Valley Palms Care Center

Based on interview and record review, the facility failed to ensure that nursing staff did not have a complete performance review for the following: 1. Provide basic activities of daily living (ADLs - toileting hygiene, shower/bathing) care training for one of five sampled staff (Certified Nursing Assistant 1). 2. Provide annual performance evaluation for four of five staff (Registered Nurse [RN] 1, Treatment Nurse [TN] 1, Certified Nursing Assistant [CNA] 1, and Certified Nursing Assistant [CNA] 2). These deficient practices had the potential for lack of knowledge and training among the staff, leading to inadequate resident care. Findings: During a review of the facility assessment tool (used to evaluate a facility's resident population, operational needs, and resource capacity to provide necessary care), revised 08/1/2025, the facility assessment tool indicated that the facility conducts an audit of all direct care staff competencies before the end of 2025. Additionally, competency training for staff continues to be an annual standard of practice within the facility. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors (the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for two of two sampled residents (Residents 76 and 39) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin administration sites. This deficient practice had the potential for adverse effect (unwanted, unintended result) of the same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up…

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 provisions of pharmaceuticals services by failing to remove two expired medications from medication carts and mark six medications with an open date in two of four medication carts (Station A Middle medication cart and Station B medication cart). These deficient practices had the potential to result in administration of expired medications, reduced therapeutic effectiveness and compromised resident safety and medication errors. Findings: During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 2 on 5/6/2026 at 10:35 a.m. of Station A Middle medication cart the following was observed: - Novolog Flexpen SYG (a pre-filled, disposable insulin pen used to manage blood sugar in adults and children with diabetes) 5X3ml was not labeled with an open date. - Lantus Solostar (a pre-filled pen containing long-acting insulin (insulin glargine) used to treat Type 1 and Type 2 diabetes by lowering high blood sugar) 100U/ml was not labeled with an open date. - Clonazepam (a prescription…

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

Based on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs when staff did not follow the portion size of grilled bratwurst, three (3) ounces (oz, unit of measurement), and served 1.5 oz portion size instead. This failure had the potential to result in decrease in food flavor, decrease in food and nutrient intake affecting 20 of 91 residents who are on regular diet, potentially resulting in unplanned weight loss. Findings: During a review of the facility's menu spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled, Spring 2026, dated 5/4/2026, the spreadsheet indicated residents on regular diet would include the following foods on the tray: - Grilled Bratwurst (3) ounces (oz, a unit of measurement) - Buttered new potatoes 1/2 cup (c, a household measurement) - Sauerkraut 1/2 c - Wheat roll 1 pc - Margarine 1 pc - Oatmeal raisin cookie 1 each - Water 8 fluid oz During an observation on 5/4/2026 at 11:12 a.m. of the food preparation, observed the Dietary Supervisor (DS) cutting 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 prepare food by methods that conserved temperature when hot foods were not served hot. This failure had the potential to result in 88 of 91 facility residents including Resident 53 at risk of unplanned weight loss, a consequence of poor food intake. Findings: During a review of Resident 53's admission Record (AR), the AR indicated the facility admitted Resident 53 on 4/15/2026 with diagnoses including, but not limited to, essential hypertension (HTN, high blood pressure), chronic respiratory failure (a sudden inability of the lungs to transfer enough oxygen into the blood, resulting in low blood oxygen levels), and acute kidney failure (the sudden and often reversible loss of the kidney's ability to filter waste products from the blood, occurring within hours or days). During a review of Resident 53's Minimum Data Sheet (MDS- a resident assessment tool), dated 4/20/2026, the MDS indicated Resident 53 understood others and make self understood. The MDS indicated Resident 53 needed set-up and clean-up…

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 on soft bite size level 6 diet (food that are bite sized pieces no more than 1.5 centimeters (cm., a unit of measurement) to 1.5 cm., soft, tender and moist food but with no liquid leaking or dripping from the food) received and consumed food in appropriate texture as prescribed by a physician. Residents were served minced and moist diet instead. This deficient practice had the potential to result in ineffective therapeutic diet, decreased in nutrient intake affecting 10 of 91 residents potentially resulting in weight loss. Findings: During a review of the facility's menu spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled, Spring 2026, dated 5/4/2026, the spreadsheet indicated residents on soft bite sized diet would include the following foods on the tray: - Soft bite grilled bratwurst with gravy three (3) ounces (oz. a unit of measurement)/1 oz - Soft bite buttered new potatoes 1/2 cup (c., household measurement) - Soft bite sauerkraut 1/2 c - Puree…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain the electrical and patient care equipment in safe operating condition for four of nine sampled residents (Residents 76, 31, 2,15, and 49) reviewed under environmental task by failing to ensure there were no frayed wires on the resident's bed remote controls. The deficient practice had the potential for residents to sustain accidents such as electrical shock and physical discomfort. Findings: 1). During a review of Resident 76's admission Record (AR), the AR indicated the facility admitted the resident on 6/9/2023, and readmitted the resident on 8/4/2025, with diagnoses including dementia (a progressive state of decline in mental abilities), disorientation, and adult failure to thrive (is a, usually in older adults, defined by a rapid, overall decline in physical and mental health). During a review of Resident 76's History and Physical (H&P), dated 8/5/2025, the H&P indicated the resident did not have a capacity to make decisions.…

