Guardian Care And Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure the use of supplemental oxygen was provided in accordance with professional standards of practice for two out of three sampled residents who received oxygen therapy (Resident 2, and Resident 3) when, oxygen in use signage was not posted at Resident 2's, and Resident 3's doorway.This failure had the potential to result in negative impacts on the health and safety of Resident 2, Resident 3, other residents in the facility, staff, and visitors.Findings:a. Review of Resident 2's admission RECORD indicated Resident 2 was admitted to the facility with diagnoses which included chronic atrial fibrillation (a persistent, long term irregular heart rhythm with symptoms including shortness of breath).Review of Resident 2's current order summary report indicated an active physician order dated 12/17/25 for oxygen therapy at 2 L/min (liter per minute, a unit of measure) via nasal cannula (two prongs that fit into the nostrils to deliver supplemental oxygen), to be administered as needed for shortness of breath,…

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

Based on interview and record review, the facility failed to implement and maintain a comprehensive QAPI (QAPI- a data driven and proactive approach to improvement used to ensure services are meeting quality standards) program and plan when the facility did not adhere to its QAPI policy and did not provide documentation or evidence of ongoing QAPI activities.These failures had the potential to impede the facility's ability to identify and correct quality of care issues which could place the residents at risk for unmet physical, psychosocial, and overall health needs.Findings:During a concurrent interview and record review on 8/29/25, at 1:55 PM, the Administrator (ADM) reviewed the QAPI program and confirmed that they did not have an appropriate monitoring and documentation portion of the QAPI program. Review of the QAPI binder showed no evidence of detailed monitoring, follow-up, or documentation of QAPI activities. The ADM acknowledged that documentation of the QAPI program should have been completed and confirmed the program lacked sufficient details and follow-through. The ADM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop and implement a comprehensive care plan when:A care plan was not developed for Resident 62's face and neck swelling; and,Resident 102's care plan intervention for two person assist with activities of daily living (ADL, skills required for self-care and independent living, including bathing, dressing, toileting, transferring, continence, and feeding) care was not followed.These failures resulted in Resident 62 not having interventions and goals for his face and neck swelling and the potential for injury to Resident 102, negatively impacting Resident 62 and Resident 102's health, safety, and well-being.Findings: 1. Review of Resident 62's admission RECORD, indicated Resident 62 was admitted to the facility with diagnoses which included chronic pain (persistent pain that lasts for more than three months) and abdominal pain. During an interview on 8/27/25, at 11:25 AM, with Resident 62, Resident 62 stated he was not happy with the care he received for his face and neck swelling. Resident 62 explained…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 professional standards of quality care were met for 2 of 32 sampled residents (Resident 83 and Resident 10), with the potential to affect the full census of 92 when: 1. Resident 83's bilateral foot pain was not assessed for over 24 hours after the licensed nurse (LN) was notified,2. Wounds on Resident 10's right forearm were not assessed for over 48 hours; and,3. Staff providing resident care could not communicate in English.These failures resulted in a delayed assessment, treatment, and pain control for Resident 83 and delayed assessment and treatment for Resident 10. In addition, these failures had the potential to negatively affect Resident 83 and Resident 10's health and well-being and had the potential for all residents in the care of non-English speaking staff to have unmet care needs.Findings: 1. A review of Resident 83's admission RECORD, indicated Resident 83 was admitted to the facility with diagnoses which included type…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 allegations of abuse were thoroughly investigated for one resident (Resident 72) in a census of 92. This failure had the potential for Resident 72 to experience further abuse, negatively affecting their physical and psychosocial well-being. Findings:A review of Resident 72's admission RECORD, indicated Resident 72 was admitted to the facility with diagnoses which included palliative care (a specialized form of medical care that focuses on improving the quality of life for people with serious or life-limiting illnesses).During a concurrent observation and interview on 8/26/25, at 2:44 PM, with Resident 72, in Resident 72's room, Resident 72 was seated in her wheelchair. Resident 72 further stated a staff member used foul language when caring for her and slapped me around a little. Resident 72 explained it had occurred recently.A review of Resident 72's clinical document titled, Progress Notes, dated 6/27/25, indicated, .resident [Resident 72] reported .that she was slapped by CNA [Certified Nursing Assistant] 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.

Based on interview, and record review, the facility failed to ensure medications were administered to meet professional standards of practice for 1 out of 32 sampled residents (Resident 7), when Resident 7's medication Midodrine (a blood pressure medication used to treat low blood pressure) was administered outside of physician ordered parameters (standard guidelines from the physician, used to categorize a patient's blood pressure reading and determine the proper course of treatment). This failure had the potential for Resident 7 to experience hypertension (high blood pressure, can damage the arteries and increase the risk of heart disease, and other health problems). Findings: A review of Resident 7's admission RECORD, indicated Resident 7 was admitted to the facility with diagnoses which included hypotension (low blood pressure). A review of Resident 7's clinical document containing physician orders, indicated, .Order Date .12/18/24 .Midodrine .by mouth .1 tablet .two times a day .hold if SBP [systolic blood pressure - the upper number on a blood pressure reading] > [greater…

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

Based on observation, interview, and record review, the facility failed to ensure the provision of care and services to ensure 1 of 32 sampled residents ( Resident 80) maintained his highest level of function when staff did not provide range of motion (ROM, the full movement of a joint) exercises to his extremities or hand hygiene to his contracted (shortening or hardening of muscles, tendons, or other tissue leading to a deformity and rigidity of joints) right hand.This failure had the potential for Resident 80 to experience a physical decline, worsening of right arm and hand contractures, and infection to his right hand.Findings:A review of Resident 80's admission RECORD, indicated he was admitted to the facility in early 2024.A review of Resident 80's clinical document titled, Care Plan Report, indicated, .Focus.Resident has a self care deficit. Requires 1-2 person extensive total assistance in ADL's [Activities of Daily Living, personal care tasks which include bathing, dressing, eating, and transferring in and out of bed].RUE [right upper extremity] contracture [A permanent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician-ordered weekly weights were completed for 1 out of 3 sampled residents (Resident 43) when Resident 43's weekly weight order was not carried out by staff.This failure resulted in Resident 43 experiencing an unmonitored 10-pound weight loss over one month (from 132 pounds on July 3, 2025, to 122 pounds on August 3, 2025), placing the resident at risk for further nutritional compromise and decline.Findings:Review of Resident 43's admission RECORD, indicated Resident 43 was admitted to the facility with multiple diagnoses including type 2 diabetes mellitus with other specified complication (high levels of sugar in the blood) and paraplegia, unspecified (inability to voluntarily move the lower parts of the body).Review of Resident 43's clinical record titled, .Order Recap Report, (summary listing of a resident's order by the physician), indicated that Resident 43's weight should be monitored weekly as ordered by the physician on 7/1/25 with a start date of 7/7/25. During a concurrent interview and record…

