Montrose Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a homelike, orderly environment for one out of three sampled residents (Resident 43) when the resident's wall clock inside the room showed an incorrect time. This deficient practice compromises the comfort and orderliness of the resident's environment. During a review of Resident 43's admission Record (AR), the AR indicated that the resident was originally admitted on [DATE], and readmitted on [DATE], with diagnoses that included Alzheimer's disease (a brain disorder affecting memory, thinking, and behavior), anxiety disorder (persistent, excessive fear or worry that interferes with daily life), and schizophrenia (a mental health condition that affects how people think, feel and behave). During a review of Resident 43's History and Physical (H&P), dated 2/11/2026, the H&P indicated that the resident does not have the capacity to understand and make decisions. During a review of Resident 43's Minimum Data Set (MDS, a 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure for one of three sampled residents (Resident 61) that a written bed-hold policy was provided to the resident and/or resident representative prior to transfer to the General Acute Care Hospital (GACH) on 3/28/2026 for a change of condition (COC). This deficient practice resulted in Resident 61 and/or their representatives not being informed of their rights regarding bed reservation during hospitalization, which could lead to confusion and disruption in continuity of care. Findings: During a review of Resident 61's admission Record (AR), the AR indicated was admitted to the facility on [DATE] with a diagnosis with a diagnosis that included fracture of the right femur (longest and heaviest bone in the body) and dementia (decline in mental abilities such as memory, thinking, and reasoning). During a review of Resident 61's History & Physical signed and dated 3/24/2026, indicated that Resident 61 did not have the capacity to understand and make…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to update one of 15 sampled residents (Resident 7) Restorative Nursing Aide program's (RNA, nursing aide program that help residents to maintain their function and joint mobility) care plan to reflect Resident 7's updated and current RNA treatment program. This deficient practice had the potential for Resident 7 to receive improper treatment and services and minimize the facility's ability to review the effectiveness of Resident 7's RNA program.Findings: During a review of Resident 7's Face Sheet (FS) dated 4/29/2026, the FS indicated Resident 7 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to cerebrovascular disease (disease of the blood vessels, especially blood vessels to the brain), hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infarction (blockage of the flow of blood brain, causing or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medication was adequately administered as ordered for one out of three sampled residents (Resident 15), by failing to: Ensure licensed vocational nurse (LVN) 1 remained with Resident 15 until the entire administered medication, Simethicone (medication used to relieve symptoms of excess gas, such as bloating) tablet chewable 80 MG (milligram, a unit of measuring weight), was swallowed. Ensure LVN 1 applied pressure over Resident 15's tear duct after the administration of Cyclosporine (eye drop medication that is administered directly to the eyes and is used to increase tear production) eye drops. This deficient practice placed Resident 15 at risk of not receiving the intended effects of the medications and could lead to the mismanagement of the resident's diseases. Findings: During a review of Resident 15's admission Record (AR), the AR indicated that the resident was admitted on [DATE] with diagnoses that included muscle weakness,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the prescribed diet order for one out of four sampled residents (Resident 66) when the resident's meal tray contained food items that did not follow the physician's order and resident care plan of Soft and Bite sized texture diet due to difficulty swallowing. This deficient practice placed the resident at risk of choking. During a review of Resident 66's admission Record (AR), the AR indicated that the resident was originally admitted on [DATE], and readmitted on [DATE], with diagnoses that included diabetes mellitus (prolonged elevated blood sugar levels), Alzheimer's Disease (a brain disorder affecting memory, thinking, and behavior), and psychosis (a collection of symptoms involving a loss of contact with reality, characterized by hallucinations (seeing/hearing things not there) and delusions (false beliefs). During a review of Resident 66's History and Physical (H&P), dated 4/23/2026, the H&P indicated that the resident does…

