Granada Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Urologist (medical doctor who specializes in treating diseases of the urinary tract in both men and women, as well as the male reproductive system) was consulted in a timely manner as ordered on 1/19/2026, and upon readmission to the facility on 2/20/2026 for one of one sampled residents (Resident 5) with an indwelling catheter (a thin, flexible tube inserted into the bladder to drain urine). This failure had the potential to place Resident 5 at risk for indwelling catheter related complications such as urinary tract infections (UTI- an infection in the bladder/urinary tract) and sepsis (a life-threatening blood infection).Findings: During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 5's diagnoses included hydronephrosis (swelling of a kidney caused by a backup of urine), hypertension (HTN-high blood pressure), presence of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the consultant pharmacist's Medication Regimen Review (MRR- a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication, to the physician) recommendation was reviewed, addressed, and followed up with the physician for pain management therapy and non-pharmacological interventions for one of two sampled residents (Resident 3). This failure had the potential to affect Resident 3's pain management, comfort, and quality of care.Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), fracture of the right fibula (calf bone), and muscle weakness (loss of muscle strength). During a review of Resident 3's…

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

Based on observation, interview, and record review, the facility failed to follow the menu and standardized recipes for one of four sampled residents (Resident 31).This failure had the potential for affecting Resident 31's meal satisfaction. FindingsDuring a review of Resident 31's admission Record, the admission Record indicated the facility admitted the resident on 3/13/2026 with diagnoses including diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness (loss of muscles strength), and hypertension (HTN-high blood pressure).During a review of Resident 31's History of Physical (H&P), dated 3/16/2026, the H&P indicated Resident 31 could make needs known but cannot make medical decisions.During a review of Resident 31's Minimum Data Set (MDS- a resident assessment tool), dated 4/6/2026, the MDS indicated Resident 31's cognition (the ability to understand and process information) was intact. The MDS indicated Resident 31 was dependent (helper does all the effort) on staff for activities of daily living (ADLs -…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 timely develop a comprehensive care plan for one out of three sampled residents (Resident 1), who refused to wear a hearing aid (a small electronic device worn in or behind the ear to amplify [increase] sounds, designed to help people with hearing loss).This failure had the potential for miscommunication and Resident 1's needs not being met. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1's diagnoses included systolic (congestive) heart failure ([CHF], a heart disorder that causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).During a review of Resident 1's care plan titled, Resident has difficulty hearing staff, dated 11/9/2022, the care plan indicated Resident 1 received hearing aids. The care plan goal indicated for Resident 1 to be able 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 two of three sampled residents (Residents 1 and 2), received proper treatment and assistive devices to maintain hearing abilities by failing to:Assist Resident 1 when the resident reported her hearing aids did not work properlyAssist Resident 2 when the resident reported he had concerns with hearing and ensure Resident 2 was assessed by the Otolaryngologist ([ENT doctor] specializing in the care for ear, nose and throat conditions) routinely.These failures had the potential for Residents 1 and 2 not being able to hear adequately during conversations with staff and other residents and could lead to misunderstanding or miscommunication between the residents and staff. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1's diagnoses included systolic (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 develop a comprehensive, person-centered care plan for one of three sampled residents (Resident 1) who had a diagnosis of osteopenia (a decrease in bone mineral density and causes bones to get weaker). This deficient practice had the potential for staff not to properly care for Resident 1 and placed the resident at risk for further injuries and fractures (broken bone). Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included fracture, contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that caused the joints to shorten and become very stiff) and other specified disorders of bone density and structure of the right shoulder. During a review of Resident 1's History and Physical (H&P), dated 1/14/2025, the H&P indicated Resident 1 did not have the capacity to understand and make…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) assessments for three of 19 sampled residents (Residents 23, 19, and 24) were completed and documented accurately. This deficient practice resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS) regarding Residents 23, 19, and 24's health status. This deficient practice also created the potential for Residents 23, 19, and 24 to not receive the care and interventions needed to reach their highest practicable physical and psychosocial well-being. Findings: 1. During a review of Resident 23's admission Record, the admission Record indicated Resident 23 was admitted to the facility on [DATE]. Resident 23's admitting diagnoses included oropharyngeal phase dysphagia (swallowing problems occurring in the mouth and/or the throat). During a review of Resident 23's Minimum Data Set (MDS, a resident assessment tool), dated 3/6/2025, the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR, a screening tool that helps identify possible serious mental illness [SMI], and if the resident requires specialized services) was submitted for one of four sampled residents (Resident 74). This deficient practice placed Resident 74 at risk of not receiving recommended or required treatments for diagnosed SMIs, or appropriate placement in a facility to meet Resident 74's needs. Findings: During a review of Resident 74's admission Record, the admission Record indicated Resident 74 was admitted on [DATE] and was most recently readmitted on [DATE]. Resident 74's admitting diagnoses included psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), depression (a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), and anxiety…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2. During an observation on 3/24/2025 at 10:05 a.m., in Resident 191's room, observed Resident 191 lying in bed receiving supplemental oxygen via a nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) at three liters per minute. Observed Resident 191's room did not have an oxygen sign posted outside of the room's doorway. During a review of Resident 191's admission Record, the admission record indicated Resident 191 was initially admitted on [DATE] and readmitted on [DATE]. The admission record indicated the following diagnoses which included Parkinson's (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), acute respiratory failure with hypoxia (when the lungs suddenly fail to adequately provide oxygen to the body, resulting in a dangerously low level of oxygen in the blood), dependence on supplemental oxygen, pneumonia (an infection/inflammation in the lungs), congestive heart failure (CHF - a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure interventions to prevent the development or worsening of pressure ulcers (PU, localized damage to the skin and/or underlying tissue usually over a bony prominence) were implemented for four of seven sampled residents (Residents 288, 74, 23, and 191) when: 1. Low-air-loss-mattress (LALM, a mattress designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) settings were incorrect for Residents 288, 74, and 191. 2. Resident 23 was not provided with a LALM as ordered by the resident's physician. 3. Resident 191's LALM was labeled with the wrong resident's name and weight settings. These deficient practices placed Residents 288, 74, 23, and 191 at risk for the development or worsening condition of existing pressure ulcers. Findings: 1. During an interview on 3/26/2025 at 9:15 a.m., with the Treatment Nurse (TN), the TN stated LALMs created air flow to stabilize pressure within the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safety was maintained for one of two sampled residents (Resident 288) by failing to pad Resident 288's siderails. This deficient practice placed Resident 288 at risk for harm and injury. Findings: During a review of Resident 288's admission Record, the admission record indicated Resident 288 was admitted to the facility on [DATE]. Resident 288's admitting diagnoses included epilepsy (a neurological condition characterized by recurrent seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]). During a review of Resident 288's Minimum Data Set (MDS, a resident assessment tool), dated 3/8/2025, the MDS indicated Resident 288 had severe cognitive impairment (a significant decline in cognitive abilities that interferes with daily functioning and daily living). The MDS indicated Resident 288 had impairments to her lower extremities (legs) on both…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 place oxygen signage at the room door entrance indicating oxygen was in use for one of six sampled residents (Resident 191) receiving oxygen therapy. This deficient practice had the potential to place all residents' and staff's safety at risk. Findings: During an observation on 3/24/2025 at 10:05 a.m., in Resident 191's room, observed Resident 191 lying in bed receiving supplemental oxygen via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) at three (3) liters per minute (LMP). Observed Resident 191's room did not have an oxygen sign posted outside of the doorway. During a review of Resident 191's admission Record, the admission record indicated Resident 191 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 191's diagnoses included Parkinson's (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 their medication error rate was less than five percent (%) when Licensed Vocational Nurse (LVN) 1 failed to administer one of four randomly selected residents' (Resident 4) medications timely