River View Post Acute

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when:1. A microwave was placed in the kitchen,2. A bun toaster was dirty with black residue,3. The kitchen walls were chipped and had cracking paint,4. Multiple pots, pan, and other cooking items were flaky and had black residue buildup,5. The stove top and drip pan were dirty and had grease buildup,6. The walk-in refrigerator and freezer had ice buildup; and,7. Vents and fans were dirty in the food prep area.These failures had the potential of leading to food borne illness (an illness that comes from eating contaminated food) for the 81 residents eating facility prepared meals.Findings:1. During a concurrent observation and interview on 12/16/25, at 8:53 AM, with the Certified Dietary Manager (CDM), in the kitchen, a microwave was observed placed next to the stove top range oven. The CDM confirmed that there was a microwave in the kitchen.During an interview on 12/18/25, at 9:53 AM, with the CDM, the…

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

Based on observation, interview, and record review, the facility failed to provide and maintain a safe, clean, comfortable, and homelike environment for a census of 85, when:1. Resident 19's overbed headlight remained continuously on because the pull string was broken; and,2. Resident 40, and Resident 7 had chipped walls and cracked paint behind their bed frames.These deficient practices demonstrated a lack of effective systems to identify, report, and correct environmental concerns resulting in Resident 19, Resident 40, and Resident 7 not feeling supported, treated with dignity and comfort, or provided a home-like living environment.Findings: 1. A review of Resident 19's admission RECORD, indicated Resident 19 was admitted to the facility with diagnoses of, but not limited to need for assistance with personal care, and generalized muscle weakness. During an interview on 12/16/25, at 10 AM, in Resident 19's room, with Resident 19, Resident 19 stated that for the past three days, the overbed headlight remained continuously on because the pull string was broken. Resident 19 stated the…

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

Based on interview, and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR- a service to ensure that individuals with mental illness are able to receive specialized services) Level II screening was completed for 1 of 24 sampled residents (Resident 6).This failure had the potential for Resident 6 not to receive adequate services to prevent mental health decline.Findings:A review of Resident 6's admission RECORD, indicated Resident 6 was admitted to the facility with a diagnosis of, but not limited to unspecified schizophrenia (a serious, chronic brain disorder that disrupts thinking, feeling, and behavior, making it hard to distinguish reality from imagination, often involving hallucinations [like hearing voices] and delusions [false beliefs]).During a review of Resident 6's clinical record titled, Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 2/25/25, the record indicated, .Result of Level I Screening : Level I - Positive for SMI (Serious Mental Illness).Diagnosis and symptoms of Schizophrenia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 or revise a comprehensive care plan for 1 of 24 sampled residents (Resident 34) when a care plan (guide that healthcare workers use to ensure a resident receives the best possible care tailored to their individual needs and goals) was not developed for pain.This failure placed Resident 34's physical and emotional well being at risk.Findings:A review of Resident 34's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses including, but not limited to muscle weakness (generalized), cerebral infarction (a type of stroke where a blood clot blocks a brain artery, cutting off oxygen and nutrients, causing brain cells to die), hemiplegia (one-sided weakness) and hemiparesis (one sided paralysis) following a cerebral infarction affecting right dominant side, aphasia (disorder that affects the ability to communicate).During a review of Resident 34's clinical record titled, Order Summary Report, dated 12/17/2025, indicated Resident 34 was prescribed Tramadol, a prescription pain medication.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 facility failed to ensure that residents received appropriate medical evaluation and treatment for a reported vision concern for 1 out of 24 sampled residents (Resident 65) when Resident 65 was not seen or examined by an ophthalmologist (a medical doctor who specializes in diagnosing and treating all eye diseases).This failure placed Resident 65 at risk for continued visual impairment, functional decline, and psychosocial distress.Findings:A review of Resident 65's admission RECORD, indicated Resident 65 was admitted to the facility with a diagnosis of, but not limited to diabetes mellitus (a condition where the body cannot control blood sugar levels), dry eye syndrome (when your eyes don't make enough good quality tears to stay lubricated leading to a scratchy, burning feeling, redness, and blurry vision), depression (a condition causing persistent sadness and loss of interest), anxiety disorder (a mental condition where you experience excessive, persistent worry, fear or nervousness that doesn't go away and interferes with daily life),…

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

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 76) was provided with appropriate care and services with enteral feeding (also referred to as G-Tube feeding, gastrostomy tube feeding, the delivery of food and nutrients through a feeding tube directly into the stomach or part of the intestines) when Resident 76's enteral feeding orders were not carried out as recommended by the Registered Dietitian (RD).This failure had the potential for Resident 76 not to receive adequate enteral nutrition and hydration.Findings:A review of Resident 76's admission RECORD, indicated Resident 76 was admitted to the facility with diagnoses including, but not limited to end stage renal disease (when kidneys are failing and cannot filter waste and extra fluid from the blood anymore), dependence on renal dialysis (medical treatment that acts like artificial kidneys filtering waste products and extra fluid from blood when kidneys can no longer do it), dysphagia (difficulty swallowing foods or liquids), and encounter for attention 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.

Based on observation, interview, and record review, the facility failed to provide a comprehensive and effective pain management for one of three sampled residents (Resident 97) when pain management interventions were not implemented when indicated.This failure had the potential for Resident 97 to experience ongoing discomfort and pain.Findings:A review of Resident 97's admission RECORD, indicated Resident 97 was admitted to the facility with a diagnosis including, but not limited to, covid 19, peripheral vascular disease (circulation problem where narrowed or blocked blood vessels (arteries or veins) outside your heart and brain reduce blood flow to your limbs and organs, most commonly the legs, causing pain), and chronic obstructive pulmonary disease (progressive lung disease that blocks airflow, making it hard to breathe).During an interview on 12/16/25, at 4 p.m., with Resident 97, Resident 97 stated she reported to a licensed nurse her pain today was a 6 out of 10 (a simple, 0- to-10 tool where patients rate their pain intensity, with 0 being no pain and 10 being the worst…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administration practices when the medication error rate was more than 5% (% or percentage-number or ratio that expressed as a fraction of 100) with a resident census of 85. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of 2 errors out of 26 opportunities which resulted in a facility wide medication error rate of 7.69% in 1 of 9 residents (Resident 6) observed for medication administration.These failures had the potential to result in unsafe medication use and medication errors affecting the health and well-being of Resident 6.Findings: 1. During a medication administration observation on 12/17/25, at 3:44 p.m., in the facility's Unit 3 hallway outside Resident 6's room, with Licensed Nurse (LN) 2, LN 2 administered a total of 3 medications to Resident 6. LN 2 emptied out a capsule and hand crushed 2 pills including a pain medication called Morphine Sulfate 15 mg ER (mg…

