Westwood Post Acute Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that professional standards of practice met resident care and needs for one of one sampled resident (Resident 38) in accordance with the facility's policy and procedures (P&P) titled Physician Orders with review and approval date of 6/10/2026 when physicians orders were not carried out as instructed for resident follow up with the Orthopedic (a medical specialty that emphasizes the treatment of injuries and diseases of the musculoskeletal system) doctor and a Computed tomography (CT - a diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body showing detailed images of any part of the body) scan post antibiotic therapy was ordered or scheduled. This deficient practice had the potential to negatively affect the appropriate care and services rendered to Resident 38.Findings: A review of Resident 38's admission Record indicated the facility admitted Resident on 5/29/2026 with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, for one out of two sampled residents (Resident 95), the facility failed to clearly label the enteral feeding (a medical process that delivers a specialized liquid nutrient formula directly into the stomach or small intestine) bottle with the date and time staff started/hanged the enteral feeding, and label the hydration infusion (water flush) bag with the flow rate, and with the date and time the hydration infusion (water flush) bag was started/hang and the correct infusion rate for the enteral feeding. This deficient practice had the potential for the resident not receive desirable nutritional and hydration needs/goals and for the facility staff not to know when to next change the enteral feeding bottle for Resident 95.Findings: A review of Resident 95's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses that include but are not limited to hemiplegia (is the complete or partial paralysis of one entire side of the body…

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

Based on observation, interview, and record review, the facility failed to follow its policy and procedures (P&P) titled, Medication Storage in the Facility reviewed 2024 and Medication ordering and receiving from pharmacy reviewed 2024 for two of three Medication Carts (MC-E and MC-W), by failing to dispose:1) One unlabeled/unidentified orange oval shaped pill found in one drawer of MC-E2) Three unlabeled/unidentified (a pink oval shaped pill, a small yellow round pill and a yellow capsule) were found in one drawer of MC-W.This failure had the potential to cause medication errors and harm to the residents.Findings; During a concurrent observation and interview with Registered Nurse (RN) 1 on 6/17/2026 at 9:19 am, in the facility hallway, one drawer in MC-E had an unlabeled/unidentified one orange oval shaped pill. RN 1 stated that, It was difficult to tell what that pill is or which resident the pill belongs to._ RN-1 stated, It's not ok. We don't know what type of medication it is. It should be in bubble pack (A method of organizing medicines in an individual plastic compartment…

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

Based on observation, interview, and record review the facility failed to label and date food items in the patient refrigerator for 81 of 86 medically compromised residents who receive nutrition orally in the facility according to the facility's policy and procedures (P&P) titled Food brought in by Visitors dated 05/22/2025. This deficient practice had the potential to result in harmful bacterial growth that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or toxins) in 81 medically compromised residents who receive nutrition orally in the facility.Findings: During an observation on 06/15/2026 at 9:15 AM at the [NAME] Nursing Station, the resident refrigerator contained a half-full bottle of kefir (a drinkable fermented dairy beverage similar in consistency to a thin yogurt) lying on its side in the middle rack of the refrigerator. During continued observation, no labeling, date, or room number was visible on the bottle. Posted on the refrigerator door is a sign printed in large font that indicates the refrigerator is for…

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

Based on interview and record review, the facility failed to ensure that the facility staff performed Restorative Nursing Session (RNS - guided practice with a nurse or nursing assistant to help a patient maintain or regain their ability to do everyday tasks) services according to physician orders, dated 1/27/2026 and the facility's policy and procedure (P&P) tiled Resident Restorative Nursing Program Guidelines, effective date 5/26/2026 for one of one sampled resident (Resident 4). This deficient practice had the potential to result in ineffective RNA services, development of contractures (is a permanent or prolonged shortening of muscles, tendons, ligaments or skin to become stiff and rigid) and further decline in Resident 4's ability to perform everyday tasks. Findings: A review of Resident 4's admission Record indicated the facility admitted Resident 4 on 1/23/2025 and readmitted Resident 4 on 10/16/2025 with diagnoses including quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), diabetes mellitus (DM-a disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to protect and safeguard the residents personal and medical records for one of one sampled residents (Resident 38) according to the facility's policy and procedure (P&P), titled, Storage and Destruction of the Designated Record Set, reviewed and approved 6/10/2026. Resident 38's intravenous (IV -within a vein) Vancomycin (antibiotic/medication used to treat infections) bag with a label intact containing Resident 38's protected health information (PHI - information maintained in the same data set that could identify the individual). This deficient practice violated health insurance portability and accountability (HIPPA - strict standards for managing, transmitting, and storing protected health information) and right to privacy for Resident 38.Findings; A review of Resident 38's admission Record indicated the facility admitted Resident on 5/29/2026 with diagnoses including infection following a procedure, spinal stenosis (narrowing of one 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 observations, interview, and record review, the facility staff failed to develop a base line individualized care plan addressing identified resident's behavior and refusal of wound care for one of four sampled residents, Resident 2. This deficient practice had the potential for delayed assessment and provision of necessary care and services for Resident 2. Findings: During a review of Resident 2's admission records, Resident 2 was admitted to the facility on [DATE] with a diagnoses including chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor airflow), depression, (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities of living), unspecified dementia (loss of memory, thinking and reasoning). A review of Resident 2's Minimum Data Set (MDS- a comprehensive resident assessment and screening tool) dated 3/17/2026, indicated Resident 2's cognitive skills (mental ability or process of acquiring…

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

Based on observation, interview, and record review the facility failed to ensure a resident's request for a lateral transfer to another skilled nursing facility closer to the resident's family was assisted and facilitated. The facility staff failed to assist a resident with required insurance changes to allow accepting facilities to process admission for one of four sampled residents Resident 2. This failure had resulted in an unreasonable delay and impeded Resident 2's right to transfer to the facility of choice. During a review of Resident 2's admission Records, the Records indicated Resident 2 was admitted to the facility on 529/2025 with a diagnoses including, hemiplegia and hemiparesis ( severe or complete loss of strength or paralysis on one side of the body), type two diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy, hemiparesis (mild or partial weakness or loss of strength on one side of the body ) essential primary hypertension (when the pressure in your blood vessels is too high ). 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.