and as ordered by Resident 4's physician. The outcome was six medication errors out of 32 opportunities for errors, with resulted in a Medication Administration Error Rate of 18.75%, based on the following: 1. Resident 4 received six medications, Lidocaine cream (medication applied to the skin to prevent or treat pain), empagliflozin (hypoglycemic medication used to lower blood sugar levels), benztropine (anti-tremor medication), primidone (anticonvulsant medication used to treat seizure disorders [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]), carbidopa-levodopa (anti-tremor medication), and docusate sodium (a stool softener), more than one hour after…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 daily menu and offer alternative menu options for one of eight sampled residents (Resident 3). This deficient practice had the potential to impact Resident 3's nutritional status, quality of life and result in food dissatisfaction leading to insufficient food intake. Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE]. Resident 3's diagnoses included muscle wasting (weakening, shrinking, and loss of muscle) and atrophy (decreased size of a body part, cell, organ or tissue), dysphagia (difficulty swallowing), aphasia (a disorder that makes it difficult to speak) following cerebral infarction (stroke - loss of blood flow to a part of the brain), and severe protein-calorie malnutrition (inadequate intake of protein, calories and other essential nutrients). During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure staff were knowledgeable of the facility's process on how to handle unlabeled resident clothes found in the laundry area and failed to complete a resident belonging list upon readmission for one of seven sampled resident's (Resident 1), to protect the resident's property from loss or theft. This failure had the potential to violate Resident 1's right to a safe and home like environment. Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of encephalopathy (a group of conditions that cause brain dysfunction such as confusion and memory loss), after being sent out to a general acute care hospital on 7/16/2024. During a review of Resident 1's Minimum Data Set ([MDS], a federally mandated resident assessment tool) dated 2/14/2025, the MDS indicated Resident 1 had moderate (average) cognitive impairment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its policy and procedures (P&P) titled, Comprehensive Care Planning, and Falls by a Resident, for one of seven residents (Resident 2) who had a fall on 2/19/2025, by failing to: 1. Conduct an Interdisciplinary Team ([IDT] group of healthcare professionals, including resident/ resident representative, working together to provide residents with needed care) meeting with Resident 2 and the family representative, to discuss and revise (change) the plan of care after Resident 2's fall on 2/19/2025. 2. Reassess and revise care plan interventions to ensure Resident 2's safety and to prevent recurrent fall. These failures placed Resident 2 at risk for recurrent falls and injuries. Findings: During a review of Resident 2's admission Record, the admission Record indicated, Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included polyneuropathy (a condition where multiple nerves in 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 implement its infection prevention and control measures for five out of seven residents (Residents 1, 2, 3, 6, and 7) by failing to: a. Ensure Residents 1 and 3 were not cohorted (grouped together) with a resident (Resident 2) who had orders for contact isolation (a set of precautions used to prevent the spread of germs that can be transmitted by direct or indirect contact with a patient or their environment). b. Ensure clear signage was posted to inform staff and visitors the Enhanced Barrier Precautions ([EBP] use of gown and gloves during high-contact resident care activities to reduce the transmission of multidrug-resistant organisms ([MDROs] bacteria or other microorganism resistant to multiple classes of antibiotics)) that were to be implemented when providing care for Residents 6 and 7. c. Ensure staff wore personal protective equipment ([PPE] specialized clothing or equipment such as gloves and gown worn to minimize exposure to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow up and ensure all required documents were sent to the General Acute Care Hospital (GACH) Rehabilitation (Rehab) Center for evaluation, to address one of three sampled residents (Resident 1), requested transfer. This deficient practice resulted to the delay in transfer and physical therapies in a GACH Rehab and had the potential to affect in maintaining Resident 1 ' s highest practicable physical, mental, and psychosocial well-being. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis (weakness or paralysis on one side of the body), muscle weakness (loss of muscle strength), and difficulty in walking (gait disorders). During a review of Resident 1 ' s History and Physical (H&P), the H&P dated 1/15/2024, indicated Resident 1 did not have the mental capacity to understand and make medical decisions. During…

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