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

Based on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors (the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for one of nine sampled residents (Resident 6) observed for medication administration by failing to follow the manufacturer's specific recommendation when an extended release (ER-means the drug is specially formulated to release the active ingredient slowly and steadily into the body over a prolonged period, typically 8 to 24 hours) medication was crushed and administered to Resident 6.This failure resulted in Resident 6 receiving the medication in a manner that altered its intended use in the body and could potentially affect its therapeutic effectiveness (its intended, beneficial outcome) and increased risk for adverse reactions (an undesirable effect). Findings: A review of Resident 6's admission RECORD, indicated Resident 6 was…

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

Based on observation, interview, and record review, the facility failed to ensure 1 of 24 sampled residents (Resident 3) received recommended dental services; when Resident 3 was not scheduled for dental care to adjust loose upper partials when it was identified on 9/5/25.This finding resulted in Resident 3 to have missing partials and had the potential to result in problems chewing food, weight loss, and decreased self-esteem. Findings: A review of Resident 3's admission RECORD, indicated Resident 3's diagnoses included anxiety disorder (a mental health condition causing persistent and excessive worry) and major depressive disorder (a serious mood disorder causing persistent sadness, hopelessness, and loss of interest in activities). During a review of Resident 3's clinical record titled, MDS [Minimum Data Set, an assessment tool] 3.0 Nursing Home Quarterly, dated 11/26/25, indicated Resident 3's BIMS (Brief Interview for Mental Status) assessment for cognitive patterns scored 14 out of 15 suggesting an intact cognitive functioning. During a concurrent observation and interview on…

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

Based on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutrition for one of three sample residents (Resident 1) when Resident 1's 21-pound weight loss in a 10-day period was not recognized, addressed, or reported to the physician in a timely manner.This failure had the potential to lead to malnutrition, nutrient deficiencies, loss of muscle mass, and increased muscle weakness for Resident 1.Findings:A review of Resident 1's, admission RECORD, indicated that Resident 1 was admitted to the facility with diagnoses which include, but not limited to: Malignant neoplasm of colon (cancer of the colon-large intestine), dehydration (body loses too much water), surgical aftercare following surgery on the colon, post-hemorrhagic anemia (lack of iron in the blood due to a large volume of blood loss), vitamin D deficiency (lack of enough vitamin D), muscle weakness, and need for assistance with personal care. A record review of weights for Resident 1 indicated the following:9/23/25 = 136.4 pounds (pounds or lbs.- a unit of measure)9/29/25 =…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 psychosocial well-being for one of three sampled residents (Resident 1), when the Social Services Department failed to process a referral for a psychiatric evaluation for Resident 1 in a timely manner. This failure had the potential to worsen Resident 1's feelings of sadness, loneliness, and depression. Findings: A review of Resident 1's clinical record titled, admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses which included, but was not limited to: Hemiplegia (paralysis of one side of the body) and hemiparesis (a condition characterized by partial weakness on one side of the body) following cerebral infarction (a type of stroke caused by a blockage in an artery that supplies blood to the brain), malignant neoplasm of the colon (cancer that forms in the large intestine characterized by abnormal cells that grow and invade healthy tissue), surgical aftercare following surgery on the colon (partial colon removal), muscle weakness and need for assistance with personal care. A review…

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

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 2) was free from unnecessary medication when, Resident 2 was prescribed an as needed lorazepam (anti-anxiety) medication that did not have the required 14-day stop date or a note from the doctor explaining why the lorazepam did not need a stop date.This failure had the potential for Resident 2 to not be properly evaluated for the continued need of lorazepam and could result in continued use of an unnecessary medication and possible harmful side effects.Findings:Review of Resident 2's admission RECORD, indicated Resident 2 was admitted to the facility with diagnosis including but not limited to, anxiety disorder (excessive, persistent fear and worry that significantly disrupt daily life) and depression.During a concurrent interview and record review on 12/3/25 at 12:16 PM with Licensed Nurse (LN) 1, Resident 2's .Order Summary: Lorazepam Oral Tablet 0.5 milligram [mg-a unit measure] (Lorazepam) Give 1 tablet by mouth every 6 hours as needed for anxiety/restlessness ., signed by…

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

Based on interview and record review, the facility failed to ensure one of three sampled resident's (Resident 1) Preadmission Screening and Resident Review (PASRR: required screening done before admission to identify mental illness, intellectual disability, or related conditions and ensure proper placement and services) was completed accurately when, Resident 1's diagnosis of intellectual disability (a condition that involves limitations on intelligence, learning and everyday abilities necessary to live independently) and related condition of cerebral palsy (a person's brain is injured or did not develop normally before, during, or shortly after birth) were not marked on Resident 1's PASRR. This failure had the potential for Resident 1 not being evaluated and able to receive the care and services appropriate for the resident's needs.Findings:Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnosis including but not limited to, mild intellectual disabilities and cerebral palsy.During a review of Resident 1's PASRR Level I determination…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 needed behavioral health care and services (treatments that support a person's mental and emotional well-being) for one of three sampled residents (Resident 1), when Resident 1's psychotherapy (talking treatment that helps a person manage emotions, behaviors and stress) sessions scheduled two times per week were missed on two occasions, and the facility failed to ensure timely follow-up or alternative interventions.This failure put Resident 1 at risk for worsening mental health symptoms, social withdrawal, and decreased quality of life. Findings:Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnosis including but not limited to, adjustment disorder with depressed mood (a condition where a person feels very sad or stressed after a difficult event and has trouble coping) and anxiety disorder.During a concurrent interview and record review on 12/3/25 at 12:16 PM, with Licensed Nurse (LN) 1, Resident 1's Psychologist Progress Notes dated 11/6/25 and 11/20/25 were…

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

Based on interview and record review, the facility failed to ensure a reasonable accommodation of needs were honored for one of four sampled residents (Resident 2) when the facility did not have a mechanical lift sling (soft fabric padded sling that wraps around the body and attaches to a mechanical lift to assist in a transfer from one location to another) available to transfer Resident 2 out of bed.This failure caused Resident 2 to not attend the activities of her choice and had the potential to negatively impact Resident 2's quality of life and psychosocial well-being.A review of Resident 2's admission RECORD, indicated, she was admitted to the facility in mid 2022.A review of Resident 2's clinical document titled, Care Plan Report, initiated, 7/4/22, indicated, .The resident has an ADL [Activities of Daily Living, personal care tasks which include bathing, dressing, eating, and transferring in and out of bed] self-care deficit.TRANSFER: Mechanical Lift and (X2) [two] staff for transferring.During an interview on 9/2/25, at 9:46 AM, with Family Friend (FF) 1, FF 1 stated 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 an allegation of abuse was reported to the Department timely for one of three sampled residents (Resident 1) when Resident 1 alleged certified nursing assistant (CNA) 3 forcefully grabbed her legs on 8/2/25 but the incident was not reported to the Department until 8/7/25. This failure resulted in a delay in the abuse investigation process and decreased the facility's potential to protect Resident 1 and other residents in the facility from physical and psychosocial harm.A review of Resident 1's admission RECORD, indicated, she was admitted to the facility in late 2024 with diagnoses which included bipolar disorder (a mental health condition that causes changes in a person mood, energy, and ability to function). A review of Resident 1's minimum data set (MDS, a federally mandated resident assessment and screening tool which identifies care needs) dated 7/29/25, indicated, .Section C-Cognitive Patterns. Brief Interview for Mental Status (BIMS) [a tool used to screen for cognitive impairment]. indicated, a…

