The Meadows on Sunset Post Acute

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 provide safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by, failing to ensure: 1. Three of three sampled linen carts (linen carts 10, 11, and 12) were kept in good condition that were free of holes, tears, and rips. 2. Linens were free of contamination. This deficient practice had the potential to result in contaminated linens, sheets, towels, and gowns being provided to the residents. 3. Employee COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) Vaccination Policy was updated and matched facility's practice. These deficient practices had the potential to lead to staff confusion, noncompliance with infection control practices, increasing the risk for the spread of infection among residents and within the facility. Findings: a. During a concurrent observation and interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 visitation restrictions were addressed for one (1) of three (3) sampled residents (Resident 41) when the facility was not aware of Resident 41's responsible party's (RP) request for no visitors without the RP's presence. This deficient practice had the potential for Resident 41 to have unwanted visitors that could cause anxiety or distress to the resident. Findings: During a review of Resident 41's admission Record, the admission Record indicated the resident was admitted on [DATE] with diagnoses including end stage renal disease (ESRD - irreversible kidney failure), unspecified dementia (progressive state of decline in mental abilities), hyperlipidemia (abnormally high levels of fat in the blood), anemia (a condition where the body does not have enough healthy red blood cells), pneumonia (an infection/inflammation of the lungs), and nicotine dependence (a physical and mental addiction to tobacco). During a review of Resident 41's History and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that mail is being delivered to three (3) out of ten (10) sampled residents (Resident 17, Resident 88, and Resident 130) on Saturdays. This deficiency had the potential for residents to feel isolated and worry that their mail might get lost. Findings: During a review of Resident 17's admission Record, the admission Record indicated the facility originally admitted Resident 17 on 6/01/2022 and was readmitted on [DATE] with diagnoses including fusion of spine (a surgical procedure that joins two or more spine bone together into one solid bone to stop painful movement), cellulitis (a skin infection that causes swelling and redness), muscle weakness, asthma (respiratory condition marked by spasms in the bronchi of the lungs causing difficulty in breathing), diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) and major depressive disorder (a mood disorder that causes a persistent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to inform and provide written information to all adult residents concerning the right to accept and refuse medical and surgical treatment and, at the resident's option, to formulate an advance directive (a legal document indicating resident preference on end-of-life treatment decisions) for two (2) of four (4) sampled residents (Resident 12 and 71) with the Social Services Director (SSD) by failing to ensure the Advanced Healthcare Directive Acknowledgement Form was completed. This deficient practice violated the resident's rights and/or representative's right to be fully informed of the option to formulate their advanced directives. Findings: 1. During a review of Resident 12's admission Record (AR), the AR indicated Resident 12 was originally admitted on [DATE] and re-admitted on [DATE] to the facility with a diagnosis of encounter for orthopedic aftercare following surgical amputation (care and treatment a patient receives after an arm, legs, fingers,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a homelike environment for one of one sampled resident (Resident 54) by not maintaining functional closet drawers. This deficient practice violated Resident 54's rights to a safe, clean, sanitary, and homelike environment. Findings: During a review of Resident 54's admission Record (the front page of the chart that contains a summary of basic information about the resident), the admission Record indicated Resident 54 was admitted to the facility on [DATE], with diagnoses including chronic kidney disease (progressive damage and loss of function in the kidneys), Diabetes Mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN - high blood pressure). During a review of Resident 54's History and Physical (H&P - a document with resident's medical history and physical examination done by a physician), dated 9/27/2024, the H&P indicated that Resident 54 had a Brief Interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents are screened using the Preadmission Screening and Resident Review (PASRR - a federal requirement to help ensure that individuals are not appropriately placed in nursing homes for long-term care) for a mental disorder (MD - a health condition that significantly affects a person's thinking, emotional regulation, mood, or behavior, making it difficult to cope with daily life) or intellectual disability (ID - a condition that limits intelligence and disrupts abilities necessary for living independently) prior to admission and that individuals identified with serious mental illness (SMI - a health condition that significantly affects how a person thinks, feels, behaves, or interacts with others) and/or ID/developmental disability (DD - a group of conditions due to an impairment in physical, learning, language, or behavior areas)/related conditions (RC) receive the care and services in maintaining his/her highest practicable level 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 observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one (1) of 1 sampled resident (Resident 106) reviewed under Preadmission Screening and Resident Review (PASRR - a federal requirement to help ensure that individuals are not appropriately placed in nursing homes for long-term care) care area addressing the resident's diagnoses of schizophrenia (a mental illness that is characterized by disturbances in thought). These deficient practices had the potential for a delay in the delivery of the necessary care and services the resident needs. Findings: During a review of Resident 106's admission Record (AR), the AR indicated the facility admitted the resident on 3/18/2024, with diagnoses including paraplegia (paralysis that affects the legs, making it impossible to stand or walk), schizophrenia, and generalized…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 effective communication for one of one sampled resident (Resident 61) with hearing impairment, when the facility did not provide communication board (a device that displays symbols, photos, or illustrations to help individuals with limited hearing or language skills to communicate) or other alternative communication tools. This deficient practice had the potential to result in Resident 61's unmet needs, misunderstanding of care and instructions, decreased participation in care, and increased risk for harm due to inability to effectively communicate. Findings: During a review of Resident 61's admission Records (the front page of the chart that contains a summary of basic information about the resident), the admission Records indicated the facility admitted Resident 61 on 4/21/2023, and readmitted on [DATE] with diagnoses including Huntington disease (inherited condition that affects movement, thinking and behavior), hemiplegia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide necessary Activities of Daily Living (ADL - activities such as bathing, dressing and toileting a person performs daily) care, specifically grooming, including nail care, for one of one sampled resident (Resident 43). This failure had the potential to result in poor hygiene, increased risk of infection, skin injury from scratching for Resident 43. Findings: During a review of Resident 43's admission Record (the front page of the chart that contains a summary of basic information about the resident), the admission Record indicated Resident 43 was originally admitted to the facility on [DATE], then readmitted to the facility on [DATE], with diagnoses including Diabetes Mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), peripheral vascular disease (a common condition in which narrowed arteries reduce blood flow to the arms or legs), atrial fibrillation (an irregular and often very…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents with pressure ulcers/injury (a skin and tissue injury caused by prolonged pressure on the skin, often over bony areas) received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one of four sampled residents (Resident 85) reviewed under pressure ulcer/injury by failing to ensure the low air loss mattress (LALM, a specialized bed mattress that helps prevent and treat pressure ulcers by using a continuous flow of air to regulate temperature and moisture on the skin) of Resident 85 was set according to the resident's weight. The deficient practices had the potential for worsening of Resident 85`s pressure injury. Findings: During a review of Resident 85's admission Record (AR), the AR indicated the facility admitted the resident on 3/10/2026, with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on…