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

Based on interview, and record review, the facility failed to provide the necessary behavioral health care and services for 1 of 32 sampled residents (Resident 81) when a referral was not made to a psychiatrist (psych, a medical doctor who can diagnose and treat mental health conditions) or psychologist (psych, scientific discipline that studies mental states and processes and behavior in humans) for Resident 81 who had a behavior of food hoarding (keeping or storing food for long periods of time before consuming or discarding the food). This failure had the risk for Resident 81's behavioral health care needs being unmet. It also had the potential for Resident 81 to eat spoiled food and cause a food borne illness.Findings:A review of Resident 81's admission RECORD, indicated Resident 81 was admitted to the facility with a diagnosis of, but not limited to, inappropriate diet and eating habits. During a concurrent observation and interview on 8/26/25, at 1:49 PM, with Resident 81, Resident 81's bed was observed with multiple food trays. Resident 81 stated he was saving the food trays…

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

Based on observation, interview, and record review, the facility failed to ensure safe medication handling practices with a resident census of 92 based on the facility's policy and standards of practice when:1. Medication delivery documents from the provider pharmacy were not consistently signed and documented upon receipt from delivery courier for accuracy and accountability of prescription medication receipt; and, 2. Non-controlled prescription (non-opioid drugs that only prescribed by a doctor) medication destruction and disposition were not consistently documented with co-signature witness by two licensed staff. These failed practices could contribute to unsafe drug handling and risk of drug diversion (drug loss due to unauthorized use). Findings:1. During a concurrent observation and interview with Licensed Nurse (LN) 15, in Station 1 medication room, on 8/26/25, at 9:32 AM, the record for medication receipts and delivery was reviewed. The white binder had sheets of delivery record from the provider pharmacy. The paper sheets titled Packing Slips, listed the name and quantity…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assess and review the long-term use of two medications, part of a class of drugs called Protein Pump Inhibitors (or PPI, a class of drugs that reduce stomach acid production and works by inhibiting the enzyme known as the proton pump, which is responsible for generating acids for food digestion), on two out of five residents reviewed for unnecessary medications (Resident 7 and Resident 36) based on FDA (or Food and Drug Administrations, a federal agency that addresses safety of medication use) and the manufacturer warnings on long term use of PPI medications.These failures could pose risks of adverse drug effects on vulnerable elderly residents.Findings:1. During a review of Resident 7's electronic medical record, dated 8/27/25, the record indicated Resident 7 was admitted to the facility with multiple medical conditions including diabetes (blood sugar disease), mental health issues, epilepsy (a condition characterized by recurrent seizures when disruption of brain activity cause jerking movements and loss 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, interview, and record review, the facility failed to ensure safe medication storage practices in one out of two medication rooms (a locked room used to store medications and supplies) and one out of four medication storage carts (a mobile cart stored medications and supplies needed for administration) with a resident census of 92 when:1. Unlabeled discontinued prescription medication box called Kristalose (or lactulose, a laxative drug in power packet form also used to treat liver disease) was stored in the active storage areas of the medication room at Station 1.2. Expired (outdated) medication called Dorzolamide/Timolol eye drop (DOROZOL/TIMOLOL or Cosopt, two drugs in one bottle, used to treat glaucoma, an eye disease that damages the eye nerves which leads to vision loss) was stored in the active medication storage cart at station 1B.These failed practices could contribute to unsafe medication storage and use of outdated eye drops into a resident's eye.Findings:1. During a concurrent observation, interview, and inspection of the facility's medication room…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 have 1 of 32 sampled residents (Resident 48) ready in time for a neurologist (medical specialist in the treatment of disorders of the nervous system) appointment. This failure resulted in Resident 48 feeling upset and frustrated due to the missed appointment and had the potential to delay his treatment.Findings:Review of Resident 48's admission RECORD, indicated Resident 48 was admitted to the facility in late 2024 with diagnoses including hemiplegia and hemiparesis (weakness or paralysis one side of the body) following a nontraumatic intracerebral hemorrhage (bleeding within the brain tissue) affecting the left non-dominant side, and polyneuropathy (a condition where multiple peripheral nerves [nerves that extend outside the brain and spinal cord] in the body become damaged).During a concurrent observation and interview on 8/28/25, at 4:44 PM, in Resident 48's room, Resident 48 and his family member (FM) 1, were visibly upset. Resident…

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

Based on observation, interview, and record review, the facility failed to ensure safe infection prevention and control practices for 5 of 12 residents (Resident 45, Resident 67, Resident 39, Resident 102, and Resident 49) observed for medication administration when shared glucometers (a device used to measure how much glucose (sugar) is present in the bloodstream at a given moment in time) were not cleaned and sanitized in between resident use. These failures had the potential to spread infection and cause health problems for residents in the facility.Findings:1. During a medication administration observation with Licensed Nurse (LN) 3, on 8/26/25, at 11:15 AM, LN 3 used a glucometer (glucometer 1) to measure Resident 45's blood sugar. LN 3 placed supplies in a tray and went into the room with the supplies. With gloved hands, LN 3 poked the left middle finger with a lancet (small, sharp objects that are used to prick the skin to get drops of blood); then soaked the test strip (a strip that is attached to glucometer to measure the sugar level) with Resident 45's blood to measure the…