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

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), had a comprehensive, person-centered care plan created for known behaviors related to the diagnosis of dementia.During the investigation, Resident 1 had known behaviors that included noncompliance with safety interventions, such as the resident's inability to consistently remember to use the call light and repeated attempts to get out of bed or chair without seeking staff assistance. Despite a documented history of three prior falls, Resident 1's care plans lacked individualized interventions and measurable goals to effectively manage Resident 1's behaviors. This failure has further potential to result in a decline in the resident' physical and psychosocial well- being due to the lack of individualized and effective care.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility initially admitted the resident on 11/26/2025, with a diagnosis of dementia (a decline in mental ability such as memory, and problem solving,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to store medications safely, labeled with expiration or discard date and store controlled drugs (medications that can create mental and physical addiction or dependency) in a locked in compartments that are separately locked in storage of controlled drugs for two of two sampled residents receives (Residents 37 and 40) in accordance to the facility's policy and procedure (P&P) titled, Storage of Medications. by failing to ensure: 1. Resident 37 does not store two bottles of Flonase nasal suspension (a nasal spray that treats allergy symptoms like sneezing, itching and a runny or stuffy nose) in his nightstand drawer who was not a candidate for Self Medication Adminitration. 2. Resident 40's Lorazepam (a controlled medication medications that can create mental and physical addiction or dependency used to treat anxiety [fear of the unknown]) was separately locked from other non controlled medications (not addictive or habit forming) in the…