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

Based on interview and record review, the facility failed to ensure appropriate notification was provided for one of four sampled residents (Resident 1) when, Resident 1's responsible party (RP, health care decision maker) was not informed of Resident 1's allegation of abuse.This failure had the potential to affect the ability of the RP to be informed of and participate in Resident 1's plan of care.Findings:A review of Resident 1's admission RECORD, indicated, she was admitted to the facility with diagnoses which included schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves).A review of Resident 1's clinical document titled, Progress Notes, dated 7/21/25, at 1:43 PM, indicated, .DON [director of nurses] NOTE.Report received that resident claimed she was hit on the head early this morning. Resident stated that around 2 AM, a tall man hit him with a stick.stated I have lumps and bumps up here on my head.A review of Resident 1' s clinical document titled, Care Plan Report, initiated 7/21/25, indicated, .The resident has a potential psychosocial…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care plan interventions were implemented for two out of three sampled residents (Resident 1 and Resident 2) when, Resident 1 and Resident 2's care plan intervention of alert charting (documentation of assessments completed after an incident occurs to monitor for negative affects to health or well-being) was not completed for Resident 1 after an allegation of abuse was made and for Resident 2 after a verbal altercation occurred.This failure had the potential for Resident 1 and Resident 2 to have unassessed care needs that could negatively impact their health and well-being.Findings:A review of Resident 1's admission RECORD, indicated, she was admitted to the facility with diagnoses which included schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves).A review of Resident 1's clinical document titled, Progress Notes, dated 7/21/25, at 1:43 PM, indicated, .DON [director of nurses] NOTE.Report received that resident claimed she was hit on the head early this morning. 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 provide a safe and comfortable homelike environment for two of seven sampled residents (Resident 6 and Resident 7) when:1. Resident 6 and Resident 7 requested their room doors be kept closed due to the disruptive behavior of another resident (Resident 3) in the hallway outside of their rooms; and2. Resident 7 did not stay in the activities room for activities due to another Resident (Resident 3) yelling and cussing at everyone. These failures removed Resident 6 and Resident 7's right to a dignified homelike environment, with the potential to result in a negative psychosocial outcome.Findings:A review of Resident 3's admission Record indicated Resident 3 was admitted to the facility with diagnoses which included bipolar disorder (a serious mental illness that causes unusual shifts in mood, ranging from extreme highs (mania or manic episodes) to extreme lows (depression or depressive episode).A review of Resident 6's admission Record indicated Resident 6 was admitted to the facility with diagnoses which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a safe environment and adequate supervision for one of seven sampled residents (Resident 1) when Resident 1 fell from her wheelchair in the facility's smoking area, unsupervised, at 12:25 a.m. on 12/11/25. This failure resulted in a broken nasal bone (broken nose), a nosebleed, and subarachnoid hemorrhage (bleeding in the area between the brain and the thin tissues that cover and protect it) for Resident 1.Findings:A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility with diagnoses which included muscle weakness and osteoarthritis (a degenerative joint disease in which the tissues in the joint break down over time).During an interview on 6/12/25, at 10:15 a.m., Resident 1 stated, . my nose got hurt, there was blood on my nose, my nose broke. I was outside in the smoking area. I was sitting on my wheelchair.I think I fell. I was trying to have a cigarette.During an interview on 6/12/25, at 12:39 p.m., Certified Nurse Assistant (CNA) 1 stated Resident 1 used to be a smoker. CNA…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one of three residents (Resident 1) when Resident 1 was not provided routine showers. This failure caused Resident 1 to feel upset with not having his care needs met and had the potential to negatively impact his psychosocial well -being. Findings: A review of Resident 1 ' s admission RECORD, indicated, he was admitted to the facility in early 2024 with diagnoses which included muscle weakness. A review of Resident 1 ' s Brief Interview for Mental Status (BIMS) Evaluation, (a tool used to screen for cognitive impairment) indicated, a score of 15, 13-15 points: Intact cognitive response. A review of Resident 1 ' s Minimum Data Set (MDS, a federally mandated resident assessment and screening tool which identifies care needs) Section GG-Functional Abilities Self -Care Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self. The area was coded 03. Mobility Tub/shower transfer: The ability to get in and out of a tub/shower. The area was coded 02. The legend indicated,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and interview the facility failed to maintain a safe, clean, comfortable, sanitary and homelike environment for the two unsampled residents (Resident 4 and Resident 5) who shared a bathroom, when their toilet seat was contaminated with residue from a bowel movement (BM). This failure created an unsanitary environment and placed the residents at risk of injury and/or infection. Findings. During an observation on 4/25/25, at 10:24 AM, in the bathroom between Resident 4 and Resident 5 ' s rooms, a clump of brown bowel movement was observed smeared on the toilet seat. During an observation on 4/25/25, at 11:05 AM, housekeeper (HSK) 1 was observed mopping the floor of Resident 4 ' s room. During a concurrent observation and interview on 4/25/25, at 12:04 PM, Housekeeper (HSK) 1 confirmed the toilet in the bathroom shared by Resident 4 and Resident 5 contained smeared BM and there was urine in the toilet bowl. HSK 1 stated she cleaned Resident 4 ' s room earlier in her shift but had not cleaned the bathroom. HSK 1 stated she had planned on cleaning the bathroom later…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and interview the facility failed to provide a safe and hazard free environment for one of three sampled residents (Resident 2) when wheelchairs, a recliner, and an overbed table were stored in Resident 2 ' s bedroom. These failures had the potential to obstruct Resident 2 ' s access to his room, personal belongings, and created a potential risk of fall or injury to Resident 2. Findings: A review of Resident 2 ' s admission RECORD, indicated, he was admitted to the facility in early 2023 with diagnoses which included repeated falls. A review of Resident 2 ' s care plan, revised 12/16/24, indicated, [Resident 2] is at risk for falls r/t [related to] poor safety awareness. If Resident is a fall risk, initiate fall risk precautions. During a concurrent observation and interview on 4/25/25, at 11:34 AM, three standard wheelchairs, one high back wheelchair, an overbed table, and a reclining medical chair were observed inside Resident 2 ' s room on the side closest to the door. Resident 2 ' s bed and belongings were observed on the opposite side of the room. 