Based on observation, record review and interview the facility failed to remove expired food from refrigerator as per their policy.This deficient practice had the potential to cause food borne illness.During an observation on 12/15/2025 at 1:46 p.m., in the refrigerator, there was a bin of tomatoes with a use by date of 12/12/2025 and a bin of wilted (limp) celery with no date.During a review of the produce storage guidelines, the guidelines indicated tomatoes can be stored for 1 week at room temperature and celery can be stored in the refrigerator for one week.During an interview on 12/15/2025 at 1:48 p.m. with the dietary supervisor (DS), the DS stated all deliveries are labeled upon receipt and should be disposed of past the use by date.During a review of the facility policy and procedure (P&P) titled, Food Storage and Handling, revised 2/2024, the P&P indicated {.}Fresh vegetable storagea. Fresh vegetables should be checked and sorted for ripenessb. Store at a room temperature of 41 degrees or lessc. Unwashed produce should not be placed in the refrigerator near prepared foodsd.…

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

AMENDEDBased on observation and interview in the facility failed to ensure:1. The kitchen stove top did not have dried food and debris.2. Food was labelled and/or dated.This deficient practice had the potential to result in food borne illness to residents who consumed food prepared by the facility.Findings:During an observation and concurrent interview in the facility kitchen with the Dietary Supervisor (DS) and Dietary [NAME] (DC) 1 on 11/4/25 at 10:20 a.m., the following were observed.1. The kitchen stove top with dried food and debris.2. The refrigerator was noted with unlabeled and undated slices of cheese, a large container of egg salad, and a large container of tuna.During the same observation and interview, the DC initially stated that he had not started preparing lunch for the residents. When asked to open the oven for cleanliness inspection, the surveyor and the DS observed that the oven was set at 250 degrees and two large pans of partially cooked chicken and zucchini inside the oven. The DC stated he was not cooking the chicken and zucchini but was just storing 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 and interview, the facility failed to ensure one of three sample residents, Resident 3, had call lights (a call system a resident uses to call for help from staff) within reach while in bed as required to maintain immediate access to staff assistance. This deficient practice had the potential to place Resident 3 at risk for unmet care needs and delayed response by staff to emergencies. Findings: A review of Resident 3's admission records indicated Resident 3 was admitted to the facility on [DATE] with a diagnosis including blindness in the right and left eye, hypertension (when the pressure in your blood vessels is too high), generalized muscle weakness (a lack of strength in the muscles). A review of Resident 3's progress notes dated 9/23/2025 at 6:45 PM indicated, resident 3 was admitted to the facility from a General Acute Care Hospital (GACH) with muscle weakness (a lack of strength in the muscles), dysphagia (difficulty swallowing), Alzheimer's disease (a progressive disease that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview for one of three sampled residents, Resident 1. The facility failed to: 1. Ensure regular re-evaluation of discharge plan. 2. Coordinate with resident representative (RR) in the discharge planning process. 3. Ensure Resident 1 was discharge with supply of hydroxyzine (medication given for itching). 4. Ensure the assisted living facility (ALF- a residential care facility the provides non-medical care and supervision for senior who need assistance with daily living activities but don ' t require 24-hour nursing care) was notified that Resident 1 had a gastrostomy tube (g-tube: a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) during discharge planning process. 5. Ensure Resident 1 was set up with home health. 6. Follow up with Resident 1 post discharge. These deficient practices lead to the discharge of Resident 1 to the ALF with a g-tube in place, no home health set up and no supply…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 for two of three sampled residents (Resident 1 and Resident 3). The facility failed to: 1. Develop a care plan for the gastrostomy tube (g-tube: a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) for Resident 1. 2. Develop a discharge care plan for Resident 3. This deficient practice placed Resident 1 at risk of infection and placed Resident 3 at risk of inaccurate discharge plan. Findings: A review of Resident 1 ' s admission record indicated the facility admitted this [AGE] year-old male on 12/28/2024 with diagnoses including, Hemiplegia (paralysis) and hemiparesis (total weakness of the arm, leg, and trunk on the same side of the body) following cerebral infarction (CI-stroke, loss of blood flow to a part of the brain) affecting the right dominant side, primary thrombophilia (a condition that increases the likelihood of blood clots forming), depression (mental health condition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 5) had a call light the resident was able to use within reach. This failure resulted in Resident 5's inability to call staff for assistance due to inability to push the call light button. Findings: During a review of Resident 5's admission Record , dated 4/18/25, indicated Resident 5 was admitted to the facility on [DATE], with a diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), abnormal posture, muscle wasting and atrophy (thinning of muscle mass), generalized osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and muscle weakness. During a review of Resident 5's Minimum Data Set (MDS-resident assessment tool) dated 2/13/25 indicated Resident 5 had intact cognitive (thinking, reasoning, judgement and learning) function and required maximal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1) their care plan intervention of Low Air Loss (LAL-mattress designed to prevent and treat pressure injuries by reducing moisture and heat buildup using a system of inflated air cells that continuously circulate air) mattress was implemented. This failure resulted in a decline in Resident 1's pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). Findings: During a review of Resident 1's admission Record , dated 4/18/25, indicated Resident 1 was admitted to the facility on [DATE], with a diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), abnormal posture, muscle weakness, generalized osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), heart failure (a condition where the heart cannot pump enough blood to meet the body's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the medical record documentation of ADLs was accurate and complete for one of five sampled residents (Resident 1). This failure resulted in an inaccurate and incomplete medical record for the resident. Findings: During a review of Resident 1's admission Record , dated 4/18/25, indicated Resident 1 was admitted to the facility on [DATE], with a diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), abnormal posture, muscle weakness, generalized osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), heart failure (a condition where the heart cannot pump enough blood to meet the body's needs), hypertension (high blood pressure) and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set (MDS-resident assessment tool) dated 2/2/25 indicated Resident 1 had severe cognitive (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.