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

Based on observation, interview, and record review, the facility failed to store, prepared, distribute and serve food in accordance with professional standards for food service safety when .1. Dishes were stacked on top of each other while wet; and,2. Pots, pans, and food holding containers were dirty and damaged from use; and,3. A container of scoops, serving ladles, and utensils were left open; and,4. A steamer container had a yellowish residue located inside of it; and,5. A stove top had black sticky grime and food residue on top of it.These failures had the potential of leading to food borne illness in the 94 residents eating facility prepared meals.Findings:1. During a concurrent observation and interview on 6/24/25 at 9:09 AM with the Dietary Services Supervisor (DSS), in the kitchen, a stack of pots and food holding containers were stacked on top of each other while wet. The DSS confirmed that the dishes were still wet. During an interview on 6/24/25 at 12:44 PM with Dietary Aide (DA) 1, DA 1 stated she washed the dishes that morning. DA 1 confirmed that the pots and other…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 garbage and refuse was properly contained when 1 of 2 outside dumpster lids were observed to be propped open with a stick for a census of 91.This failure had the potential to expose the residents' environment to pests, odors, or diseases.Findings:During a concurrent observation and interview on 6/24/25 at 10:10 AM with the Dietary Services Supervisor (DSS) in the outside dumpster area of the facility, a dumpster was observed to have the lid propped open. The DSS confirmed that the dumpster had the lid propped open with a stick. During an interview on 6/24/25 at 1:19 PM with [NAME] 2, [NAME] 2 stated that the dumpster lids should always be closed. [NAME] 2 also stated that if the dumpster lids are not closed, cats, rats, and other rodents could enter the dumpster. [NAME] 2 further stated maggots could grow in the dumpster if not properly closed. During an interview on 6/24/25 at 1:35 PM with the DSS, the DSS stated there was an infection control risk if the dumpster was left open. The DSS also stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 use safe and appropriate transfer methods according to resident care needs for one of three sampled residents (Resident 3) when Resident 3 was transferred from a shower chair (a waterproof chair on wheels used to transport residents to and from the shower room) into his bed without the use of a mechanical lift (a device used to safely transfer Resident 3 from one surface to another). This failure could have been the cause of Resident 3 ' s right proximal tibia (upper part of the shin bone where it widened to help form the knee joint) fracture and right lower leg skin breakdown, which could have negatively affected his health and well-being. Findings: During a review of Resident 3 ' s admission RECORD, the document indicated Resident 3 ' s diagnoses included muscle weakness and disorders of bone density and bone structure (conditions that led to weakened bones and increased fracture risk). A review of Resident 3 ' s Minimum Data Set, (MDS- a federally…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 report a change in condition and/or medical treatment to the physician and the Responsible Party (RP, the person responsible to direct the care of a loved one admitted into a nursing facility) for one of four residents (Resident 4) when: 1. Resident 4 refused her medications on multiple days; 2. Resident 4 refused fingerstick blood sugar monitoring (FSBS, poking a finger to apply a drop of blood to a test strip. The test strip is inserted into a small electronic device which measures blood sugar levels) tests on multiple days; and 3. Resident 4 refused her physical therapy treatments on multiple days. These failures resulted in Resident 4 ' s physician and RP being uninformed of a change in condition, and did not allow for the RP to participate in medical decisions and/or treatment options. These failures also had the potential for a decline in function for Resident 4. Findings: 1. A review of Resident 4 ' s admission RECORD indicated that Resident 4 was admitted to the facility with diagnoses which included…

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

Based on interview and record review, the facility failed to complete the required steps prior to discharging one of one sampled resident (Resident 1) from the facility when the reason for discharge was not documented in Resident 1 ' s medical record. This failure resulted in Resident 1's facility initiated discharge not being properly documented in Resident 1's medical record and had the potential to not reflect the actual experience of Resident 1 while in the facility. Findings: During an interview with the Administrator (ADM) on 3/4/25 at 12:22 PM, the ADM stated that Resident 1 had been at the facility since spring of 2024 and left the faciity on 2/20/25 for a scheduled medical appointment. The ADM further stated Resident 1 was admitted directly from the appointment to the hospital due to a needed surgery. During a concurrent interview and record review on 3/4/25 at 12:46 PM with the ADM and the Director of Nursing (DON), the ADM stated that the hospital where Resident 1 had his surgery sent a request packet for re-admission to the facility on 3/2/25. On 3/3/25 the NOTICE OF…

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

Based on interview and record review, the facility failed to complete the required steps prior to discharging one of one sampled resident (Resident 1) from the facility when the discharge notice issued to Resident 1 ' s Responsible Party (RP) and sent to the long-term care ombudsman (resident advocate) did not include the correct information on how to appeal the discharge. This failure resulted in Resident 1 ' s RP being uninformed of how to appeal the decision of a facility-initiated discharge and had the potential to cause Resident 1 psychosocial distress. Findings: 1. During an interview with the Administrator (ADM) on 3/4/25 at 12:22 PM, the ADM stated that Resident 1 had been at the facility since spring of 2024 and left the faciity on 2/20/25 to go to a scheduled medical appointment. The ADM further stated Resident 1 was admitted directly from the appointment to the hospital due to a needed surgery. During a concurrent interview and record review on 3/4/25 at 12:46 PM with the ADM and the Director of Nursing (DON), the ADM stated that the hospital where Resident 1 had his…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 right to return to the facility was protected for one of one sampled resident (Resident 1) when Resident 1 was sent to the hospital on [DATE] and was not allowed to return to the facility on [DATE], when the hospital was ready to discharge Resident 1 back to the facility. This placed Resident 1 at risk for emotional distress, depression, and anxiety. Findings: During an interview with the Administrator (ADM) on [DATE] at 12:22 PM, the ADM stated that Resident 1 had been living at the facility since Spring of 2024 and left the faciity on [DATE] to go to a scheduled appointment. The ADM further stated Resident 1 was admitted directly from the appointment to a hospital due to a needed surgery. The ADM explained on [DATE] a seven-day bed hold (a residents right to have their own bed held for seven days while they are in the hospital) was initiated. During a concurrent interview and record review on [DATE] at 12:46 PM with the ADM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Licensed Nurses (LNs) had competencies and skill sets necessary to provide treatment for one of four sampled residents (Resident 4) when milking [massage to help with swelling] of Resident 4's right leg was not done consistently by licensed staff. This deficient practice placed Resident 4 at a potential risk for potential worsening of edema on Resident 4's right leg. Findings: During a review of Resident 4's admission Record, the record indicated Resident 4 was admitted to the facility in May 2024 with diagnoses which included, AORTOCORONARY BYPASS GRAFT [a surgical procedure that reroutes blood around an artery in the heart, CORONARY ANGIOPLASTY IMPLANT AND GRAFT [a treatment used to widen and open up narrowed or blocked arteries supplying heart muscles]. Resident 4 was discharged from the facility in early June 2024. A review of Resident 4's Minimum Data Set (MDS, an assessment and care screening tool) dated 5/13/24, indicated Resident 4 had the ability to understand and be understood by others 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.

