imbalance in the blood), dementia (a syndrome that causes a decline in cognitive abilities, such as memory, thinking, and problem-solving, that can interfere with daily activities), and dysphagia (difficulty swallowing). During a review of Resident 5 ' s H&P dated 4/9/2023 indicated, Resident 5 did not have the capacity to consent. During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 1. That licensed nurses had the specific competencies and skill sets necessary to adequately assess stage Pressure Ulcers (PU-injuries to skin and underlying tissue resulting from prolonged pressure on the skin. They most often develop on skin that covers bony areas of the body, such as the heels, ankles, hips, and tailbone. They range from stage 1 through stage 4: I-intact skin with redness, II-broken skin or intact blister involving top layer of the skin, III- broken skin extending to the fatty tissue, and IV- broken skin extending to the muscle or the bone) for one out of three sampled residents by failing to grade the stage 3 pressure ulcer. 2. To implement abuse policy and procedure when the facility did not Identify and assess all possible incidents of abuse (Resident 5). This failure had the potential to result in improperly treating the wound which may lead to the wound getting infected and also exposed Resident 5 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 interviews and record review the facility failed to have a full-time abuse coordinator (Administrator) in the facility. As a result, the incidents of abuse and neglect were not managed and addressed for three of three residents (Residents 3, 4, and 5). Cross Reference: F609 Findings: 1. During a review of Resident 3's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses that included hepatic encephalopathy (a serious and potentially reversible condition that can affect individuals with advanced liver dysfunction), alcoholic cirrhosis of the liver (a condition that occurs when the liver is permanently damaged by alcohol, causing scar tissue to replace healthy tissue), and insomnia (a common sleep disorder that makes it difficult to fall asleep, stay asleep, or get quality sleep). During a review of Resident 3's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 6/24/2024 indicated Resident 3 was cognitively (the mental 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 observation, interview and record review, the facility failed to maintain medical records for one of nine sampled residents (Resident 1) in accordance with accepted professional standards and practices by ensuring accurate documentation. This deficient practice had the potential to result in confusion in the care and services rendered to Resident 1 as evident by the inaccurate information entered into Resident 1's clinical record. Findings: During a review of Resident 1 ' s admission record indicated the facility initially admitted the on 2/17/2024 and readmitted on 7/12//2024 with diagnoses that included toxic encephalopathy, dementia (loss of cognitive functioning-thinking, remembering, and reasoning), chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), and aphasia (loss of ability to understand or express speech, caused by brain damage). During a review of Resident 1 ' s Minimum Data Set (MDS- standardized data collection tool used…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 person-centered care plan that included dementia (a disorder of mental processes caused by brain disease or injury and marked by memory disorder, personality changes, and impaired reasoning) care needs for one of three sampled residents (Resident 1). This deficient practice had the potential to negatively affect the delivery of care and services. Finding: A review of Resident 1's admission Record (Face Sheet) indicated the facility originally admitted the resident on 4/10/2023, and readmitted on [DATE], with diagnoses including dementia, history of falling, and metabolic encephalopathy (a problem in the brain caused by an illness or organs that are not working as well as they should). A review of Resident 1 ' s Minimum Data Set (MDS – a comprehensive assessment and care screening tool) dated 1/18/2024, indicated the resident's cognitive skills (ability to think, remember, and make decisions) for daily decision making was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to sufficiently prepare one of three sampled resident (Resident 1) for a safe and orderly discharge from the facility to the resident ' s home, by failing to include the resident ' s significant other who was the primary care giver in the discharge process and by failing to ensure all necessary medical equipment and supplies were ordered. This failure resulted in resident 1 not having the appropriate Durable Medical Equipment (DME - any medical equipment used in the home to aid in a better quality of living) necessary for safe ambulation and transfer, and with no support/relief for the caregiver (CG). Placing Resident 1 at risk for accidents, injuries, and/ death. Findings: A review of Resident 1 ' s admission record indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including functional quadriplegia (complete inability to move due to severe disability or frailty caused by another medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety by not labeling: A.Sliced ham with the use by date. B. Ground chicken with the use by date. C. Chicken meat with the use by date D. Sliced Bacon with the use by date. E. Creamy Italian Dressing with the use by date. F. Sausage with the use by date The facility failed to discard ground beef that was still being stored in the refrigerator after its use by date of 3/21/2024 and failed to maintain the refrigerator and freezer temperature log on 3/30/2024 and 3/31/2024. These deficient practices had the potential to cause food-borne illnesses. Findings: During a concurrent observation and interview on 4/1/2024 at 7:52 A.M., the following was in the refrigerator: - Sliced ham in a transparent plastic container with a blue lid with an open date of 3/30/24 and no use by date label. - Ground chicken inside a white plastic bag with an open date of 3/22/24 and no use by 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 provide care in a manner that maintained or enhanced residents dignity and respect in full recognition of their individualities for two of ten sampled residents (Resident 85 and Resident 92). For Resident 85, the facility failed to cover the urinary collection bag (designed to collect urine drained from the bladder via a catheter) with a privacy bag. For Resident 92, the facility failed to provide dignity by standing over the resident while assisting her during a meal. These deficient practices had the potential to negatively affect the residents psychosocial wellbeing and loss of dignity. Findings: a. A review of Resident 85's admission Record indicated the facility admitted the resident on 12/6/2023, with diagnoses including muscle weakness, and paraplegia (loss of ability to move that affects your legs, but not your arms). A review of Resident 85's Minimum Date Set (MDS) dated [DATE], indicated the resident had 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.