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 maintain infection prevention and control practices for a census of 91 residents when: Urinals (a urine collection container), wash basins, kidney basins (used for tooth brushing), personal grooming items, and bedpans (a container to collect stool and/or urine for a person while in bed), were not labeled and stored in a sanitary manner. This failure increased the risk of infectious diseases to spread for residents in the facility. Findings: During an observation of a shared bathroom on 12/12/24 at 11:24 AM, there were two cups, one placed into the other, with a toothbrush and a small tube of toothpaste on the side of the faucet not labeled to identify which resident it belonged to. During an observation of a shared bathroom on 12/12/24 at 11:26 AM there was a kidney basin with a toothbrush wrapped in paper towel with no labeling placed on top of the paper towel dispenser. During an observation of a shared bathroom on 12/12/24 at 11:29 AM, there was a wash basin on the floor, not labeled to identify which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 was provided to meet the needs of one of five residents (Resident 1), receiving wound care when: 1. Resident 1 was to be evaluated by a podiatrist (specializes in foot disorders) and interventional radiology (studies and treats disease) within 1-2 weeks following his discharge from the hospital to the facility, and the facility did not arrange for this; 2. The facility did not consult with the physician regarding removal of Resident 1's right foot surgical sutures, which were in place from his admission on [DATE] to discharge on [DATE]; and, 3. The facility did not follow up on a recommendation Resident 1 required an evaluation for further surgery, and Resident 1 was discharged without this communicated. These failures may have contributed to Resident 1 experiencing an infection to his wound and subsequent amputation of his right leg below the knee. Findings: A review of Resident 1's discharge summary from Hospital A indicated, .date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain standards of infection prevention and control for 9 out of 89 residents residing in the facility when the Certified Nursing Assistant (CNA) assigned to their care wore a loosened gauze dressing on her right hand. This failure had the potential to spread infection to the nine residents in her care and those residents who were not assigned to her but were assisted by the CNA . Findings: During an observation on 10/1/24, at 1:30 PM, CNA 1 was observed in the hallway of Station 1 wearing a gauze dressing on her right hand. During an observation and interview, with the Director of Staff Development (DSD), on 10/1/24, at 1:40 PM, CNA 1 was observed on Station 1 wearing a gauze dressing partially covered with an occlusive dressing (air and watertight dressing) on her right hand. CNA 1 ' s dressing was observed to be dislodged near the thumb and the top of the hand. CNA 1 stated she had burned her hand at home over the weekend and covered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure respiratory care was provided in accordance with professional standards of practice for three of eleven sampled residents (Resident 53, Resident 90, and Resident 30) receiving oxygen therapy when: 1. Resident 53 received oxygen therapy without a physician's order, 2. Resident 53 and Resident 90 did not have a care plan developed for oxygen use; and, 3. Resident 30's nasal cannula (NC- flexible tubing that sits inside the nostrils and delivers oxygen) was labeled with a date which was expired and Resident 30's oxygen humidifier bottle (a plastic bottle filled with water which moistens the oxygen) was not labeled with a date of when it was changed. These failures had the potential to result in negative health impacts for the residents. Resident 53 and Resident 90 were at risk of ineffective oxygen therapy and respiratory distress. Resident 30 was placed at risk for infection. Findings: 1. A review of Resident 53's admission 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe medication storage practices in two out of four medication carts and two out of two medication storage rooms when: 1. Expired, unlabeled, and undated prescription medications were stored in the active storage areas of medication cart 2, 2. Undated prescription medications were stored in the active storage areas of medication cart 4, 3. Undated and discontinued prescription medications were stored in the active storage areas of the two medication storage rooms; and, 4. Containers of over the counter (OTC) liquid medications with dry, crusty debris around their rims and sides were stored in the active storage areas of medication carts 2 and 4. These failures had the potential for the use of discontinued medications, possible medication ineffectiveness, and the possibility for a medication to be administered to the wrong resident. Findings: 1. During a concurrent observation and inspection of medication cart 2, on [DATE], at 1:59…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 production in accordance with professional standards for food safety for the 91 residents who received facility prepared meals when: 1. Opened food packages and/or containers were not labeled with an open date, 2. Spoiled and expired food products were not removed, 3. Kitchen equipment and food contact surfaces were not cleaned; and, 4. A partially consumed bottle of drinking water was found on a shelf with food items in the dry food storage area. These failures had the potential to put residents eating facility prepared meals at risk for foodborne illnesses. Findings: On 8/13/24, at 8:30 a.m., during an initial tour of the kitchen accompanied by the Dietary Director (DD), the following findings were observed: 1a. During a concurrent observation and interview on 8/13/24, at 8:32 a.m., with the DD in the kitchen food prep area. The DD confirmed an open container of ground mustard had an illegible label with no open date. 1b. During a concurrent observation and interview on 8/13/24, at 8:33…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 1 of 29 sampled residents (Resident 1) was provided with alternate methods of communication and entertainment when Resident 1's physical limitations prevented the use of a cell phone or tablet device. This failure had the potential to negatively impact Resident 1's psychosocial well-being. Findings: A review of Resident 1's admission RECORD, indicated Resident 1 was readmitted to the facility in early 2024 with diagnoses which included, spastic diplegic cerebral palsy (a chronic neuromuscular condition that causes muscle stiffness and spasms in a person's legs and sometimes arms) and adjustment disorder with mixed anxiety and depressed mood (a mood disorder with symptoms of nervousness, worry, difficulty concentrating, and feeling overwhelmed). During an interview on 8/13/24, at 2:53 PM, family member (FM) 1 stated due to the limited movement of Resident 1's arms the family had provided Resident 1 with an [NAME] device to allow her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and interview, the facility failed to accommodate the needs of 1 of 29 sampled residents (Resident 1) when Resident 1's call light (device used to contact staff for assistance) was not within her reach. This failure placed Resident 1 at risk of falls and unmet care needs. Findings: A review of Resident 1's admission RECORD, indicated Resident 1 was readmitted to the facility in early 2024 with diagnoses which included, spastic diplegic cerebral palsy ( a chronic neuromuscular condition that causes muscle stiffness and spasms in a person's legs and sometimes arms) and adjustment disorder with mixed anxiety and depressed mood (a mood disorder with symptoms of nervousness, worry, difficulty concentrating, and feeling overwhelmed). During a concurrent observation and interview on 8/13/24, at 9:03 AM, with Resident 1 in Resident 1's room, Resident 1 was observed with contractures (shortening or hardening of muscles, tendons or other tissue leading to deformity and rigidity of joints) of both arms and hands which were held against her chest. Resident 1's call light…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident's right to be free from physical abuse for 1 of 29 sampled residents (Resident 33) when Resident 33 was assaulted by Resident 20 and witnessed by Certified Nurse Assistant (CNA) 7 on 8/3/24. This failure had the potential to cause physical injury, and could negatively affect Resident 33's psychosocial well-being. Findings: On 8/5/24, the Department received a report from the facility regarding an alleged resident to resident physical altercation when Resident 20 pinched Resident 33 on the right arm and hit Resident 33 on the right side of her face, on 8/3/24. The investigation was conducted during the facility's unannounced annual recertification survey. A review of Resident 33's admission RECORD, indicated Resident 33 was admitted to the facility in early 2023 with diagnoses which included Alzheimers Disease (AD, brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the…