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, and interview, the facility failed to ensure the call light (an alerting device for residents to call a nursing personnel to assist them when needed) within reach of the resident for two of two sampled residents (Residents 10, 88). The deficient practice had the potential to place the resident at risk for delayed assistance, potentially affecting safety and timely care. Findings: 1. During a review of Resident 10's admission Record, the admission record indicated that Resident 10 was initially admitted to the facility on [DATE] , with diagnoses including hypertension (high blood pressure), history of falling, seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) and atrial fibrillation (an irregular and very rapid heart rhythm that and can lead blood clots in the heart). During a review of Resident 10's Minimum Data Set (MDS - a resident assessment tool) dated 04/19/2026, the MDS indicated 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 interview and record review, the facility failed to ensure a copy of the Advanced Healthcare Directive (a legal document indicating resident preference on end-of-life treatment decisions) was uploaded in a resident`s electronic health record to be readily available if needed for one of three sampled residents (Resident 15). The deficient practice violated the resident's rights and/or representative's right to ensure the resident's end-of-life treatment decisions were readily available for staff to honor and implement. Findings: During a review of Resident 15's admission Record (AR), the AR indicated the facility admitted the resident on 6/27/2017, and readmitted the resident on 10/15/2018, with diagnoses including dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), cognitive communication deficit (difficulty with speaking, listening, reading, or writing caused by problems with thinking skills rather than just language ability). During a review of 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 interview, and record review, the facility failed to ensure one of one sampled resident (Resident 75) had the right to be free from misappropriation (the unauthorized, improper, or unlawful use of funds or other property for purposes other than that for which intended) of the resident's property, when Resident 75's [NAME] stick (a traditional tool used by many Native American tribes to ensure respectful communication during meetings) was missing and the facility failed to: - Update Resident 75's Resident Inventory List (a simple, detailed record of all personal belongings a person brings into an assisted living facility) with [NAME] stick on the resident's possession. - Replace reported lost [NAME] stick promptly. - Keep track of deliveries of the resident`s orders from outside vendors. This failure resulted in Resident 75 experiencing loss of personal property and the potential for misappropriation without timely identification, investigation, and prevention of further occurrences. Findings: During a…

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

Based on interview and record review, the facility failed to ensure residents` drug regimen was free from unnecessary drugs for one of two sampled residents (Resident 4) reviewed for psychotropic medication (drugs that change how the brain works to treat mental health conditions) use by failing to ensure: 1. Resident 4's Lorazepam (a prescription medication used for the short-term treatment of severe anxiety, panic attacks, and insomnia) Oral Tablet 0.5 milligrams (mg, a unit of weight) had an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered). 2. Resident 4's Risperdal (is a medication that works in the brain to treat schizophrenia) had the current informed consent. The deficient practices had the potential to result in the use of unnecessary psychotropic drugs for Resident 4 and can lead to side effect/adverse effect (refers to the negative or harmful results that follow from a particular action or event) such as a decline in quality of life and functional capacity.…

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

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse (an action that intentionally causes harm or injures another person), neglect (failing to care for, pay attention to, or do something you are responsible for), exploitation or mistreatment (the act of treating someone unfairly), including injuries of unknown source and misappropriation of resident property (unauthorized, improper, or unlawful use or taking of someone else's assets, funds, or property), are reported immediately, but not later than two (2) hours after the allegation is made for one of thirteen sampled residents (Resident 76) reviewed for accidents by failing to report an injury of unknown origin (a physical injury that was not witnessed by anyone, and cannot be explained by the injured person) when the resident was found on the floor on 12/3/2025 and was noted with the right lateral (side) head bump and abrasion (a superficial wound that occurs when your skin rubs against, presses on, a rough surface), with right lateral great toe skin tear (cut) and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to submit a new Preadmission Screening and Resident Review level 1 (PASRR - a federal requirement to ensure that individuals with a mental disorder [MD - a person's mind makes it hard to think, feel, or act normally in daily living] or intellectual disability [ID - a person has trouble learning, understanding, or solving problems like most people their age] are properly screened and evaluated to determine appropriate placement and services in a nursing facility) for (1) of three (3) sampled residents (Resident 11), when Resident 11 was diagnosed by a Psychologist on 9/8/2026 with schizophrenia (a mental health condition that affects thinking, emotions, and understanding reality). This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 11. Findings: During a review of Resident 11's admission Record (AR), the AR indicated the facility originally admitted the resident on 9/4/2025 and…

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

Based on interview and record review, the facility failed to ensure that the comprehensive care plan (a document outlining a detailed approach to care customized to an individual resident's need) is reviewed and revised by an interdisciplinary team (IDT, a group of experts from different fields like doctors, nurses, therapists, and social workers who work together closely to create a single, unified care plan for a patient) composed of individuals who have knowledge of the resident and his/her needs for one of thirteen sampled residents (Resident 76) reviewed for accidents by failing to review and revise the resident`s fall care plan to reflect an alleged unwitnessed fall on 12/3/2025. The deficient practice had the potential for delayed and unnecessary care for residents. Findings: During a review of Resident 76's admission Record (AR), the AR indicated the facility admitted the resident on 6/9/2023, and readmitted the resident on 8/4/2025, with diagnoses including difficulty in walking, muscle weakness, and lack of coordination. During a review of Resident 76's History 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, interview, and record review, the facility failed to monitor and assess the healed pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) on the affected site for one of one sampled resident (Resident 53). This deficient practice had the potential for reopening of healed pressure ulcer for Resident 53. Findings: During a review of Resident 53's admission Record, the admission record indicated that Resident 53 was initially admitted to the facility on [DATE] , with diagnoses including hypertension (high blood pressure), history of falling, cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body) and atrial fibrillation (an irregular and very rapid heart rhythm that and can lead blood clots in the heart). During a review of Resident 53's Minimum Data Set (MDS - a resident assessment tool), dated 04/20/2026, the MDS indicated that 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 that the respiratory care provided to residents was consistent with professional standards of practice for one of one sampled resident (Resident 39) reviewed for respiratory care by failing to ensure Resident 39's oxygen via nasal cannula (a lightweight, flexible plastic tube that delivers extra oxygen (supplemental oxygen) directly into the nostrils via two small, comfortable prongs) tubing was labeled with the date it was last changed. The deficient practice had the potential for the resident to develop complications such as shortness of breath, desaturation (low levels of oxygen in the blood) and respiratory infections. Findings: During a review of Resident 39's admission Record (AR), the AR indicated the facility admitted the resident on 8/22/2016, and readmitted the resident on 2/17/2025, with diagnoses including chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), pneumonia (an infection/inflammation in the lungs), and acute respiratory failure (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 effectively manage a resident's pain for one of one sampled resident (Resident 12) by failing to reassess pain within one hour of administration of hydrocodone-acetaminophen (medication used for moderate to severe pain) oral tablet. This deficient practice placed Resident 12 at risk of inadequate pain relief and experienced health complications from their medication therapy. Findings: During a review of Resident 12's admission Record, the admission record indicated that Resident 12 was initially admitted to the facility on [DATE] , with diagnoses including end-stage renal disease (ESRD-a medical condition in which a person's kidney [organ in the body that lifters waste and excess fluid from the blood] function stop functioning on a permanent basis) with dependence of hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), cellulitis (bacterial skin…