Based on observation, interview, and record review, the facility failed to ensure that a call light was within reach for one of four sampled residents (Resident 90) investigated for the call lights care area. This deficient practice had the potential to result in the residents not being able to call for facility staff assistance. Findings: A review of Resident 90's admission Record indicated the facility admitted the resident on 12/19/2023 with diagnoses including Huntington disease (an inherited disease that causes the progressive breakdown [degeneration of the tissue to a less functional active form] of nerve cells in the brain), hypertension (a condition in which blood pressure is higher than normal), and abnormalities in gait and mobility. A review of Resident 90's History and Physical, dated 12/22/2023, indicated the resident had limited capacity to consent. A review of Resident 90's Minimum Data Set (MDS - an assessment and care screening tool), dated 12/26/2023, indicated the resident had mildly impaired cognition (a slight decline in mental abilities, memory and completing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Advance Directive Acknowledgement forms (document provided by the facility that indicates whether a resident has an Advance Directive [AD- a written instruction, recognized under State law, relating to the provision of health care when the individual is unable to make decisions for themselves], would like information regarding creation of an advance directive, or refusal to create an advance directive) were completed thoroughly for two of seven sampled residents (Residents 36 and Resident 85). These deficient practices had the potential for the facility to not honor the residents' medical decisions regarding end-of-life treatment. Findings: a. A review of Resident 36's admission Record (Face Sheet) indicated that the facility admitted the resident on 6/8/2023, and readmitted on [DATE], with diagnoses including polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body), dementia (decline in mental ability…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident was provided a communication device or board with the language that the resident was able to understand for one of one sampled resident (Resident 25). This deficient practice had the potential to delay the delivery of necessary care to the resident. Findings: A review of Resident 25's admission Record indicated that the facility admitted Resident 25 on 10/17/2022 readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), hypertension (a condition in which blood pressure is higher than normal) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 25's History and Physical, dated 9/18/2023, indicated the resident had fluctuating…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assistance with Activities of Daily Living (ADL- refer to an individual's daily self-care activities such as eating, dressing/grooming, bathing/personal hygiene, mobility and toileting) for one of three sampled residents (Resident 29) who had severely impaired vision. This deficient practice had the potential for the resident to experience poor oral intake and be at risk for weight loss. Findings: A review of Resident 29's admission Record indicated the facility admitted the resident on 3/18/2021, and with diagnoses including glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye), need for assistance with personal care, type two diabetes ( high blood sugar), and depression (a mood disorder that causes feeling of sadness and loss of interest). A review of Resident 29's Minimum Data Set (MDS - an assessment and care screening tool) dated 2/4/2024, indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that one of the six sampled staff Certified Nursing Assistant (CNA 2) had a Basic Life Support (BLS - an emergency lifesaving procedure that includes recognition of the signs of sudden cardiac arrest, heart attack, and stroke, as well as the performance of cardiopulmonary resuscitation [CPR] when the heart stops beating) certificate was up to date. This deficient practice had the potential to result in facility residents receiving emergency care that was not up to date, which could lead to resident harm and/or death. Findings: A review of CNA 2's employee file indicated the CNA 2 had a BLS certificate that expired on 3/2024. A review of the Nursing Staffing Assignment and sign-in sheet dated [DATE] indicated that CNA 2 was working in the facility on [DATE]. During a concurrent interview and record review on [DATE] at 9:50 AM, CNA 2's employee file was reviewed with the Director of Staff Development (DSD). The DSD verified that CNA 2's BLS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 out of six sampled residents (Resident 42), who was identified with visual impairment and functional limitation, was provided with activities that stimulate the resident's senses as evidenced by -Failing to provide Resident 42 with a radio and television. -Failing to formulate a care plan for activities for Resident 42. -Failing to perform an activity participation review quarterly for Resident 42. This deficient practice resulted in Resident 42 experiencing emotional distress verbalizing she felt her days were empty; and indicating she was frustrated and uncomfortable because she was bored. Findings: A review of Resident 42's admission Record indicated the facility originally admitted the resident on 11/6/2020 and re-admitted the resident on 10/27/2021 with diagnoses including adult failure to thrive (a decline in older adults that manifests as a downward spiral of health and ability), cachexia (a general state of ill health involving great weight loss and muscle loss), muscle weakness, dysphagia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 98) received pressure ulcer (localized skin and soft tissue injuries that form as a result of prolonged pressure and shear, usually exerted over bony prominences) care as indicated in their policy and procedure as evidenced by: -Failing to ensure Resident 98's wound vac (negative pressure wound therapy, a therapeutic technique using a suction pump, tubing, and a dressing to remove excess drainage and promote wound healing) was on and functioning. -Failing to revise Resident 98's Stage 4 pressure ulcer (pressure injuries that extend to muscle, tendon, or bone) care plan. These deficient practices had the potential to cause the development and worsening of Resident 98's pressure ulcer that could lead to severe illness, hospitalization, and death. Findings: A review of Resident 98's admission Record indicated the facility admitted the resident on 3/14/2024 with diagnoses that included metabolic encephalopathy (a condition in which brain function is disturbed either…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three sampled resident's (Resident 84) urinary indwelling urinary catheter (Foley catheter [brand name] a flexible tube (a catheter) inserted into the bladder that remains (dwells) there to provide continuous urinary drainage) was securely anchored (secured to the resident). This deficient practice had the potential for the resident to endure pain from potential pulling tractions and dislodgement of the catheter that may result in urethral (a muscular structure that helps keep urine in the bladder until voiding can occur) trauma. Findings: According to the admission record, the facility admitted Resident 84 on 2/11/2024, and readmitted on [DATE], with diagnoses that included urinary tract infection, diabetes and chronic kidney disease. The Minimum Data Set (MDS, assessment and care-screening tool), dated 3/4/2024, indicated the resident had severe cognitive (ability to acquire and understand knowledge) impairment. The 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 provide respiratory care and services according to professional standards of practice for one of three sampled residents (Resident 39). The facility implemented the following deficient practices: - the facility administered oxygen via a non-rebreather mask without a physician order and without administering 10 -15 LPM oxygen as required for correct functioning of mask. - failed to monitor oxygen saturation level in accordance with the physician's order - develop/revise a plan of care for Resident 39 who was using oxygen and had had shortness of breath Findings: A review of Resident 39's admission record indicated Resident 39 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included myocardial infarction (heart attack), type 2 diabetes (high blood sugar) and high blood pressure. A review of the History and Physical, dated 8/4/2023, indicated the resident's lung sounds were diminished…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 18 sampled residents (Resident 32) who was dependent upon hemodialysis (a medical procedure to remove fluid and waste products from the body) had an emergency kit at resident's bedside. This deficient practice had the potential for resident to receive delay intervention during accidental bleeding. Findings: A review of the admission record, indicated the facility admitted Resident 32 on and re-admitted on [DATE] and readmitted the resident on 3/25/2024 with diagnoses that included end stage renal disease (ESRD, when kidneys are no longer able to work as they should to meet the needs of the body) requiring hemodialysis, type 2 diabetes mellitus (adult onset diabetes - a chronic condition that affects the way the body processes blood sugar), legal blindness, right foot amputation. A review of the Physician's Orders, dated 3/25/2024, indicated Resident 32 required hemodialysis every Monday, Wednesday and Friday at 11:30 AM. 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.