Based on interview, and record review, the facility failed to ensure ongoing medication refusals were communicated to the medical doctor in a timely manner for 1 out of 25 sampled residents (Resident 16). This failure could contribute to adverse health consequences and an untreated medical condition when prescribed medication was not administered over a long period of time. Findings: During a review of Resident 16's medical record titled, Physician Progress Note, dated 5/27/24, the record indicated Resident 16 had multiple medical diagnoses including heart failure (heart does not pump well enough to meet the body's needs), atrial fibrillation (or A.Fib, a dangerous type of heart rhythm that could result in blood clot in the heart if not treated), hypothyroid (thyroid function with low hormone level), and depression. Resident 16 was taking 15 routine medications for treatment of her medical conditions. During a review of Resident 16's medical record titled, Medication Administration Record, (or MAR, a legal document that lists drugs given and monitoring done) dated for June and July…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 training, including a written policy and procedure (P&P) was provided for licensed staff regarding the use of continuous glucose monitoring (CGM, tracks your blood sugar levels in real time on a Reader, which captures the data from a sensor inserted under the skin) for nine of nine residents who used CGMs in the facility. This failure had the potential for staff not being competent in the implementation of CGM and increased the risk of residents with CGMs receiving improper blood glucose management and nursing care. Findings: During a concurrent observation and interview on 7/18/24, at 10:19 a.m., with Licensed Nurse (LN) 13, in Resident 14's room, LN 13 identified Resident 14's CGM Reader and stated it was for testing blood sugar. LN 13 indicated she was not sure how often the sensor was to be changed, and stated she was not sure how to change it. LN 13 stated she had not had any training on the CGM from the facility and was not provided any reading material. LN 13 further stated it would be helpful…

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

Based on observation, interview, and record review, the facility failed to ensure safe medication labeling and storage practices for a census of 97 when: 1. The medication refrigerator contained undated medication, the sealed Emergency Kit (Ekit- a box containing medications for urgent use) contained drugs covered with white material, and the medication cart in Station 2 contained undated products; 2. Resident 27's chemotherapy medication called capecitabine (or Xeloda, a cancer treatment drug) was not properly labeled, stored, and dispensed as an identifiable hazardous (dangerous) medication; 3. Resident 27's prescribed inhaler was not properly secured or labeled with Resident 27's name or other identifier on the medication; and, 4. Resident 5 and Resident 14's continuous glucose monitoring (CGM-tracks glucose (blood sugar) levels in real time) Readers (displays glucose data collected by a sensor inserted under the skin of the upper arm and displays a current blood sugar) were not labeled with their name or another identifier. These deficient practices could contribute to unsafe…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1 of 25 residents (Resident 27) was assessed for the ability to independently use her prescribed inhaler (a device used to administer inhaled medication). This failure had the potential to result in an unsafe self- administration of medication by Resident 27. Findings: Review of Resident 27's Order Summary Report, indicated Resident 27 was admitted to the facility with a diagnosis which included lung cancer. Review of Resident 27's MEDICATION ADMINISTRATION RECORD, (MAR) indicated, .Budesonide-Formoterol Fumarate Inhalation Aerosol .2 puff inhale orally two times a day related to [chronic lung disease] .order date 7/10/2024 . During an observation on 7/16/24, at 11:47 a.m., Resident 27 was observed sleeping in her bed and an inhaler was observed on her bedside table. During a concurrent observation and interview on 7/16/24, at 12 p.m., in Resident 27's room, Licensed Nurse (LN) 12 confirmed Resident 27's budesonide inhaler was on her bedside table. LN 12 confirmed the inhaler did not have Resident 27's…

