Vintage Faire Nursing & Rehabilitation Center

Based on interview and record review, the facility failed to ensure one of twenty-seven residents' (Resident 17) medical records were complete and accurate when Resident 17's dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are not functioning properly) medical record was in another resident's (Resident 21) clinical records. This failure had the potential to result in Resident 17's private health care information and personal information being disclosed to the unauthorized person. Findings: A record review of Resident 21's clinical record titled, admission RECORD, indicated Resident 21 was admitted to the facility with diagnoses that did not include dialysis. A record review of Resident 17's clinical record titled, admission RECORD, indicated Resident 17 was admitted to the facility with diagnoses that included a dependence on dialysis. A review of Resident 21's electronic health record (EHR) revealed Resident 17's clinical document titled, DIALYSIS CARE COMMUNICATION COORDINATION, dated 3/8/24, was contained in Resident 21's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure assessments were completed accurately for 2 or 27 sampled residents (Resident 25 and Resident 28), when: 1. Resident 25's and Resident 28's weekly nursing evaluations were not completed accurately for the presence of pain and pressure ulcers (localized damage to the skin and underlying soft tissue, usually over a bony prominence, caused by prolonged or severe pressure); and 2. Resident 28's change of condition evaluation did not accurately reflect the location and/or description of the pressure ulcer located on the left thumb. These failures had the potential for Resident 25 to have inadequate pain relief and emotional distress and for Resident 28 to have delayed wound healing. Findings: 1a. Review of admission RECORD indicated Resident 25 was admitted to the facility with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (the right side of the brain has been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurately complete a Pre-admission Screening and Resident Review (PASRR, a required assessment for individuals with mental illness, intellectual or developmental disabilities, or related conditions, so that a determination of need, appropriate setting, and a set of recommendations for services to be included in the individual's plan of care is provided) for one of twenty-seven sampled residents (Resident 46) when, Resident 46's level I PASRR did not reflect his diagnosis of bipolar (a mental disorder characterized by periods of extreme mood swings, and causes shifts in mood, energy, activity levels, and concentration) and diagnosis of lack of expected normal psychological development in childhood (refers to a developmental delay in one or more areas such as a way a person thinks, interacts with and communicates with others and persists into adulthood). This failure resulted in a level II PASRR (a mental health screening for additional services) never…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 plans were developed and implemented for 1 of 27 sampled residents (Resident 79) when, Resident 79's care plan for depression was not developed and implemented. These failures had the potential to negatively affect Resident 79's psycho-social well-being. Findings: A review of Resident 79's clinical record titled, admission RECORD, indicated Resident 79 was admitted to the facility with diagnoses which did not include depression (a common mental health condition characterized by a persistent low mood, loss of interest in activities, and other symptoms that can significantly interfere with daily life). A review of Resident 79's clinical document titled, Order Details, (contains physician orders), dated 3/26/25, indicated, .Mirtazapine [an antidepressant medication given for depression] Give 1 tablet by mouth at bedtime for Depression . A review of Resident 79's clinical document titled, Care Plan Report, dated 4/8/25, indicated, .[Resident 79] has a mood problem r/t [related to] depression .Date Initiated:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 twenty-seven sampled residents (Resident 64) received activities that met their interests and needs when Resident 64 did not attend group activities and in room activities had not been provided since 9/9/24. This failure had the potential to affect Resident 64's psychosocial well-being. Findings: During an interview with Resident 64 on 4/8/25, at 10:31 AM, Resident 64 stated, Activities don't bring me anything to do. The last time was a packet with word search puzzles last year. I prefer activities in my room. During a review of Resident 64's activities care plan dated 8/16/23, the care plan indicates Resident 64 prefers to spend most of her free time resting in the comfort of her room. The care plan also indicated Resident 64 would be empowered to make independent leisure choices daily and would be offered room visit check-ins 4 times weekly. During a record review of Resident 64's, Activities Progress Notes dated 9/9/2, at 1:37 PM, the progress note indicated, .Activity packet received with…

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

Based on interview and record review, the facility failed to provide appropriate blood glucose (BG; sugar in the blood) monitoring for a diabetic (blood sugar disease) condition for one of twenty-seven sampled residents (Resident 77) when, Resident 77's blood sugar check order did not contain monitoring parameters (when to notify the provider) related to the blood sugar readings and Resident 77's high blood sugar readings were not reported to the Medical Doctor (MD). This failure could have contributed to unsafe blood glucose monitoring without proper notification of the medical doctor and could have impacted the Resident 77 well-being, including the wound healing process. Findings: Review of Resident 77's admission RECORD, indicated Resident 77 was admitted to the facility with a diagnosis of diabetes mellitus (DM) and wound care among other diagnosis. During a concurrent observation and interview on 4/8/25, at 1:05 p.m., Resident 77 was observed eating her lunch and stated she was diabetic and was not receiving a diabetic meal. Resident 77 stated she did not have any insulin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that one of twenty-seven sampled residents (Resident 28) received the necessary treatment and services consistent with professional standard of practices to prevent a pressure ulcer (PU - localized damage to the skin and underlying soft tissue, usually over a bony prominence, caused by prolonged or severe pressure) from developing and to promote healing when: 1. Interventions were not developed to prevent a PU from occurring to Resident 28's left contracted (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) hand; and 2. A wound evaluation was not completed when a PU was identified to Resident 28's left hand; and 3. Treatment interventions such as splinting (a medical technique used to immobilize a limb or body part, typically to support healing from injuries like fracture, sprains or dislocations) and range of motion exercises (designed to move a joint…