Based on observation, interview, and record review the facility failed to post staffing information per the facility policy and procedure titled, 'Posting Direct Care Daily Staffing Numbers. This deficient practice had the potential for residents, staff, and visitors of the facility to not have knowledge of the facility's staffing information. Findings: During an observation on 4/23/2024 at 4:15 PM, the facility's staff posting was observed displayed at the nursing station. The staff posting did not indicate the facility's name. During a concurrent interview and record review on 4/4/2024 at 10:51 AM, the facility's staff posting was reviewed with the Director of Staff Development (DSD). The DSD stated the staff posting did not include the facility's name and that it was important for the facility's name to be included in the staff posting so residents, visitors, and staff know the information is for the facility. During a concurrent interview and record review on 4/4/2023 at 1:14 PM, the facility's staff posting was reviewed with the Director of Nursing (DON). The DON verified 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 meet the nutritional needs for two out of six sampled residents (Resident 14 and Resident 29) by failing to provide double portion meals as ordered by the physician. These deficient practices had the potential to result in decreased nutritional intake and weight loss. Findings: a. A review of Resident 14's admission Record indicated that the facility admitted the resident on 8/16/2019, and readmitted him on 3/26/2024, with diagnoses including polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body), chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), dysphasia (swallowing difficulties), fibromyalgia (chronic, widespread pain throughout the body or at multiple sites), and urinary tract infection (an infection in any part of the urinary system). A review of Resident 14's Minimum Data Set (MDS- a standardized assessment and screening tool),…