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 that resident receives care and services for the provision of hemodialysis (HD - filtering the blood of a person whose kidneys are not working normally) consisted with professional standard of practice by not implementing the fluid restriction and monitor fluid intake and output for one of two sampled residents (Resident 12). This deficient practice had the potential to cause fluid overload (excess water in the body) or dehydrating (insufficient water in the body) for Resident 12. Findings: During a review of Resident 12's admission Record, the admission record indicated that Resident 12 was initially admitted to the facility on [DATE] , with diagnoses including end-stage renal disease (ESRD-a medical condition in which a person's kidney [organ in the body that lifters waste and excess fluid from the blood] function stop functioning on a permanent basis) with dependence of hemodialysis (a treatment to cleanse the blood of wastes and extra fluids…

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 accurately and safely provide pharmaceutical services to residents for one of one sampled resident (Resident 93) by failing to notify the pharmacist for review and proper labeling of a medication brought into the facility from an outside appointment prior to administration and failing to ensure the medication was incorporated into the resident's car plan. This deficient practice had the potential to result in medication errors, improper dosing, and adverse effects to the resident. Findings: During a review of Resident 93's admission Records (AR - the front page of the chart that contains a summary of basic information about the resident), the AR indicated the facility admitted Resident 93 on 3/9/2026, with diagnoses including pneumonia (an infection/inflammation in the lungs), malignant neoplasm of pancreas (pancreas [a gland behind the stomach that helps digestion and controls blood sugar] cancer), type II Diabetes Mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound…

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 medication error rate was less than five percent (%). Two medication errors out of 25 total opportunities contributed to an overall medication error rate of 8 % for one of four residents (Resident 45) observed during medication administration. For Resident 45, the facility failed to ensure: 1. The physician's order for vitamin B12 (a vitamin the body uses to make and support healthy nerve cells) dosage matched with the dosage for vitamin B12 available in the in-house supply. 2. Miralax (an Over-the-Counter [OTC - drugs you can purchase off the shelf at pharmacies, grocery stores, or online without a doctor's prescription] flavorless powder used to relieve occasional constipation) administered in accordance with physician orders, when Licensed Vocational Nurse (LVN) 2 poured powdered medication into the cup first and then added water up to the 8 oz (ounce - unit of measurement for weight) measurement line. These deficient…

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 document the placement of the low air loss mattress (LAL - a mattress designed to prevent and treat pressure wounds [localized damage to the skin and/or underlying tissue usually over a bony prominence]) for one of one sampled resident (Resident 53). This deficient practice had the potential not to receive the necessary care for prevention of pressure ulcers for Resident 53. Findings: During a review of Resident 53's admission Record, the admission record indicated that Resident 53 was initially admitted to the facility on [DATE] , with diagnoses including hypertension (high blood pressure), history of falling, cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body) and atrial fibrillation (an irregular and very rapid heart rhythm that and can lead blood clots in the heart). During a review of Resident 53's Minimum Data Set (MDS - a resident 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 observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to ensure the mobile linen cart was covered after removing needed linen supplies observed during resident screening. This deficient practice had the potential to cause cross-contamination (when harmful germs, chemicals, or allergens are unintentionally transferred from one object, surface, or person to another) of infection among residents and staff. Findings: During an observation on 5/4/2026 at 10:25 a.m., observed Certified Nursing Assistant (CNA) 4 bring the mobile linen cart to Room A, opening the mobile linen cart getting all needed supplies for the resident. The mobile linen cart was left open facing the room of the resident. CNA 4 provided care to the resident without replacing the cover of the mobile linen cart. During a concurrent observation and interview on 5/4/2026 at 10:26…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its antibiotic (ATB - a medicine that fights bacterial infections by killing bacteria or stopping them from multiplying) stewardship program (a coherent set of actions which promote using antimicrobials responsibly) that includes antibiotic use protocols and a system to monitor antibiotic use for two of three sampled residents (Residents 39 and 2) reviewed for antibiotic use by failing to ensure: 1. Resident 39's Hiprex (a prescription medicine used to prevent or reduce the frequency of chronic urinary tract infections [UTIs - an infection in the bladder/urinary tract] had a duration of use and had monitoring for adverse effects. 2. Resident 2's Amoxicillin-Pot Clavulanate Oral Tablet (a combination antibiotic used to treat bacterial infections like sinusitis [the inflammation or swelling of the tissue lining your sinuses], pneumonia [an infection/inflammation in the lungs], ear infections, and skin infections) 875-125 milligrams (mg - 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 offer the pneumonia (a lung infection) vaccine (medication that helps protect against pneumococcal infections, including invasive disease) yearly when the resident refused the immunization on 10/11/2023 for one of 5 sampled residents (Resident 54) reviewed for immunizations. This deficient practice had the potential to place residents at risk for respiratory infection including pneumonia. Findings: During a review of Resident 54's admission Record (AR), the AR indicated the facility admitted the resident on 5/25/2020, and readmitted the resident on 11/20/2025, with diagnoses including pneumonia, adult failure to thrive (a general, rapid decline in an older person's physical and mental health that cannot be explained by a single disease), and personal history of coronavirus disease 2019 (COVID-19 - a disease that spreads primarily through air droplets when an infected person breathes, talks, coughs, or sneezes, causing symptoms ranging from mild [fever, cough, loss of taste/smell] to severe pneumonia). 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.