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

Based on observation, interview, and record review, the facility failed to ensure a census of 89 residents were safe from accidental hazards when: 1. Resident 63 kept cigarettes and a lighter in her purse, unsecured in her room, and received oxygen (O2) via nasal canula (NC- tubing that delivers oxygen into resident's nose); 2. Smoking paraphernalia (items used to smoke which may include cigarette wrapper or cigarette paper, and tobacco) items were observed to be unsecured and on top of Resident 65's bed and Resident 65 did not have a lock box in the room; and These failures exposed residents, staff, and visitors to be at risk of burns, fire, and/or explosion while in the facility. Findings: 1. Review of Resident 63's Smoking Safety Screen, dated 3/13/25, indicated, Resident 63, .Has expressed continued desire to smoke despite explained health and safety risks .Expresses an understanding that smoking is not allowed near oxygen delivery systems (devices used to provide oxygen to a patient who is unable to obtain enough oxygen from their own breathing) even if the delivery system is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 2 of 27 sampled residents' (Resident 30 and Resident 79) nutrition and hydration requirements were met when: 1. Nutritional recommendations of the Registered Dietitian (RD) to address Resident 30's significant weight loss were not followed. 2. Resident 79's significant weight loss was not addressed and monitored. These failures had the potential to result in Resident 30 not to receive the necessary intervention to prevent further weight loss and Resident 79's continued weight loss, negatively affecting Resident 30 and Resident 79's health and well-being. Findings: 1. Review of Resident 30's admission RECORD, indicated Resident 30 was admitted to the facility with a diagnosis of gastrostomy status (Gastrostomy Tube (GT); a soft tube surgically placed into the stomach to provide nutrition and medications). During a concurrent interview and record review on 4/9/25, at 2:22 PM, with Licensed Nurse (LN) 11, Resident 30's Medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 twenty-seven sampled residents (Resident 77) who received parenteral fluids (delivery of fluid or medication through a vein) was provided services consistent with professional standards of practices when: 1. Resident 77's PICC (Peripherally Inserted Central Catheter; a thin, soft, long catheter (tube) that is inserted into a vein in the arm with the tip of the catheter positioned in a large vein that carries blood into the heart to provide medications) clear dressing was not changed within seven days according to the physician order; and, 2. There was no care plan created in relation to Resident 77's PICC line. These failures had the potential to result in a PICC line malfunction and/or infection for Resident 77. Findings: 1. Review of Resident 77's admission RECORD, indicated Resident 77 was initially admitted to the facility with a diagnosis of diabetes (a chronic condition that affects the way the body processes blood sugar), wound care, management of vascular access (a medical device used 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 identify, assess and treat pain to the extent possible for one of twenty-seven sampled residents (Resident 25), when 1. Resident 25 did not receive a pain medication as ordered when he had rated his pain level between 4-6 (on a pain scale of 0- 10 ( 0 = no pain and 10 = severe pain), and 2. Resident 25 did not have a pain regimen for pain level of 7 to 10. These failures resulted in the potential for inadequate pain relief and emotional distress for Resident 25. Findings: 1. During a concurrent observation and interview on 4/8/25 at 10:03 AM Resident 25 was observed to have nonverbal signs of pain which included facial expression of grimacing, wincing, and moaning as he attempted to reposition himself in his bed. Resident 25 stated that when he got pain medication it sometimes helped the pain in his back. Review of admission RECORD indicated Resident 25 was admitted to the facility with multiple diagnoses including malignant neoplasm of prostate, hemiplegia and hemiparesis following cerebral infarction…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Attending Physician/Medical Doctor/Medical Director (MD) failed to provide blood glucose (sugar, BG) monitoring parameters for diabetic (blood sugar disease) condition, and physician oversight for one of twenty-seven sampled residents (Resident 77) when, Resident 77's blood sugar monitoring orders from February 2025 and March 2025 did not provide parameters for management of blood sugar. This failure could have contributed to unsafe blood sugar monitoring with high or low blood sugar levels. Findings: Review of Resident 77's admission RECORD, indicated Resident 77 was initially admitted to the facility in 12/2024 and a readmission date of 3/2025, with a diagnosis of diabetes and wound care among other diagnosis. Review of Resident 77's admission history and physical, dated 12/18/24, written by the MD, indicated diabetic diagnosis and under recommendation included .DON'T SEE DM (diabetes, same as blood sugar disease) diet MED (medications) AC/HS (before meals and at bedtime) FS (fingerstick) on DM . During a concurrent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that two of three certified nursing assistants (CNA 1 and CNA 2) had the appropriate competency to provide individualized resident care for a census of 89 residents when, CNA 1 and CNA 2 were not aware of how to access the resident [NAME] (a concise, centralized, and easily accessible record of essential resident information, used by staff to quickly summarize resident care and guide daily actions) in the residents medical record. This failure had the potential for resident centered interventions not to be implemented with the risk for residents not to meet their identified goals or suffer declines in their Activities of Daily Living. Findings: During a concurrent observation and interview on 4/9/25, at 2:26 PM, CNA 1 stated she had worked at the facility for about one month. CNA 1 confirmed she was assigned to care for Resident 28 for her shift. CNA 1 stated she was not aware that Resident 28 had a pressure injury (PI; localized…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 appropriate behavioral health treatment and services to meet the psychosocial needs for one of twenty-seven sampled residents (Resident 46), when 1. Resident 46's mental health consult notes and therapy recommendations via telehealth care (use of technology, video, or phone to provide long distance mental health care) dated 9/19/24 were not communicated to the Medical Doctor (MD) and the licensed nursing (LN) staff; and, 2. Resident 46 displayed episodes of anger and was refusing his treatments and medications, including his medication, and the resident's psychological evaluation (a comprehensive evaluation focused on the diagnosis, treatment and prevention of mental, emotional and behavioral disorders) and/or consultation was not provided as ordered by the physician on 2/13/25. This deficient practice had the potential to negatively affect the Resident 46's psychosocial (the mental, emotional, social, and spiritual effects of a disease) well-being. Findings: 1. Review of Resident 46's admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the psychosocial well-being of one resident (Resident 79), in a sample of 27, when there was no documented evidence of Social Services following up with Resident 79 following initiation of three separate psychotropic (drugs that affect the mind and brain to treat mental health conditions) medication. These failures, due to lack of documented follow-up from social services, had the potential to negatively effect Resident 79's mental health and psychosocial well-being. Findings: A review of Resident 79's clinical record titled, admission RECORD, indicated Resident 79 was admitted to the facility on [DATE], with diagnoses which included a need for assistance with personal care and a primary diagnosis of hypo-osmolality (a low concentration of solutes (like sodium) in a fluid) and hyponatremia (a condition where there's a low concentration of sodium in the blood). Further review of Resident 79's admission RECORD, did not include any psychiatric…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow safe disposition and destruction of controlled prescription medications (a drug with the potential for misuse and abuse) based on facility's policy with a census of 89 when controlled medication disposal bins or containers (where unused prescribed medications were held for ultimate safe disposal) were not secured, sealed, and rendered unusable (medication that has been altered in a way that it was no longer available for use) to prevent unauthorized access and risk of drug diversion (unsafe drug acquisition and unauthorized use by someone other than for whom it is prescribed) when stored in the shared Interim Director of Nursing (DON) and Assistant Director of Nursing (ADON) office. These failures had the potential to contribute to unsafe medication handling and risk of drug diversion. Findings: During a concurrent observation and interview on [DATE] at 3:52 p.m., accompanied by the DON and Pharmacist Consultant (PC), in the shared…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 3. A review of Resident 25's admission RECORD, indicated Resident 25 was admitted to the facility with a diagnosis that included anxiety disorder, unspecified. A record review of Resident 25's physician order dated 1/20/25 indicated Mirtazapine (a medication used to treat depression) 7.5mg (milligram - a metric unit of mass) 1 tablet at bedtime for appetite stimulation related to depression. A record review of Resident 25's clinical document titled; Psychotropic/Behavior Management IDT Review dated 3/14/25 indicated the Interdisciplinary team (IDT - group of professionals from different disciplines or fields who work together on a project or task, leveraging their unique expertise to achieve a common goal) made a recommendation to discontinue the Mirtazapine. A record review of Resident 25's Pharmacy consultation report indicated the IDT's recommendation to discontinue the Mirtazapine was faxed to the MD (Medical Doctor) on 3/13/25. Further review of Resident 25's health record indicated that there was no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurate medication labeling practices were followed when a blood pressure (BP-the force of blood pushing against the walls of arteries as heart pumps blood throughout the body) medication label was not updated with a new hold parameter (a number reflecting a change in the order for direction of use) for one resident (Resident 440) with a census of 89. This failure had the potential for Resident 440 to not receive blood pressure medication as prescribed to manage fluctuations in blood pressure. Findings: During a medication administration observation on 4/9/25 at 7:40 a.m. with Licensed Nurse (LN) 6 at medication cart 4, Resident 440's medication label on the bubble pack (a card that packages dosed of medication inside clear or light-colored bubbles or blisters) for amlodipine (a medication to treat high blood pressure; high blood pressure-when the force of blood pushing against artery walls is consistently too high) was not consistent with the Medication Administration Record (MAR-a legal record of…