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

Based on observation, interview, and record review, the facility failed to ensure staff providing care and services to the resident who had a feeding tube (are soft plastic tubes through which liquid nutrition travels through the gastrointestinal tract [the series of organs that food and liquids pass through as they are digested, absorbed, and leave the body as feces]) were aware of, competent in, and utilized facility protocols regarding feeding tube nutrition and care for one of twenty-two sampled residents (Resident 136) observed during initial screening of the residents by failing to label the water flush bag for enteral fluid hydration (is the process of delivering water and essential fluids directly into the stomach or small intestine to keep the body hydrated, typically using a feeding tube) with the rate of infusion. The deficient practice had the potential for under or overhydrating the resident causing fluid imbalance. Findings: During a review of Resident 136's admission Record (AR), the AR indicated the facility admitted the resident on 3/27/2026, with diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 parenteral fluids (are liquids that are administered intravenously or by injection to bypass the digestive system) were administered consistent with professional standards of practice for one (1) of one (1) sampled resident (Resident 28) reviewed during a random observation by failing to ensure Resident 28's midline catheter (a long, thin, flexible tube that is inserted into a large vein in the upper arm) indicated the date of the last dressing change. This deficient practice had the potential to place Resident 28 at risk for developing complications such as inflammation of the vein and infection. Findings: During a review of Resident 28's admission Record, the admission Record indicated the facility originally admitted the resident on 7/18/2025, and readmitted in the facility on 3/2/2026, with diagnoses including osteomyelitis (inflammation of bone or bone marrow, usually due to infection), absence of right toes, and absence 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 respiratory care provided to residents was consistent with professional standards of practice for two of two sampled residents (Residents 71 and 78) reviewed for respiratory care by failing to ensure: 1. Resident 71's oxygen tubing (a small, soft plastic tube used to give someone extra oxygen) was kept off the floor. The deficient practice had the potential for residents to develop complications such as shortness of breath and desaturation (low levels of oxygen in the blood) and respiratory infections. 2. Resident 78`s oxygen tubing was not touching the floor, trash can, and under the bedside table. This deficient practice had the potential to result in placing Resident 78 at risk for infection. Findings: 1. During a review of Resident 71's admission Record (AR), the AR indicated that the facility admitted the resident on 10/2/2023, with diagnoses including chronic respiratory failure (a long-term condition where the lungs cannot…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, Licensed Vocational Nurse (LVN) 2 failed to accurately identify the resident and assess the resident's pain level (also known as the pain scale, a 0-10 numerical scale to help healthcare providers assess pain severity and manage treatment that ranges from 0 [no pain] to 10 [worst imaginable pain], with 1-3 being mild, 4-6 moderate, and 7-10 severe) prior to administrating pain medication for one (1) of 1 sampled resident (Resident 117). This deficient practice has the potential to result in medication error and effective pain management, which may negatively impact Resident 117's comfort, safety, and overall well-being. Findings: During a review of Resident 117's admission Record (AR), the AR indicated the facility admitted Resident 117 on 3/19/2025, with diagnoses including alcoholic cirrhosis of the liver without ascites (the liver has been damaged from alcohol but it has not caused fluid to collect in the abdomen); heart failure, unspecified (the heart is weak and cannot pump blood around the body properly); hypothyroidism,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one sampled resident's (Resident 61) hearing assessment was accurately documented to reflect Resident 61's impaired hearing. This deficient practice resulted in inaccurate clinical documentation and had the potential to impact Resident 61's care planning and communication interventions. Findings: During a review of Resident 61's admission Records (the front page of the chart that contains a summary of basic information about the resident), the admission Records indicated Resident 61 was originally admitted to the facility on [DATE], then readmitted to the facility on [DATE] with diagnoses including Huntington disease (inherited condition that affects movement, thinking and behavior), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or the inability to move on one side of the body) of the right side, obstructive uropathy (a blockage in the urinary system that…

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

Based on interview and record review, the facility failed to ensure that the hospice (compassionate care for people who are near the end of life) provides services to the resident in a way that meets his/her needs in a timely manner including review of the resident's record for pertinent documentation regarding the delivery of hospice care for one of one sampled resident (Resident 5) reviewed for hospice and end of life by failing to ensure hospice care services were provided according to Hospice Orders/Visit Frequency List. The deficient practice had the potential to result in a delay or lack of coordination in delivery of hospice care and services to residents. Findings: During a review of Resident 5's admission Record (AR), the AR indicated the facility admitted the resident on 10/4/2025, and readmitted the resident on 12/15/2025, with diagnoses including malignant neoplasm of pancreas (a dangerous, fast-growing tumor that starts when cells in the pancreas (an organ aiding digestion and blood sugar control) mutate and multiply uncontrollably), malignant neoplasm of bone (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 interview and record review, the facility failed to implement its antibiotic (ATB - a medicine that fights bacterial infections by killing bacteria or stopping them from multiplying) stewardship program (a coherent set of actions which promote using antimicrobials responsibly) that includes antibiotic use protocols and a system to monitor antibiotic use for (1) of three (3) sampled residents (Resident 28) reviewed for antibiotic use by failing to ensure the physician indicated a reason for the continued use of antibiotics when the resident did not meet the criteria. This deficient practice placed Resident 28 at risk for development of resistance to antibiotics which may lead to multidrug resistant organisms (MDRO - organisms primarily bacteria that have developed resistance to multiple classes of antibiotics making infections difficult to treat). Findings: During a review of Resident 28's admission Record, the admission Record indicated the facility originally admitted the resident on 7/18/2025 and readmitted in the facility on 3/2/2026 with diagnoses including…

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

Based on observation, interview, and record review, the facility failed to maintain mechanical, electrical, and resident care equipment in safe operating condition for one (1) of nine (9) sampled residents (Resident 129) reviewed under the environment task by: 1. Failing to ensure Resident 129's bed controller (device used to change the height and angle of the bed) cord did not have exposed wires and was covered with black plastic tape. 2. Failing to ensure Resident 129's bed control's touch pad cover was not peeling off and properly functioning. These deficient practices had the potential to place Resident 129 at risk of incurring injury. Findings: During a review of Resident 129's admission Record, the admission Record indicated the facility admitted the resident on 3/14/2026 with diagnoses including dementia (a progressive state of decline in mental abilities), difficulty in walking, and generalized muscle weakness. During a review of Resident 129's History and Physical (H&P), dated 3/16/2026, the H&P indicated that Resident 129 did not have the capacity to understand and make…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was functioning in the bathroom located in resident's room for three of three sampled residents (Resident 1, 2, and 3). This deficient practice had the potential to delay assistance and increase the risk of falls for Residents 1, 2, and 3. Findings: a. During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 1/14/2013 and readmitted on [DATE] with diagnoses including congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), chronic kidney disease (long-term, irreversible loss of kidney function), muscle weakness, and lack of coordination. During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 1/23/2026, the MDS indicated Resident 1 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 facility failed to develop and implement a person-centered care plan (a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) for one of three sampled residents (Resident 1) to address Resident 1's left upper chest port catheter (a long-term vascular access device placed in chest pain for easy access to vein for renal dialyses [a life-sustaining treatment for kidney failure that uses an external machine and a specialized filter to remove waste products and excess fluid from the blood]).This failure had the potential to delay care and negatively affect Resident 1's well-being. Findings: During a review of Resident 1's admission Record, the admission record indicated the facility originally admitted Resident 1 on 12/13/2023 and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), dependence on renal dialyses, chronic kidney disease stage four (CKD-a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement their policy and procedure on ensuring the medications in the facility were checked and maintained by failing to:a. Ensure one of 15 locked e-kit (e-kit - a pre-packed set of medications used in emergency situations) medication boxes did not contain expired medications. The intramuscular (IM - medication administered into a muscle) e-kit medication box located at station 2 had an expired medication in it for 75 days. b. Ensure the licensed nurses checked 15 out of 15 e-kits in the facility every shift. c. Ensure licensed nurses disposed of the medications of one of four sampled residents (Resident 4) within 90 days after discharge. Resident 4's medications were in the facility for 179 days after the resident was discharged from the facility.d. Ensure two licensed nurses signed off at the disposition of residents' medications on two out of three nurse stations. These deficient practices had the potential for medication errors and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) receive treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial (relating to the interrelation of social factors and individual thoughts and behavior), by failing to: 1. Initiate Change of Condition (COC -major decline or improvement in a resident's status that will not resolve without intervention) form, notify the physician, and complete a post-fall assessment of Resident 1, when on 6/29/2025, at approximately 9:50 p.m., Resident 1 sustained a fall in the bathroom, in Room A (Resident 1's room). 2. Obtain orders from the physician for Resident 1's right wrist and distal forearm splint (a strip of rigid material used for supporting and immobilizing a broken bone when it has been set) care. 3. Coordinate and schedule Occupational Therapy (OT) and Physical Therapy (PT) appointments on the days when Resident 1 had scheduled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prompt attempts were made to resolve the grievances for one of three sampled residents (Resident 1) when the facility failed to investigate the concerns reported by Resident 1. This deficient practice had the potential to violate Resident 1's rights.Findings: During a review of Resident 1's admission Record, the admission record indicated the facility admitted Resident 1 on 6/27/2025 with diagnoses including muscle weakness, polyneuropathy (damage to many nerves outside the brain and spine, causing weakness, numbness, tingling, and pain, typically starting in the feet and hands), unspecified fracture (a partial or complete break in a bone) of right lower leg, and unspecified fracture of right hand. During a review of Resident 1's History and Physical (H&P), dated 7/6/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its Policy and Procedures (P&P) titled, Discharge Planning Process, for one of three sampled residents (Resident 1) by failing to: 1. Initiate a Care Plan (a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) for Resident 1's discharge plan upon admission. 2. Provie the Discharge Transition Plan to Resident 1 prior to discharge on [DATE]. 3. Provide the Notice of Transfer or Discharge (a mandatory legal document formally informing the resident about the transfer or discharge, stating the reason for discharge or transfer, and their rights to appeal the decision) form to Resident 1 prior to discharge on [DATE]. This deficient practice had the potential to violate Resident 1's rights. Cross Reference with F842.Findings: During a review of Resident 1's admission Record, the admission record indicated the facility admitted Resident 1 on 6/27/2025 with diagnoses including 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 interview and record review, the facility failed to develop and implement a person-centered care (CP, a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) for one of three sampled residents (Resident 1), by failing to: 1. Develop a care plan to address Resident 1's discharge planning. 2. Develop a care plan to address Resident 1's right wrist and distal forearm splint (a strip of rigid material used for supporting and immobilizing a broken bone when it has been set). These failures had the potential to delay care and negatively affect Resident 1's well-being. Findings: During a review of Resident 1's admission Record, the admission record indicated the facility admitted Resident 1 on 6/27/2025 with diagnoses including muscle weakness, polyneuropathy (damage to many nerves outside the brain and spine, causing weakness, numbness, tingling, and pain, typically starting in the feet and hands), unspecified fracture (a partial 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 interview and record review, the facility failed to ensure the medical records for one of three sampled residents (Resident 1) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented, by failing to: 1. Ensure facility staff did not sign Resident 1's Notice of Transfer or Discharge (a mandatory legal document formally informing the resident about the transfer or discharge, stating the reason for discharge or transfer, and their rights to appeal the decision) form to show that Resident 1 had received the Notice of Transfer or Discharge form prior to Resident 1's discharge on [DATE]. This deficient practice resulted in inaccurate documentation to misrepresent (give a false or misleading representation of usually with an intent to deceive) that Resident 1 had acknowledged receiving a copy of the The Notice of Transfer or Discharge form prior to Resident 1's discharge on [DATE]. 2. Ensure Resident 1's Fall Risk Assessment and Nursing Documentation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of five sampled residents (Resident 1 and Resident 2) were free from significant medication errors by failing to ensure the physician orders were followed. The facility failed to ensure Resident 1 and 2's calcium carbonate oral tablet (a medication, taken by mouth, used for calcium supplement, relieve heartburn, indigestion, and upset stomachs) 600 milligrams (mg - unit of measurement) was administered on multiple dates. This deficient practice had the potential to cause Resident 1 and Resident 2's discomfort. Findings: During a review of Resident 1's admission Record (undated), the admission Record indicated the facility admitted Resident 1 on 1/14/2013 with diagnoses including chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), and muscle weakness. 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 three of seven sampled residents (Resident 4, Resident 5, and Resident 6) were free of any significant medication error when Licensed Vocational Nurse (LVN) 2, failed to administer medication as ordered and there was a delay in administration of four hours to six hours and 30 minutes. These deficient practices had the potential to negatively affect Resident 4, Resident 5, and Resident 6. Findings: a. During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted Resident 4 on 3/17/2022 and readmitted on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), essential (primary) hypertension (HTN-high blood pressure), and peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs). During a review of Resident 4's Order Summary Report, dated 11/14/2023, the Order Summary…