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

Based on interview, and record review, the facility failed to ensure the Physician Orders for Life-Sustaining Treatment [POLST- a legal document communicating the resident's medical wishes for end-of-life care] was completed accurately for 1 of 25 sampled residents (Resident 27) when Resident 27's POLST was not signed by the physician. This failed practice could result in Resident 27 not having her choices being honored. Findings: Review of Resident 27's Order Summary Report, indicated Resident 27 was admitted to the facility with diagnoses which included cancer. Review of Resident 27's Physician Orders for Life-Sustaining Treatment, dated 7/4/24, indicated, . A copy of the POLST form is a legally valid physician order . The POLST was marked in section C, .Trial period of artificial nutrition, including feeding tubes . There was no signature by the physician or their representative on the POLST. There was a printed name, signature, and date on the POLST by Resident 27. During concurrent interview and record review on 7/17/24, at 12:05 p.m., the Minimum Data Set Coordinator (MDSC) (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 ensure 1 of 25 sampled resident's (Resident 20) Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN-a document that provides information of the potential liability for payment of services not covered by Medicare A, a federal insurance program for specialized services requiring skilled nursing or rehabilitation services) provided the estimated cost of services Resident 20 could be held responsible for. This failure increased the risk of Resident 20 and her representative not having adequate information to make financial decisions. Findings: A review of Resident 20's admission RECORD, indicated she was re-admitted to the facility in 2023. A review of Resident 20's Notice of Medicare Non-Coverage (NOMNC- a document that informs a beneficiary when their Medicare services will be ending and provides information to appeal the decision) form indicated, The Effective Date Coverage of Your Current Nursing Services Will End 1/02/24 . A review of Resident 20's SNFABN dated 12/29/2023, indicated, .Medicare…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 privacy was protected for one of ten residents observed during medication pass (Resident 37), when a licensed nurse (LN) used a personal phone to take a picture of Resident 37's medication labels which displayed the drug and Resident 37's name. This failure and unauthorized photography of resident's medical information with a personal phone violated medical privacy. Findings: During a concurrent interview and observation of medication administration, on 7/16/24, at 9:24 AM, with LN 12, at Unit 1's hallway, LN 12 removed three medications bubble packs (a packet of medication with individual pills labeled with a drug's direction and resident's name) from the medication cart for Resident 37. LN 12 then put the pills into a small cup and took a picture of the bubble packs with a smart phone for the three medications. LN 12 stated she was taking a picture so she could review them later, to make sure she did not miss any medication. LN 12 stated she would delete the pictures afterward, as it was her personal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the rights of 1 of 25 sampled residents (Resident 45), when Resident 45 informed staff he was missing 25 dollars and the loss was not investigated. This failure had the potential to cause Resident 45 to feel vulnerable and to suffer psychosocial distress. Findings: A review of Resident 45's admission RECORD, indicated, he was admitted to the facility in 2018. During an interview on 7/17/24, at 11:06 AM, Resident 45 stated he was missing 25 dollars. Resident 45 further stated the facility had not investigated his loss. A review of Resident 45's Progress Note, dated 7/15/24, at 6:38 AM, indicated, .At 5am during rounds resident reported someone stole my small bag of quarters approximately $25. Search patient room everywhere but did not find the money. This will be endorsed to next shift nurse to follow up with SS [social services]. When their office will be open . During an interview on 7/18/24, at 8:42 AM, the Social Services Director (SSD) stated when staff were informed of a missing resident item, they slipped 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 protect 1 of 25 sampled residents (Resident 62) from misappropriation (the unauthorized use of funds or other property for purposes other than that for which intended) of property and personal belongings, when Certified Nursing Assistant (CNA) 6 took Resident 62's wallet containing money, Automated Teller Machine (ATM) card, health insurance card and ID (Identity Document) without Resident 62's consent. This failure caused Resident 62 emotional distress and had the potential for continued loss and/or theft of other residents' property/money. Findings: A review of Resident 62's admission Record, indicated Resident 62 was admitted to the facility in May 2024 with multiple diagnoses which included chronic kidney disease. A review of Resident 62's Minimum Data Set (MDS, an assessment and care screening tool) dated 5/26/24, indicated Resident 62 had the ability to understand and be understood by others with a Brief Interview for Mental Status (BIMS) score of 15 ( a score of 13 to 15 suggests memory is intact). 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.

Based on interview, and record review, the facility failed to report an allegation of stolen property to the facility Administrator and the Department within twenty-four hours for 1 of 25 sampled residents (Resident 22) when, Resident 22 reported to staff her suspicion that staff stole 200 dollars during the first week of July 2024, and the facility reported the incident to the Department on 7/19/24. This failure resulted in Resident 22 feeling upset by the loss, caused a delay in the facility and the Department's investigation of the alleged incident, and placed other residents at risk for abuse by the accused employee. Findings: During an interview on 7/18/24, at 12:20 p.m., Resident 22 stated that she took 200 dollars out of the bank at the end of June and kept the money in her wallet. Resident 22 further stated a certified nursing assistant (CNA) came in about a week later and asked if she had change for twenty dollars. Resident 22 stated when she pulled her purse out, she noticed her 200 dollars was gone, and she told Licensed Nurse (LN) 10. Resident 22 further stated this…

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

Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plan (an individualized plan for the nursing care) was resident centered, when 1 of 25 sampled resident's (Resident 87) care plan for refusal to wear a smoking apron (protection to prevent burns) while smoking was not revised and updated in a timely manner. This deficient practice had the potential for Resident 87 to not receive education about the risks associated with his expressed choices, and had the potential Resident 87 would be injured while smoking. Findings: A review of Resident 87's admission Record, indicated Resident 87 was admitted to the facility with multiple diagnoses which included respiratory failure (a serious condition that makes it difficult to breathe on your own) and quadriplegia (a form of paralysis that affects all four limbs). A review of Resident 87's Minimum Data Set (MDS, an assessment and care screening tool) dated 6/27/24, indicated Resident 87 had the ability to understand and be understood by others and a Brief Interview for Mental Status (BIMS)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1 of 25 sampled residents (Resident 89) received activities that met their interests and needs, when Resident 89 did not attend group activities and in room activities were offered infrequently. This failure had the potential to adversely affect the psychosocial needs and well-being of Resident 89. Findings: A review of Resident 89's admission RECORD, indicated he was admitted to the facility in 2024 with diagnoses which included, nontraumatic intracerebral hemorrhage (bleeding in the brain/stroke) and adult failure to thrive (a syndrome of weight loss, decreased appetite and poor nutrition, inactivity, dehydration, and impaired immunity). During an interview on 7/17/24, at 10:48 AM, in Resident 89's room, Certified Nurse Assistant (CNA) 1 stated Resident 89 did not attend activities because he did not get out of bed. A review of Resident 89's care plan dated 6/6/24, indicated, Goal .Resident responds to sensory stimulation activities daily .The resident needs 1:1 bedside/in room visits and 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.