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

Based on observation, Interview, and record review the facility failed to ensure proper food handling practices by: Failing to prepare food in a manner to prevent food born illness by using bare hand contact while plating food. Failing to label with the Use by Date potentially hazardous food in the refrigerator and freezer. These deficient practices had the potential to result in foodborne illness for those who receive and consume food prepared from the facility kitchen. Findings: During an initial tour of the kitchen on 4/7/2025 at 8:16 AM and concurrent interview with the Dietary Supervisor (DS), there were multiple plastic cups observed labeled whole milk and juice stored in the refrigerator. The cups labeled with poured date of 4/6/2025 but did not include a use by or expiration date. Dietary Supervisor stated the date on label reflects the date the milk and juice had been poured into cups and further stated the Use by Date was not necessary. During the continuation of the kitchen tour with the DS, observed in the reach- in freezer one bag of green beans, loosely wrapped and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews the facility failed to provide respect and dignity to one of 18 sampled residents (Resident 1) who received a meal tray 20 minutes after the other residents she was seated with in the dining table received their trays. When Resident 1 received her meal tray, she ate by herself. This deficient practice violated the rights of Resident 1 to have dignified, equal care and potentially affect Resident 1's self-esteem and self-worth. Findings: During an observation on 4/8/25 at 12:40 PM in Activity/Dining Room, Resident 1 was observed sitting in the dining room waiting for the lunch tray while other residents at the same table were eating. During a review of Resident 1's admission Record (AR), indicated Resident 1 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that include but not limited to heart failure (the heart muscle doesn't pump blood as well as it should), schizophrenia (a mental illness that is characterized by disturbances in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 licensed nurse to document the accurately and timely after medications were administered to one of four residents (Resident 37) in accordance with the facility ' s policy and procedure (P&P) titled, Administering Medications, as evidenced by: 1.Document Resident 37's medications that were scheduled at 9 AM as administered on the Medication Administration Record (MAR) before the actual medication administration. 2. Document Resident 37's ASA (Aspirin medication that thins the blood to prevent blood clot to form) that was not administered, as administered on the MAR. The deficient practices had result in Resident 37 not receiving ASA as scheduled and put him at risk for medication error, including overdosing and underdosing on medications. Findings: During a review of Resident 37's admission Record (AR), the AR indicated the facility originally admitted Resident 37 on 4/28/2022 and readmitted him on 1/5/2025 with diagnoses that included dementia (a term for a range of conditions that affect the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to assist one of three sampled residents (Resident 9) who unable to carry out activities of daily living (ADLs) and incontinent (no control) of bladder and bowel receives assistance with perineal care and changed incontinent brief timely. Resident 9 was observed with wet incontinent brief with pink colored urine and had foul smell that was not changed from 7am to 3:10 pm on 4/7/2025. This deficient practice had the potential to place Resident 9 at risk for infection and skin breakdown and to negatively impact Resident 9's self-esteem. Findings: During a review of Resident 9's admission Record (AR), the AR indicated that Resident 9 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including sepsis (a life-threatening blood infection), obstructive and reflux uropathy (a condition in which the flow of urine is blocked and backward from the bladder into a ureter and toward a kidney), and anemia (a condition where…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide necessary care and interventions to prevent development or recurrence of pressure injury (PI-localized damage to the skin and/or underlying tissue usually over a bony prominence) for one of three sampled residents (Resident 9) who was not repositioned and turned, skin was not assessed and documented in the resident's clinical record the skin condition daily and weekly as indicated in the residents care plan, and facility ' s policy and procedures titled Prevention of Pressure Injuries. These deficient practices placed Resident 9 and all other residents at risk for skin breakdown to develop PI or reopening of a healed PI that could lead to discomfort, pain and infection. Findings: During a review of Resident 9's admission Record (AR), the AR indicated that Resident 9 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including sepsis (a life-threatening blood infection), obstructive and reflux uropathy (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, the facility failed to provide an environment free of accident and hazard, monitoring and supervising as indicated in the facility's policy and procedure and resident's care plan for one out of 4 residents (Resident 2) who was at risk for fall due to poor safety awareness and unable to see clearly due to an eye infection and wandering behavior (walking in places aimlessly), Resident 2 was walking in the room with eyes closed and hands outstretched, running into wall several times near the restroom area without staff present to assist or redirect the resident. This failure had the potential to result in serious physical harm, psychosocial isolation, and unmet care needs, compromising both the resident ' s safety and quality of life. Findings: During a review of Resident 2's admission Record indicated Resident 2 was originally admitted on [DATE] with a diagnosis of dementia (a disease that affects ability perform everyday activities, memory and thinking) ,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to accurately monitor signs and symptoms of urinary tract infection (UTI- an infection in the bladder/urinary tract) for one of one sampled resident with suprapubic catheter (SPC- a tube that is used to drain urine from the bladder through a cut in the abdomen) was secured with anchor (a catheter securement device) as indicated in the facility ' s policy and procedure titled Catheter Care, Urinary by failing to ensure: 1. Resident 9 was monitored for presence of foul urine smell and pink urine stain in the incontinent brief (undergarment used due to incontinence (no control) bladder and bowel. 