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

Based on observation, interview, and record review, the facility failed to implement its activities program for one of seven sampled residents (Resident 2) when on 11/18/2025 at 2 p.m. the resident activity room was observed closed with no activities being held, when the facility activities calendar indicated on 11/18/2025 at 2 p.m., Crossword Club, would be held. This deficient practice had the potential to negatively affect Resident 2. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 6/1/2022 and readmitted the resident on 1/19/2024 with diagnosis that included essential (primary) hypertension (HTN-high blood pressure), muscle weakness (generalized), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 10/2/2025, the MDS indicated Resident 2 had the ability to understand and be understood. During an interview on 11/18/2025 at 1 p.m. with Resident 2, Resident 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident who received dialysis (process of removing waste products and excess fluid from the body when the kidneys stop working properly) received treatment in accordance with standards of practice for two of seven sampled resident (Resident 1 and Resident 3) by falling to complete post dialysis assessment after the residents' return to the facility that included: 1. Failing to assess the dialysis access site (Coronary arteriovenous AV shunt: an access made by joining coronary arteries [blood vessels that distribute oxygen-rich blood to your entire body] and venous [blood vessels located throughout your body that collect oxygen-poor blood and return it to your heart] side of heart). 2. Failing to assess the residents' vital signs (temperature, pulse rate [the number of times the heart beats per minute], blood pressure [pressure of blood pushing against the walls of your arteries], respiration rate [number of breaths a person takes per minute],…

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

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from significant medication errors by failing to ensure the physician orders were followed. The facility failed to ensure Resident 1's metoprolol oral tablet (a medication, taken by mouth, used to treat high blood pressure) 25 milligrams (mg - unit of measurement) was not administered for systolic blood pressure (SBP - the pressure in the arteries when the heart beats) of less than 110 or heart rate (HR) of less than 60 beats per minute (bpm) on multiple dates.This deficient practice placed Resident 1 at risk for inadequate blood pressure management which can cause hypotension (low blood pressure) and irregular heartbeat.Findings: During a review of Resident 1's admission Record (undated), the admission Record indicated the facility admitted Resident 1 on 7/22/2025 with diagnoses including metabolic encephalopathy (an alteration in consciousness due to brain dysfunction), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood…

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

Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a written or electronic record containing all the information the resident needs to effectively manage their own health) for one out of three sampled residents (Resident 1) by failing to ensure Resident 1's care plan was updated and revised after Resident 1 refused a blood draw for complete blood count (CBC- a routine blood test that gives doctors a snapshot of your overall health by measuring the types and quantities of cells circulating in your bloodstream) test. This deficient practice had the potential to result in lack of delivery of care and services to Resident 1. Findings:During a review of Resident 1's admission Record, undated, the admission Record indicated the facility admitted Resident 1 on 7/22/2025 with diagnoses of metabolic encephalopathy (a condition in which the brain does not function properly due to an imbalance in body chemistry), altered mental status (a state of confusion, change in consciousness or unusual behavior), type 2 diabetes mellitus (DM -…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 services provided or arranged by the facility as outlined by the comprehensive care plan met professional standards of quality for two out of three sampled residents (Resident 4 and Resident 6) when Resident 4 and Resident 6 were not monitored as indicated in the residents' care plans.These deficient practices could lead to the residents' condition to decline and could delay providing care to residents.Finding: A. During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 11/6/2024 with diagnoses including non-pressure chronic ulcer (a deep, slow healing skin sore not caused by constant pressure, often on legs, or feet, resulting from poor blood flow, nerve damage, or other conditions, creating a persistent open wound that needs special care to prevent infection and heal) and heart failure (the heart can't pump enough blood and oxygen to meet the body's needs).During 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.