Based on interview and record review, the Administrator failed to demonstrate or provide evidence of sufficient oversight over the activities of the facility's Medical Doctor (MD 1), who also served as the facility's Medical Director. This deficient practice had the potential to affect all 90 facility residents as the Medical Director was responsible for providing adequate oversight to ensure care and services provided for the 90 in-house residents in the facility met professional standards of quality. Cross Reference: F-tag F658, F552, F758, and F841 Findings: During an interview on 3/29/2024 at 1:56 p.m., with the Administrator (ADM), the ADM stated he had been the facility ADM since 2/2024 and stated Medical Doctor (MD) 1 was already serving as the medical director prior to his assumption of the ADM role. The ADM stated he was not made aware by MD 1 of any systemic facility issues when he assumed the role. The ADM further stated he was unaware of any concerns related to psychotropic medications (medications that affect the mind, emotions, and behavior) and informed consents. The…

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

Based on interview and record review, Medical Doctor (MD) 1, who also served as the facility's Medical Director, failed to follow the facility's policies and procedure outlining the responsibilities of the Medical Director. This deficient practice had the potential to affect all 90 facility residents due to a lack of facility staff oversight, and the potential for unidentified resident care concerns. Cross Reference: F-tag F658, F552, F758, and F835 Findings: During an interview on 3/29/2024 at 1:56 p.m., with the facility Administrator (ADM), the ADM stated he had been the ADM since 2/2024, and stated MD 1 was already serving as the Medical Director when he assumed the role. The ADM stated MD 1 had not reported any issues to him related to the findings identified by the survey team. The ADM stated MD 1, in the role of Medical Director, was responsible for overseeing the other physicians and advanced practice providers (APP, a health care provider who is not a physician but who performs medical activities typically performed by a physician, most commonly nurse practitioners or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Obtain informed consent, per its policy and procedure, prior to the initiation and administration of psychotropics (medications that affect the mind, emotions, and behavior) for four of 17 sampled residents (Residents 75, 40, 82, and 20). 2. Ensure that facility staff were aware of the facility policy and procedure for obtaining informed consent prior to the initiation and administration of psychotherapeutic medications (psychotropics). These deficient practices placed Residents 75, 40, 82, and 20 at risk for avoidable harm from unwanted adverse effects (a harmful and undesired effect resulting from a medication or intervention) related to psychotropic medication use. The above failures also removed the residents' rights to make decisions about the care and treatments they received in the facility. Cross Reference: F-tag F658 Findings 1. During a review of Resident 75's admission Record, the record indicated Resident 75 was admitted to the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to ensure the care provided met professional standards for nine of 17 sampled residents (Residents 75, 82, 200, 94, 40, 20, 3, 13, and 60) when the following occurred: 1. Informed consents were not obtained per the facility's policy and procedure prior to the initiation of psychotropic medications for Residents 75, 40, 82, and 20. 2. Psychiatric care provided to Residents 75, 82, 200, 94, 40, 20, 3, 13, and 60 under Medical Doctor (MD) 2 (facility psychiatrist) and Nurse Practitioner (NP) 1 was not regularly overseen or monitored by the facility Medical Director (MD 1) for potential concerns or compliance with facility policies and procedures. 3. Performance of MD 1, serving as the facility's Medical Director, was not overseen by the facility Administrator (ADM). These deficient practices removed Resident 75, 40, 82, and 20's rights to make decisions related to their care and placed the residents at risk for avoidable harm from unwanted adverse effects…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff initiated the administration of psychotherapeutic (also called psychotropics, medications that affect the mind, emotions, and behavior) for eight of 17 sampled residents (Residents 75, 82, 200, 94, 40, 3, 13, and 60) without behavioral justification to warrant the necessity of the medications. This deficient practice placed Residents 75, 82, 200, 94, 40, 3, 13, and 60 at risk for avoidable harm from unwanted adverse effects (a harmful and undesired effect resulting from a medication or intervention) related to psychotherapeutic medication use. Findings 1. During a review of Resident 75's admission Record, the record indicated Resident 75 was admitted to the facility on [DATE] with admitting diagnoses that included transient cerebral ischemic attack (a brief blockage of blood flow to the brain). The admission record further indicated a new diagnosis of bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 date food items for 89 out of 95 residents. This deficient practice had the potential to cause food borne illnesses (food poisoning, any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins) for 89 out of the 95 residents receiving food items from the facility. Findings: During an observation on 3/18/2024, at 8:22 a.m., in Refrigerator 1, pork sausage was dated 3/4 (March 4 th), with no year and no expiration date indicated. Freezer 2 had a box of beef and vegetable enchiladas dated 4/30 (April 30th), with no year indicated. During a concurrent observation and interview on 3/18/2024, at 8:45 a.m., of the facility's freezer, the freezer 5 had 15 single unit popsicles and ice cream that were undated, two of the wrapped popsicles and ice cream were stuck together and the plastic wrap was sticky. During an interview on 3/18/2024, at 9:09 a.m., with the Dietary Manager (DM), the DM stated he did not see or find any dates…