2. Resident 9 ' s suprapubic catheter was secured with an anchor to prevent or minimize dislodging. These deficient practices had the potential for Resident 9 to develop recurrent UTI and bladder trauma and receive delayed care and treatment from infection that could lead to a decline in the residents well being. Findings: During a review of Resident 9…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 aspirin (ASA, a drug used to treat pain, fever and reduce the risk of heart attack) 81 milligram (mg, a unit of measurement) one tablet for one of four residents (Resident 37) as ordered by the physician. The deficient practice had resulted in Resident 37 not receiving ASA as physician ' s order which put the resident at risk for cerebrovascular accident (CVA, also known as a stroke, which occurs when blood flow to the brain is interrupted, leading to long-term disability or death). Findings: During a review of Resident 37 ' s admission Record (AR), the AR indicated the facility originally admitted Resident 37 on 4/28/2022 and readmitted him on 1/5/2025 with diagnoses that included dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function normally) and atherosclerotic heart disease (build up of fat in the blood vessels on the heart, causing blockage of blood flow to the heart and leading to heart attack and stroke). During a review of Resident 37 ' s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with the updated facility ' s policy and procedure (P&P) titled, Charting and Documentation, for one of three residents (Resident 52). The facility staff did not document vital signs (measurement of the blood pressure, heart rate, respiratory rate and body temperature) updated plan of care, and document the treatment and services provided completely and accurately on Resident 52 ' s clinical record with declining condition and was being considered for hospice care (end of life care) by the family and was found unresponsive on [DATE]. This deficient practice had the potential to negatively impact the delivery of services to Resident 52 and other potential residents in the facility. Findings: During a review of Resident 52 ' s admission Record (AR), the AR indicated the facility admitted Resident 52 on [DATE] with diagnoses that included dementia (a term for a range of conditions that affect…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed implement the facility ' s policy and procedure to Certified Nursing Assistant (CNA) 1 wear personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) during care activities for one of four sampled residents (Resident 33) who was placed on enhanced barrier precaution (EBP- an infection control measure designed to reduce transmission of multidrug-resistant organisms [MDROs-a germ that is resistant to many antibiotics.]) This deficient practice had the potential to result in the spread to infection in the facility that could affect the well being of the residents, staffs and visitors. Findings: During an observation and concurrent interview on 4/7/25 at 10:35 am, observed CNA 1 was in Resident 33 room with a sign for EBP posting at room entrance. CNA 1 was observed inside the room not wearing PPE. In an interview CNA 1 stated she was just looking 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide reasonable accommodation of need for two of four sampled resident (Resident 27 and Resident 14) who were at risk for fall, by failing to ensure the residents call light was within reach as indicated in the facility's policy and procedure, titled Call Lights and resident's Care Plan. These deficient practices had the potential for Resident 27 and Resident 14 not to receive or received delayed care to meet the necessary care and services that could result in fall and accident. Findings: a. During a review of Resident 27's admission Record, the admission record indicated the facility admitted Resident 27 on 3/24/2023 with diagnoses that included history of falling. A review of the Minimum Data Set (MDS- a resident assessment and care screening tool) dated 3/27/2024, indicated Resident 27 had no cognitive (ability to remember and process information) impairment that requires supervision or touching assistance and helper provides verbal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of four sampled resident (Residents 51 and 54) were provided a homelike environment to maintain a comfortable noise level in accordance with the facility ' s Policy and Procedure (P&P), when Resident 12 ' s disruptive behavior of yelling cursing and swearing kept Residents 51 and 54 awake at night and disturbed their sleep. This failure resulted in residents 51 and 54 to feel tired and/or frustrated that could potentially result the residents to experience a decline in their health, quality of life and psychosocial (mental and emotional) wellbeing. Findings: During a review of the facility's daily census report, dated 4/18/2024, the daily census report indicated Residents 12, 51, and 54, were roommates, all residing in the same room. During a review of Resident 12's admission Record (AR), the AR indicated Resident 12 was admitted to the facility on [DATE] with multiple diagnoses including fracture (broken bone) of the right…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 post actual worked nursing hours at the start of each shift in the nursing stations visible to the residents and visitors according to the facility ' s Policy and Procedure. This failure resulted in the facility inaccurately reflecting the number of staff providing direct care to the residents which could result in the residents not receiving the necessary care they needed. Findings: During a concurrent interview and record review on 4/20/2024 at 3:57 pm with the Director of Staff Development (DSD), the facility's Daily Staffing Posting dated 4/20/2024 and the facility's 7am - 3 pm staffing assignment, untitled, dated 4/20/2024 were reviewed. The staffing assignment indicated there were 10 Certified Nursing Assistants (CNA) assigned to care for residents during the morning shift. The DSD stated there were 10 CNAs working the morning shift. The Daily Staffing Posting indicated there were only 7 CNAs working the morning shift. The DSD stated she posted the Daily Staffing Posting the night before the shift started and that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medication room free from expired medications for one out of one medication storage room. During a review of the facility ' s policy and procedure, titled, Labeling of Medication Containers, revised 3/2023, indicated, Labels for individual resident medications include all necessary information, such as: the expiration date when applicable. This failure had the potential to result in the residents to recieve medications that are not effective to treat their diseases and result in a worsened health condition. Findings: During an inspection of the facility's medication storage room on 4/20/2024 at 9:23 am, with the Minimum Data Set Coordinator (MDSC), there were two bottles of undated opened Gabapentin oral solution (medication to treat seizures [a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations or states of awareness] and/or…