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

Based on observation, interview, and record review, the facility failed to ensure 1 of 29 sampled residents (Resident 19) was free of restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) when; Resident 19 was observed trying to get up from his Geri chair (geriatric wheelchair, a comfortable, fully reclining chair with wheels) which was reclined with the chair footrest placed in an elevated position, and Resident 19 could not freely get out of the chair. This failure resulted in Resident 19 not being able to move freely and had the potential to affect Resident 19's dignity, and to cause an avoidable injury to him. Findings: Review of Resident 19's admission RECORD, indicated Resident 19 was admitted to the facility in 2023 with a diagnosis of history of falling, fracture of left acetabulum (break of the hip joint), fracture of the left femur (break of thigh bone) and altered mental status. Review of Resident 19's physician progress notes dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a resident specific care plan (provides direction on the type of nursing care the resident may need based on their health, medication, behavioral, and psychosocial needs) for 3 of 29 sampled residents when: 1. Resident 32 did not have a care plan developed for the dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) services she was receiving, 2. Resident 197 did not have a care plan developed for splint care to the left arm; and, 3. Resident 46 did not have a care plan developed after an altercation involving Resident 23 (unsampled). These failures had the potential for care needs not being met for Resident 32, Resident 46, and Resident 197. Failure to address behavioral health needs placed Resident 46 and Resident 23 at risk for psychosocial harm and injury. Findings: 1. A review of Resident 32s admission RECORD, indicated Resident 32 was admitted 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.

Based on interview, and record review, the facility failed to update or revise the comprehensive care plan for 2 of 29 sampled residents (Resident 83 and Resident 71) when: 1. Resident 83 had a documented change in condition related to a skin wound or ulcer (an open sore caused by a break in the skin); and, 2. Resident 71's smoking care plan was not updated. This failure had the potential to result in Resident 83 and Resident 71 not receiving adequate and appropriate care and services necessary to reach their highest practical physical, mental, and psychosocial well-being. Findings: 1. During a review of Resident 83's SBAR (Situation, Background, Assessment, and Recommendation- a written communication tool used in healthcare) Summary for Providers Record, dated 7/23/24, the SBAR indicated Resident 83 had a change in condition related to a skin wound or ulcer. Further review of the record indicated, .Resident noted to have new wounds to right knee measuring 0.7 x 0.5, left knee 2.5 x 1.5, left foot 2x1, left heel 2.3x3. MD [physician] notified and ordered wound care consult . 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 observation, interview, and record review, the facility failed to follow a physician's order for 1 of 29 sampled residents (Resident 197) when Resident 197's orthopedic referral was not carried out in a timely manner. This failure placed Resident 197 at risk to not receive immediate and appropriate treatment. Findings: During a review of Resident 197's admission RECORD, indicated Resident 197 was admitted to the facility in early 2024 with diagnoses which included chronic pain syndrome and history of falling. Resident 197's Minimum Data Set (MDS- an assessment tool) dated 5/10/24 revealed a BIMS (Brief Interview for Mental Status) score of 15 out of 15 indicating an intact cognitive functioning. During an interview on 8/14/24, at 8:30 a.m., with Resident 197, Resident 197 stated she was admitted to the facility with a splint (brace) to her left arm down to her wrist and was wrapped with an ace bandage due to complaint of pain. Resident 197 further stated she had the splint (brace) due to an injury she suffered while at another facility. Resident 197 explained she received a…

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

Based on observation, interview, and record review, the facility failed to ensure vision care was provided to 1 of 29 sampled residents (Resident 46) when, Resident 46 complained of worsening eyesight and requested to be seen by an ophthalmologist (physician who specializes in eye and vision care), and the facility did not assist her in obtaining vision appointments. This failure had the potential for Resident 46 to develop worsening eyesight and had the potential to negatively impact her activities of daily living and quality of life. Findings: Review of Resident 46's admission RECORD indicated Resident 46 was initially admitted to the facility in 2022 with diagnoses including palliative care (providing relief from pain and other symptoms of a serious illness), history of falling, major depressive disorder (persistent feeling of sadness and loss of interest), and anxiety disorder (experience fear and worry that is both intense and excessive). Review of Resident 46's Medication Review Report, indicated, .MAY HAVE PODIATRY/DENTAL/EYE/HEARING EVAL AND TX [treat] .Order date…

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

Based on observation, interview, and record review, the facility failed to ensure 1 of 29 sampled residents, (Resident 83) received consistent treatment to promote the healing and prevention of pressure ulcers (localized damage to the skin and/or underlying tissue, as a result of pressure or pressure in combination with friction) when Resident 83's physician order for heel protectors (devices that help reduce the risk of pressure damage to the heels of patients by completely offloading the heel) was not followed. This deficient practice placed Resident 83 at risk for worsening his current pressure ulcer and increased the chance for the development of new pressure ulcers. Findings: Review of Resident 83's admission Record indicated Resident 83 was admitted to the facility in 2024 with diagnoses including pressure ulcer to the sacral region (portion of the spine between lower back and tailbone) and pressure ulcer to the left heel. During a review of Resident 83's Treatment Administration Record, (TAR, a written record of treatments ordered by the physician) dated August 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.

Based on observation, interview, and record review, the facility failed to ensure the provision of care and services to assure 1 of 29 sampled residents (Resident 74) maintained his highest level of range of motion (ROM, the full movement potential of a joint) when: 1. Resident 74's order for Restorative Nurse Assistant (RNA) services (care to improve or maintain the functional mobility of residents) was not implemented; and, 2. Resident 74 did not have a care plan developed for his arm and hand contractures (shortening or hardening of muscles, tendons or other tissue leading to deformity and rigidity of joints). These failures placed Resident 74 at risk of a decline in ROM and worsening contractures. Findings: 1. A review of Resident 74's admission RECORD, indicated he was admitted to the facility in mid-2024 with diagnoses which included quadriplegia (loss of movement that affects all limbs and the body from the neck down). During an observation on 8/13/24, at 11:22 AM, in Resident 74's room, Resident 74 stated he had not had therapy in two weeks. Resident 74 further stated he had…