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 was free from medication errors: 1. By failing to follow physician ' s order to hold the medication Empagliflozin (brand name Jardiance- medication that treats type 2 diabetes by helping kidneys remove sugar from blood), LVN1 attempted to administer the medication on 4/8/2024 am shift. 2. LVN1 left the medication Empagliflozin/Jardiance unattended. This deficient practice had the potential harm by putting Resident 1 at risk of low blood sugar level. Findings: A review of Admissions Record indicated, Resident 1 was admitted to the facility on [DATE] from General Acute Care Hospital (GACH) with a diagnosis of not limited to specified diabetes mellitus (a disease in when your body does not produce enough insulin needed to control sugar levels in the blood), hypertension (when the pressure in your blood vessels is too high), Atherosclerotic heart disease (a condition where plaque builds up in the arteries…

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

Based on observation, interview, and record review the facility failed to treat twelve of twelve sampled residents in need of feeding assistance, with respect and dignity by calling them feeders, and keeping a list of their room numbers labeling them Feeders for the purposes of making the assignments. Sampled residents included (21), (16), (247), (30), (6), (53), (8), (36), (248), (37), (54), and (19). This deficient practice caused or had the potential to cause depression (a prolonged feeling of sadness, hopelessness, or loss of interest in activities). Findings: A review of Resident 21's admission record, indicated Resident 21 was admitted to the facility (skilled nursing facility [SNF]) on 1/15/25, with the diagnosis of, but not limited to, diabetes Type 2 (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), muscle weakness (a lack of physical or muscle strength, throughout the body). A review of Resident 21's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/1/25, indicated Resident 21's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the residents' clinical records were complete and updated with advance directives (a written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for three out of four sampled residents (Residents 18, 50 and 246) by failing to maintain an accurate and current copy of the resident's advance directives in the resident's clinical record. This failure resulted in or had the potential to cause conflict with te wishes regarding health care for Residents 18, 50 and 246. Findings: 1. During a record review, Resident 18's admission Record, indicated Resident 18 was admitted to the facility on [DATE], with diagnoses that included, muscle weakness (a lack of physical or muscle strength, throughout the body), Rheumatoid Arthritis, (a disease where the body's defense system mistakenly attacks the joint linings, causing pain, swelling and stiffness),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an unknown Liaison (a person who helps different groups communicate and work together) did not have access and retained the medical records for one of six residents (Resident 48). This failure resulted in a Health Insurance Portability and Accountability Act (HIPPA - is a federal law enacted in 1996 that aims to protect individuals' health information and ensure the continuity of their health insurance coverage) violation of medical records for Resident 48. Findings: During a record review, Resident 48's admission record indicated Resident 48 was re-admitted to the facility on [DATE] with a diagnosis of paraplegia complete (a person has lost all feeling and movement in their legs and lower body, usually due to a complete spinal cord injury), essential hypertension (the most common type of high blood pressure where the cause is unknown). During a record review, Resident 48'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.

Based on interview and record review, facility failed to accurately and completely document diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) education in the resident's chart for one of four sampled residents (Resident 76). This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 76. Findings: During a record review, Resident 76's history and physical (H&P -a thorough medical evaluation performed by the doctor) dated 9/17/2024 indicated Resident 76 had diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) During a record review, Resident 76's admission Record indicated the facility admitted Resident 39 on 5/4/2024 with diagnoses including DM, hyperlipidemia (HLD - high cholesterol, too much fats) and cerebral vascular accident (CVA- Stroke) without residuals, and hypertension (HTN - elevated blood pressure). During a record review, Resident 76'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.

Based on observation, interview, and record review, facility failed to ensure that one of ten sampled residents (Resident 38) was assessed for medication self-administration. This deficient practice had the potential to cause over medication or harm to Resident 38. Findings: During a record review, Resident 38's admission Record indicated the facility admitted Resident 38 on 2/3/2025, with diagnoses of hypertension (HTN-high blood pressure), generalized weakness (a feeling of weakness in most parts of the body), and diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a record review, Resident 38's Self Administration Assessment of medication dated 2/11/2025 indicated that resident required assistance with administering ointments, and topical medication. The Self Administration Assessment also indicated that Resident 38 was not approved for medication self-administration or to keep medication at the bedside. During a record review, Resident 38's Minimum Data Set (MDS - a resident assessment tool) dated 2/16/2025,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a safe, comfortable, and a homelike environment for one out of four residents sampled (Resident 64). This failure resulted: 1. Resident 64 not having access to hot water for grooming and personal hygiene. 2. Resident 64 got wet from the splashing water faucet to get wet. Also, this Failure paused the potential for accidents and falls with injuries Cross Reference F689. Findings: During a record review, Resident 64's admission Record indicated Resident 64 was admitted to the facility on [DATE] with diagnoses that included, hypertension (Also known as high or raised blood pressure, a condition in which the blood pressure readings are consistently high), and muscle weakness (a lack of physical or muscle strength, throughout the body). During a record review, Resident 64's Minimum Data Set (MDS- a resident assessment tool), dated 2/2/2024, indicated Resident 64 is cognitively intact (able to make decisions concerning care, alert to situation 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, for one of six residents (Resident 48) the facility failed to arrange and ensure a safe discharge home for Resident 48 through discharge planning prior and conduct interdisciplinay team (IDT - A team brings together professionals from various disciplines to collaborate and provide holistic care for patients) meeting with Resident 48 and the resident's family prior to discharging Resident 48 from the facility for 1 of 6 residents (Resident 48). This failure resulted in unsafe discharge home for Resident 48 and Family Member (FM) 1 making sudden arrangements and life style changes at home to accommodate Resident 48. FM 1 wasvery upset, cried, was uncomfortable, and felt helpless. Cross Reference F842 Findings: During a record review, Resident 48's admission record indicated Resident 48 was re-admitted to the facility on [DATE] with a diagnoses of paraplegia complete (a person has lost all feeling and movement in their legs and lower body, usually due to 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 develop a baseline care plan in accordance with the facility's policy and procedures (P&P) titled Comprehensive Person-Centered Care Planning revised 3/21/2025 for one of four sampled residents (Resident 55). These deficient practices had the potential to negatively affect the delivery of necessary care and services for Resident 55. Findings: During a record review, Resident 55's admission Record indicated the facility admitted Resident 55 on 6/14/2023, and readmitted Resident 55 on 10/14/2024 with diagnoses including Cerebral vascular (CVA-stroke, loss of blood flow to a part of the brain)), generalized weakness (a feeling of weakness in most parts of the body), and diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a record review, Resident 55's Minimum Data Set (MDS - a resident assessment tool) dated 3/19/2025, indicated Resident 55 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making 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 conduct an interdisciplinary team meeting (IDT - a group of experts from several different fields) for one of three sampled residents (Resident 55), per the facility's policy. This deficient practice had the potential to result in Resident 55's care needs not being met comprehensively when resident/resident's representative were not involved in developing a care plan and making decisions for Resident 55. Findings: During a record review, Resident 55's admission Record indicated the facility admitted Resident 55 on 6/14/2023, and readmitted Resident 55 on 10/14/2024 with diagnoses including Cerebral vascular (CVA-stroke, loss of blood flow to a part of the brain)), generalized weakness (a feeling of weakness in most parts of the body), and diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a record review, Resident 55's Minimum Data Set (MDS - a resident assessment tool) dated 3/19/2025, indicated Resident 55 had cognitive impairment (when a person has trouble…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, for one of three sampled resident (Resident 56), the facility failed to: 1. Ensure that on 319/2025 at 4:30 PM, Resident 56 received Humalog KwikPen insulin (a rapid-acting hormone for regulating blood sugar levels) 10 units (a unit of measurement) subcutaneous (SQ- injecting into the fatty tissue layer just beneath the skin) for a blood sugar (BS) of 541 milligrams per deciliter (mg/dL- unit of measurement. Normal BS is 70mg/dL-120 mg/dL) and notify a physician of the high BS according to physician order. 2. Licensed Vocational Nurse (LVN) 6 did not administer Humalog KwikPen before checking Resident 56's BS before meals on 3/20/2025 at 11:30 AM and on 3/20/2025 at 4:30 PM. 2. LVN 6 checked Resident 56's BS before administering Humalog KwikPen insulin 5 units SQ on 3/20/2025 at 10:30 PM. 3. LVN 6 rechecked Resident 56's BS after administering Humalog KwikPen insulin 5 units SQ on 3/20/2025 at 10:30 PM. These deficient practices had the potential to cause confusion among…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a safe, comfortable, and a homelike environment for one out of four residents sampled (Resident 64). This failure paused the potential for accidents and falls with injuries for Resident 64 Cross Reference F584. Findings: During a record review, Resident 64's admission Record indicated Resident 64 was admitted to the facility on [DATE] with diagnoses that included, hypertension (Also known as high or raised blood pressure, a condition in which the blood pressure readings are consistently high), and muscle weakness (a lack of physical or muscle strength, throughout the body). During a record review, Resident 64's Minimum Data Set (MDS- a resident assessment tool), dated 2/2/2024, indicated Resident 64 is cognitively intact (able to make decisions concerning care, alert to situation and oriented to place and time). Resident 64 is primarily independent and able to perform all his daily needs for living. During an interview on 04/01/25 at 10:34 AM,…