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

Based on observation, interview and record review, the facility's kitchen staff failed to follow the facility's infection control policies to ensure the department operates under sanitary conditions at all times by failing to wear a hair net (a net worn over the hair to keep it in place) in food preparing area. This failure had the potential to result in food contamination and food-borne illnesses (illness caused by consuming food or beverages containing disease causing organisms) to the residents. Findings: During an observation on 4/19/2024 at 5:36 pm, in the facility's kitchen, Dietary Supervisor (DS) was working in the food preparing area without wearing a hair net. During a concurrent interview, the DS stated that the DS forgot to wear a hair net before entering the kitchen's food preparing area. The DS stated anyone entering the kitchen should wear a hair net before walking in. The DS stated that wearing a hair net could prevent hair from falling in food and cause food contamination. The DS stated that food contamination could put residents at risk for food borne illness.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide information of Advance Directive (AD, a written preferences regarding treatment options, a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions.) for one out of two sample residents (Resident 36). This failure had the potential to result in the violation of the residents right and the facility staffs to provide medical or surgical treatment against the resident's will. Findings: During a review of Resident 36's admission Record indicated Resident 36 was readmitted on [DATE], with diagnoses that included dysphagia (difficult swallowing) and malignant neoplasm of prostate cancer (abnormal cell growth in the gland of male reproductive system). During a review of Resident 36's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 2/23/2024, 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 observation, interview and record review, the facility failed to follow the professional standard of care and the facility's policy and procedure on documenting the medication as given right after medication was administered for one out of five residents (Resident 6). This failure had the potential to result in medication error and a potential for the residents not to receive medications as prescribed by the physician or the same medication causing decline in the resident health condition. Findings: During medication administration observation on 4/20/2024 at 8:59 am with Registered Nurse 2 (RN 2), RN 2 completed administering Ceftriaxone (antibiotic or medication to treat bacterial infection) intravenously (IV, refers to a way of giving a drug or other substance through a needle or tube inserted into a vein) to Resident 6. After the medication administration RN 2 did not sign the Medication Administration Record (MAR, a record used to document medications taken by each individual) after administering…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 indwelling catheter (foley catheter - a tube inserted in the bladder to drain urine into a drainage bag) and ensure foley catheter touching the trash Bin as indicated in the facility ' s policy and procedure, titled Urinary Catheter Care and the resident ' s care plan for one of one sampled residents ( Resident 48) by failing to ensure: 1. Resident 48 was assessed and monitored the presence of white sediments (visible particles in the urine that may contain red or white blood cells, casts, bacteria, fungi, parasites in the urine that could indicate presence of infection or dehydration [fluid deficit]) and cloudiness in the urine. 2. The indwelling catheter was not touching the trash bin. These deficient practices had the potential for Resident 48 to receive no care or delayed care and treatment for urinary tract infection (UTI, condition in which bacteria invade and grow in any part the urinary system). Findings: During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 6) received care and services for parenteral (liquid solution administered into the vein) antibiotic (a drug used to treat infections caused by bacteria and other microorganisms) consistent with professional standards of practice and the facility's policy and procedure titled General Policy for IV therapy on documentation of intravenous catheter (IV-a plastic device inserted into the vein used to deliver fluids) insertion date This deficient practice had the potential for the resident to develop infection and worsen health condition. Findings: During an observation on 4/19/2024 at 6:13 pm, in Resident 6's room, Resident 6 ' s right hand was wrapped with gauze (a pad covers the IV site) with an IV port (part of the IV catheter that inserted into the skin) protruding out of the gauze. The IV site was not labeled with date of insertion. During a concurrent interview with Registered Nurse 1 (RN 1),…