Based on observation, interview, and record review, the facility failed to ensure the facility staff were wearing proper personal protective equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) when changing resident who were in Enhance Barrier Precautions (EBP - infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs - germs that have become so tough they shrug off most common medicines (antibiotics) designed to kill them, making infections much harder to treat) for one of eight sample residents (Resident 2).This deficient practice had the potential to spread infections and illnesses among residents and staff. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 4/21/2023 with diagnoses including Huntington's Disease (inherited brain disorder where nerve cells progressively break down, causing uncontrollable jerky movement, severe personality changes, impaired judgment, and decline in thinking,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow professional standards of practice for one of three sampled residents (Resident 1) by failing to: 1. Ensure licensed nurses communicated with the transport services the correct dialysis (process of removing waste products and excess fluid from the body when the kidneys stop working properly) center for Resident 1. 2. Ensure licensed nurses communicated Resident 1 ' s late transport to the dialysis center. 3. Ensure that Resident 1's decreased dialysis treatment time was communicated among licensed nurses. 3. Ensure the Attending Physician (MD) was notified of Resident 1 ' s decreased dialysis treatment duration. This deficient practice resulted to Resident 1 being transported to the wrong dialysis center. On 6/2/2025 Resident 1 was brought to the wrong dialysis center. This resulted to a decrease in Resident 1's dialysis treatment duration from three hours to two hours that could potentially place Resident 1 at risk for fluid overload (there was too much fluid or blood in the body) which could negatively impact 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 ensure safe provision of pharmaceutical services for one of three sampled residents (Resident 6) by failing to ensure the resident ' s medications were not left unattended at bedside. This deficient practice had the potential to cause medication errors and can possibly lead to unsafe drop in Resident 6's blood sugar and may have other adverse side effects. Findings: A review of Resident 6 ' s admission Record indicated the facility admitted the resident on 1/14/2013 with diagnoses that included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), and major depressive disorder (mental health condition that causes a persistently low or sad mood and a loss of interest in activities that once brought joy). During a review of Resident 6 ' s Physician Order, dated 8/7/2022, the Physician Order indicated Novolin R solution (an insulin…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 promote care for residents in a manner and an environment to maintain or enhance each resident ' s dignity in full recognition of his or her individuality when 151 of 158 sampled residents received their meals in a plastic container and utensils. This failure had the potential to result in psychosocial distress, a lack of self esteem and frustration for 151 residents. Cross Reference F804 Findings: During a review of Resident 5 ' s admission Record, the admission Record indicated the facility initially admitted Resident 5 on 6/1/2022 and readmitted on [DATE] with diagnoses that included hypertension (high blood pressure – when the force of your blood pushing against the walls of your blood vessels is too high). During a review of Resident 5 ' s Minimum Data Sheet (MDS – a resident assessment tool) dated 1/13/2025, the MDS indicated Resident 5 understood others and made self-understood. During a review of the Physician's Orders dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved temperature, flavor and appearance. The residents' food was served in plastic food containers and staff distributed this food via the stairs as the elevator was in disrepair. This deficient practice placed 151 of 158 facility residents on regular, therapeutic diets (a meal plan that controls the intake of certain food and nutrients) and puree diets (food with soft pudding like consistency) at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen. Cross Reference F557 Findings: During a review of Resident 5 ' s admission Record, the admission Record indicated the facility initially admitted Resident 5 on 6/1/2022 and readmitted on [DATE] with diagnoses including hypertension (high blood pressure – when the force of your blood pushing against the walls of your blood vessels is too high). During a review of Resident 5 ' s Minimum Data Sheet (MDS – a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to: -Maintain infection control by storing Certified Nursing Assistant (CNA) 1 personal cup inside the clean linen cart and drinking in the hallways. -Implement Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO, microorganisms, mainly bacteria, that are resistant to one or more classes of antibiotics] that uses targeted gown and glove use during high contact resident care activities) when CNA 7 was observed not wearing a gown after showering one of 10 sampled residents (Resident 10). -Maintain infection control when CNA 2 retrieved clean linen from Resident 2's bed and returned it to a clean linen cart parked outside the resident's…

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

Based on observation, interview, and record review, the facility failed to follow the meal ticket and ensure residents receive their dietary preferences for one of three sampled residents (Resident 7). Resident 7's meal tray was observed in his room with onions but Resident 7 did not like onions. This deficient practice had the potential to result in decreased food and nutrient intake which may result in unintended (not planned) weight loss for the resident. Findings: During a review of Resident 7 ' s admission Record, the admission Record indicated the facility admitted Resident 7 on 2/14/2025 with diagnoses including hypertension (high blood pressure – when the force of your blood pushing against the walls of your blood vessels is too high). During a review of Resident 7 ' s Minimum Data Set (MDS – a resident assessment tool), dated 3/12/2025, the MDS indicated Resident 7's cognition (the process of knowing, understanding, and thinking) was intact with thought process and required clean up assistance from staff during eating. During a review of Resident 7 ' s Physician's Order…

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

Based on interview and record review, the facility failed to ensure a licensed staff administered medication for one of three sampled residents (Resident 1). This deficient practice had the potential to result in a medication error. Findings: During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 1/14/2013 with diagnoses that included right ankle and right foot acute hematogenous (originating in the blood or spread through the bloodstream) osteomyelitis (inflammation of bone or bone marrow, usually due to infection), unspecified (unconfirmed) peripheral vascular disease (PVD- a slow progressive narrowing of the blood flow to the arms and legs), and generalized muscle weakness. During a record review of Resident 1's History and Physical Examination (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 5/9/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a record review of…

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

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Resident 1) by failing to ensure a licensed staff administer medication for one of three sampled residents (Resident 1). This deficient practice had the potential to result in a medication error. Findings: During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 1/14/2013 with diagnoses that included right ankle and right foot acute hematogenous (originating in the blood or spread through the bloodstream) osteomyelitis (inflammation of bone or bone marrow, usually due to infection), unspecified (unconfirmed) peripheral vascular disease (PVD- a slow progressive narrowing of the blood flow to the arms and legs), and generalized muscle weakness. During a record review of Resident 1's History and Physical Examination (H&P-a medical examination that involves a doctor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain accurate and complete medical record for one of three sampled residents (Resident 1). This deficient practices had the potential to cause confusion in the care and the medical records containing inaccurate documentation. Findings: During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 1/14/2013 with diagnoses that included right ankle and right foot acute hematogenous (originating in the blood or spread through the bloodstream) osteomyelitis (inflammation of bone or bone marrow, usually due to infection), unspecified (unconfirmed) peripheral vascular disease (PVD- a slow progressive narrowing of the blood flow to the arms and legs), and generalized muscle weakness. During a record review of Resident 1's History and Physical Examination (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 5/9/2024, the H&P indicated Resident 1 had the capacity 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 an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of four sampled residents (Resident 1) by failing to: 1. Implement Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO, microorganisms, mainly bacteria, that are resistant to one or more classes of antibiotics] that uses targeted gown and glove use during high contact resident care activities) when Certified Nursing Assistant 1 (CNA 1) did not don (put on) a gown while providing care to Resident 1. 2. Perform hand washing after CNA 1 remove his gloves. These deficient practices had the potential to spread infections and illnesses among residents and staff. Findings: During a review of Resident 1's Record of Admission, the Record 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 residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body, cannot be removed easily by the resident, and restricts the resident's freedom of movement or normal access to his/her body) for six of seven sampled residents (Resident 137, 61, 132, 123, and 42) investigated during review of the physical restraints care area when the facility failed to obtain a physician's order, informed consent, and conduct a restraint assessment on the use of bed placement against the wall. These failures had the potential to result in the restriction of residents' freedom of movement, a decline in physical functioning, psychosocial harm, physical harm from entrapment (when a resident becomes caught, trapped, or entangled in the spaces in or about the bed rail, mattress, or bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards to four out of 4 sampled residents (Residents 29, 42, 402, and 134) investigated under insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) and heparin (an anticoagulant [blood thinner] that stops the blood from forming blood clots or making them bigger) by failing to: 1. Rotate (a method to ensure repeated injections are not administered in the same area) Residents 29 and 402's (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin and heparin administration sites. 2. Rotate Resident 42 and 134's insulin subcutaneous administration sites. These failures had the potential to result in adverse effects (unwanted, unintended result) of same site subcutaneous administration of insulin and enoxaparin such as bruising, lipodystrophy (abnormal distribution of fat), and cutaneous…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident environment was free of accident hazards for six of 6 sampled residents (Residents 495, 61, 402, 11, 52, and 137) investigated under accidents by failing to ensure: 1. Resident 495's tube of triamcinolone acetonide cream 0.1 percent (helps relieve redness, itching, swelling, or other discomfort caused by skin conditions), travatan (travoprost ophthalmic solution) 0.004 % (to reduce pressure in the eyes with glaucoma [a common eye condition where the optic nerve, which connects the eye to the brain, becomes damaged] and high pressure in the eyes), bisacodyl 5 milligrams (mg, a unit of weight) tablet (used to treat constipation), bromonidine tartrate ophthalmic Solution 0.2 % (used to lower pressure in the eyes), and dorzolamide HCl and timolol maleate ophthalmic solution, 2 %/0.5 % (used to treat glaucoma) were not left at the bedside of the resident. This failure increased the risks of harm to the resident due to the…