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

Based on interview, observation, and record review, the facility failed to ensure 1 of 29 residents (Resident 12) had appropriate fall precaution measures in place when, Residents 12's bedside table was not in reach and two fall mats (used to cushion a fall) were not in place next to Resident 12's bed and were not included in Resident 12's care plan. This failure had the potential for Resident 12 to be injured during a fall. Findings: A review of Resident 12's admission RECORD indicated Resident 12 was admitted into the facility in 2015 with diagnoses including muscle weakness, low back pain, and Alzheimer disease (a brain disorder which gets worse over time and affects memory, thinking, and behavior). During a concurrent observation and interview on 8/13/24 at 9:27 a.m., in Resident 12's room, Certified Nurse Assistant (CNA) 1 confirmed there was one fall mat folded up and resting against the wall of Resident 12's room, there was a second fall mat located directly under Resident 12's bed, and Resident 12's bedside table was out of reach. CNA 1 stated Resident 12 needed fall mats…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 obtain a physician's order for an indwelling foley catheter (a flexible, sterile tube inserted externally into the bladder to drain urine in a collection bag outside of the body) for one of three sampled residents (Resident 1) with an indwelling foley catheter. This failure placed Resident 1 at risk of a catheter- associated urinary tract infection (CAUTI- infection caused when germs enter the body through a urinary catheter), skin breakdown, and discomfort. Findings: A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility in early 2024 with diagnoses which included urinary tract infection (UTI), acute kidney failure (condition in which kidneys suddenly stop filtering waste from the blood), and retention of urine. A review of Resident 1's Minimum Data Set (MDS, a resident assessment and screening tool which identifies care needs) dated 7/12/24, indicated, .Section H- Bladder and Bowel .Appliances .Indwelling catheter . A review of Resident 1's care plan revised 11/16/23,…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 297) who received intravenous (IV) therapy (infusion of liquid medication directly into the vein) was provided services consistent with professional standards of practice when Resident 297's IV tubing (thin flexible plastic tubing that connects the IV infusion bag to the residents IV access site) was lying on the floor during administration of the medication and Resident 297's IV infusion bag was not labeled with the date, time, and initials of the staff who administered the medication. These failures had the potential to adversely affect Resident 297's health and safety, including an increased risk of developing a new or worsening infection. Findings: A review of Resident 297's admission RECORD, indicated she was admitted to the facility in mid- 2024 with diagnoses which included methicillin resistant staphylococcus aureus infection (MRSA, a type of germ that is resistant to many commonly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 practice appropriate infection prevention and control measures for a census of 93, when 1 of 29 sampled resident's (Resident 90) urinal was unlabeled. This failure had the potential for spread of infection if Resident 90's urinal was used by another resident. A review of Resident 90's admission Record, indicated Resident 90 was admitted to the facility in the spring of 2024 with multiple diagnoses including end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), dependance on renal dialysis (a type of treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to), and anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues) in chronic kidney disease. During an observation on 8/13/24, at 11:34 AM, Resident 90 was observed resting in bed. Resident 90's unlabeled urinal was placed on his bedside table. During a concurrent observation and…

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

Based on interview and record review, the facility failed to ensure professional standards of practice were followed for one of seven sampled residents (Resident 1) when Resident 1 did not receive his medication as prescribed, and the physician was not informed the medication was unavailable for administration. This failure may have contributed to Resident 1 ' s increased seizure activity and hospitalization. Findings: A review of Resident 1 ' s admission RECORD, indicated he was admitted to the facility early 2024, with diagnoses which included epilepsy (a condition involving the brain that makes people more susceptible to having recurrent unprovoked seizures). A review of Resident 1 ' s care plan initiated 3/1/2024, indicated, .The resident has a seizure disorder r/t [related to] epilepsy .Give seizure medication as ordered by doctor . A review of Resident 1 ' s medication administration record (MAR) for May 2024, indicated, .clobazam oral suspension (liquid seizure medication) 2.5 milligrams (mg, unit of weight) per ml (milliliter, unit of measure) give 8 ml by mouth every 12…