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

Based on observation, interview, and record review, the facility failed to ensure that one of four sampled residents (Resident 55) received appropriate treatment and services. This deficient had the potential to cause inadequate nutrition and possible infection. Findings: During a record review, Resident 55's admission Record indicated the facility admitted Resident 55 on 6/14/2023, and readmitted Resident 55 on 10/14/2024 with diagnoses including Cerebral vascular (CVA-stroke, loss of blood flow to a part of the brain), generalized weakness (a feeling of weakness in most parts of the body), and diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a record review, Resident 55's physician order dated 3/29/2025, indicated enteral feed order, two times a day provide glucerna1.5 at 75 milliliters (ml- metric unit of measurement, used for liquids) per hour . During a record review, Resident 55's Minimum Data Set (MDS - a resident assessment tool) dated 3/19/2025, indicated Resident 55 had cognitive impairment (when a person…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that Liaison did not have access and retain the medical records and identifiable documents for one of six residents (Resident 48). This failure resulted in the facility violating the Health Insurance Portability and Accountability Act of 1996 standards for privacy of individually identifiable Health Information (HIPPA privacy standards) for Resident 48. Cross Reference F624 Findings: During a record review, Resident 48's admission record indicated Resident 48 was re-admitted to the facility on [DATE] with a diagnoses of paraplegia complete (a person has lost all feeling and movement in their legs and lower body, usually due to a complete spinal cord injury), and essential hypertension (the most common type of high blood pressure where the cause is unknown). During a record review, the hospice (a type of care focused on comfort, quality of life, and symptom management for individuals with a terminal illness) contract for Resident 48 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 ensure Pneumonia (PNA-infection that inflames air sacs in one or both lungs which may fill with fluid) vaccines were offered and/or administered to two of five sampled residents (Resident 58, and Resident 71) per facility policy. This deficient practice had the potential for Resident 58 and Resident 71 to acquire and/or transmit PNA infection to other residents in the facility and possible hospitalization. Findings: 1. During a record review, Resident 58's admission Record indicated the facility admitted Resident 58 on 1/12/2023, and readmitted Resident 58 on 11/30/2023 with diagnoses including spinal stenosis (a condition where the spinal canal, the space that surrounds the spinal cord becomes barrowed), muscle spasm (an involuntary and sudden, often painful contraction of the muscle, that can last from a few seconds to several minutes), and Gastroesophageal reflux disease (GERD-a condition where the stomach acid flow back up into the esophageal [tube…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that COVID-19 (a viral infection, highly contagious, that easily transmits from person to person, causing respiratory problems and may cause death) vaccination was offered and/or administered for two of five sampled residents (Resident 58, and Resident 71) per facility policy and procedures. This deficient practice placed Resident 58, and Resident 71 at risk for COVID-19 infection and/or hospitalization. Findings: 1. During a record review, Resident 58's admission Record indicated the facility admitted Resident 58 on 1/12/2023, and readmitted Resident 58 on 11/30/2023 with diagnoses including spinal stenosis (a condition where the spinal canal, the space that surrounds the spinal cord becomes barrowed), muscle spasm (an involuntary and sudden, often painful contraction of the muscle, that can last from a few seconds to several minutes), and Gastroesophageal reflux disease (GERD-a condition where the stomach acid flow back up into the esophageal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide care in a manner that promote or enhanced resident ' s dignity and respect by failing to ensure staff was not standing over resident while feeding for two out of two sampled residents (Resident 5 and Resident 8). This deficient practice had the potential to cause psychosocial harm to the resident and could violate resident ' s right to be treated with dignity and respect. Findings: 1. A review of the admission Record indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dysphagia (difficulty swallowing) and dementia (a progressive state of decline in mental abilities). A review of the Minimum Data Set (MDS - resident assessment tool) dated 10/30/2024, indicated Resident 5 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident ' s call light (a device used to notify the nurse that the resident needs assistance) were answered promptly for one of three sampled residents (Resident 4). This deficient practice had the potential to result in the residents not being able to summon staff for assistance for care and services as needed, which could lead to accidents such as falls with injuries. Findings: A review of the admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (afib- an irregular and very rapid heart rhythm that and can lead blood clots in the heart), muscle weakness and polyneuropathy (a condition in which a person's peripheral nerves are damaged). A review of the Minimum Data Set (MDS – resident assessment tool) dated 12/16/2024, indicated Resident 4 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement a comprehensive care plan that met the care/services based on the resident's individual assessed needs for one of three sampled residents (Resident 1) by failing to ensure that a comprehensive (CP) was developed after Resident 1 had a fall incident with injury on 12/5/24. This deficient practice had the potential to result negative impact on residents ' health and safety, as well as the quality of care and services received. Findings: A review of the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (loss of the ability to move in one side of the body) following nontraumatic subarachnoid hemorrhage (lack of blood flow resulting in severe damage to some of the brain tissue) affecting left dominant side, difficulty in walking and congestive heart 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident received treatment and care in accordance with professional standards of practice for one of three sampled residents, Resident 1 by failing to implement facility ' s policy and procedure (P&P) titled, Death of a Resident when Resident 1 expired on [DATE]. This deficient practice resulted in incomplete assessment and documentation required per facility ' s policy and procedure upon death. Findings: A review of the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (loss of the ability to move in one side of the body) following nontraumatic subarachnoid hemorrhage (lack of blood flow resulting in severe damage to some of the brain tissue) affecting left dominant side, difficulty in walking and congestive heart failure (CHF-a heart disorder which causes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 respiratory care services for