Based on interview and record review, the facility failed to document the explanation of the risk and benefits of refusing coronavirus disease 2019 (COVID-19 - a highly contagious respiratory illness caused by the SARS-CoV-2 virus, which first emerged in late 2019) vaccines for one of five sampled residents (Resident 36) reviewed for immunizations. This deficient practice had the potential to place residents at risk for respiratory infection including COVID-19. Findings: During a review of Resident 36's admission Record (AR), the AR indicated the facility admitted the resident on 7/19/2024, and readmitted the resident on 2/16/2026, with diagnoses including protein-calorie malnutrition (a serious condition caused by not eating enough calories and protein, leading to significant muscle loss, weight loss, and fatigue) and personal history of antineoplastic chemotherapy (specialized medications designed to treat cancer by stopping or slowing the growth of cancer cells). During a review of Resident 36's History and Physical (H&P), dated 9/5/2024, the H&P indicated the resident had 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 and interview, the facility failed to have an effective pest control program when a dead cockroach was found on the bathroom floor for one of nine sampled residents (Resident 78). This deficient practice had the potential in transmitting harmful bacteria to the residents and Resident 78 feeling disturbed. Findings: During a review of Resident 78's admission Record, the admission record indicated that Resident 78 was initially admitted to the facility on [DATE] , with diagnoses including hypertension (high blood pressure), acute pancreatitis (condition characterized by inflammation of the pancreas [organ in the abdomen]) and acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood). During a review of Resident 78's Minimum Data Set (MDS - a resident assessment tool), dated 04/21/2026, the MDS indicated that Resident 53's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its written abuse policy and procedure (P&P) titled, Abuse and Neglect Exploitation or Misappropriation-Reporting and Investigating Policy designed to prevent, respond to and report abuse-related incidents after a physical abuse (includes, but is not limited to, hitting, slapping, punching, biting, and kicking) for one of three sampled residents (Resident 1) when staff did not immediately separate roommates Residents 1 and Resident 2 who had a physical altercation on 4/10/2026.This failure had the potential for Resident 1 to be subjected to further abuse from Resident 2 while under the care of the facility. Findings: During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/20/2025 with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), peripheral vascular disease (PVD - 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 interview and record review, the facility failed to report an allegation of physical abuse within two hours for one of three sampled residents (Resident 1) when on 4/10/2026 there was an allegation that Resident 2 threw a bottle of lotion and landed on Resident 1's right shin. This deficient practice had the potential to place Resident 1 at an increased risk for further abuse which could have led to additional unreported incidents. Findings: During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/20/2025 with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs) , and quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury).During a record review of Resident 1's Minimum Data set…

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 revise a resident's care plans for one of four sampled residents (Resident 2). This failure had the potential to result in Resident 2 receiving inappropriate care because the care plan was not updated to address and meet the resident's needs.Findings: During a record review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 9/16/2025 with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dysphagia (difficulty swallowing), schizophrenia (a mental illness that is characterized by disturbances in thought)During record review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 4/12/2026 indicated that Resident 2's cognition (the mental process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired (never/rarely made decisions). The MDS indicated that Resident 2 required maximal assistance (helper does more than half 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 interview and record review, the facility failed to implement its abuse policy and procedure by failing to thoroughly investigate allegation of resident-to-resident physical abuse for two of three sampled residents (Residents 1 and 2) by failing to interview and obtain a written statement from Certified Nursing Assistant 1 (CNA 1).This deficient practice had the potential to result in unidentified abuse in the facility and had the potential for further resident abuse.Findings:a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 4/21/2022, with diagnoses that included multiple right rib fracture (break in a bone), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and essential hypertension (HTN-high blood pressure).During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam,…

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 residents received care consistent with professional standards of practice for one of three sampled residents (Resident 1) by failing to ensure changes in Resident 1's skin was measured as indicated in the facility's policy and procedure.This failure resulted in Resident 1's incomplete medical record.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 4/21/2022, with diagnoses that included multiple right rib fracture (break in a bone), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and essential hypertension (HTN-high blood pressure).During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 12/24/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free from physical abuse for one of four sampled residents (Resident 1) when on 12/9/2025 at 11 a.m., Resident 2 hit Resident 1 on the left cheek.This failure resulted in Resident 1 being grabbed in the left arm and getting hit on the left cheek by Resident 2.Findings:During a review of Resident1's admission Record, the admission Record indicated the facility admitted Resident 1 on 3/3/2023, with diagnoses that included unspecified (unconfirmed) transient cerebral ischemic attack (or mini-stroke, is a brief interruption of blood flow to the brain), unspecified encephalopathy (when the brain is not working right due to illness) and generalized muscle weakness.During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 4/7/2023, the H&P indicated Resident 1 had the capacity to understand…