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

Based on interview and record review, the facility failed to ensure the call light was within reach for one of 20 sampled residents (Resident 94). This deficient practice had the potential to cause avoidable harm to Resident 94 from an inability to call staff for assistance and the potential for falls and associated injuries. Cross Reference F-tag F656. Findings: During a review of Resident 94's admission Record, the record indicated the facility admitted Resident 94 on 2/13/2024. Resident 94's admitting diagnoses included difficulty walking, generalized muscle weakness, unsteadiness on his feet, and history of falling. During a review of Resident 94's Minimum Data Set (MDS, a standardized assessment and care screening/planning tool), dated 2/17/2024, the MDS indicated Resident 94 required substantial to maximal assistance from staff when transferring between surfaces, and when transitioning from a sitting to standing position, a sitting to lying position, or a lying to sitting position. During a review of Resident 94's medical record titled, Fall Risk Assessment, dated 2/13/2024,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to implement or develop a resident-specific care plan for three of 20 sampled residents (Resident 40, Resident 94, and Resident 30) when the following occurred: 1. Resident 40's care plan did not indicate the level of assistance he required for eating and drinking. 2. Resident 94's care plans indicated his call light needed to be within reach, and Resident 94's call light was observed hanging behind his bed and not within reach. 3. Resident 30's care plan did not indicate a physician ordered medical appointment. These deficient practices placed Resident 40 at risk of not receiving his required level of assistance while eating and drinking, creating the potential for avoidable weight loss, dehydration, or complications such as aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident). These deficient practices also placed Resident 94 at risk of being unable to call for help, creating the avoidable…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff were aware of the level of assistance required by one of two sampled residents (Resident 40) for completion of activities of daily living (ADLs, activities related to personal care, including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). This deficient practice placed Resident 40 at risk of not receiving his required level of assistance while eating and drinking, creating the potential for Resident 40 to experience avoidable weight loss and dehydration, or complications such as aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident). Cross Reference F-tag F656 Findings: During a review of Resident 40's admission Record, the record indicated the facility admitted Resident 40 on 8/19/2019, and most recently re-admitted Resident 40 on 3/12/2024. Resident 40's admitting diagnoses included muscle wasting and atrophy (decrease in size or wasting away of a body part or tissue), protein-calorie…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain the nutritional status of one out of four residents (Resident 29) by not ensuring the registered dietitian (RD, health professional who has special training in diet and nutrition) recommendations were implemented for Resident 29. This deficient practice had the potential to cause further avoidable weight loss and malnutrition (lack of sufficient nutrients in the body) for Resident 29. Findings: During a review of Resident 29's admission Record, the record indicated Resident 29 was admitted to the facility on [DATE], and most recently re-admitted on [DATE]. Resident 29's admitting diagnoses included diabetes mellitus (elevated blood sugar levels), severe protein-calorie malnutrition, and adult failure to thrive (a syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol). During a review of Resident 29'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 staff accurately and thoroughly completed Resident 7's Intake and Output Weekly Assessments. This deficient practice placed Resident 7 at risk for avoidable fluid balance problems, such as dehydration or hypervolemia (a condition in which the liquid portion of the blood [plasma] is too high). Findings: During a review of Resident 7's admission Record, the record indicated the facility admitted Resident 7 on 4/12/2022, and most recently re-admitted Resident 7 on 2/26/2024. Resident 7's admitting diagnoses included neuromuscular dysfunction of bladder (lack of bladder control due to brain, spinal cord, or