two of two sampled residents (Resident 2 and Resident 4) by failing to ensure a physician ' s order was in place for oxygen (O2) therapy for Resident 4 and the nasal cannula (NC -a connector attached to oxygen) tubing and humidifier (a device used to make supplemental oxygen moist) was changed for Resident 2 and Resident 4 per facility ' s policy. These deficient practices had the potential to cause complications associated with oxygen therapy. Findings: 1. A review of the admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (afib- an irregular and very rapid heart rhythm that and can lead blood clots in the heart), muscle weakness and polyneuropathy (a condition in which a person's peripheral nerves are damaged). A review of the Minimum Data Set (MDS – resident assessment tool) dated 12/16/2024, indicated Resident 4 ' s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to protect two of four sampled residents (Resident 1 and Resident 2) from misappropriation (the unauthorized, improper, or unlawful use of funds or other property for purposes other than that for which intended) of property and personal belongings. This deficient practice resulted in Resident 1 ' s missing clothes and Resident 2 ' s missing neck pillows. Findings: A. A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included left femur fracture (a break, crack or crush injury of the thigh bone), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and -depression (a mood disorder that causes persistent feeling of sadness and loss of interest). A review of the Resident 1's Minimum Data Set (MDS – resident assessment tool) dated 9/5/2024, indicated Resident 1's cognitive (mental action…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 supervise and monitor one out of three sampled Residents (Resident 1) to prevent falls. Resident 1 had a history of recurrent falls and was assessed as a high risk for falls. As a result, on 11/08/2024 at 8pm, Resident 1's suffered a fall from a wheelchair and sustained a left eyebrow laceration (skin tear) with bleeding and swelling. Resident 1 was transferred to a general acute care hospital (GACH) for further evaluation and management. GACH applied three sutures (a stitch or row of stitches holding together the edges of a wound or surgical incision) on Resident 1's laceration. The fall placed Resident at increased risk for severe injury and or death. Findings: During a review of Resident 1s admission record indicated Resident 1 was originally admitted to the facility on [DATE], with diagnoses that included lack of coordination (poor muscle control that causes clumsy movements), hypertension (HTN - high blood pressure), repeated falls,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review the facility failed provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of diseases for three out of four residents (Residents 1, 3, and 4) by failing to ensure: 1. To assess Residents 1, 3 and 4 ' s skin rash. 2. To place Residents 1, 3, and 4 on contact precautions due to the presence of an unidentified rash. 3. Failing to notify Resident 3's physician that the treatments ordered were not effective. These deficient practices had the potential to spread infection to the residents, visitors, and the community. Findings: During a review of Resident 1 ' s admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing), encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), and cognitive communication deficit (occurs when a person has…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to meet professional standards of quality by failing to: 1. Ensure Resident 1 had an abdominal binder to prevent her Gastrostomy Tube (often called a G tube, is a surgically placed device used to give direct access to the stomach for supplemental feeding, hydration, or medicine) from frequently being dislodged. 2. Ensure that Resident 1 was sent to General Acute Care Hospital (GACH) timely after her G tube was dislodged. 3. Ensure Resident 1 ' s abdominal assessment (a physical examination of the abdomen that includes inspection, auscultation, percussion, and palpation. It's a key part of a patient's physical exam and can help determine the cause of gastrointestinal or genitourinary issues) was performed 3 times a week. 4. ensure staff were trained or in-serviced on the signs and symptoms of bowel impaction. These deficient practiced placed residents at a risk for unnecessary hospitalizations, malnutrition, dehydration, and bowel impactions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 attempt was made to resolve grievances for one of six sampled residents (Resident 6). This deficient practice violated Resident 6 ' s right to have grievances addressed. Findings: A review of Resident 6 ' s admission Record indicated Resident 6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (also called ischemic stroke, a cerebral infarction occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting right non-dominant side and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 6 ' s History and Physical (H&P) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to effectively manage a resident's pain by not following physician ' s order for one of two sampled residents (Resident 2). This deficient practice resulted in Resident 2 experienced unnecessary pain. Findings: A review of Resident 2's admission Record indicated resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including malignant neoplasm of stomach (a tumor that has developed from unhealthy cells in the stomach lining), muscle weakness and dysphagia (difficulty swallowing). A review of Resident 2 ' s History and Physical (H&P), dated 9/23/2024, indicated, physician plan is for Resident (2) to continue Norco (is used to relieve moderate to severe pain) every six hours as needed for pain and Resident 2 has a potential negative impact on therapy due to pain. A review of the Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 9/12/2024, indicated Resident 2's cognitive (mental action…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident received treatment and care in accordance with professional standards of practice for one of three sampled residents, Resident 1 by failing to implement facility ' s policy and procedures (P&P) titled, Death of a Resident when Resident 1 expired on [DATE]. This deficient practice placed Resident 1 in incomplete assessment and documentation required per facility ' s policy and procedure upon death. Findings: A review of Resident 1 ' s admission Record indicated resident was admitted to the facility on [DATE] with diagnoses including hypertension (HTN - elevated blood pressure), diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]) and dementia (loss of cognitive functioning-thinking, remembering, and reasoning). A review of Record of Death, indicated, Resident 1 passed away on [DATE] at 9:48 a.m. A review of Resident 1 ' s Medical Record (electronic and paper charting) as of [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their infection control policy and procedure (P&P) and implement the comprehensive care plan for one of two sampled resident (Resident 4) by failing to provide education about transmission-based precaution and offer personal protective equipment (PPE-a barrier precaution which includes the use of gloves, gown, mask, face shield, when anticipating