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

Based on interview and record review the facility failed to develop and implement a coordinated plan of care with Hospice (provides comfort and support for individuals facing a terminal illness, focusing on improving quality of life during the final stages of life) for two of two sampled residents (Resident 28 and Resident 47), when 1. The facility did not invite or include Resident 28's and Resident 47's hospice staff in the facility's interdisciplinary team (IDT - group of professionals from different disciplines or fields who work together to assess, coordinate, and plan resident care) meetings for care coordination, 2. The facility did not ensure that the hospice agencies nurses progress notes, IDT notes, and plan of care updates were available to the facility staff for Resident 28 and Resident 47. These failures had the potential for Resident 28 and Resident 47 to not receive proper, appropriate, and coordinated care and services from the facility and the hospice agency; and had the potential for Resident 28's and Resident 47's medical record to have insufficient information 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 ensure one of five sampled residents (Resident 23) received vaccine (a process whereby a person is made resistant to a disease by the administration of vaccines) education prior to administration of Pneumococcal (vaccine to prevent pneumonia) and Influenza (a contagious respiratory illness cause by influenza viruses) vaccines. These failures resulted in Resident 23 to not be aware or informed of the benefits, risks, and potential side effects of the immunizations, prior to receiving the vaccines. Findings: During a concurrent interview and record review on 4/11/25, at 10:00 AM, the Infection Preventionist (IP) stated Resident 23 received the influenza vaccine on 9/23/24, and Resident 23 received the pneumococcal vaccine on 9/26/24. During record review the IP was unable to find documented evidence where Resident 23 was educated on the risk and benefits of the influenza or pneumococcal vaccines. During an interview on 4/11/25, at 10:15 AM, the IP stated the importance of giving the education and benefits of the vaccines to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure quality care was given to one of four sampled residents (Resident 1), when the Medical Doctor (MD) was not notified when Resident 1 had six days of low body temperature. This failure could have contributed to Resident 1 being found unresponsive on 2/1/25 and transferred to [ACUTE CARE HOSPITAL NAME] for further evaluation and treatment in the Hospital Intensive Care Unit (ICU). Findings: During a review of Resident 1 ' s clinical record titled, admission Record (a document that contained Resident 1 ' s demographic information), indicated Resident 1 ' s diagnoses included dementia (general term for a decline in mental abilities that affects memory, thinking, and behavior), bariatric surgery (weight loss surgery), protein calorie malnutrition (health problems associated with consuming a lack of calories), and anemia (low red blood cells that resulted in low oxygen in the blood). A review of Resident 1 ' s clinical record titled, SBAR [Situation,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to maintain the hydration status for 1 of 4 sampled residents (Resident 1) when Resident 1's fluid intake was not monitored and documented accurately. This failure resulted in Resident 1 being hospitalized for dehydration (a condition that occurs when the body loses too much water and other fluids that it needs to work properly) and an electrolyte imbalance (the body's mineral levels are too high or too low). Findings: A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses including cerebral infarction (disrupted blood flow to the brain), dysphagia (difficulty swallowing), acute kidney failure (sudden loss of kidney function) and hyperkalemia (high potassium level in the blood). A review of Resident 1's care plan titled, Altered nutrition and hydration risk ., revised on 2/25/24, indicated, .Labs as per MD order .RD [registered dietician] evaluation as needed . A review of Resident 1's care plan…

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

Based on interview, and record review, the facility failed to ensure the Physician Orders for Life-Sustaining Treatment [POLST- a legal document communicating the resident's medical wishes for end-of-life care] was completed accurately for 7 of 25 sampled residents (Resident 22, Resident 62, Resident 79, Resident 491, Resident 3, Resident 63, and Resident 78), when: 1. Resident 22's POLST did not contain the resident representative (RR- the person who acts on behalf of the Resident) contact information, 2. Resident 62's POLST did not include Resident 62's contact information; and the date Resident 62 signed was missing, 3. Resident 491's POLST did not contain Resident 491's conservator (CON) 1 (a person who manages the resident's financial and healthcare issues when the resident is not able) contact information; and the date signed was missing, 4. Resident 3's POLST was signed by Resident 3, who did not have the capacity to sign for herself, 5. Resident 63's POLST was not dated when prepared, and the Advanced Directive (explains the type of health care you prefer in case you can't…

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

Based on observation, interview, and record review, the facility failed to ensure a clean, comfortable, and homelike environment for 4 out of 46 facility rooms (Room A, Room B, Room C and Room D) when: 1. The floor in Room A, under the nightstand, next to the first bed, contained stained, broken tiles and trash, 2. Room B had two areas of deep scratches in the drywall behind the first bed, 3. Room C had two deep scratches in the dry wall behind the second bed, the bathroom door had a broken, jagged edged striker plate (protective plastic disc used to prevent the bedroom doorknob breaking the bathroom door) partially covering a splintered, cracked area in the door, the bathroom sink was pulling away from the wall; and, 4. The toilet in Room D had been leaking for an unknown period of time. These failures resulted in the facility residents not being provided a clean, comfortable, and homelike environment with the potential to negatively impact the residents physical and psychosocial well-being. Findings: 1. During a concurrent observation and interview on 4/22/24, at 9:53 AM, in Room…