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

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 3) was medicated for pain as per physician's order.This deficient practice had the potential to result in Resident 3's uncontrolled pain. Findings:During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 8/5/2025, with diagnoses that included multiple fracture (bone breaks) of the ribs, fall, and hypertensive heart disease (heart has been damaged or overworked because of long-term, uncontrolled high blood pressure, making it harder to pump blood, leading to issues like a thickened heart muscle) with heart failure (heart is not pumping blood as well as it should).During a review of Resident 3's Order Summary Report, dated 12/4/2025, the Order Summary Report indicated hydrocodone-acetaminophen (medication used to treat pain) oral tablet 5-325 milligram (mg- metric unit of measurement, used for medication dosage and/or amount), give one tablet by mouth every four hours as needed for moderate to severe pain level of four…

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 follow the physician's order for one of three sampled residents (Resident 3) when Licensed Vocational Nurse 2 (LVN 2) administered sacubitril-valsartan (medication used to treat heart failure [heart was not pumping blood as well as it should to meet the body's needs]) to Resident 3 who had a blood pressure of 109/77 millimeter of mercury (mmHg-unit for measuring pressure) despite a physician's order to hold (suspend the medication) the sacubitril-valsartan for blood pressure below 110 mmHg.This failure had the potential to result in Resident 3's hypotension (low blood pressure). Findings:During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 8/5/2025, with diagnoses that included multiple fracture (bone breaks) of the ribs, fall and hypertensive heart disease (heart has been damaged or overworked because of long-term, uncontrolled high blood pressure, making it harder to pump blood, leading to issues like a thickened heart muscle) with heart failure (heart 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 interview and record review, the facility failed to report an allegation of physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1) when on 8/22/2025, at approximately 9:30 p.m., Resident 1 reported to facility staff that Resident 2 had hit her (Resident 1) legs. This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect Resident 1 from further abuse.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 2/14/2025 and readmitted on [DATE] with diagnoses including anxiety disorder (feeling of anxiousness that affects daily life), multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), and chronic pain syndrome (an ongoing pain that lasts longer than three months, persisting even after the initial injury or illness has…

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 1) received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial (relating to the interrelation of social factors and individual thoughts and behavior) by failing to: 1. Complete a body assessment when on 8/22/2025 Resident 1 reported an allegation of physical abuse by Resident 2. On 8/22/2025, at approximately 9:30 p.m., Resident 1 informed Certified Nurse Assistant (CNA) 1 that Resident 2 hit Resident 1's legs with Resident 2's hands.2. Notify the physician of Resident 1's allegation of physical abuse by Resident 2, when on 8/22/2025, at approximately 9:30 p.m., Resident 1 informed CNA 1 that Resident 2 hit Resident 1's legs with Resident 2's hands.These deficient practices had the potential to delay Resident 1's care and negatively affect Resident 1's well-being.Findings: During a review of Resident 1's admission Record, 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 that one of three sampled residents (Resident 1) who had a urostomy (a surgical procedure where an opening, is created in the abdomen to allow urine to exit the body) received proper care and services by: 1. Failing to notify the physician that Resident 1's urinary tubing had sediments (particles that can make your urine look cloudy or have visible specks) and cloudy urine. 2. Failing to assess, monitor and document Resident 1 for signs of urinary tract infection (UTI- an infection in the bladder/urinary tract) as indicated in Resident 1's care plan. 3. Failing to monitor and document urine output in milliliter (ml-unit of volume) as per physician order. These failures had the potential to result in UTI and had potential to lead to urosepsis (a potentially life-threatening complication of urinary tract infection). Findings: a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/13/2024, with diagnoses that included multiple sclerosis…

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 care in a manner that maintained the resident's dignity for one of the three sampled residents (Resident 1) by failing to ensure Resident 1's urinary collection bag was covered with a privacy bag. This failure had the potential to negatively affect Resident 1's self-esteem and self-worth. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/13/2024 with diagnoses that included multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), unspecified (unconfirmed) malignant neoplasm (also known as a cancerous tumor, is an abnormal growth of cells that can invade surrounding tissues and spread to other parts of the body) of the bladder (a hollow, spherical-shaped organ that holds urine), and acute pyelonephritis (a bacterial infection causing inflammation of the kidneys). During a review of Resident 1's Minimum Data Set (MDS - a resident 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 observation, interview, and record review, the facility failed to implement a person-centered care plan for one of three sampled residents (Resident 1) by failing to monitor, record and report to the physician signs of urinary tract infection (UTI- an infection in the bladder/urinary tract) as indicated in Resident 1's Care Plan for urostomy (a surgical procedure where an opening, is created in the abdomen to allow urine to exit the body). This failure had the potential for delayed provision of necessary care and services and had the potential for the development of UTI. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/13/2024, with diagnoses that included multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), unspecified (unconfirmed) malignant neoplasm (also known as a cancerous tumor, is an abnormal growth of cells that can invade surrounding tissues and spread to other parts of the body) of the bladder (a hollow,…