Based on interview, observation, and record review, the facility failed to ensure one of seven residents (Resident 38) would remain free of urinary catheter (medical device that helps drain urine from your bladder) complications, when Resident 38's urinary catheter drainage bag was on the floor in his room. This failure had the potential to cause infection and urinary complications for Resident 38. Findings: Review of Resident 38's Order Summary Report, indicated Resident 38 was admitted with a diagnosis which included, .Foley Catheter [medical device that drains urine from bladder] .Dx: [Diagnosis] URINARY RETENTION [bladder does not empty completely or at all] . During a concurrent observation and interview on 7/16/24, at 1 p.m., in Resident 38's room, Certified Nurse Assistant (CNA) 5 confirmed Resident 38's urinary bag was hanging off Resident 38's bed and was resting on the floor. CNA 5 stated the urinary catheter bag should be off the floor. CNA 5 stated the risk to the resident was infection if it was touching the floor. CNA 5 further stated Resident 38's urinary catheter bag…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 appropriate care to one of ten residents (Resident 76) who received enternal nutrition (the use of a medical device called a feeding tube to provide liquid nourishment, liquids, and medications directly into the stomach) when Resident 76's enteral tube feeding liquid nourishment was not discontinued approximately five hours past its expiration This failure increased the potential for complications, including, but not limited to; nausea, vomiting, diarrhea, and stomach cramping for Resident 76. Findings: Review of Resident 76's Order Summary Report, indicated Resident 76 was admitted with a diagnosis which included a gastrostomy tube (G tube, a tube placed surgically through the skin and stomach wall and used to deliver nutrition). The report indicated, .Enteral Feed Order one time a day ADMINISTER ENTERAL FORMULA [name of feeding product] . During an observation on [DATE], at 9:15 a.m., Resident 76 was observed in his room…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1 of 26 residents receiving oxygen (Resident 27) received respiratory care according to professional standards when: 1. Resident 27's nasal cannula (NC- tubing that delivers oxygen into your nose) was not labeled with a date when it was changed; and, 2. Resident 27's oxygen humidifier bottle (a plastic bottle filled with water which moistens the oxygen) was not labeled when it was changed. These failures had placed Resident 27 at risk for infection. Findings: Review of Resident 27's Order Summary Report, indicated Resident 27 was admitted to the facility with a diagnosis which included lung cancer and chronic obstructive pulmonary disease (makes breathing difficult). The report indicated, .OXYGEN AT 2-5 [Liters per minute-the flow rate of oxygen] PER NASAL CANULA (NC) CONTINUOUSLY (order date 7/4/24) .CHANGE O2 [oxygen] CANNULA/MASK TUBING Q [every] 7 DAYS OR PRN [as needed] SOILAGE every night shift every Wed [Wednesday] (order date 7/4/24) .CHANGE MISTY OXYGEN HUMIDIFIER Q7 DAYS OR PRN (as needed)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe use and accountability of controlled narcotic medications (prescription opioid drugs of abuse) when: Resident 91's Norco (Hydrocodone-APAP; an opioid pain medication) was removed from the Controlled Drug Record (CDR, an accountability sheet that tracks narcotic removal with the nurse's initial, date, and time) without the corresponding administration documentation in Resident 91's MAR (Medication Administration Record- a legal document that lists the drugs given to a resident). This failure could contribute to unsafe drug handling, poor pain control, and risk of drug diversion (medication taken by someone other than for whom it is prescribed). Findings: During a review of Resident 91's Controlled Drug Record (CDR) for Norco, with date range of 6/15/24 to 7/15/24, the record listed Norco removal for PRN (as needed) use. A comparative review of Resident 91's CDR with the Medication Administration Record (MAR) for the same time period, indicated the following: 6/23/24 at 5:30 PM; No MAR documentation 6/29/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to ensure the safe use of psychotropic medications (mind altering drugs) for 2 of 25 sampled residents (Resident 45 and Resident 92) when: 1. Resident 45's documented diagnosis of bipolar disorder (a chronic mood disorder that causes intense shifts in mood, energy levels and behavior) in the medical record for use of the mind-altering psychotropic medication called risperidone (or Risperdal, a drug used to treat mental health or behavior issues) was not reflected in the medical doctor's progress notes and assessments. 2. Resident 92's use of PRN (as needed) anti-anxiety medication called alprazolam (or Xanax, a drug used to treat anxious feelings) was not evaluated and re-assessed by the facility and medical doctor despite frequent use. These failures could contribute to unsafe use of mind-altering medications that could put Resident 45 at risk for adverse consequences and Resident 92 at risk for dependence on a medication. Findings: 1.…

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

Based on observation, interview, and record review, the facility failed to ensure safe food storage for 92 residents who received food service from the kitchen when: 1. Food items were not dated and were not labeled with a use-by date in the refrigerator and freezer; and, 2. Thawing bacon trays were not labeled with a pulled-out date. These failures had the potential to expose residents to food borne illnesses (illnesses caused by the ingestion of contaminated food or beverages). Findings: During an initial tour of the kitchen on 7/16/24, at 8:36 a.m., accompanied by the Dietary Supervisor (DS) 1, the following findings were observed: 1.a. During a concurrent observation and interview on 7/16/24, at 8:53 a.m., with DS 1 in the walk-in refrigerator, DS 1 confirmed an opened 2 pound (unit of weight) bottle of minced garlic had no use-by date. DS 1 stated there should have been a use-by date on the opened bottle. b. During a concurrent observation and interview on 7/16/24, at 8:57 a.m., with DS 1 in the walk-in refrigerator, DS 1 confirmed an opened 1 gallon (a unit of volume) bottle…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infection prevention practice for a census of 97 when, 1. Staff placed a dirty cup on the same cart with the clean water pitchers; and, 2. Resident 65's urinal was not labeled with a resident identifier such as his room number or name. Findings: These failures increased the potential risk for the spread of infection to residents in the facility. Findings: During a concurrent observation and interview on 7/18/24, at 2:58 p.m., with Certified Nursing Assistant (CNA) 3 in the hallway of Station II, CNA 3 took a clean water pitcher into a resident's room. CNA 3 exited the room and placed a dirty cup on the cart with the clean water pitchers. CNA 3 stated the dirty cup should not be on the clean cart. During an interview on 7/19/24, at 8:35 a.m., with Licensed Nurse (LN) 8, LN 8 stated that if a dirty cup was disposable, it should be put in the garbage. Otherwise, she would take the dirty cup away or would put it on the resident's tray after the meal for removal. LN 8 further stated she could not put 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 ensure the sufficient supply of prescribed medications for one of five sampled residents (Resident 1). This failure resulted in Resident 1 not receiving 43 routine and PRN (as needed) medications during the month of January 2024 and could have resulted in uncontrolled pain and increased discomfort. Findings: During a review of Resident 1's clinical record titled, admission Record (a document that contains the resident's demographic information) indicated Resident 1's diagnoses included cancer of the tongue, major depressive disorder, pain, and dysphagia (difficulty swallowing). A review of Resident 1's clinical record titled, [HOSPITAL NAME EMERGENCY MEDICINE] History and Physical , dated 11/15/2023, indicated, . Patient lives in board and care in [CITY NAME] . Patient reports 10/10 left tongue and neck pain, missed evening medications . A review of Resident 1's clinical record titled, Order Summary Report , dated 12/28/2023, indicated Resident 1 was ordered Doxepin oral concentrate (used to treat anxiety and insomnia) 10…