nerve problems), hydronephrosis (excess fluid in a kidney due to a backup of urine), generalized swelling, congestive heart failure (CHF, a chronic condition where the heart does not pump blood as well as it should), hypo-osmolality (where the levels of electrolytes, proteins, and nutrients in the blood are lower than normal) and hyponatremia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administer artificial tears drops (for dry eyes) on time for one out of three residents (Resident 79) according to their policies and procedures. This deficient practice had the potential to result in Resident 79's discomfort and worsening of dry eyes. Findings: During a review of Resident 79's admission Record, the record indicated the facility admitted Resident 79 on 11/1/2023 with admitting diagnoses that included diabetes mellitus (a group of diseases that result in too much sugar in the blood) and glaucoma (a group of eye conditions that can cause blindness from too much pressure on the nerve connecting the eye to the brain). During a review of Resident 79's History and Physical (H&P), dated 11/3/2023, the H&P indicated Resident 79 had the capacity to understand and make medical decisions. During a review of Resident 79's Minimum Data Set (MDS, a comprehensive assessment and care screening tool), dated 2/6/2024, the MDS indicated Resident 79 was cognitively intact (ability to think and reason). 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 observation, interview, and record review, the facility failed to ensure medications were not expired in the dialysis (treatment that helps your body remove extra fluid and waste products from the blood) emergency kit (E-kit, a small supply of medications to quickly treat symptoms in an emergency). This deficient practice had the potential to cause contamination and loss of efficacy of the medications in the dialysis E-kit. Findings: During a review of Resident 58's admission Record, dated 3/22/2024, the admission record indicated Resident 58 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses which included end stage renal disease (ESRD, the last stage of chronic kidney disease [gradual loss of kidney function]), type 2 diabetes mellitus (condition that results in too much sugar circulating in the blood), hypertension (high blood pressure), hyperlipidemia (an abnormally high concentration of fat particles in the blood), and dependence on renal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prevent cross-contamination when placing soiled linens on top of a shared resident surface. This deficient practice had the potential to spread infectious microorganisms to staff and residents. Findings: During a concurrent observation and interview on 3/18/2024, at 9:42 a.m., with Certified Nursing Assistant (CNA) 1, in the shared resident bathroom for room [ROOM NUMBER] and room [ROOM NUMBER], a soiled towel with brown and yellowish residue was observed on top of the toilet. CNA 1 entered the bathroom and picked up the soiled towel. CNA 1 stated she placed the dirty towel there temporarily while she went to get a bag to put it in. CNA 1 stated dirty linens should have gone directly into a plastic bag and not on community surfaces to prevent infection spreading to other residents. During an interview on 3/21/2024, at 8:52 a.m., with the Infection Preventionist Nurse (IPN), the IPN stated linen bags were easily accessible outside of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that influenza (flu - a very contagious viral infection that affects the nose, throat, and lungs) and pneumococcal (any infection caused by bacteria called Streptococcus pneumoniae) vaccinations (a method used to protect against harmful germs), were offered as required to one of five sampled residents (Resident 83). This deficient practice placed Resident 83 at a higher risk of acquiring the flu and pneumonia (an infection of the lungs caused by bacteria, viruses, or fungi), which could increase the resident's risk of developing serious complications. This deficient practice also had the potential to increase the risk of flu and pneumonia transmission to other residents in the facility. Findings: During a review of Resident 83's admission Record, dated March 21, 2024, the admission record indicated Resident 69 was admitted to the facility on [DATE] with the following diagnoses which included fracture (break) of the neck and left…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Treatment Nurse (TN) 3 had the specific competencies and skill sets necessary to safely perform a nephrostomy tube (small tube that helped drain urine from kidney) dressing change for one of one sampled resident (Resident 1). This failure resulted in Resident 1 ' s nephrostomy tube being cut, requiring transfer to a general acute care hospital (GACH) and increased the risk for infection and medical complications for the resident. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including hydronephrosis with renal and ureteral calculous (kidney swelling due to back up of urine), obstructive and reflux uropathy (inability for urine to drain through the urinary tract), and benign prostatic hyperplasia (enlarged prostate). During a review of Resident 1 ' s History and Physical (H&P) dated 12/27/2023, the…

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