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 2) with indwelling urinary catheter (a flexible plastic tube inserted into the bladder that helps provide continuous urinary drainage) received proper care and services by failing to ensure Resident 2's urinary catheter drainage bag had a dignity bag (a bag used to cover and hold the catheter drainage or collection bag so it would not be visible). This deficient practice had the potential to affect Resident 2's sense of self-worth and self-esteem. Findings: During a record review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 2/25/2025 with diagnoses including cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) due to unspecified occlusion (blockage) or stenosis (narrowing) of the left anterior cerebral artery (a blood vessel in the brain that supplies oxygenated blood to the front part of the brain). During a record review of Resident 2's Physician Order, 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 observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) with indwelling urinary catheter (a flexible plastic tube inserted into the bladder that helps provide continuous urinary drainage) received proper care and services by failing to ensure Resident 2's urinary catheter drainage bag was not touching the floor. This deficient practice had the potential to cause Resident 2 urinary catheter-associated complications including urinary tract infection (UTI - an infection in any part of the urinary system [kidneys, bladder, or urethra]), discomfort, and pain. Findings: During a record review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 2/25/2025 with diagnoses including cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) due to unspecified occlusion (blockage) or stenosis (narrowing) of the left anterior cerebral artery (a blood vessel in the brain that supplies oxygenated blood to the front part of the brain). During a…

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

Based on interview and record review, the facility failed to follow its Policy and Procedures (P&P) titled, Change in a Resident's Condition or Status, for one of three residents (Resident 1) when the facility failed to notify the Medical Doctor (MD 1) and the Family Member 1 (FM 1) that the facility did not collect the ordered urinalysis (UA- a medical test that examines urine samples) with a culture and sensitivity test (CS- tells you if bacteria are present in a sample from your body [like urine or a wound], and if so, which antibiotics are most likely to effectively kill those specific bacteria). This deficient practice resulted in a delay of delivery of care and services to Resident 1 who was diagnosed with a urinary tract infection (UTI- an infection in the bladder/urinary tract). Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 2/24/2020 and readmitted the resident on 3/3/2023 with diagnoses including dementia (a progressive state of decline in mental abilities), UTI, hemiplegia (total paralysis…

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

Based on interview and record review, the facility failed to complete a physician ordered urinalysis (UA- a medical test that examines urine samples) with a culture and sensitivity test (CS- tells you if bacteria are present in a sample from your body [like urine or a wound], and if so, which antibiotics are most likely to effectively kill those specific bacteria) for one of three sampled residents (Resident 1). This deficient practice resulted in the delay of care and services to Resident 1 who was diagnosed with a urinary tract infection (UTI- an infection in the bladder/urinary tract). Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 2/24/2020 and readmitted the resident on 3/3/2023 with diagnoses including dementia (a progressive state of decline in mental abilities), UTI, hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a condition that causes weakness or an inability to move on one side of the body), following cerebral infarction (a type 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 b. During a review of Resident 53's admission Record, the admission Record indicated the facility admitted the resident on 4/28/2021 and readmitted the resident on 12/10/2024 with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), end stage renal disease (ESRD - irreversible kidney failure), and dependence on hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), glaucoma (an eye condition causing gradual loss of sight), and dementia (a progressive state of decline in mental abilities). During a review of Resident 53's MDS, dated [DATE], the MDS indicated the resident was able to understand others and was able to make herself understood. The MDS further indicated the resident required partial/moderate assistance from staff for oral hygiene, upper and lower body dressing, personal hygiene, and bed mobility; and was independent with eating. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure resident received care consistent with professional standards of practice to prevent pressure injury (PI - the breakdown of skin integrity due to pressure) for three (3) of four (4) sampled residents (Residents 242, 24, and 26) investigated under pressure injury by: 1. Failing to ensure Resident 242 was provided a low air loss mattress (LALM - a mattress that helps prevent and treat pressure wounds by circulating air and relieving pressure on the body) when the resident had Stage 4 PI (full thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) on the right buttock upon admission to the facility. 2. Failing to perform an accurate assessment of Resident 242's Stage 4 PI. 3. Failing to develop and implement a baseline care plan addressing Resident 242's Stage 4 PI on the buttock. 4. Failing to follow the manufacturer guideline for LALM for Residents 24 and 26. These deficient practices placed…

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

Based on interview and record review, the facility failed to ensure a resident who received hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) was assessed after dialysis treatment and to document the assessment for one of one sampled resident (Resident 76) investigated during review of dialysis care area. This deficient practice had the potential for unidentified complications such as swelling, pain, bleeding, and bruising and had the potential to result in lack of provision of necessary treatment and services after dialysis treatment. Findings: During a review of Resident 76's admission Record the facility admitted the resident on 11/7/2024 with diagnoses including end stage renal disease (ESRD -irreversible kidney failure), dependence on renal (kidney) dialysis, and heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 76's Minimum Data Set (MDS, a resident assessment tool), dated 11/22/2024,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY d. During a review of Resident 62's admission Record, the admission Record indicated the facility admitted the resident on 6/30/2022 and readmitted the resident on 12/19/2024 with diagnoses that included essential (primary) hypertension (high blood pressure with an unknown cause), aphasia (a disorder that makes it difficult to speak) following cerebral infarction (CVA-stroke, loss of blood flow to a part of the brain), and angina pectoris (chest pain or discomfort that occurs when the heart muscle doesn't receive enough oxygen). During a review of Resident 62's MDS dated [DATE], the MDS indicated the resident usually was able to understand others and was sometimes able to make himself understood. The MDS further indicated the resident required partial/moderate assistance from staff for oral hygiene, lower body dressing, toileting, and bathing. During a review of Resident 62's Order Summary Report, the report indicated an order for metoprolol tartrate oral tablet, give 50 milligrams (mg, a unit of measurement) by…