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

Based on observation, interview, and record review, the facility failed to ensure necessary care and services were provided for 2 of 25 sampled residents (Resident 3 and Resident 8), when: 1. Resident 3 and Resident 8's nails were not cleaned and trimmed; and 2. Resident 3 did not receive showers as per her shower schedule. These failures had the potential for Resident 3 and Resident 8 to experience decreased self esteem from poor hygiene, poor skin integrity, and scratches which could lead to infection for Resident 8. Findings: 1a. Review of the admission Record indicated Resident 8 was admitted to the facility in early 2023 with multiple diagnoses including hemiplegia with hemiparesis following cerebral infarction (paralysis of partial or total body function on one side of the body after stroke), need for assistance with personal care. During an observation on 4/22/24, at 10:22 a.m., Resident 8 had long fingernails with dirt in them. Resident 8 had scratch marks on her left forearm. During a concurrent observation and interview on 4/23/24, at 11:39 a.m., Certified Nursing…

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

2c. A review of Resident 53's admission Record indicated Resident 53 was admitted to the facility in 2024 with diagnoses including acute respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), acute respiratory failure with hypercapnia (excessive carbon dioxide in the bloodstream), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) with (acute) exacerbation. During an observation on 4/22/24, at 9:12 a.m., Resident 53 was observed lying in bed receiving oxygen at three LPM via nasal cannula via an oxygen concentrator. No oxygen in use signs were posted outside Resident 53's room. During a concurrent observation and interview on 4/22/24, at 10:49 a.m., with the DON, the DON stated there should be signs placed outside of the rooms to alert everyone that a resident was on oxygen. The DON further stated it was a safety concern if signs were not posted. The DON's expectation was for signs to be placed on all rooms for residents who had oxygen for safety reasons.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 disposition practices for a census of 91 residents, when discontinued and discharged medications were stored and disposed of with no documentation and without cosignatory of the licensed staff. This unsafe practice could put the facility at risk of drug diversion and prescription medications mishandling. Findings: During a concurrent observation and interview with the Director of Nursing (DON), in the facility's medication room, at Station 1 and 2, on [DATE] at 9:44 AM, the discontinued prescription medications were piled up on a countertop in a corner next to the sink. The DON stated the pile of medications belonged to residents who were discharged , or medications discontinued by the doctor. The DON stated the nursing staff were responsible to destroy them when they had time. During an interview with Licensed Nurse (LN) 1, at station 1-2, on [DATE], at 9:56 AM, LN 1 stated she was not aware of any documentation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe medication use and monitoring in three out of seven residents (Resident 342, Resident 33, Resident 343) reviewed for unnecessary drug use when: 1. Resident 342's high risk blood thinner medication, called Apixaban (or Eliquis, drug used to prevent blood clot formation and can cause bleeding) was not monitored and care planned (Care Plan, a document that listss resident's medical issues and how the nursing staff should monitor and care for the resident) for safe use, 2. Resident 33's heart medication called metoprolol (a medication used to lower blood pressure and heartbeat) was not monitored according to hold parameters per doctor's order, 3. Resident 33's pain medication called Celebrex was continued upon admission without reassessment of its safe use and potential for side effects; and, 4. Resident 343's duplicate use of Vitamin D (a type of vitamin that could accumulate in the body when used in high doses) was not addressed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe use and monitoring of psychotropic medications (drugs used to treat mental health such as anxiety, depression, or anger outburst) in four out of seven residents (Resident 33, Resident 342, Resident 343, and Resident 390) reviewed for unnecessary medication use (when medications are used without adequate monitoring or without adequate indication) when: 1. Resident 33's antidepressant medication called citalopram (or Celexa, a drug used to treat depression and anxiety) was not monitored for resident specific symptoms and behaviors that affected the mental health of the resident, 2. Resident 342's antidepressant medication called Effexor (or venlafaxine, a mood elevating drug that helps with depression and anxiety) was not monitored for resident specific behavior or symptoms of depression and anxiety, 3. Resident 343's antidepressant medication called escitalopram (or Lexapro, a medication used for treatment of depression) was not monitored for resident specific behavior or symptoms which accompanied…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three out of three medication rooms and two out of the four medication and treatment carts for a census of 91 when: 1. The Automated Dispensing Device (or ADD, an electronic medication storage device that controls access and usage of prescription medications) was stored in the same room as a hopper (a disposal and washing/rinsing device where bedpans [container used to collect urine or feces, shaped to fit under a person lying or sitting in bed], urinals [urine bottle, a bottle for urination for residents who find it impossible or difficult to get out of bed to urinate], and other body fluids were disposed), and the room was accessible to nursing assistants. The room's temperature log was not consistently monitored or documented, 2. Undated and unlabeled prescription medication was stored in the medication room active storage areas in Medication rooms at nursing station 1 & 2 (Med room [ROOM…

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

Based on observation, interview, and record review, the facility failed to ensure the therapeutic diets prescribed by the physician were followed for 3 of 90 residents receiving meals (Resident 5, Resident 344, and Resident 8) when: 1. Salt packets were added to Resident 5's meal tray, 2. Resident 344 did not receive his prescribed diet texture; and, 3. Resident 8's therapeutic diet order change was not confirmed/obtained from the physician. These failures had the potential to adversely affect Resident 5 and Resident 8's health and well-being and put Resident 344 at risk of choking or decreased oral intake which could lead to weight loss. Findings: 1. A review of Resident 5's admission RECORD, indicated she was re-admitted to the facility in 2024 with diagnoses which included hypertensive chronic kidney disease (high blood pressure caused by damage to the kidneys). A review of Resident 5's Order Listing Report, dated 4/24/24, indicated, .Regular diet .NO SALT PX [packet] for CARDIAC DIET . A review of Resident 5's care plan, dated 3/7/24, indicated, .Focus .The resident is at risk…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and sanitary food storage practices for a total of 90 residents who received food from the kitchen when: 1. Food items available for use were stored in undated and unlabeled containers, 2 The unit snack/nourishment refrigerator contained ice buildup in the freezer, food debris, and stains, 3. The unit snack/nourishment refrigerator contained moldy foods and foods past their use by dates; and, 4. The unit snack/nourishment refrigerator did not have a temperature log. These failures had the potential to expose the facility residents to expired foods and placed these residents at risk of food borne illnesses (eating or drinking something that is contaminated with germs that can cause illness). Findings: 1. During a concurrent observation and interview on 4/22/24, at 8:24 AM, during the initial kitchen tour, three 5-gallon (unit of measurement for volume) containers were observed on the bottom shelf of a rack in the food storage room. The Dietary Service Supervisor (DSS) stated one bin contained…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff failed to maintain complete and accurate medical records in accordance with accepted professional standards for 3 of 25 sampled residents (Resident 390, Resident 3, and Resident 8) when: 1. Resident 390's wound care was not documented in a timely manner on 4/14/24, 2. Resident 3 and Resident 8's records indicated nail care was provided, but Resident 3 and Resident 8 had long dirty nails; and, 3. Resident 3's shower schedule in the electronic and physical record did not match. These deficient practices had the potential to result in confusion in the care and services for Resident 390 and placed the resident at risk for not receiving appropriate care due to inaccurate and incomplete documentation, and resulted in inaccurate medical records for Resident 3 and Resident 8, and missed showers for Resident 3. Findings: 1. A review of Resident 390's admission Record indicated Resident 390 was admitted to the facility with diagnoses including an open wound on the right and left thighs, and an infection of the skin and subcutaneous…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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' needs were accommodated promptly for 2 of 25 sampled residents( Resident 190 and Resident 63) when call lights were not answered in a timely manner. This failure resulted in needs not being met promptly and had the potential to cause psychosocial and/or physical harm for Resident 190, and Resident 63. Findings: 1. During a concurrent observation and interview on 4/22/24, at 9:18 a.m., Resident 190 was noted resting in bed in her room. Resident 190 stated she did not have her hearing aids on and could not hear well without her hearing aids. During a continued observation on 4/22/24, at 9:21 a.m., Resident 190 pressed her call light for staff to come help give her hearing aids from her nightstand drawer. During a continued observation and interview on 4/22/24, at 9:30 a.m., a staff member was heard talking outside the room in the hallway. Resident 190 stated in a frustrated tone that she wished she could get her hearing aids herself. During a continued observation on 4/22/24, at 9:37 a.m.,…