coming in contact with blood, body fluids or other communicable toxins or agents) use to the visitor of Resident 4. This deficient practice had the potential to spread infection to the residents, visitors, and the community. Findings: A review of Resident 4 admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia (loss of strength in the arm, leg, and sometimes the face on one side of the body) and hemiparesis (loss of use in the arm, leg, and sometimes the face on one side of the body)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure to change and update to a menu to meet the nutritional needs for one of the three sampled residents (Resident 1) who was identified as being at a risk for unplanned weight loss. This deficient practice resulted in Resident 1 experiencing significant weight loss (unplanned weight loss) and was transferred to General Acute Care Hospital (GACH) for further evaluation and treatment. Cross reference F755. Findings: During a review of Resident 1 ' s admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including prostate cancer, encephalopathy (a general term for a group of conditions that cause brain dysfunction. It can be caused by many different things, including disease, injury, drugs, or chemical), and obstruction of bile duct (a blockage in the tubes that carry bile from the liver to the gallbladder and small intestine. The biliary system is comprised of the organs and duct 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews the facility failed to implement its own policies and procedure by failing to ensure the accurate administration of a medication Darolutamide 300 milligrams [mg] (Nubeqa- a prescription medicine used to treat adults with prostate cancer that has spread to other parts of the body and responds to medical or surgical treatment that lowers testosterone (metastatic hormone-sensitive prostate cancer [a disease that occurs when malignant cells grow in the prostate gland, which is located below the bladder in the male reproductive system] or mHSPC), for one out of three sampled residents (Resident 1) for . This deficient practice had the potential to result in Resident 1 ' s prostate cancer worsening. Findings: During a review of Resident 1 ' s admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including prostate cancer, encephalopathy (a general term for a group of conditions that cause brain dysfunction. It can be caused by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility failed to ensure the licensed nurse notified the physician about the change of condition (COC- a sudden or acute deviation from a patient's baseline that may lead to complications or death if left untreated) for one out of three sampled residents (Resident 1) by: - Failing to report to the physician about resident 1 ' s abdominal distention (when the abdomen is abnormally swollen outward and can be caused by a buildup of fluid, tissue, or digestive contents, or by gas and may be related to constipation) on [DATE]. - Failing report the inconsistent bowel movement (BM). This deficient practice had the potential to result in Resident 1 being constipated and lead to bowel obstruction (occurs when the lumen of the bowel becomes either partially or completely blocked. Obstruction frequently causes abdominal pain, nausea, vomiting, constipation-to-obstipation [severe or complete constipation], and distention). Findings: During a review of a care plane with 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 maintain safe and functional area to prevent the infestation of roaches and provide a clean environment in one of one staff ' s breakroom in the facility. This deficient practice had the potential to negatively impact the psychosocial wellbeing of the staffs. Findings: During a concurrent observation and interview with Maintenance Supervisor (MS) on 3/29/2024 at 9:35 a.m. in the staff ' s breakroom on the lower level, observed multiple dead roaches under the sink. Observed dirty ground, dusty floors with the dead roaches with baits under the sink. MS stated, it appears that the roaches has been dead for quite a long time, and it has not been cleaned. MS stated, it should have been cleaned and they should remove the dead roaches. During an interview with Administrator (ADM) on 3/29/2024 at 12:06 p.m., ADM stated, he will make sure that the Maintenance Staffs and Housekeeping staffs will clean the staff ' s breakroom and remove the dead roaches. A review of the facility ' s policy and procedures (P&P) titled,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to promote dignity and respect for two of seven sampled residents (Residents 200 and 21) by failing to: 1. Conduct a personal property inventory upon admission for Resident 200. 2. Ensure staff did not speak in a language not understood by Resident 21 in the presence of the resident. These deficient practices had the potential to decrease self-worth, create anxiety and powerlessness, and affect the physical, mental, and psychological wellbeing of Residents 200 and 21. Findings: a. A review of Resident 200's admission record indicated Resident 200 was originally admitted to the facility on [DATE] with diagnoses including supra ventricular tachycardia (an irregularly fast or erratic heartbeat), muscle weakness, cognitive communication deficit (difficulty with thinking and how someone uses language), and end stage regional disease (ESRD- a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comfortable sound levels at night for three of eight sampled residents (Residents 52, 246, and 83). This deficient practice resulted in Residents 52, 83 and 246 not being able to sleep undisturbed through the night, compromising the health, safety, psychosocial, behavioral, and environmental needs of residents to obtain or maintain the highest physical, mental, and psychosocial well-being. Findings: A review of Resident 52's admission record indicated the resident was admitted to the facility on [DATE] with medical diagnoses including atrial fibrillation (A fib- abnormal heartbeat), subdural hemorrhage (bleeding between the brain and the skull), and hypertension (HTN - elevated blood pressure). A review of Resident 52's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 12/31/2023, indicated Resident 52 had intact cognition (capable of remembering, learning new things, concentrating, or making…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to conduct Pre-admission Screening Resident Review (PASRR -an evaluation to determine if an individual has a serious mental illness, intellectual disability, developmental disability, or related condition) for two of three sampled residents (Residents 33 and 60). This deficient practice had the potential to result in inappropriate care and services necessary for Residents 33 and 60. Findings: a. A review of Resident 33's admission record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with medical diagnoses including major depressive disorder (constant feeling of sadness and loss of interest), anxiety disorder (excessive worry about everyday issues and situations), and post-traumatic stress disorder (PTSD -when a person has experienced or witnesses a scary, shocking, terrifying, or dangerous event). A review of Resident 33's PASRR level 1 screening dated 8/19/2020 section V- Mental illness -suspected mental illness…