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

Based on observation, interview, and record review, the facility failed to follow the menu for 88 of 92 residents when on 1/19/2025 [NAME] 1 did not prepare the breakfast omelet and used scrambled eggs for 88 residents for breakfast. This deficient practice had the potential to result in an increased food and nutrient intake resulting in unintended (not done on purpose) weight gain. Cross Reference F804 Findings: During a concurrent observation and interview on 1/19/2025 at 5:40 a.m., [NAME] 1 stated the menu for breakfast has oatmeal and for the puree diet it has cream of wheat, has muffins, toast, and scrambled eggs along with bacon, and sausage. During an interview on 1/19/2025 at 6:12 a.m., [NAME] 1 stated she made a mistake by making scrambled eggs instead of the breakfast omelet that are on the menu for today (1/19/2025). During an interview on 1/19/2025 at 7:53 a.m., the Dietary Supervisor (DS) stated [NAME] 1 made scrambled eggs instead of the omelet that was on the menu. The DS stated it would affect the taste and texture because the scrambled eggs and breakfast omelet are…

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

Based on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs for 88 out of 92 residents when on 1/19/2025 [NAME] 1 did not prepare the breakfast omelet and used scrambled eggs for 88 residents for breakfast. This failure had a potential to result in 88 the facility residents to be at risk for unplanned (not done on purpose) weight gain. Cross Reference F803 Findings: During a concurrent observation and interview on 1/19/2025 at 5:40 a.m., [NAME] 1 stated the menu for breakfast has oatmeal and for the puree diet it has cream of wheat, has muffins, toast, and scrambled eggs along with bacon, and sausage. During an interview on 1/19/2025 at 6:12 a.m., [NAME] 1 stated she made a mistake by making scrambled eggs instead of the breakfast omelet that are on the menu for today (1/19/2025). During an interview on 1/19/2025 at 7:53 a.m., the Dietary Supervisor (DS) stated [NAME] 1 made scrambled eggs instead of the omelet that was on the menu. The DS stated it would affect the taste and texture because the scrambled eggs 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 safe and sanitary food storage and food preparation practices in the kitchen when: 1. Resident foods were not labeled and dated. 2. Staff foods were stored in the kitchen refrigerator. These deficient practices had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 88 of 92 medically compromised residents who received food. Findings: During an initial tour of the kitchen on 1/18/2025 at 7:14 a.m. observed: - a container half empty humus, no dates noted. - a container with a prepared mashed up food item covered, no dates noted. - Three (3) bowls with cut oranges no dates noted. During a concurrent observation and interview on 1/18/2025 at 7:34 a.m. with Dietary Aide 3 (DA 3), DA 3 stated the mashed up food item was mashed potatoes. DA 3 stated both the humus and the mashed potatoes do not…

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

d. During a review of Resident 246's admission Record, the admission Record indicated the facility originally admitted the resident on 12/5/2024 and readmitted in the facility on 1/17/2025, with diagnoses including heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), lack of coordination, and generalized weakness. During a review of Resident 246's History and Physical (H&P) dated 1/18/2025, the H&P indicated Resident 246 had the capacity to understand and make decisions. During a review of Resident 246's Minimum Data Set (MDS, a resident assessment tool), dated 12/10/2024, the MDS indicated the resident had an intact cognition (having the ability to think, learn, and remember clearly). The MDS indicated Resident 246 required supervision or touching assistance with eating; partial/moderate assistance with oral hygiene and personal hygiene; total assistance shower transfers, sit to lying and lying to sitting; substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must…

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 (Residents 83) reviewed for unnecessary (any medication in excessive dose, excessive duration, without adequate monitoring) medications was free from the use of unnecessary psychotropic (any medication capable of affecting the mind, emotions, and behavior) medications in accordance with the facility policy and procedure by failing to obtain an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for Resident 83's use of lorazepam (a psychotropic medication use to treat feelings of anxiousness). This deficient practice had the potential to result in the use of unnecessary psychotropic drugs and adverse effects (an undesired and harmful result of a treatment or intervention, such as a medication or surgery) of the medication. Findings: During a review of Resident 83's admission Record, the admission Record indicated the facility admitted the resident on 10/1/2024, with diagnoses…

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 reasonable accommodation of resident needs and preferences by failing to ensure the call light (CL, an alerting device for nurses or other nursing personnel to assist a patient when in need) was withing reach for one of two sampled residents (Resident 16) reviewed under the Environment task. This deficient practice had the potential to result in the delay of care and services and possible injury to residents when they are unable to summon health care workers. Findings: During a review of Resident 16's admission Record, the admission Record indicated the facility admitted the resident on 6/9/2023 and readmitted the resident on 7/1/2024 with diagnoses that included dementia (a progressive state of decline in mental abilities), difficulty walking, muscle weakness, history of falling, and metabolic encephalopathy (an alteration in consciousness due to brain dysfunction). During a review of Resident 16's Minimum Data Set (MDS - resident assessment tool) dated 12/11/2024, the MDS indicated the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of 1 resident (Resident 247) investigated under the pain management care area by failing to develop a care plan addressing the resident's screaming behavior. This deficient practice had the potential to cause a delay in the delivery of necessary care and services the resident need. Findings: During a review of Resident 247's admission Record, the admission Record indicated the facility admitted the resident on 1/10/2025 with diagnoses including history of falling, dementia (a progressive state of decline in mental abilities), and generalized muscle weakness. During a review of Resident 247's History and Physical (H&P), dated 1/13/2025, the H&P indicated the resident did not have the capacity to make decisions. During a review of Resident 247's Minimum Data Set (MDS - a resident assessment tool), dated 1/14/2025, the MDS indicated the resident had moderately impaired…