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

Based on interview and record review the facility failed to include the verifying signatures of either the Director of Nursing (DON) or a Registered Nurse (RN) along with Licensed Vocational Nurse (LVN) on the Antibiotic or Controlled Drug Record accountability logs for two (2) of two (2) sampled records awaiting disposal (removal, destroying) in DON's office. As a result, control and accountability of Controlled Substances ([CS] - also known as Controlled Drug and Controlled Medications [CD, CM]- medications which have a potential for abuse and may also lead to physical or psychological dependence) did not follow state and federal regulations and facility policy and procedures. These failures increased the opportunity for CS diversion (the transfer of a controlled medication or other medication from a lawful to an unlawful channel of distribution or use,) and accidental exposure to harmful medications to all residents in the facility, possibly leading to physical and psychosocial harm and hospitalization. Findings: During a concurrent interview and record review , on 12/31/2024, at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 its medication error rate was less than five (5) percent (%). Four (4) medication errors out of 27 total opportunities contributed to an overall medication error rate of 14.81% affecting two (2) of seven (7) residents observed for medication administration (Resident 71 and 88.) The medication errors were as follows: 1. Resident 71 did not receive psyllium husk powder (a medication used to form a bulky stook to pass easily) as ordered by Resident 71's physician and received a dose of oyster shell calcium (a medication used as a dietary supplement to provide support to bones) that was different than the one ordered by Resident 71's physician. 2. Resident 88 received a form of multivitamin (a medication used as a dietary supplement to provide essential vitamins, minerals, and other nutritional elements) and calcium with vitamin D (a combination medication used as a dietary supplement to provide support to bones) that 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 c). During a review of Resident 63's admission Record, dated 12/31/24, the admission Record indicated Resident 63 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis including DM2. During a review of Resident 63's Order Summary Report, dated 12/31/24, the report indicated Resident 63 was prescribed Lantus to inject 7 un SQ at bedtime for DM, starting 11/20/24. During a review of Resident 63's Medication Administration Record ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record], for December 2024, the MAR indicated Resident 63 was prescribed insulin Lantus 7 units SQ at bedtime for DM, at 9 PM, and that Resident 63 received 10 doses of expired insulin Lantus from the following nurses at 9 p.m. on the following dates: - Registered Nurse (RN) 4 - 1 dose on 12/20/24 - Licensed Vocational Nurse (LVN) 6 - 6 doses (on 12/21/24, 12/22/24, 12/23/24, 12/26/24, 12/27/24, 12/30/24) - LVN 8 - 1 dose on 12/24/24 - LVN…

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

Based on observation, interview, and record review the facility failed to: 1. Remove and discard from use two (2) open, expired insulin (a medication used to control high blood sugar levels) Lantus (brand name insulin for glargine, a long-acting insulin) pens stored at room temperature for Resident 63 and 71 in accordance with manufacturer's requirements and facility policy and procedures, in one (1) of two (2) observed medications carts (Medication cart 4.) 2. Remove and discard from use one (1) open, expired insulin Humulin 70/30 (brand name combination insulin for isophane human and regular human; an intermediate-acting insulin combined with rapid onset regular insulin) pen stored at room temperature for Resident 141 in accordance with manufacturer's requirements and facility policy and procedures, in one (1) of two (2) observed medications carts (Medication cart 4.) 3. Remove and discard from use one (1) open Aplisol (also known as Tubersol - medication used to diagnose tuberculosis [infection in the lungs]) vial for facility stock, in accordance with manufacturer's requirements…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dispose garbage and refuse properly when the garbage dumpsters located in the facility parking lot were overflowing with garbage. This deficient practice had the potential to attract pests and possibly spread infection to 138 out of 138 facility residents. Findings: During an observation on 1/2/2025, at 7:15 a.m., in the facility parking lot, the lids of two black dumpster bins were left open with bags of garbage stacked over opening of the bin. During an observation on 1/2/2025, at 7:41 a.m., in the facility parking lot, the lids of two black dumpster bins were left open with bags of garbage stacked over opening of the bin. During an observation on 1/3/2025, at 7:31 a.m., in the facility parking lot, the lid of a black dumpster bin was resting on top bags of garbage. The dumpster lid was unable to completely close. During an interview with the Housekeeping Supervisor (HSKS), on 1/3/2025, at 1:50 p.m., the HSKS stated garbage from the facility is thrown out into the dumpsters in the parking lot. The HSKS…

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

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to: 1.Ensure the Housekeeping Supervisor (HSKS) did not place two pillows from the ground on top of clean linens, observed during the Infection Control task. 2. Ensure the resident's right floor mat did not have any damage on the top exposing the foam for one (1) of 1 sampled resident (Resident 402). These failures had the potential to spread infections and illnesses among residents and staff. Cross-reference F584 Findings: a. During a tour of the facility laundry area, on 1/2/2025, at 11:30 a.m., with the HSKS and Laundry Attendant (LA), observed the clean laundry room with the HSKS and LA. In the clean laundry room, the HSKS moved a large rolling bin to the side and two pillows were laying on the ground. The HSKS picked the pillows up off the ground and placed them on top of a folded…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 honor the resident's right to a dignified existence for one of one sampled resident (Resident 23), investigated under dignity, by failing to ensure the staff kept the curtains drawn to a confused resident that kept on removing her hospital gown while only being covered with a thin white sheet in her room. The deficient practice violated the resident's right to a dignified existence. Findings: During a review of Resident 23's admission Record, the admission Record indicated the facility admitted the resident on 6/5/2018, and readmitted the resident on 11/19/2024, with diagnoses including metabolic encephalopathy (a change in how the brain works due to an underlying condition), dementia (a progressive state of decline in mental abilities), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 23's History and Physical (H&P), dated 11/22/2024, the H&P indicated the resident did not have the capacity to understand and to make…

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

Based on observation, interview, and record review, the facility failed to provide a safe, comfortable, and homelike environment for one of two sampled residents (Resident 402) investigated under Environmental Task by failing to ensure Resident 402's floor mat did not have a tear on the top cover with the foam exposed. This deficient practice has the potential to negatively affect the resident's quality of life. Cross Reference F689 Findings: During a review of Resident 402's admission Record, the admission Record indicated the facility admitted the resident on 12/11/2024, with diagnoses including type 2 diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing); abnormalities of gait and mobility; and generalized muscle weakness. During a review of Resident 402's Order Summary Report, the Order Summary Report indicated the following physician's order dated 12/12/2024: - Floor mats next to bed every shift for monitor proper placement as landing pad and fall precautions. During a review of Resident 402's Minimum Data Set (MDS - 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 interview and record review, the facility failed to accurately code one (1) of two (2) sampled residents (Resident 103) Preadmission Screening and Resident Review (PASARR - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) when the PASARR prior to admission did not indicate Resident 103 had major depressive disorder (a major disorder that causes persistent feeling of sadness and loss of interest). This deficient practice had the potential to result in the resident's medical and nursing care needs not being met. Findings: During a review of Resident 103's admission Record, the admission Record indicated the facility admitted the resident on 12/11/2023, with diagnoses including major depressive disorder; schizophrenia (a mental illness that can affect thoughts, mood, and behavior) and anxiety disorder (a mental health condition that causes excessive and persistent feelings of fear, dread, and worry). During a review of Resident 103's PASARR, date started 12/12/2023, the PASARR indicated that the resident…