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

Based on observation, interview, and record review the facility failed to store and label food in accordance with professional standards and facility policy to ensure the safety of food service by failing to: 1. Label and date food items stored in the kitchen refrigerator. 2. Discard expired food stored in the resident's refrigerator. 3. Provide a refrigerator for the residents to store food brought in from the outside. 4. Label and date food items stored on the shelves in the kitchen. 5. Discard expired food items stored on the kitchen shelves. 6. Label and date food items stored in the resident's refrigerator. Those deficient practices placed residents with compromised health status at risk for foodborne illnesses. Findings: During the initial tour of the Kitchen on 3/18/24 at 8:46 AM, with Dietary Supervisor (DS). There were seven (7) food items in the refrigerator with past expiration dates and eight (8) food items on the shelves with no expiration dates on them. During a concurrent interview on 3/18/24 at 8:46 AM, DS stated it is all of the kitchen staff's responsibility 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 protect residents' rights for one of one sampled resident (Resident 60) by failing to obtain an out on pass physician's order for Resident 60. This deficient practice had the potential to affect Resident 60's psychosocial well-being, optimal functioning leading to low sense of self-worth and self-esteem. Findings: A review of Resident 60's admission record indicated Resident 60 was originally admitted to the facility on [DATE] with diagnoses that included muscle weakness, diabetes mellitus (elevated blood sugar), hypertension (HTN- elevated blood pressure) and morbid obesity (when a person weighs more than 100 pounds [lbs - unit of measurement] above ideal body weight). A review of Resident 60's Minimum Date Set (MDS-a standardized assessment and care screening tool) dated 1/12/2024, indicated Resident 60's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure a comprehensive assessment for pre-admission screening Resident Review (PASRR -an evaluation to determine if an induvial has a serious mental illness, intellectual disability, developmental disability, or related condition) for one of three sampled residents (Resident 33). This deficient practice had the potential to negatively affect the provision of necessary care and services for Resident 33. Findings: A review of Resident 33's admission record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with medical diagnoses including major depressive disorder (constant feeling of sadness and loss of interest), anxiety disorder (excessive worry about everyday issues and situations) and post-traumatic stress disorder (PTSD -when a person has experienced or witnesses a scary, shocking, terrifying, or dangerous event). A review of Resident 33's PASRR level 1 screening dated 8/19/2020 section V- Mental illness…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the assessment entries on the Minimum Data Set (MDS- an assessment and care screening tool) related to active diagnoses, were accurately documented to reflect the resident's psychiatric/mood disorder (related to mental illness and its treatment) for one of three sampled residents (Resident 12). This deficient practice had the potential to negatively affect the plan of care and delivery of necessary care and services for Resident 12. Findings: A review of Resident 12's admission record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including anxiety disorder (excessive worry about everyday issues and situations), dementia (loss of cognitive function- thinking, remembering, and reasoning interfering with individuals' daily life and activities), and hypertension (HTN - elevated blood pressure). A review of Resident 12's MDS dated [DATE], indicated the resident was cognitively (relating 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 ensure one of 23 sampled residents (Resident 22), who was unable to carry out activities of daily living (ADL's: activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating), received the necessary services to maintain good personal oral hygiene. This deficient practice resulted in Resident 22 having dry and cracked lips and had the potential to cause dental caries (tooth decay), bleeding, thrush (overgrowth of yeast in mouth), oral infection, leading to unnecessary hospitalization. Findings: A review of Resident 22's admission record indicated Resident 22 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including hepatic encephalopathy (dysfunction caused by liver when toxins that are normally cleared from the body by the liver accumulate in the blood), anoxic brain damage (caused by a complete…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide skin care and pressure ulcer (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) care consistent with professional standards of practice and per physician's orders for one of three sampled residents (Resident 89) on Low Air Loss Mattresses (LALM - a pressure-relieving mattress used to prevent and treat pressure injuries) by failing to ensure the LALM was set to Resident 89's weight. This deficient practice had the potential to delay healing and increased the risk of developing new pressure injuries, worsening of existing pressure injuries, and complications related to pressure injuries for Resident 89. Findings: A review of Resident 89's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes (elevated blood sugar) and Morbid Obesity (when the body weight is more than 80 to 100 pounds above the ideal body weight) due to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed implement its policy and procedure in accordance with the care plan of the resident to monitor signs and symptoms of urinary tract infection (UTI- an infection involving any part of the urinary system, including urethra, bladder, and kidney) for one of six sampled residents (Resident 35). This deficient practice resulted in Resident 35 developing sediment (matter that settles to the bottom of a liquid) in urine and a UTI. Findings: A review of Resident 35's admission record (Face Sheet) indicated the resident was admitted to the facility on [DATE], with diagnoses that included neuromuscular dysfunction of bladder (bladder is not functioning normally), quadriplegia (person cannot move arms and legs), muscle weakness and dependence on wheelchair. A review of Resident 35's History and Physical (H&P) dated 11/28/23, indicated Resident 35 had the capacity to understand and make decisions for daily living. A review of Resident 35's Minimum Data Set…