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

Based on observation , interview, and record review, the facility failed to ensure a comprehensive care plan was developed and revised for 3 of 25 sampled residents (Resident 6, Resident 8, and Resident 16), when: 1. A care plan was not developed for Resident 6 and Resident 16's oxygen therapy use; and, 2. Resident 8's nutrition care plan was not revised. These failures had the potential for Resident 6, Resident 8, and Resident 16's plan of care not being followed. Findings: 1a. A review of Resident 16's admission RECORD, indicated, she was re-admitted to the facility in 2024 with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD, long term lung disease that causes airflow blockage and shortness of breath). A review of Resident 16's MAR dated April 2024, indicated, .Oxygen at 2 LPM (Liter Per Minute) via nasal cannula (NC: a small, flexible tube that contains two open prongs intended to sit just inside the nostrils). continuous .Order Date 03/14/2024 . During a concurrent interview and record review on 4/24/24, at 9:22 AM, Licensed Nurse (LN) 12 confirmed 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 administer parenteral fluids (fluids/medications administered through the vein, also known as IV or intravenous) within the professional standards of practice for two of five residents on IV therapy (Resident 22 and Resident 191) when: 1. Resident 22's IV tubing (plastic tubing that delivers the medication to the vein) did not have a cap (a covering device that covers the opening of the tubing and reduces the risk of infection to the resident) at the end of the tubing when the IV tubing was not in use; and, 2. Resident 191's PICC line (Peripherally Inserted Central Catheter: a long, thin tube that is inserted through a vein in the arm, neck or leg and passed through to the larger veins near the heart for long term intravenous (IV) antibiotics, nutrition, medication or blood draws) dressing was not changed. These failures could have resulted in Resident 22 acquiring an infection, and resulted in Resident 191's PICC line dressing not changed per physician order and increased the risk for infection at 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 food preferences were honored for 3 of 90 residents (Resident 23, Resident 41, and Resident 344) receiving meals from the kitchen, when pasta was added to Resident 23's meal tray, salt packets were added to Resident 41's meal tray, and rice was served to Resident 344. These failures had the potential to result in unintended weight loss and other adverse health effects for Resident 23, Resident 41, and Resident 344. Findings: a. During a concurrent tray line observation and record review on 4/24/24, between 11:45 AM- 12:45 PM, Resident 23's tray card indicated, .Dislikes .Pasta . Dietary staff were observed adding pasta to Resident 23's tray. The tray was placed on the cart to be delivered to the residents. The Dietary Services Supervisor (DSS) confirmed pasta was added to Resident 23's plate and should not have been. A review of Resident 23's care plan indicated, .Focus .The resident is at risk for impaired nutritional status r/t [related to] at risk for wt [weight] fluctuations .Goal .encourage…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 their infection control policies and procedures when there was no signage posted on the door or the wall outside of Resident 64's room indicating the type of transmission-based precautions (TBP- precautions implemented based upon means of transmission to prevent or control the spread of germs) and required personal protective equipment (PPE- gowns, gloves, eye protection, facemasks or respirators used to prevent the spread of germs) needed prior to entering Resident 64's room. This failure could have resulted in the spread of infection and the need for additional medical interventions (medications/treatments) with a census of 91 residents. Review of Resident 64's admission Record indicated Resident 64 was admitted to the facility with diagnoses which included a nephrostomy tube (a tube that lets urine drain from the kidney through an opening in the skin). During a concurrent observation and interview with Resident 64 on 4/22/24, at 9:20 a.m., Resident 64 stated, There are gowns and gloves outside 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 services provided to one of three sampled residents (Resident 1) met professional standards of quality, when Resident 1's insulins ( medication used to treat high blood sugar levels) were not administered timely. This failure resulted in delayed medication administration and had the potential for the medication to not be fully effective and to cause high blood sugar levels for Resident 1. Findings: Review of Resident 1's admission record indicated Resident 1 was admitted to the facility in early November 2023 with multiple diagnoses including diabetes mellitus (a metabolic disease, involving inappropriately elevated blood sugar levels) with foot ulcer, and heart failure. Review of Resident 1's Medication Administration Record (MAR) for November 2023 indicated Resident 1's HumaLog Solution (insulin used to treat high blood glucose levels) and Lispro (used to treat high blood sugar levels) were scheduled to be given three times a day at 6:30 a.m., 11:30 a.m. and 4:30 p.m. Further review of Resident 1's MAR 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify one of 3 sampled resident's (Resident 1) emergency contact person/s of Resident 1's change in condition (COC), when Resident 1 had a low blood sugar (BS) level, fell with resulting head injury, became unresponsive, and was sent to the hospital on [DATE]. This failure resulted in Resident 1's family being uninformed and unaware of Resident 1's COC. Findings: Review of Resident 1's admission record indicated Resident 1 was admitted to the facility in early November 2023 with multiple diagnoses including diabetes mellitus (a metabolic disease, involving inappropriately elevated blood sugar levels) with foot ulcer, difficulty with walking and mobility, need for assistance with personal care, and had a history of falling. Further review of the admission record indicated Resident 1's Family Member (FM) 1 was listed as his emergency contact #1 and power of attorney (a document outlining who is responsible for making decisions for another person) for…