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

Based on observation, interview, and record review, the facility failed to implement a fall care plan to prevent falls for one of three sampled residents (Resident 3), when a fall care plan intervention for a floor mat was not placed on the floor next to Resident 3's bed. This failure had the potential to result in further falls and potential injuries for Resident 3. Findings: A review of Resident 3's admission Record indicated Resident 3 was admitted to the facility in 2017 with diagnoses which included absence of left leg above the knee. A review of Resident 3 ' s clinical record titled, Fall IDT [IDT, interdisciplinary team- a team of professional staff or a care team consisting of different disciplines], dated 7/26/23, indicated, .LN [licensed nurse] noted [Resident 3] sitting on the floor .Resident stated she rolled out of bed .Resident is a fall risk .IDT RECOMMENDATIONS .Floormat [sic] @ [at] the open side of the bed . During a concurrent observation and interview on 8/8/23, at 3:08 p.m., with licensed nurse (LN) 3 in Resident 3 ' s room, LN 3 stated there was no floor mat…

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

Based on observation, interview, and record review, the facility failed to ensure safe practices in handling hazardous medication (Drugs that pose short-or long-term harm upon exposure to human via skin or inhalation) during storage and administration for a resident census of 85. This failure resulted in the unsafe handling of hazardous medications which could pose health risks to staff and residents. Findings: During an observation and inspection of the facility medication cart 1B (a mobile cart stored medications for daily administration) in Station number One, on 7/24/23, at 10:55 AM, accompanied by Licensed Nurse 2 (LN 2), the medication cart stored multiple bottles of a medication called valproic acid solution (medication in liquid form; commonly used for seizure or nerves) labeled with a bright yellow sticker indicating Caution: Hazardous Drug; Observe Special Handling, Administration and Disposal Requirements. Furthermore, one liquid bottle had traces of sticky colored spills on the outer surface and was not stored in a plastic zip-lock bag like another bottle of the same…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain complete and accurate medical records for 2 of 28 sampled residents (Resident 3 and Resident 60) when the hospice (specialized in end-of-life care for all residents with an advanced, life-limiting illness) agency's nurse progress notes were not contained in the clinical record. This failure had the potential to not provide sufficient information that reflected the condition, care, and services provided for Resident 3 and Resident 60. Findings: 1. A review of Resident 3's admission Record indicated Resident 3 was admitted to the facility in 2023 with diagnoses which included dementia (general term for loss of memory, language, problem- solving and other thinking abilities that are severe enough to interfere with daily life) and palliative care (specialized medical care for people living with a serious illness). A review of Resident 3's Order Summary Report, indicated, .Admit to [facility name] under .Hospice . A review of Resident 3's hospice…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infection control practices were followed when a disinfectant cleaning solution to clean the shower chairs after every use was not supplied to five out of five shower rooms in the facility. This failure had the potential for cross-contamination of equipment used in the shower room that could lead to the spread of germ-causing diseases. Findings: During a concurrent observation and interview on 7/25/23 at 3:12 p.m. with the Housekeeping Supervisor (HS) in shower room number six, the HS explained a disinfectant cleaning solution in a spray bottle was used to clean the shower chairs after every use. The HS confirmed there was no disinfectant cleaning solution inside the glass cabinet where the cleaning solution should have been kept. The HS stated she would have expected to have the disinfectant cleaning solution in the shower room and be accessible to staff for use. During a concurrent observation and interview on 7/25/23 at 3:12 p.m. with the Maintenance Supervisor (MS) in shower rooms number five,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility record review, the facility failed to ensure 1 of 28 sampled residents (Resident 68) had a physicians order, a care plan, and an assessment ordered and developed for safe self administration of medication. Resident 68 and Resident 68's Family Member (FM) 1's wishes were not honored for Resident 68 to continue self administration of medication. These failures had the potential to negatively impact Resident 68's sense of independence, when the medication was removed from his bedside. Findings: A review of Resident 68's admission Record, indicated, Resident 68 was admitted to the facility in late Summer of 2021, with diagnoses which included, dementia (problems with thinking, remembering, and reasoning) and weakness. A review of Resident 68's Brief Interview of Mental Status (BIMS), revealed Resident 68 had a BIMS of 7, indicating on a scale of 0-15, severe cognitive (issues with thinking and reasoning) impairment. During an observation on 7/24/23, at 2:54 PM, in Resident 68's room, Resident 68 appeared to be sleeping. Resident 68's overbed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 report to the Department an injury of unknown origin for 1 of 28 sampled residents (Resident 20) when Resident 20 had a nondisplaced fracture (broken bones that were not moved far enough during the break to be out of alignment) of the left tibia (the shinbone, the larger of the two bones in the lower leg) and fibula (calf bone, the outer and smaller of the two bones in the lower leg between the knee and ankle) on 6/29/23. This failure resulted in a delay in the Departments investigation into Resident 20's fractures, and had the potential for an occurrence of abuse to go undetected. Findings: A review of Resident 20's admission RECORD, indicated Resident 20 was admitted to the facility in mid 2012 with diagnoses which included dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), cerebral infarction (a result of disrupted blood flow of the brain due to problems…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 all of the identified components of a baseline care plan, within 48 hours of admission as required, to address resident-specific care needs for 1 of 28 sampled residents (Resident 74) when Resident 74's peripherally inserted central catheter (PICC, a type of long catheter that is inserted through a peripheral vein, often in the arm, passed through to larger veins near the heart and used to give fluids, nutrition, drugs, or other treatments) care plan was not created. This failure had the potential to result in unmet PICC line needs for Resident 74. Findings: A review of Resident 74's admission Record indicated Resident 74 was admitted to the facility in 2023 with diagnoses which included cellulitis (bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin), absence of the right toe, and diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). A review of Resident 74's clinical record titled, ADMISSION/RE-ADMISSION, dated 7/3/23,…