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

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was evaluated promptly for injury following an incident of alleged abuse by Resident 2. This failure placed the victim, Resident 1, at risk for physical injury and/or psychosocial harm to not be identified and treated timely and appropriately by facility staff. Findings: During a review of Resident 1's medical record, CARE PLAN, initiated on 11/28/23, indicated, .Resident to resident altercation on 11/27/23 in the facility activity room .Resident will be free of further altercations through review period .monitor for delayed s/s (signs and symptoms) of distress .monitor for safe whereabouts . Review of Resident 1's medical record, IDT Review, dated 11/28/23, indicated, .Resident (1) was struck in the chest by another resident, no injuries noted .IDT recommendations: monitor whereabouts . Upon further review of Resident 1's medical record, no documentation of a nursing assessment to identify physical injuries or mental distress following the physical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. A full-time, qualified Certified Dietary Manager (CDM) or Registered Dietician (RD) was employed to oversee the daily operations of the kitchen and food preparation for 82 residents who received food from the kitchen. 2. One of 28 Residents sampled (Resident 50) received nutritional assessments on admission and quarterly from the RD. These failures had the potential to effect food safety and sanitation for the 82 residents receiving facility prepared food and placed Resident 50 at risk of impaired nutritional status which could further compromise her medical status. Findings: 1. During the initial kitchen tour on 7/10/23, at 8:17 AM, with the dietary supervisor (DS), the tour revealed an unsanitary ice machine, cutting boards that were gouged and stored wet, stained pitchers and cups, and undated, unlabeled, expired and freezer burned food items. [cross reference 812] During an interview on 7/12/23, at 8:53 AM, the DS stated he began training for CDM certification in May 2023. He passed the first…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for a total of 82 residents who received facility prepared foods when: 1. The ice machine contained a yellow substance around the ice chute area (where prepared ice comes out and lands in an ice storage bin), a pink substance was found on the lip of the ice bin (held prepared ice), specks of a black and pink substance were found inside the upper portion of the ice machine (contained the mechanical working parts), the ice machine filter was covered with a thick layer of a gray colored debris, and the ice machine was not cleaned correctly and at regular intervals (last cleaned 3/20/23); 2. The dishwasher temperature was below the required 120 degrees Fahrenheit (F, a unit of temperature measurement) for proper cleaning and sanitization; 3. A plastic bag was tied around the dishwashing sprayer handle; 4. Three cutting boards found with gauges…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident's rights to be treated with dignity were honored for three of twenty-eight sampled residents (Resident 36, Resident 57, and Resident 186) when: 1. Certified Nursing Assistant (CNA) 3 did not provide professional care to Resident 36, Resident 57, and Resident 186, 2. CNA 3 limited their availability to provide care to Resident 57; and, 3. Staff was unaware that Resident 39 preferred only female staff to care for her. These failures had the potential to negatively impact the residents' psychosocial well-being and physical health. Findings: 1a. During an interview on 7/11/23, at 8:17 AM, Resident 57 stated she was at therapy and had an accident in her brief. Resident 57 stated she was brought back to her room and put on her call light. Resident 57 stated CNA 3 answered the call light, closed the privacy curtain in a manner that was rude, and asked me to pick out clothes to change into. Resident 57 stated she was trying to tell him that she still needed to use the bathroom, but CNA 3 was not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a comprehensive person-centered care plan (tool that outlines the plan of action that will be implemented during a patients' care) for six of twenty-eight sampled residents (Resident 25, Resident 28, Resident 32, Resident 39, Resident 43, and Resident 33) when: 1a. Multiple pressure injuries (PI-injuries to skin and underlying tissue resulting from prolonged pressure on the skin) that were identified did not have their own separate or dedicated care plan developed for Resident 25, 1b. An activities of daily living (ADL-refer to people's daily self-care activities) care plan was not developed for Resident 28, 2a. An anticoagulant (medication to prevent blood clots) care plan was not developed for Resident 32 to address monitoring side-effects of the medication, 2b. A care plan was not developed for Resident 39's preference for only female staff to care for her, 2c. Resident 43 did not have a care plan developed for oxygen use; and, 3. A Urinary tract Infection care plan was not developed for 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 respiratory care provided was consistent with professional standards of practice for three of twenty-eight sampled residents (Resident 32, Resident 43, and Resident 288) when: 1. Oxygen therapy was provided without a physician order for Resident 43; and, 2. The oxygen flow rate was not followed per physician order for Resident 32 and Resident 288. These failures placed Resident 32, Resident 43, and Resident 288 at risk for respiratory distress and inadequate treatment. Findings: 1. A review of Resident 43's admission Record indicated Resident 43 was admitted to the facility in 2023 with diagnoses which included pulmonary edema (a condition caused by too much fluids in the lung making it difficult to breathe). During a concurrent observation and interview on 7/10/23, at 1:43 p.m., with licensed nurse (LN) 3 in Resident 43's room, LN 3 confirmed Resident 43 was using oxygen and the oxygen concentrator was on and running at 4 liters per minute (LPM, a unit of measurement for oxygen delivery) via nasal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe medication storage practices for a census of 85 when: 1. One of two treatment carts was left unlocked, 2. Staff's personal belongings were stored in two of two medication storage rooms, 3. Opened and unlabeled multi-dose medication vials were stored in one of two medication rooms, 4. Opened and unlabeled medications were stored in two of four medication carts; and, 5. An expired ointment medication was stored in one of two treatment carts. These failures had the potential to contribute to medication error, unsafe medication use, and storage. Findings: 1. During a concurrent observation and interview with central supply (CS) on 7/10/23, at 8:36 a.m., an unlocked treatment cart (a mobile cart used by nurses to store supplies for the prevention and treatment of skin issues) was observed to be parked next to the copy machine against the wall. CS confirmed treatment cart 1 was unlocked. CS stated she did not know who left it…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reasonable accommodation of needs were honored for two of twenty-eight sampled residents (Resident 16 and Resident 33) when: 1. Resident 16 was not provided with an appropriate call light device per resident need; and 2. Resident 16 and Resident 33's call lights were not within reach. These failures had the potential for Resident 16's and Resident 33's needs to go unmet with the potential to cause physical and/or psychosocial harm. Findings: 1. Review of Resident 16's admission RECORD indicated Resident 16 was admitted to the facilty with a diagnosis of Rheumatoid arthritis (a chronic inflammatory disease affecting the hand joints and leading to impairment in hand functions). During a concurrent observation and interview on 7/11/23, at 9:13 AM, Resident 16 stated she could not use her call light and then said, Look at my hands. Resident 16's fingers on both hands were bent inwards and she was unable to move them when asked. Resident 16 demonstrated slight movement of both thumbs. Resident 16 stated she…

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

Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS- a resident assessment tool used to guide care) for one of twenty-eight sampled residents (Resident 5) when, Resident 5's MDS Section I for Active Diagnoses dated 6/15/23 was marked with schizophrenia (a serious mental illness that affects how a person thinks, feels, behaves, and relates to others) but did not have a schizophrenia diagnosis on admission. This failure had the potential for Resident 5 to receive inappropriate care due to an inaccurate diagnosis. Findings: Review of Resident 5's admission RECORD (a document that contains demographic and clinical data) indicated Resident 5 was admitted to the facility with a diagnosis of unspecified hallucinations (an experience involving the apparent perception of something not present). During a concurrent interview and record review, on 7/13/23, at 8:35 a.m., the MDS Coordinator (MDSC) confirmed Resident 5's MDS Section I-Active Diagnoses dated 6/15/23 indicated schizophrenia was coded as one of Resident 5's diagnosis. The MDSC…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 all of the identified components of a baseline care plan, within 48 hours of admission as required, to address resident-specific care needs for two of twenty-eight sampled residents (Resident 288 and Resident 50) when; 1. Resident 288's oxygen use care plan was not created; and 2. Resident 50's tube feeding (used to provide nutrition to people who cannot obtain nutrition by mouth) and psychiatric behavior care plans were not created. This failure had the potential to results in unmet oxygen use needs for Resident 288 and unmet psychiatric behavior monitoring and tube feeding needs for Resident 50. Findings: Review of Resident 288's admission RECORD indicated Resident 288 was admitted to the facility on [DATE] with diagnoses of acute respiratory failure (inability of the respiratory system to meet the oxygen needs of the body), pneumonia (an infection of one or both of the lungs caused by germs), and dependent on supplemental oxygen (when there…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ongoing activities based on resident needs and preferences for one of twenty-eight sampled residents' (Resident 16) when, Resident 16 was not provided with in room activities at least three times a week. This failure had the potential to effect Resident 16's psychosocial well-being. Findings: During an interview on 7/10/23, at 3:11 PM, Resident 16 stated she was not offered any activities. Resident 16 stated it was hard for her to get out of bed because of her pain in her joints from rheumatoid arthritis (A chronic inflammatory disorder affecting many joints, including those in the hands and feet). Resident 16 stated she liked to do activities such as reading, drawing, gardening, and enjoyed cooking, but those things were not offered to her. Resident 16 stated that she did not like to be read to. Resident 16 stated she had a subscription to a newspaper, that she read but it did not last very long because she was a fast reader. During a concurrent interview and record review on 7/13/23, at 2:03 PM, Resident 16's…