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

Based on observation, interview, and record review, the facility failed to evaluate the food preferences for one of six sampled residents (Resident 1), as evidenced by failing to perform a Nutrition Evaluation for the resident quarterly. This deficient practice had the potential for Resident 1 to feel their needs were not being met and experience emotional distress. Findings: A review of Resident 1's admission Record indicated the facility initially admitted the resident on 11/13/2003 and re-admitted the resident on 5/30/2019 with diagnoses that included chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), hypertension (high blood pressure), depressive episodes (a person experiences a depressed mood (feeling sad, irritable, empty), type 2 diabetes (a long-term medical condition in which your body doesn't use insulin properly, resulting in unusual blood sugar levels), and hyperlipidemia (high cholesterol levels in the blood). A review of Resident 1's History and Physical dated 7/27/2022, indicated the resident 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 interview and record review, the licensed nursing staff failed to maintain accurate medical records in accordance with accepted professional standards for one sampled resident (Resident 16). The facility failed to ensure the licensed nursing staff maintained accurate information regarding the Physician's Order for Life-Sustained Treatment (POLST) for Resident 16. This deficient practice had the potential for the facility to not honor the resident's medical decisions regarding end-of-life treatment. Findings: A review of Resident 16's admission Record indicated the facility admitted the resident on [DATE] and readmitted on [DATE] with diagnoses including encephalopathy (brain disease, damage, or malfunction of brain), acute and chronic respiratory failure with hypoxia (a serious condition that occurs when the air sacs of the lungs cannot release enough oxygen into the blood ), dysphasia (a swallowing difficulties), encounter for attention for gastrostomy (a surgical procedure to insert a tube through 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 confirm the identity of two of three sampled residents (Resident 1 and Resident 2). Resident 1 who had an audiology (hearing tests that use different techniques to identify hearing loss) appointment on 2/28/24, the facility failed to use identifiers (information directly associated with an individual that reliably identifies the individual as the person for whom the service or treatment is intended) to confirm the identities of Resident 1 and Resident 2. The facility sent Resident 2 to the audiology examination appointment instead of Resident 1. This deficient practice resulted in Resident 1 missed his appointment, had to be rescheduled and had the potential to delay of treatment. Findings: 1. A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 11/17/23 with diagnoses including dementia (loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life) and…

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

Based on interview and record review the facility failed to notify the responsible party (RP) before changing rooms for one of three sampled residents (Resident 1). This deficient practice had the potential to violate the resident and responsible party's rights in participating in decision making, care planning and treatment choices. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 3/18/21 with diagnoses including glaucoma (group of eye disease that can cause vision loss and blindness by damage to the optic nerve [nerve that connects the eye to the brain]), muscle weakness and diabetes mellitus (increased blood glucose [sugar]). A review of the Minimum Data Set (MDS, standardized care and health screening tool) dated 2/4/24, indicated Resident 1 was cognitively (relating to process of thinking, reasoning, and remembering) intact. Resident 1 required supervision with toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear and needed set up with eating, oral and personal hygiene. A review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its' policy and procedures titled, Abuse Investigation and Reporting, for one of three sampled residents, (Resident 1) by failing to report an alleged abuse incident to the State Survey Agency (SSA), the local Ombudsman (examines complaints from people who resides in skilled Nursing Facilities who feel they have been unfairly treated by facility staff) and law enforcement. This deficient practice resulted in a delay of an onsite inspection by the SSA to rule out abuse placing Residents 1 and others residents at risk for further abuse. Findings: An unannounced visit was made to the facility to investigate an alleged abuse on 11/3/2023. A review of Resident 1's admission Record indicated Resident 1 was originally admitted to the facility on [DATE], with diagnoses including aftercare following surgery of the digestive tract, delayed milestone in childhood (developmentally delayed), difficulty walking, and generalized muscle weakness. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the Notice of Proposed Transfer/Discharge was provided to the resident or to the responsible party prior to transfer/Discharge for three of six rsampled esidents (Resident 1, 2, and 3). The facility also failed to provide documentation to show that the State Long Term Care Ombudsman (public advocate) was notified of the transfer/discharge from the facility for one of the six sampled residents (Resident 3). These deficient practices had the potential to deny residents being informed of their rights and protect residents from transfer/discharge without due process for Resident 1, 2, and 3. Findings: a. A review of Resident 1's admission Record indicated the facility admitted the resident on 1/20/2022 with diagnoses including hypertension (HTN - elevated blood pressure), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), hemiplegia (weakness on one side of the body) and…

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