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

Based on interview and record review, the facility failed to ensure nursing staff met the skills and staff competency evaluation requirements. This deficient practice had the potential for a knowledge, training, and certification deficit among the nursing staff, leading to inadequate or delayed resident care. Findings: A review of employee file for licensed vocational nurse 1 (LVN 1), indicated there was no skills competency check list or a completed staff competency assessment in the employee file. The N95 (the most common particulate-filtering facepiece respirator) fit testing validation was incomplete. A review of employee file for LVN 2 indicated there was no skills competency check list or a completed staff competency assessment in the employee file. The N95 fit testing validation was incomplete. A review of employee file for certified nursing assistant 2 (CNA 2) indicated there was no skills competency check list or a completed staff competency assessment in the employee file. The N95 fit testing validation was incomplete. During an interview with LVN 1 on 03/20/24 10:18 AM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, The facility failed to label medications for one of six sampled residents (Resident 89). This deficient practice had the potential to result in unsafe medication administration. in Resident 89 ingesting unlabeled medication, use expired medications and cause confusion about what the medication is. Findings: A review of Resident 89's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes (a chronic condition with high blood sugar) and morbid obesity (severe overweight) due to excess calories and muscle weakness. A review of Resident 89's History and Physical (H&P) Examination dated 2/26/24, indicated Resident 89 had the capacity to understand and make decisions for daily living. A review of Resident 89's Minimum Data Set (MDS- a care assessment and screening tool), dated 3/4/24, indicated the resident was cognitively (relating to mental process such as thinking, reasoning, and remembering)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure resident ' s right were honored and implemented accordingly to his decision on health care treatment for one of five sampled residents, Resident 1. This deficient practice violated resident ' s right to make an informed decision and resulted to failure in the delivery of necessary care and services for Resident 1. Findings: During a review of Resident 1 ' s admission Record, indicated the facility admitted Resident 1 on [DATE] with diagnoses including hemiplegia and hemiparesis (loss of the ability to move in one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting right dominant side, type 2 diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), and peripheral vascular disease (PVD - a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). During a review of Resident 1 ' s Minimum…

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

Based on interview and record review, the facility failed to protect residents ' rights for one of three residents (Resident 1). As a result, the facility discontinued a physician for Resident 1 ' s to go out on pass (permission of a patient to leave the hospital in a specified time). Cross Reference F689 Findings: A review of Resident 1 ' s admission Record (Face sheet), indicated the facility admitted Resident 1 on 11/28/2023 with diagnoses including, difficulty in walking, history of falls, and intertrochanteric (hip) fracture (a partial or complete break in the bone) of the left femur (thigh bone). A review of Resident 1 ' s Minimum Date Set (MDS-a standardized assessment care screening tool), dated 12/5/23, indicated Resident 1 was cognitively intact (mental ability to make decisions of daily living) and required between partial/moderate to supervision or touching assistance for his activities of daily living (ADL). A review of Resident 1 ' s undated care plan titled The resident has had an actual fall with no injury, unsteady, indicated the goals included Resident 1 will…

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

Based on interview and record review, for one of three residents (Resident 1), the facility failed to conduct a root cause analysis for falls for Resident 1. As a result, Resident 1 suffered two falls and had the potential to experience additional falls and injuries. Cross Reference F550 Findings: A review of Resident 1 ' s admission Record (Face sheet), indicated the facility admitted Resident 1 on 11/28/2023 with diagnoses including, difficulty in walking, history of falls, and intertrochanteric (hip) fracture (a partial or complete break in the bone) of the left femur (thigh bone). A review of Resident 1 ' s Minimum Date Set (MDS-a standardized assessment care screening tool), dated 12/5/23, indicated Resident 1 was cognitively intact (mental ability to make decisions of daily living) and required between partial/moderate to supervision or touching assistance for his activities of daily living (ADL). A review of Resident 1 ' s undated care plan titled The resident has had an actual fall with no injury, unsteady, indicated the goals included Resident 1 will resume usual activities…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) had a change of condition (COC, a change in a resident's mental, psychosocial, or physical functioning that requires a change in the resident's comprehensive plan of care) for significant weight loss completed timely. This failure resulted in Resident 1 not being referred to the Registered Dietician (RD) for possible new weight loss interventions and delayed the monitoring of the weight loss or gain for three weeks. Findings: During a review of Resident 1's admission Record dated 1/25/24, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including essential (primary) hypertension (high blood pressure), muscle weakness, protein-calorie malnutrition (a condition where not enough protein and calories are consumed resulting in muscle loss), and dysphagia (difficulty swallowing). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and screening tool),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure four of six sampled residents (Residents 2, 3, 4, & 5) who were smokers were supervised when smoking. The facility was aware Resident 2, 3, 4 and 5 used a personal lighter to light a cigarette unattended. This deficient practice had the potential for fire related accidents in the facility among residents, staffs and visitors. Findings: A. A review of Resident 2's admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including alcoholic cirrhosis of liver (permanent scarring that damages the liver and interferes with its functioning), muscle weakness, difficulty in walking, and major depressive disorder (a mood disorder that causes persistent feeling of sadness and loss of interest). A record review of Resident 2's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 9/25/2023, indicated Resident 2's cognitive skill (mental action or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a functioning call light for one of three sampled residents (Resident 3). This deficient practice had the potential to result in a delay in meeting the resident 's need for assistance and treatment including the resident 's pain management. Findings: A review of the admission Record (Face Sheet) indicated Resident 3 was admitted on [DATE] with diagnoses that included amputation (removal of a body part) of the right great toe, seizures, muscle weakness, diabetes (high blood sugar) and hypertension (high blood pressure). A review of Resident 1's Minimum Data Set (MDS, a comprehensive assessment tool) indicated Resident 3 's cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. A review of the Physician Orders, dated 9/8/2023, indicated Resident 3 has an order for oxycodone 10 mg 1 tablet by mouth every four (4) hours as needed for severe pain. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of two sample residents (Resident 1) was allowed to return to the facility after therapeutic leave essentially initiating an involuntary discharge. As a result of this deficient practice, Resident 1 ' s Responsible Party (RP) 1 hadto appeal the involuntary discharge which delayed Resident 1 ' s readmission to the facility. Findings: During a review of Resident 1's admission Record, dated 8/9/23, the admission record indicated, the resident was admitted to the facility originally on 6/14/23 and readmitted on [DATE] with diagnoses including hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke), hypertensive (high blood pressure) heart disease and respiratory failure (condition where it is difficult to breath on your own). The admission record further indicated RP 1 was to make care decisions for Resident 1. During a review of Resident 1 ' s History and Physical (H&P) dated 8/9/23, the H&P 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.