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

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 16) with limited range of motion (ROM) received care and services to maintain or improve mobility when; 1. Resident 16 was not provided with all ordered ROM services; and 2. ROM services were not documented as completed over a three-week period for Resident 16. These failures removed the opportunity to potentially improve ROM and had the potential to result in a decline of ROM for Resident 16. Findings: During an interview on 7/13/23, at 7:34 AM, Restorative Nursing Assistant (RNA) 3 stated Resident 16 received ROM services three times a week. RNA 3 stated ROM services provided to Resident 16 included upper (arms) and lower body (legs) ROM. RNA 3 stated she did not offer for Resident 16 to sit up on the edge of the bed as indicated in the ROM order. During an interview on 7/13/23, at 7:57 AM, RNA 2 stated when she worked with Resident 16, she provided upper and lower body ROM services. RNA 2 stated she did not provide or offer for Resident 16 to sit up on the side of the bed…

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

Based on interview and record review, the facility failed to assess the nutritional status for one of twenty-eight sampled residents (Resident 50), when Resident 50's nutritional assessment was not completed by the registered dietitian (RD). This failure had the potential for Resident 50 to lose weight, become dehydrated, or develop skin breakdown which could result in a decline of health status for Resident 50. A review of Resident 50's admission RECORD, indicated, she was admitted to the facility in early 2023 with diagnoses which included, dysphagia (difficulty swallowing), cerebral infarction (stroke-damage to the brain from interruption of its blood supply). A review of Resident 50's, Medication Review Report, indicated, Enteral Feed [nutrition provided as a liquid through a tube] Order every 6 hours Flush G-tube [gastric tube, a tube inserted through the abdomen that brings nutrition directly to the stomach] with 150 cc [cubic centimeter, unit of measure] H2O [water] before and after each feeding administration for a total of 600 ml [milliliter, unit of measure]/day Order Date…

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

Based on observation and interview, the facility failed to ensure direct care staffing information was posted in a prominent place as required for a census of 85. This failure prevented the residents and visitors to view the hours and number of direct care staff providing care to the residents of the facility on a daily basis. Findings: During a concurrent interview and record review on 7/13/23, at 2:40 p.m., Staffing Coordinator (SC) stated she completes the facility's Direct Care Service Hours Per Patient Day (DHPPD-the total number of hours worked per patient/day divided by the average daily resident census to determine the amount of nursing hours allotted per day) on a daily basis. When asked if the DHPPD information was posted daily, the SC responded the DHPPD information had not been posted since the middle of June and there were no DHPPD hours posted today. The SC also stated she did not know the reason the facility stopped posting the DHPPD information. The SC acknowledged the DHPPD information should have been posted. During a subsequent observation and interview on…

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

Based on interview and record review, the facility failed to provide appropriate social services support following a grievance made about treatment for one of twenty-eight sampled residents (Resident 57) when, there was no social services follow-up provided for Resident 57 after Resident 57 reported a concern with treatment provided by a staff person. This failure had the potential for Resident 57 to not achieve the highest practicable mental and psychosocial well-being. Findings: During an interview on 7/11/23, at 8:17 AM, Resident 57 stated she was at therapy and had an accident in her brief. Resident 57 stated she was brought back to her room and put on her call light. Resident 57 stated CNA 3 answered the call light, closed the privacy curtain in a manner that was rude, and asked her to pick out clothes to change into. Resident 57 stated she was trying to tell CNA 3 that she still needed to use the bathroom, but CNA 3 was not listening. Resident 57 stated she had been physically abused in the past and the incident brought her back to that spot. Resident 57 stated CNA 3 had a bad…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 monitoring for a high-risk blood thinning medication (A medication used to prevent blood clots with potential side effects of abnormal bleeding) was completed daily for 1 of 19 residents (Resident 32) who received blood thinning medication. This failure had the potential to result in undetected adverse effects that could occur when blood thinning medications were administered. Findings: A review of Resident 32's admission Record indicated Resident 32 was admitted to the facility in 2023 with diagnoses which included atrial fibrillation (an irregular heart rhythm that can lead to blood clots in the heart). A review of Resident 32's clinical record, titled, Order Summary Report, indicated, .Apixaban [blood thinner] Tablet 5 MG [milligram, unit of measurement] Give 1 tablet by mouth every 12 hours .Order Date .11/1/22 . During a concurrent interview and record review on 7/13/23, at 2:37 p.m., Resident 39's clinical record was reviewed with licensed nurse (LN) 3. LN 3 confirmed there was no documentation for monitoring…

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

Based on interview and record review the facility failed to ensure one of four sampled residents (Resident 50) antipsychotic (medication used to treat mental distress) medication regimen was safely managed when the facility failed to monitor Resident 50 for behaviors related to her schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly) diagnosis. This failure had the potential for Resident 50 to receive unnecessary antipsychotic medications with potential side effects. Findings: A review of Resident 50's admission RECORD, indicated Resident 50 was admitted in early 2023, with diagnoses which included schizophrenia. A review of Resident 50's Medication Review Report, indicated, risperidone [medication used to treat schizophrenia] Oral Tablet 1 MG [milligram, unit of measure] (Risperidone) Give 1 tablet via G-tube at bedtime for schizophrenia order date 1/23/23 and ZyPREXA [medication used to treat schizophrenia] Oral Tablet 10 MG (Olanzapine [generic name for Zyprexa]) Give 1 tablet via G-tube one time a day for schizophrenia order date 1/23/23.…

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 observation, interview, and record review the facility failed to ensure that dietary assistant (DA) 1 had the appropriate competencies and skills to carry out the duties of the kitchen when DA 1 incorrectly monitored the water temperature of the dishwasher and did not follow the instructions on the dishwashing temperature log. This failure had the potential to spread food born illness to the 82 residents who received meals from the kitchen. Findings: During a concurrent observation and interview on 7/12/23, at 9:03 AM, DA 1 was observed operating the dishwasher. DA 1 stated it was a low temperature machine and the temperature should be between 120-140 degrees Fahrenheit (F) (a scale of temperature). DA 1 stated she checked the temperature of the water with strips. DA 1 put a test strip in the wash water (The strip DA 1 used actually tested the chlorine level of the water). When asked to look at the dishwashers water temperature gauge DA 1 confirmed the water temperature was between 100 -110 degrees Fahrenheit. During a concurrent interview and observation on 7/12/23, 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.

Based on interview, and record review, the facility failed to maintain complete and accurate medical records for two of twenty- eight sampled residents (Resident 10 and Resident 39) when the hospice (specialized 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 10 and Resident 39. Findings: 1. A review of Resident 10's hospice IDT [Interdisciplinary Team, a team of professional staff from different disciplines] note, dated 2/8/2023, indicated a primary diagnosis of hypertensive heart disease (disease caused by high blood pressure) with heart failure. Under the heading changed visit frequency orders, the note indicated, SN [skilled nurse] 1x/wk [1 time per week] . A review of a document in Resident 10's hospice binder titled, FACILITY VISIT RECORD, indicated a licensed nurse (LN) visited Resident 10 on:1/4/23, 1/31/23, 2/16/23, 3/16/23, 3/27/23, 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.