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

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 (initial written guide that organizes information about the resident's care) addressing the use of oxygen for one (1) out of 1 sampled resident (Resident 129) reviewed for respiratory care. This deficient practice had the potential for Resident 129 not to receive the appropriate care and treatment specific to the resident's needs. Findings: During a review of Resident 129's admission Record, the admission Record indicated the facility originally admitted the resident on 10/15/2024 and readmitted Resident 129 into the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), urinary tract infection (UTI - an infection in the bladder/urinary tract) and generalized muscle weakness. During a review of Resident 129's Minimum Data Set (MDS - a resident assessment tool) dated 10/22/2024, the MDS indicated Resident 129 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (CP, a document outlining a detailed approach to care customized to an individual resident's need) for one of six sampled residents (Resident 137) investigated under the accident hazards care area, one of seven sampled residents (Resident 137) investigated under the physical restraints (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body, cannot be removed easily by the resident, and restricts the resident's freedom of movement or normal access to his/her body) care area, and one of five sampled residents (Resident 128) investigated under infection control task, when: 1. The facility failed to implement Resident 137's care plan for storing the resident's smoking material. 2. The facility failed to develop a care plan for placement of Resident 137's bed against the wall. 3. The facility failed to develop…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents with a urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) received appropriate care and services to prevent urinary tract infections (UTI, an infection in the bladder/urinary tract) for one (1) of 1 sampled resident (Residents 129) investigated under the urinary catheter or UTI care area by failing to: 1. Ensure Resident 129's urinary catheter tubing did not have a loop while hanging on the side the bed. 2. Apply a catheter securement device on Resident 129's urinary catheter. This deficient practice had the potential to result in the resident's urine not to flow freely which may lead to development of recurrent UTI. Findings: During a review of Resident 129's admission Record, the admission Record indicated the facility originally admitted the resident on 10/15/2024 and readmitted the resident in the facility on 12/14/2024 with diagnoses including chronic obstructive pulmonary disease…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents receiving enteral feeding (EF - also known as tube feeding, a method of supplying nutrients directly into the stomach) received appropriate care and services to prevent complications of enteral feeding for two (2) of two (2) sampled residents (Residents 52 and 104) investigated under the tube feeding care area by failing to: 1. Ensure the EF formula bag indicated the administration rate prescribed by the physician for Resident 52. 2. Ensure the EF formula bag and water flush bag dated 12/31/2024 at 2 p.m. was primed (refers to prepared for immediate use) and hung as observed on 12/31/2024 at 9:46 a.m. for Resident 52 3. Cover the feeding tube tip with a cap when the feeding tube was disconnected from Resident 104. These deficient practices had the potential to result in altered nutritional status that can lead to gastrointestinal infection to the resident. Findings: a. During a review of Resident 52's admission Record, 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 ensure parenteral fluids (are liquids that are administered intravenously or by injection to bypass the digestive system) were administered consistent with professional standards of practice for one of 1 sampled resident (Resident 132) investigated under peripheral intravenous catheter (PIVC, a thin, flexible tube that is inserted into a vein through the skin to administer fluids, medications, or blood products) by failing to: 1. Clarify with the primary physician if the PIVC was still needed in the facility. 2. Change the dressing of the PIVC of the resident, dated 12/18/2024 on the day of observation. 3. Assess the site of insertion for signs and symptoms of infiltration (a complication that occurs when intravenous [IV, within a vein] fluid leaks out of the vein and into the surrounding tissue) or infection per facility protocol. 4. Place a swab cap/orange cap (an alcohol-containing caps that twist onto I.V. access points for disinfection and protection) on the flush port (serves as an access to deliver…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 evaluate and assess Registered Nurse (RN) 1 for specific clinical competency and skills with specialized training to care for residents with indwelling urinary catheters (also called foley catheter [FC] - a hollow tube inserted into the bladder to drain or collect urine) reviewed under the Sufficient and Competent Nurse Staffing task. This failure had the potential to result in missed opportunities to address identified staff's performance issues that could impact resident safety and satisfaction. Cross-reference F690 Findings: During a concurrent interview and record review on 1/2/2025 at 2:38 p.m. with the Director of Staff Development (DSD - a licensed nurse that provides education and training designed to increase the professional knowledge and skills of staff members), the DSD reviewed RN 1's employee file and noted the following: 1. RN 1 became a registered nurse on 8/29/2024 and was hired by the facility on 10/14/2024. 2. There was no documented evidence that RN 1 completed a clinical skills competency 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.

Based on interview and record review, the facility failed to arrange provisions of hospice services (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill) in a consistent manner for one of one sampled resident (Resident 11) investigated during review of hospice services by failing to: 1. Ensure the hospice staff including the registered nurse (RN), licensed vocational nurse (LVN), and hospice aide (HA), provided nursing and visitation notes to the facility. 2. Ensure the calendar of visits from 9/23/2024 to the most current visits was provided by Hospice Provider 1 (HP 1). These deficient practices had the potential to negatively affect the residents' physical comfort and psychosocial well-being and had the potential to result in the delay or lack of necessary hospice care and services. Findings: During a review of Resident 11's admission Record, the admission Record indicated the facility admitted the resident on 9/12/2024 with diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2024/2025 COVID-19 (a highly contagious viral infection that can trigger respiratory tract infection) booster vaccine (a supplemental dose of medication that is administered annually and used to prevent complications from COVID-19) was administered and the vaccination status of residents was known and documented in the resident's clinical record for one of five sampled residents (Resident 77) reviewed during the Infection Control task. This failure had the potential to result in increased risk of residents developing complications from COVID-19 including acute respiratory failure (a serious condition that occurs suddenly when the lungs cannot get enough oxygen). Findings: During a review of Resident 77's admission Record, the admission Record indicated the facility admitted the resident on 7/7/2022 and most recently readmitted the resident on 7/31/2024 with diagnoses that included acute pyelonephritis (a urinary tract infection that occurs when bacteria travels from the bladder to the kidneys), diabetes mellitus…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three sampled residents (Resident 3) was treated with dignity and care in a manner that promotes maintenance or enhancement of their quality of life by failing to ensure Resident 3's urinary drainage bag (a device that collects urine from a urinary catheter [a hollow tube inserted into the bladder to drain or collect urine] that is inserted into the bladder) had a dignity bag (a special pouch or cover that discreetly hides the drainage bag from view, allowing someone using a catheter to maintain privacy). This deficient practice had the potential to negatively affect Resident 3 psychosocially (involving mental, emotional, social, and spiritual aspects of a person's life). Findings: A review of Resident 3's admission Record indicated the facility admitted the resident on 2/28/2024 with diagnoses including quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), major depressive disorder (a mood disorder that causes a persistent feeling of sadness…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that one of three sampled residents (Resident 3) who was a quadriplegic (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury) and was dependent (helper does all the effort) on care received the necessary services to maintain grooming, and personal hygiene when on 10/28/2024 Certified Nursing Assistant 1 (CNA 1) described Resident 3's fingernails as long and curving in and toenails as long and needed to be cut. This deficient practice had the potential to cause Resident 3 to scratch or harm self. Findings: A review of Resident 3's admission Record indicated the facility admitted the resident on 2/28/2024 with diagnoses including quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and muscle weakness (generalized). A review of Resident 3's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated…

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

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 3) had a call light (a device that patients use to request assistance from nursing staff in a healthcare facility) that was within Resident 3's reach. This deficient practice had the potential to result in a delay in meeting Resident 3's need for assistance. Findings: A review of Resident 3's admission Record indicated the facility admitted the resident on 2/28/2024 with diagnoses including quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and muscle weakness (generalized). A review of Resident 3's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 8/22/2024, indicated Resident 3 had the ability to understand and be understood. The MDS indicated Resident 3 was dependent (helper does all the effort) on eating, oral hygiene, toileting, showering, upper and lower body…