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

Based on observation, interview, and record review the facility failed to ensure a reasonable accommodation of needs for 1 out of 4 sampled residents (Resident 3) when Resident 3 needed assistance and was unable to access the call light. This failure caused Resident 3's needs to be unmet and had the potential to cause physical and psychosocial harm. Findings: A review of Resident 3's admission RECORD, indicated, Resident 3 was admitted to the facility in November of 2023, with diagnoses which included, systemic lupus erythematosus (SLE, an inflammatory disease caused when the immune system attacks healthy tissue), anxiety disorder, and fibromyalgia (a chronic disorder that causes pain and tenderness throughout the body). During a concurrent observation and interview on 12/1/23 at 9:31 AM, in Resident 3's room, Resident 3 was lying in bed asking for help. Resident 3 stated she needed to be changed. Resident 3 further stated she had no call light, so she yelled to get help. Resident 3 stated she had needed help for a few hours. During a concurrent observation and interview at 9:32 AM,…

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

Based on observation, interview, and record review the facility failed to ensure 2 out of 4 sampled residents, (Resident 2 and Resident 4), were assisted with nail care as a part of their activities of daily living (ADL's, normal daily functions related to personal care needs) when staff did not trim their fingernails. These failures had the potential for Resident 2 and Resident 4 to acquire an infection or sustain injuries related to having long, jagged, and unclean nails. Findings: a. During a phone interview on 11/30/23, at 3:40 PM, family member (FM) 1 stated they had requested Resident 2's fingernails to be trimmed three weeks ago. FM 1 further stated Resident 2's fingernails were chipped, broken, and sharp. FM 1 stated a request was made again on 11/29/23 due to Resident 2 scratching himself. A review of Resident 2's admission RECORD, indicated, Resident 2 was admitted to the facility in November of 2023 with diagnoses which included, weakness, type 2 diabetes mellitus (a chronic disease that affects blood sugar levels), and chronic kidney disease. During a concurrent…

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

Based on observation, interview, and record review, the facility failed to implement interventions to reduce the risk of elopement for one resident (Resident 1) in a sample of three, when the monitoring of a sensor device (an device worn by the resident used to alert staff of attempts to exit the building) worn by Resident 1 was not entered into Resident 1's electronic health record (EHR, resident health information that can be accessed across different disciplines) after Resident 1 eloped from the building on 7/2/23. This failure resulted in Resident 1's sensor device not being monitored by staff to ensure it was in working order and resulted in the sensor device not being checked for placement on Resident 1's body, potentially resulting in Resident 1 eloping from the facility. Findings: A review of Resident 1's admission RECORD indicated Resident 1 was admitted to the facility with diagnoses which included dementia (a condition characterized by loss of memory and thinking, and often personality changes). A review of Resident 1's Minimum Data Set (MDS - an assessment tool) dated…

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

Based on interview and record review the facility failed to ensure the facility's arbitration agreement (a document that designates a third party to resolve a dispute between others), that was presented to residents to sign, contained the selection of a neutral arbitrator (an impartial, or unbiased third-party decision maker, contracted with, and agreed to by both parties to resolve their dispute) and a venue (a location to carry out the arbitration proceedings that was agreed upon by both parties) that was convenient to both parties for a census of 90. This deficient practice had the potential for facility residents to be misinformed and to potentially negatively affect the ability to resolve disputes fairly. Findings: During a concurrent interview and record review on 4/14/23, at 3:59 p.m., the facility's undated arbitration agreement titled DISPUTE RESOLUTION AGREEMENT, was reviewed with the Administrator (ADM). The ADM stated the Dispute Resolution Agreement was presented to residents and/or their responsible parties within 72 hours of their admission to the facility. 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 a safe and comfortable homelike environment when: 1. No follow up occurred after two of three residents (Resident 73 and Resident 45) reported missing personal property; 2. One of three residents (Resident 73) inventory check list was incomplete; 3. One of thirty sampled residents (Resident 59) bedside table had a large hole in it; 4. Meals were served on trays for ten of ten residents eating in the dining room; and, 5. Towels were used as clothing protectors during mealtime for seven of ten residents eating in the dining room. These failures removed residents' rights to a dignified homelike environment, with the potential to result in psychosocial harm. Findings: 1a. During an interview on 4/11/23, at 9:30 a.m., Resident 45 stated, .someone stole my stuff on February 15th, and the facility didn't do anything about it. Resident 45 further stated the missing items included: brand new clothes, shoes, boots, a zippo lighter with sentimental value, jewelry boxes, and a black lock box. During an interview…

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

Based on observation, interview, and record review, the facility failed to meet the interests and support the physical, mental, and psychosocial needs for three of thirty sampled residents (Resident 75, Resident 63, and Resident 83) when in-room activities were not provided for the three residents who remained in their own rooms and were unable to attend out-of-room activities. This failure had the potential to affect the psychosocial needs and wellbeing of Resident 75, Resident 83, and Resident 63. Findings: 1. A review of Resident 75's admission RECORD indicated Resident 75 was admitted to the facility in 2022 with diagnoses which included end stage renal disease (last stage of long-term kidney disease), cerebral edema (swelling of the brain) and left sided hemiplegia (a severe or complete loss of strength). During an interview on 4/11/23, at 3:09 p.m., Resident 75 stated, .They said they would get me up . Resident 75 stated she had not attended any out of room activities and indicated she was provided a wheelchair. Review of Resident 75's clinical record, Activity .Assessment,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure a safe environment when: A smoking assessment and smoking care plan was not completed in a timely manner for 2 of 15 residents who smoked cigarettes, (Resident 81 and Resident 244). These failures had the potential to result in smoking accidents for Resident 81 and Resident 244. Findings: a. A review of the admission RECORD, (a document containing clinical and demographic data) for Resident 81 indicated, Resident 81 was admitted to the facility in 2023 with diagnoses which included, weakness and altered mental status (a change in mental function). A review of the Minimum Data Set (MDS-an assessment tool), section C, Cognitive Patterns, Resident 81 scored 99, indicating severe cognitive impairment (Problems with a person's ability to think, learn, remember, use judgement, and make decisions). A review of Resident 81's admission Nursing Assessment, dated 3/2/23, the admission Nursing Assessment indicated, .C. SOCIAL HISTORY/LIFESTYLE…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 was provided in accordance with professional standards of practice for four out of four residents sampled (Resident 17, Resident 45, Resident 59, and Resident 43) when: 1. Resident 17 and Resident 45's oxygen flow rates did not match their physician orders; 2. Resident 45's oxygen humidifier bottle (medical device used to increase moisture and decrease dryness from supplemental oxygen) was empty; 3. Resident 17's, Resident 43's, and Resident 45's nasal cannula (flexible tubing that sits inside the nostrils and delivers oxygen) was not dated; 4. No oxygen care plan was created for Resident 17; and, 5. Resident 43, Resident 59, and Resident 45's oxygen concentrator (a machine used to deliver extra oxygen to a person) filters were covered in dust/debris; These failures had the potential to result in negative impacts on Resident 17, Resident 45, Resident 59, and Resident 43's health and safety, including risks for ineffective oxygen therapy and respiratory distress. Findings: 1a. During a…