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

Based on interview, and record review, the facility failed to implement a comprehensive person-centered care plan (tool that outlines the plan of action that will be implemented during a resident's care) intervention for 1 of 28 sampled residents (Resident 85) when Resident 85's psychological evaluation (psych eval, an assessment by a professional used to determine a resident's mental state and guide recommendations for the best treatment) was not completed. This failure had the potential for Resident 85 to not receive adequate care and unmet psychosocial needs. Findings: A review of Resident 85's admission Record indicated Resident 85 was admitted to the facility in 2023 with diagnoses which included dementia (general term for loss of memory, language, problem- solving and other thinking abilities that are severe enough to interfere with daily life), schizophrenia (a serious mental disorder in which a person interprets reality abnormally), and anxiety. A review of Resident 85's physician's order, dated 2/24/23 indicated, Order Summary Report .PSYCHIATRIC EVAL & TX [treatment] PER…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1 of 28 sampled residents (Resident 93) was assisted with nail care as a part of Activities of Daily Living (ADLs, normal daily functions required to meet basic needs) when staff did not trim Resident 93's toenails. This failure had the potential for Resident 93 to sustain injury and/or for the resident to acquire an infection. Findings: A review of Resident 93's admission Record indicated Resident 93 was admitted to the facility in 2023 with diagnoses which included morbid obesity (a disorder involving excessive body fat that increases the risk of health problems), venous insufficiency (a condition in which veins have problems moving blood back to the heart) and an abnormal gait. A review of Resident 93's Minimum Data Set (MDS, an assessment tool) dated 6/20/23, indicated Resident 93 needed extensive assistance with ADLs including his personal hygiene. During a concurrent observation and interview on 7/24/23 at 2:28 p.m. with Resident 93 in his room, Resident 93's toenails were noted to be long and…

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

Based on observation, interview, and record review, the facility failed to implement a physician's order and person centered care plan for one of four residents (Resident 79) when, Resident 79 did not receive one-to-one feeding assistance during the breakfast meal. This failure could potentially place Resident 79 at risk for health problems related to aspiration (inhaling of food into the airways) including choking and pneumonia. Findings: During a review of Resident 79's admission RECORD, indicated Resident 79 was admitted to the facility with diagnoses including cerebral infarction (when blood supply to part of the brain is interrupted or reduced) and dysphagia (difficulty with swallowing). During a review of Resident 79's Minimum Data Set (MDS-an assessment tool), dated 6/13/23, indicated Resident 79 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, suggesting moderate cognitive deficit. Further review of Resident 79's MDS under Section G-Functional Status indicated a need for extensive assistance with one person physical assist with eating. In addition,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 respiratory care provided was consistent with professional standards of practice for 1 of 28 sampled residents (Resident 57) when: 1. Oxygen therapy was provided without a physician order for Resident 57; and, 2. An oxygen in use sign was not posted outside of Resident 57's room. These failures placed Resident 57 at risk for respiratory distress and inadequate treatment. Findings: 1. A review of Resident 57's admission Record indicated Resident 57 was admitted to the facility in 2023. During a review of Resident 57's oxygen care plan, dated 7/22/23, the care plan indicated, Interventions .Administer oxygen as ordered . During a concurrent interview and record review on 7/24/23 at 2:14 p.m. with licensed nurse (LN) 6, Resident 57's current physician orders were reviewed, LN 6 stated there was no oxygen order when Resident 57 was admitted to the facility. LN 6 further stated she received the oxygen order today and had just now entered the order for Resident 57. LN 6 explained Resident 57 was using oxygen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe monitoring and assessments of high-risk medication (medications that pose harm when not monitored or prevented) use in 3 out of 28 sampled residents (Resident 5, Resident17, and Resident 33) when: 1. The facility did not monitor safety parameters for a blood thinner medication called apixaban (or Eliquis an anticoagulant medication that could cause bleeding) for Resident 5; and 2. The facility did not monitor or provide parameters for safe monitoring of diabetic medications (medications used to treat blood sugar disease) for Resident 5, Resident 17, and Resident 33. These failures could contribute to unsafe medication use and further side effects for Resident 5, Resident17, and Resident 33. Findings: 1. During review of Resident 5's medical record titled Medication Administration Record (or MAR, a document listed medications and monitoring parameters), dated 7/2023, the document indicated a blood thinner medication called apixaban as follow: Apixaban Oral Tablet 5 MG . [MG is a unit of measurement]; Give 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility record review, the facility failed to ensure 1 resident in a sample of 28 (Resident 83) had a call light that was in working order consistently. This failure resulted in waiting long periods of time for care and had the potential to result in Resident 83's physical and emotional needs to go unmet. Findings: During a concurrent observation and interview on 7/24/23, at 10:44 AM, Resident 83 stated when he rings his call light staff did not show up. Resident 83 pressed his call light and no staff arrived. After 10 minutes had elapsed, it was noted that the call light indicator was not illuminated (to indicate the call light was on) outside of the room. During a concurrent observation and interview on 7/24/23, at 10:56 AM, with certified nursing assistant (CNA) 1, CNA 1 pressed Resident 83's call light twice, noting that it did not turn on. On the third try it did turn on. CNA 1 stated the resident should not have to press the call light multiple times before it turned on. During an interview on 7/27/23, at 12:38 PM, with the Director 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.