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

Based on observation, interview, and record review, the facility failed to provide one of five sampled residents (Resident 1) a safe, clean, comfortable, and homelike environment when on 9/6/2024 at 1:39 p.m. the Maintenance Supervisor (MS) measured the temperature of Resident 1 room with a laser thermometer (measures the temperature of an object from a distance by using a laser to target the object and measuring the infrared radiation [a type of energy that is invisible to the human eye but can be felt as heat] it emits) measuring 88 degrees Fahrenheit (°F- a scale for measuring temperature, in which water freezes at 32 degrees and boils at 212 degrees). This deficient practice resulted in Resident 1 being uncomfortable with the temperature of his room. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 1/14/2013 and readmitted the resident on 5/26/2023 with diagnoses including type 2 diabetes mellitus (disease in which glucose [a type of sugar] levels in the blood are higher than normal because the body does not make enough insulin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a homelike environment for two of three sampled residents (Resident 1 and Resident 2) by failing to ensure the walls in the resident ' s room was in good condition and free from peeling paint and plaster debris. This deficient practice had the potential to cause injuries and altered comfort level. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 4/16/2024 with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), unsteadiness on feet, and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). A review of Resident 1 ' s History and Physical (H&P), dated 5/9/2024, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident received care consistent with professional standards of practice to prevent pressure ulcer (a localized injury to the skin and or underlying tissue usually over a bone prominence as a result of pressure or pressure in combination with shear [occur between the internal body structures and skin tissues typically moving in opposite directions and may lead to deep tissue injury]) for one of three sampled residents (Resident 1) by: 1. Failing to ensure the low air loss mattress (LALM- a mattress, composed of inflatable air cushions that is used to relieve pressure on the body parts) was turned on. 2. Failing to ensure only one sheet of linen was placed over the LALM mattress top cover as indicated in the manufacturer's guidelines. These deficient practices had the potential for the development and worsening of pressure ulcers/injuries. Findings: A review of Resident 1 ' s, admission Record, indicated the facility admitted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 respond to a functioning call light for one of two sampled residents (Resident 1). This deficient practice had the potential to result in a delay in meeting Resident 1's needs for assistance, pain management and could cause frustrations to Resident 1. Findings: A review of the admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including but not limited to anxiety disorder (excessive and persistent worry and fear about everyday situation), major depressive disorder (mood disorder that causes a persistent feeling of sadness, and loss of interest and can interfere with daily life). A review of the Minimum Data Set (MDS - a comprehensive standardized assessment and screening tool), dated 2/5/2024, indicated Resident 1 was cognitively (a mental process that take place in the brain, including thinking, attention, language, learning, memory, and perception) intact and required assistance set-up 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 ensure residents had the right to receive mail for three of 10 sampled residents (Resident 35, 82, and 86). Resident 35, Resident 82, and Resident 86 stated they do not receive mail on Saturdays. This deficient practice violated the residents' right to receive mail on Saturdays and had the potential to negatively affect the resident's psychosocial well-being. Findings: During the Resident Council meeting on 12/27/2023, at 10:38 a.m., Resident 35, Resident 82, and Resident 86 stated they do not receive mail on Saturdays. During an interview with the Social Services Assistant 1 (SSA 1) on 12/27/2023 at 3:28 p.m., SSA 1 stated she works Sundays through Thursdays and is off Fridays and Saturdays. SSA 1 stated that once mail arrives, either the business office manager (BOM) or the activities assistant will collect, process, and deliver the mail to the residents. SSA 1 stated that the facility does not have a log of the mail that they receive for the residents. SSA 1 stated that when the business office is closed, she makes sure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 person-centered care plan for four out of 27 sampled residents (Residents 33, 36, 54, and 87) by failing to: 1. Ensure Resident 33 had a care plan addressing the use of insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood). 2. Ensure Resident 36 had a care plan addressing the use of antidepressants, Lexapro (a type of medicine used to treat clinical depression d [mood disorder that causes a persistent feeling of sadness and loss of interest]) and Buspirone (a type of medicine used to treat anxiety disorders [persistent and excessive worry that interferes with daily activities]). 3. Ensure Resident 54 had a care plan addressing the use of Sertraline (a medication used to treat depression and panic attacks). 4. Ensure Resident 87 had a care plan addressing the use of Lovenox (an anticoagulant that helps prevent the formation of blood clots). These deficient practices had the potential for failure to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards to three out of sixteen sampled residents (Residents 87, 33, and 23) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin (a hormone that lowers the level of sugar in the blood) and Lovenox (enoxaparin sodium, an anticoagulant medication that prevent blood clots) administration sites. The deficient practice had the potential for adverse effects (unwanted, unintended result) of same site subcutaneous administration of insulin and Lovenox such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs). Findings: 1. A review of Resident 87's admission Record indicated the facility admitted the resident on 2/1/2023 and readmitted the resident on 6/7/2023, with diagnoses including joint replacement…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility's nursing staff failed to ensure that a resident received a medication as prescribed by his physician for two out of 22 sample residents (Resident 14 and 57) by: a. Resident 14 received his insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) two hours and 30 minutes later than ordered by his physician on 12/23/2023 at 9:28 a.m. and 12/23/2023 at 9:29 a.m. [NAME] b. Resident 57 did not receive his medication supplement ordered for Osteoporosis (a condition in which bones become weak and brittle). The facility failed to notify the physician when a medication supplement ordered for Osteoporosis was unavailable and the facility continued to document the administration of the medication for Resident 57 on the resident's Medication Administration Record (MAR) between 12/13/2023 through 12/27/2023. These deficient practices increased the risk that Resident 14 and Resident 57 may not have received their medications according…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free from unnecessary drugs for two of four sampled residents (Residents 7 and Resident 40) by failing to: a. Monitor and document Resident 7's adverse effects and behavior manifestations when taking Trazadone (antidepressant for treating major depressive disorders). b. Monitor and document Resident 40's postural/orthostatic hypotension- (a drop in blood pressure [hypotension] due to a change in body position when a person moves to a more vertical position: from sitting to standing or from lying down to sitting or standing postural/orthostatic hypotension and can lead to falls and injuries of the residents) readings while taking Seroquel (an antipsychotic medication-used to treat disordered thinking associated with severe mental illness) per physician's order. These deficient practices had the potential to result in overuse of an antipsychotic medication and antidepressant medication, without monitoring for the effectiveness…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 in a manner that promoted dignity and respect for one of four sampled resident (Resident 6) investigated under the dignity investigative care area, by failing to ensure Resident 6's preference for use of hot water during peri-care was honored and respected. This deficient practice had the potential to affect resident's sense of self-worth and self-esteem. Findings: A review of Resident 6's admission Record indicated the facility originally admitted the resident on 3/8/2023 and readmitted the resident on 12/23/2023 with diagnoses including unspecified fracture (break-in bone) of upper end of left humerus and anxiety disorder (a condition that is characterized by persistent and excessive worry that interferes with daily activities). A review of Resident 6's History and Physical, dated 3/10/2023, indicated the resident has the capacity to understand and make decisions. A review of Resident 6's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/29/2023, indicated the…

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

Based on observation, interview, and record review the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) within reach of the resident for one out of eleven 11 sampled residents (Resident 87). These deficient practices had the potential to result in the resident not being able to call for facility staff assistance and delay in the provision of necessary care and services that can negatively affect the resident's comfort and well-being. Findings: A review of Resident 87's admission Record indicated the facility initially admitted the resident on 2/1/2023 and readmitted the resident on 6/7/2023 with diagnoses including other abnormalities of gait and mobility, muscle weakness, and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills) A review of Resident 87's History and Physical dated 6/26/2023, indicated the resident has the capacity to understand and make decisions. A review of Resident 87's Minimum Data Set (MDS, a standardized assessment and care 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 interview and record review, the facility failed to complete and provide a notice of bed-hold policy and return form (reserving a resident's bed while the resident is absent from the facility) when the resident was transferred to the general acute care hospital 1 (GACH 1) for one of sixteen sampled residents (Resident 82). This deficient practice had a potential to result in the resident's responsible party being unaware of the bed hold policy and can lead to a transfer of the resident to another skilled nursing facility not of the resident's or responsible party's preference. Findings: A review of Resident 82's admission Record indicated the facility admitted the resident on 6/1/2022 and readmitted the resident on 12/10/2023, with diagnoses including cord compression (a condition that puts pressure on the spinal cord), polyosteoarthritis (a condition where pain and inflammation occur in multiple joints at once), and polyneuropathy (multiple peripheral nerves become damaged). A review of Resident 82's Minimum Data Set (MDS, a standardized assessment and care screening…