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

Based on interview, record review, and facility policy and procedure review, the facility failed to ensure notification requirements were implemented for a census of 90, when: 1. Residents, Resident Representatives, and Staff were not notified of new cases of COVID-19; and, 2. Required elements of notification were not present in the facility policy and procedure and the notifications of COVID-19. These failures resulted in residents, Resident Representatives, and Staff not being notified in a timely manner of the current status of COVID-19 in the facility and not being fully informed due to missing elements in the notification process, placing residents, Resident Representatives, and Staff at increased risk for COVID-19. Findings: 1. During a concurrent interview and record review on 4/13/23, at 9:41 a.m., with the Infection Preventionist (IP), the IP stated the facility used a telephone notification system and for the latter half of March 2023, notifications went out via this system on 3/20/23, 3/23/23, and 3/24/23. On 3/21/23, one staff member and one resident tested positive for…

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

Based on observation, interview, and record review, the facility failed to ensure reasonable accommodation of needs were honored for one of thirty sampled residents (Resident 245), when Resident 245's wheelchair was not available for use due to Resident 245's wheelchair being borrowed to another resident. This failure resulted in Resident 245 not being able to get up for the lunch meal. Findings: During an observation on 4/11/23, at 12:20 p.m., Resident 245 called out from his bed, Where is my wheelchair? During an observation on 4/11/23, at 12:31 p.m., staff entered Resident 245's room. Resident 245 asked the staff where his wheelchair was. Staff responded to Resident 245 stating the facility had borrowed it for another resident to go to a doctor's appointment. During an interview on 4/11/23, at 12:31 p.m., Certified Nurse Assistant (CNA) 3 stated she took Resident 245's wheelchair around 10 a.m. today to use it for another resident who had a doctor's appointment today, who did not have a wheelchair. CNA 3 stated there were no additional wheelchairs available in the facility that…