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

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 49) received oxygen in accordance with the facility's policy and procedure by failing to: 1. Resident 49's nasal cannula tubing (flexible plastic tubing with prongs [small opening] used to deliver oxygen through nostrils and fitted over the patient ' s ears) and was touching the trash bin. 2. Resident 49 was receiving oxygen therapy without a physician's order. This deficient practice had the potential to increase the risk of the spread of infection to Resident 49 and at risk for shortness of breath and/or hypoxia (low levels of oxygen in the body tissues) which can lead to serious complications. Findings: During a review of Resident 49's admission Record, the admission record indicated the facility admitted Resident 49 on 1/27/2024 with diagnoses that included acute respiratory failure (a condition when the lungs cannot get enough oxygen into the blood) with hypoxia and pneumonia (infection that inflames the lungs). During a review of Resident 49's Minimum Data…

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

Based on observation, interview, and record review, facility failed to follow the facility ' s policy and procedure titled Management and Protection of Protected Health Information, by ensuring one of one sample residents (Resident 34) identifiable, personal and medical information were not exposed on the computer screens unattended and in view of unauthorized persons to view and access confidential information without the resident ' s consent or knowledge. This deficient practice resulted in Resident 34 ' s violation of resident ' s right for privacy. Findings: During a review of Resident 34 ' s admission record indicated, the facility admitted Resident 34 on 6/7/2023 with diagnoses that included anemia (decrease in the total amount of red blood cells in the blood) and neoplasm (abnormal cell growth with the potential to invade or spread to other parts of the body) related to pain. During a review of Resident 34 ' s History and Physical (H&P), dated 6/8/2023, the record indicated, Resident 34 had the capacity to understand and made decision. During a review of Resident 34 ' s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 14), who signed a Resident - Facility Arbitration Agreement (Binding Arbitration Agreement- is a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds), had the capacity to understand and make an informed decision. Resident 14 signed a Binding arbitration Agreement but did not have the capacity to understand and make decisions. This failure had the potential to result in Resident 14 to not be able to make an informed decision and/or her rights to be denied. Findings: During a review of Resident 14's admission Record (AR), the AR indicated Resident 14 was admitted to the facility on [DATE] with multiple diagnoses including schizophrenia (a disorder that affects a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection control practices per facility's Policy and Procedure (P&P) were followed to prevent the transmission of disease and infection for one of five sampled residents (Residents 52). The facility failed to place Resident 52 who had a Peripherally Inserted Central Catheter (PICC, a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart) on Enhanced Barrier Precautions (EBP, wearing gown and glove during high contact with resident care activities). This failure had the potential to result in the spread of infection to Resident 52 while residing at the facility. Findings: During a review of Resident 52's admission Record (AR), the AR indicated Resident 52 was admitted to the facility on [DATE] with multiple diagnoses including peritonitis (a redness and swelling of the tissue that lines the belly or abdomen), cancer of the stomach, and surgical aftercare following surgery…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 monitor and assess Resident 1 ' s surgical staples on the resident ' s surgical incision (a cut made through the skin and soft tissue to facilitate an operation or procedure) in the right upper hip for one of two sampled residents (Resident 1) in accordance with professional standards of practice. The facility ' s licensed nurses did not complete an assessment or monitor Resident 1 ' s surgical staples after Resident 1 ' s right hip surgery since admission to the facility. This deficient practice had the potential for increased risk for infection from Resident 1 ' s surgical wound with prolonged staples. Findings: A review of Resident 1 ' s Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including fracture of unspecified part of neck of right femur (the bone of the thigh), subsequent encounter for closed fracture (the bone is broken, but the skin is intact) with routine healing, chronic obstructive pulmonary…

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