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

Based on observation, interview, and record review the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcer/injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin) to one out of sixteen sampled residents (Resident 99) by: 1. Failing to ensure Resident 99's Low air-loss mattress (LALM, an air mattress designed to distribute the resident's body weight over a broad surface area and help prevent skin breakdown) was set according to the residents' weight. 2. Failing to turn and reposition Resident 99 every two (2) hours for pressure ulcer management and treatment. These deficient practices had the potential for the development and worsening of pressure ulcers to the resident. Findings: A review of Resident 99's admission Record indicated the facility admitted the resident on 12/2/2023, with diagnoses including pressure ulcer of the sacral region (at the bottom of the spine) and the right heel stage 3 (full thickness tissue loss, fat may be visible, but bone, tendon, or muscle is not exposed),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide a Restorative Nurse Aide (RNA - responsible for following a resident care plan in helping residents with range of motion [ROM - extent of movement of a joint) program for ROM for one of three sampled residents (Resident 46) when Physical Therapist 1 (PT 1, healthcare provider who improve quality of life through prescribed exercise, hands-on care, and patient education) failed to communicate to the nursing department the recommendation for ROM. This deficient practice had the potential for development of contractures (abnormal shortening of muscle tissue) and complications of immobility. Findings: A review of Resident 46's admission Record indicated the facility admitted the resident on 2/21/2020, with diagnoses including rheumatoid arthritis (a chronic progressive disease causing the inflammation in the joints and resulting in painful deformity and immobility), obesity (abnormal or excessive fat accumulation that presents a risk to health), and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure an opened box of Blood Glucose (BG) test strips had an open date. The deficient practice of failing to label BG test strips per the manufacturers' requirements increased the risk that residents with Diabetes (a serious condition where blood glucose [sugar] level is too high) could have received medication based on inaccurate BG levels which could result in health complications or hospitalization. Findings: During a concurrent observation and interview on [DATE], at 2:20 pm, with Licensed Vocational Nurse (LVN 5), Medication Cart (Med Cart) 2 on Nursing Station 1 was inspected. Inside of the Med Cart 2 was observed an open bottle of EvenCare BG test strips with no open date observed. LVN 5 stated, the bottle of BG test strips should have been dated once it was opened and that there was no open date on the bottle of BG test strips. LVN 5 stated an open date was necessary to make sure the BG test strips was not expired. LVN 5 read the label of the…

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

Based on observation, interview, and record review, the facility failed to provide meals that accommodated their food preferences to one out of 16 sampled residents (Resident 277). This deficient practice had the potential to result in decreased meal intake and can lead to weight loss and malnutrition (a serious condition that happens when your diet does not contain the right amount of nutrients). Findings: A review of Resident 277's admission Record indicated the facility admitted the resident on 12/18/2023 with a diagnoses that included cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body). A review of Resident 277's History and Physical, dated 12/27/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 277's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/22/2023, indicated the resident had the ability to make self-understood and understand others. A review of Resident 277's Order Summary Report, dated 12/19/2023, indicated 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 implement and maintain an infection control program to one out of 16 sampled residents (Resident 121) by failing to label the urinal bottle (a container used to collect urine) of the resident to prevent cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another). The deficient practice had the potential to spread infection among residents. Findings: A review of Resident 121's admission Record indicated the facility admitted the resident on 12/6/2023 with diagnoses that included benign prostatic hyperplasia (a noncancerous enlargement of the prostate gland [gland in the male reproductive system]) without lower urinary tract symptoms. A review of Resident 121's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/13/2023, indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was continent of urine and stool. During a concurrent observation and interview on…

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

Based on interview and record review, the facility failed to obtain a doctor's order for the use of oxygen for one of three sampled residents (Resident 2). This deficient practice had the potential to cause complications associated with oxygen therapy. Findings: A review of Resident 2's admission Record indicated the facility admitted the resident on 3/15/2023 with diagnoses that included diverticulosis (a condition that occurs when small pouches, or sacs, form and push outward through weak spots in the wall of your colon) of intestine (body part that are shaped like long tubes that help break down food so that the body can use it for energy), acute kidney failure (sudden episode of kidney failure or kidney damage that happens within a few hours or a few days), and hypertension (uncontrolled elevated blood pressure). A review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/21/2023, indicated resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired.…

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

Based on interview and record review, the facility failed to develop a comprehensive care plan on incontinence for one of three sampled residents (Resident 1). This deficient practice had the potential for delayed provision of necessary care and services. Findings: A review of Resident 1's admission Record (Face Sheet) indicated the facility admitted the resident on 7/11/2023 with diagnoses including malignant neoplasm (an abnormal growth of tissue that is likely to spread) of the cervix uteri (opening of the uterus [womb]), other pulmonary embolism (when one of the arteries in the lungs gets blocked by a blood clot) and acute kidney failure (sudden episode of kidney damage that happens within a few hours or a few days). A review of Resident 1 ' s History and Physical Examination (H&P), dated 7/14/2023, indicated the resident had no capacity to understand and make decisions. The H&P indicated the resident had left nephrostomy tube (a tube that lets urine drain from the kidney through an opening in the skin on the back). A review of Resident 1 ' s Nursing Documentation (ND) dated…

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

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Resident 1) byfailing to accurately document administration of morphine sulphate (controlled medication used to treat moderate to severe pain) in the Medication Administration Record (MAR) and the resident ' s progress notes. This deficient practice had the potential to result in Resident 1 ' s uncontrolled pain and medication error. Findings: A review of Resident 1's admission Record (Face Sheet) indicated the facility admitted the resident on 7/11/2023 with diagnoses including malignant neoplasm (an abnormal growth of tissue that is likely to spread) of the cervix uteri (opening of the uterus [womb]), other pulmonary embolism (when one of the arteries in the lungs gets blocked by a blood clot) and acute kidney failure (sudden episode of kidney damage that happens within a few hours or a few days). 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 ensure one of three sampled residents (Resident 2) who was receiving anticoagulant (medication used to treat blood clot) was assessed and monitored for its side effects. This deficient practice had the potential to result in Resident 2 experiencing adverse effects including bleeding, bruising, and nose bleeds from the medication. Findings: A review of Resident 2 ' s admission Record (face sheet) indicated the facility admitted the resident on 1/19/2022 with diagnoses that included moderate protein calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function), adult failure to thrive (syndrome of weight loss, decreased appetite, poor nutrition, and inactivity) and hypertension (HTN-uncontrolled elevated blood pressure). A review of Resident 2 ' s History and Physical Examination dated 11/3/2022 indicated the resident had capacity to understand and make decisions. A review of Resident 2 ' s Minimum Data Set (MDS - a standardized assessment and…

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

Based on observation, interview, and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one of five sampled residents (Resident 2) who burnt her left forehead and part of her wig (a covering of the head made of real or artificial hair) while smoking in the smoking patio on 6/24/2023. This deficient practice had resulted in inaccurate information entered into Resident 2's clinical record. Findings: A review of Resident 2 ' s admission Record (Face Sheet) indicated the facility admitted the resident on 1/19/2022 with diagnoses that included moderate protein calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function), adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity) and hypertension (HTN-uncontrolled elevated blood pressure). A review of Resident 2 ' s History and Physical Examination dated 11/3/2022 indicated the resident had capacity to understand and make decisions.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 necessary care was provided for one of three sampled residents (Resident 1), who was receiving hospice services (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill). The facility failed to conduct an interdisciplinary team (IDT- a health care team to ensure that various aspects of residents' healthcare needs are integrated, aligned, addressed, and met in a time-efficient manner) meeting with the hospice agency and Resident 1's family. This deficient practice may result on Resident 1 ' s family not to be prepared for Resident 1 ' s course of terminal illness. Findings: A review of Resident 1's admission Record (face sheet) indicated the facility admitted the resident on 7/11/2023 with diagnoses that included malignant neoplasm (an abnormal growth of tissue that is likely to spread) of the cervix uteri (opening of the uterus [womb]), other pulmonary embolism (when one of the arteries in the lungs gets blocked by a blood clot), and acute kidney failure…

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

Based on observation, interview, and record review, the facility failed to implement infection control practices by failing to ensure two of five sampled staff (Smoking Monitor 1 [SM 1] and Certified Nursing Assistant 1 [CNA 1]) wore N95 mask (filters at least 95% of particles) while inside the facility during a Coronavirus-2019 (COVID-19, a highly contagious respiratory illness in humans capable of producing severe symptoms) outbreak (a sudden rise in the number of cases of a disease). This deficient practice had the potential to result in the spread of infection placing the residents, staff, and visitors at risk to be infected with COVID-19. Findings: During an interview on 8/3/2023 at 7:05 a.m., the Administrator (ADM) stated the facility had one positive Coronavirus 2019 resident. During a concurrent observation and interview, on 8/3/2023 at 9:32 a.m., with Smoking Monitor 1 (SM 1), inside the ADM office, observed SM 1 sat across the round table and removed the top strap of his N95 mask and left his mask hanging on his neck with his nose and mouth visible. SM 1 stated he is…

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