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

Based on observation, interview, and record review, the facility failed to provide services which met professional standards of quality for one of 30 sampled residents (Resident 52), when Resident 52's order for thromboembolic deterrent hose (TED- stockings designed to promote circulation in the legs to prevent the formation of blood clots) was not followed. This failure placed Resident 52 at increased risk for developing blood clots. Findings: A review of Resident 52's admission RECORD, indicated Resident 52 was admitted to the facility in the winter of 2022 with diagnoses which included diabetes mellitus (a chronic condition that affects the way the body processes blood sugar) and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). A review of Resident 52's clinical record, Physician Orders indicated, .TED hose ON in AM, OFF at HS [bedtime] every day and evening shift . During a concurrent observation, interview and record review on 4/13/23, at 9:03 a.m., Licensed Nurse (LN) 1 confirmed Resident 52 was not wearing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure that one of 30 sampled residents (Resident 5) functional abilities did not diminish when: 1. Resident 5 had a decline in her ability to walk, and services were not provided to determine the cause and/or to maintain her ambulation status; and, 2. Resident 5 did not receive restorative nursing assistant (RNA) services five times weekly from 3/26/23-4/13/23. This failure potentially contributed to Resident 5's decline in ambulation status. Findings: 1. Review of Resident 5's admission RECORD, indicated Resident 5 was admitted to the facility in 2018 with diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or inability to move one side of the body) following cerebral vascular accident (CVA, damage to the brain from interruption of its blood supply) During a concurrent observation and interview on 4/12/23, at 8:10 a.m., Resident 5 was sitting up in 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 interview, clinical record review, and facility policy and procedure review, the facility failed to ensure acceptable parameters of nutritional status related to significant weight loss for one of four sampled residents, (Resident 86). This failure resulted in Resident 86's significant weight loss not being monitored effectively to prevent further weight loss, potentially affecting Resident 86's health and well-being. Findings: A review of Resident 86's clinical document, admission RECORD, (a document containing clinical and demographic data), indicated Resident 86 was admitted to the facility 3/12/23, with diagnoses of dysphagia (difficulty or discomfort in swallowing) and diabetes (problems with blood sugar). A review of Resident 86's weights in the clinical record indicated the following: 3/12/23 132 Lbs. (pounds) 3/19/23 125 Lbs. 4/9/23 117 Lbs. The weights indicated a weight loss of 7 Lbs. (5.3%) from 3/12/23 to 3/19/23 and an 8 Lb. weight loss (6.4%) from 3/19/23 to 4/9/23 for a total of 15 Lbs. (11.36%) in 4 weeks. There were no documented weights recorded for March…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 routine medications were provided for one of six sampled residents (Resident 153) observed during medication administration when, Resident 153 did not receive a prescribed medicated inhaler for two days because it was unavailable. This failure had the potential to cause worsening of respiratory symptoms for Resident 153. Findings: Review of Resident 153's admission RECORD indicated Resident 153 was admitted to the facility with diagnoses which included, chronic obstructive pulmonary disease (COPD, a disease of the lungs that blocks airflow and makes it difficult to breath) and dependence on supplemental oxygen. During a concurrent observation of a medication pass and interview on 4/13/23, that started at 7:05 a.m., Licensed Nurse (LN) 3 prepared Resident 153's medications for administration. LN 3 stated Resident 153's tiotropium bromide inhaler (an inhaled medication to prevent bronchospasm (the airways that connect your windpipe to your lungs are called bronchi. Sometimes the muscles that line your…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication irregularities were identified during the monthly drug regimen review (DRR) for one of thirty sampled residents (Resident 73) when, Resident 73 had an as needed (PRN) order for buspirone (medication used to treat anxiety) with no end date which was not identified and reported to the appropriate facility personnel. This failure had the potential for Resident 73 to continue to take a mind altering medication for a prolonged duration with risks for side-effects to occur. Findings: Review of Resident 73's admission RECORD indicated that Resident 73 was adminitted to the facility with diagnoses which included anxiety and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of Resident 73's Medication Administration Record (MAR, where doctor's medication orders were documented as given), dated 4/2023, indicated an order as follows: .busPIRone .Oral Tablet 10 MG [milligrams, a unit…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two of thirty sampled residents (Resident 73 and Resident 21) psychotropic medication (any drug that affects brain activities associated with mental processes and behavior) regimen were safely managed and monitored when; 1. Resident 73's PRN (as needed) order for buspirone (a medication to treat anxiety) was ordered for longer than 14 days and without an end date or medical doctor's review and assessment; and, 2. A gradual dose reduction (GDR; an attempt to taper or discontinue a medication) recommendation was not followed for two medications, olanzapine (a medication used to treat mental disorders) and trazadone (a medication used to treat depression), by the medical doctor (MD) for Resident 21. These failures had the potential for Resident 73 and Resident 21 to remain on potentially unnecessary medication for an extended duration, with the potential to result in adverse consequences (side effects) from long term use. Findings: 1. Review of Resident 73's admission RECORD indicated that Resident 73 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 observation, interview, and record review, the facility failed to ensure the medication administration error rate was less than five percent (%), when two medication errors occurred out of twenty-seven opportunities during medication administration for 2 out of 6 residents observed (Resident 153 and Resident 65). As a result of these failures, the facility's medication administration error rate was 7.41%. Findings: 1. During a concurrent observation of a medication pass and interview on 4/13/23, at 3:12 p.m., Licensed Nurse (LN) 8 prepared Resident 65's medications for administration. LN 8 removed two medications from the medication cart, pantoprazole (a medication that decreases the amount of acid made in the stomach) and another type of medication and placed them in a small plastic pouch. LN 8 crushed both of the medications with a medication crusher located on top of the medication cart. LN 8 mixed the two medications together in applesauce and entered Resident 65's room to administer the medications. LN 8 returned to the medication cart and confirmed she had crushed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the proper storage of drugs and biologicals for a census of 90 when; 1. A lock was not secured on the refrigerator that contained a controlled substance (a drug or other substance that is tightly controlled by the government because it may be abused or cause addiction); 2. Keys to the locked refrigerator that contained a controlled substance was left unattended in the medication storage room; 3. The temperature of a medication storage room was not monitored; and, 4. Two blood glucose test strips (small, plastic strips used to test and measure the blood glucose (sugar) level in the body) containers were not labeled with an open date. These failures had the potential for drug diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber), medications to become ineffective, and blood glucose readings to be inaccurate. Findings: 1. 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 observation, interview, and facility policy review, the facility failed to prepare food appropriate to meet resident's needs when; 1. A pureed food (a pudding-like texture that is smooth, blended, or pureed) was not prepared in the correct consistency for five out of five residents receiving pureed diet, and 2. Diet orders and meal textures were not verified before service of meal trays for 22 of 25 patients on a modified diet, (Patient 86, Patient 77, Patient 75, Patient 46, Patient 79, Patient 39, Patient 34, Patient 43, Patient 149, Patient 94, Patient 11, Patient 30, Patient 396, Patient 66, Patient 394, Patient 63, Patient 3, Patient 65, Patient 38, Patient 397, Patient 195, Patient 194). This failure had the potential for food aspiration (something you swallow goes down the wrong way and enters your airway or lungs) for all five residents on pureed diet and 22 residents on a modified diet. Findings: 1. During a test tray (to evaluate the quality of a meal during a normal meal service) observation of a pureed diet lunch meal tray with the Certified Dietary Manager…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility policy review, the facility failed to follow proper sanitation and food handling practices for a census of 90 when: 1. Residents were not offered hand hygiene prior to meals in the dining room, 2. Staff did not perform hand hygiene prior to passing meal trays in the dining room and in the residents' rooms at Station 4 (a unit in the facility). These failures had the potential to cause an outbreak of foodborne illnesses (eating or drinking something that is contaminated with germs or chemicals that can make people sick). Findings: 1. During a lunch meal observation in the facility's main dining room on 4/11/23, at 12:21 p.m., there were ten residents seated at six different square tables waiting for their lunch meal to be served. When the food cart arrived, the staff pulled out each of their meal trays and served it to the residents without offering hand hygiene and some of the residents had fingerfoods for lunch. During an interview with Certified Nurse Assistant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy review, the facility failed to maintain the garbage storage area in a sanitary condition when two out of two dumpsters stored outside the building and behind the kitchen were left open. This failure had the potential to attract pests. Findings: During an observation of the facility's garbage storage area with the Certified Dietary Manager (CDM) on 4/13/23, at 8:03 a.m., there were two dumpsters noted that were uncovered and one of the dumpsters was filled with trash. The CDM explained the garbage company picked up the trash three times a week and returned the dumspters uncovered. The CDM stated the dumpsters should be covered everyday due to the risk of attracting pests, pests could spread diseases, and could get into the building. During an interview with the Registered Dietician (RD) on 4/14/23, at 12:56 p.m. the RD stated, .The garbage bins [dumpters] should be covered . Review of the facility's policy and procedure titled, GARBAGE AND RUBBISH DISPOSAL, effective date February 2009, indicated, .Maintain a sanitary and safe environment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 inform residents or their representatives of the nature and implications of any proposed binding agreement when one out of three sampled residents (Resident 55) signed the arbitration agreement (a document that designates a third party to resolve a dispute between others) in a form or manner that she did not understand. This deficient practice had the potential for Resident 55 to sign a binding agreement without ensuring a complete understanding of the document that was signed. Findings: A review of Resident 55's admission Record, indicated Resident 55 was admitted to the facility with diagnoses which included developmental delay (A delay in reaching language, thinking, social, motor skills milestones). Under the section CONTACTS, listed responsible party (RP) 1 as Resident 55's responsible party for Health Care Decision Maker and Financial decisions. During an interview on 4/14/23, at 2:11 p.m., Resident 55 stated she did not recall signing an arbitration agreement. Resident 55 explained RP 1 was her decision maker and…

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

Based on observation, interview, and record review the facility failed to ensure appropriate infection control measures were completed for a census of 90 when: 1. A blood pressure cuff (used to measure a resident's blood pressure) was not cleaned between resident use; 2. The rubber seals on Resident 147's insulin pens (medication used to treat/prevent high blood sugars in the body) were not cleaned with an alcohol wipe prior to attaching the needles; and, 3. Hand hygiene was not completed during wound care for Resident 86. These failures had the potential to spread germs among residents, to inject germs into Resident 147's body, and had the potential to cause infection to Resident 86's wound. Findings: 1. During an observation on 4/13/23, at 7:01 AM, Resident 146 approached Licensed Nurse (LN) 3 in the hallway asking for pain medication. LN 3 checked Resident 146's blood pressure with the blood pressure cuff and placed it on the top of the medication cart when she was done. During an observation on 4/13/23, at 7:16 AM, LN 3 removed the blood pressure cuff from the medication cart…

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