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 care and services necessary to maintain good nutrition for one of one sampled resident (Resident 242) investigated under the activities of daily living (ADLs - routine/tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves) care area by failing to ensure Certified Nursing Assistant 9 (CNA 9) provided assistance to Resident 242 with meals. This deficient practice had the potential to result in Resident 242 having weight loss, dehydration, or nutritional problems. Findings: During a review of Resident 242's admission Record, the admission Record indicated the facility originally admitted the resident on 1/14/2025, with diagnoses including cerebral infarction (stroke - loss of blood flow to a part of the brain), dementia (a progressive state of decline in mental abilities), and generalized weakness. During a review of Resident 242's History and Physical (H&P), dated 1/17/2025, the H&P indicated Resident 242 did not have the capacity to understand and make decisions.…

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 provided needed care and services that are resident-centered for one of one sampled resident (Resident 8) reviewed under General care area when the facility failed to follow up Resident 8's lab draw for phenobarbital (medication used to control seizure [ (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) as ordered by the physician. This deficient practice had the potential to result in under treatment may cause ineffective seizure control or over treatment which may cause toxicity. Findings: During a review of Resident 8's admission Record indicated the facility originally admitted the resident on 8/22/2016 and readmitted on [DATE] with diagnoses including epilepsy (seizures), anxiety disorder (an abnormal condition characterized by persistent and excessive worries that interfere with daily activities), and chronic obstructive pulmonary disease (COPD-a chronic…

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 b. During a review of Resident 7's admission Record, the admission Record indicated the facility admitted the resident on 3/11/2024 and readmitted the resident on 11/30/2024 with diagnoses that included metabolic encephalopathy (an alteration in consciousness due to brain dysfunction), major depressive disorder (persistent feelings of sadness and loss of interest that can interfere with daily living), difficulty swallowing, and insomnia (inability to sleep). During a review of Resident 7's MDS dated [DATE], the MDS indicated the resident was able to understand others and was able to make herself understood. The MDS further indicated the resident required partial/moderate assistance from staff for personal hygiene and substantial/maximal assistance from staff for toileting, upper body dressing, and mobility. During a review of Resident 7's Care Plan (CP) titled, The resident uses antidepressant medication related to depression, trazodone HCL (a medication to treat insomnia) .at bedtime for depression manifested…

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 properly label the open date of Senna (a natural laxative that comes from the leaves and fruit of the senna plant) for one of two Medication Carts (Medication Cart 2 [MC 2]). This deficient practice had the potential for the medication to be ineffective. Findings: During a concurrent observation and interview during a review of the medication storage on 1/20/2025 at 10:18 a.m. with Licensed Vocational Nurse 7 (LVN), MC 2 was observed with Senna 8.6 mg with expiration date of 9/2027 with no open date observed. LVN 7 stated opened Senna container today and did not label it with an open date. LVN 7 stated must put open date on medications so that the facility knows when the medication was opened. During an interview on 1/22/2025 at 12:54 p.m., the Director of Nursing (DON) stated over the counter medication should have an open date. The DON stated medications should have open date because we should not follow expiration date, medications should be discarded three months after opening. During a review of the…

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

Based on observation, interview, and record review, the facility failed to store drugs and biologicals in locked compartments for three of five sampled medications carts and treatment cart (Medication Cart B, Middle Cart, Treatment Cart B) when Medication Cart B, Middle Cart was not locked on 11/27/2024/2024, at 6:17 a.m. and treatment cart B was not locked on 11/27/2024, at 6:30 a.m This deficient practice could lead other residents or unauthorize staff have an access in medications. Findings: During a concurrent observation and interview on 11/27/2024 at 6:17 a.m., with License Vocational Nurse LVN 2, observe at the nurse's station 1 that medication cart B and middle cart was unlock. LVN 2 stated medication cart must be locked at all times so other residents will not have access to any unauthorized medication. During a concurrent observation and interview on 11/27/2024 at 6:30 a.m., with Registered Nurse 3 (RN 3), observe at the nurse's station 1 that treatment cart B was unlock. RN 3 stated treatment cart must be lock at all times because other residents can just take medications…

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 administer insulin per physician's order to one of three sampled residents (Resident 1). This deficient practice had the potential for Resident 1 to have uncontrolled blood sugar. Findings: During a record review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 8/12/2024 with diagnoses that included metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood resulting to confusion and memory loss), acute respiratory failure with hypoxia (condition in which not enough oxygen passes the lungs into your blood) and diabetes mellitus (uncontrolled elevated blood sugar). During a record review of Resident 1 ' s Care Plan (CP) on at risk for uncontrolled blood sugar dated 8/12/2024, the CP indicated an intervention for diabetes medication as ordered by the physician and insulin regular human injection (act of administering a liquid, especially a drug, into a person's body using a needle and a syringe) solution per sliding scale (the dose is based…

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 a safe, comfortable, and homelike environment for two of three sampled residents (Resident 2 and Resident 3) when on [DATE] at 6 p.m. Resident 1 expired in the facility and was left in his room that he shared with Resident 2 and Resident 3 until his (Resident 1's) dead body was moved on [DATE] at 7 a.m. This deficient practice had the potential to affect Resident 2's and Resident 3's homelike environment. Cross-reference F745 Findings: A review of Resident 2's admission Record indicated the facility admitted Resident 2 on [DATE] and readmitted the resident on [DATE] with diagnoses that included unspecified psychosis (a mental disorder that causes people to lose touch with reality, resulting in a disruption of their thoughts and perceptions), dysphagia (swallowing difficulties), anxiety disorder (a condition that causes excessive fear, worry, and feelings of dread and uneasiness that persist over time), and schizophrenia (a mental disorder…

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 medically-related social services (services provided by the facility's staff to assist residents in attaining or maintaining their mental and psychosocial health) to maintain the highest practicable psychosocial well-being for two of three sampled residents (Resident 2 and Resident 3) when the social services department did not provide follow-up visits to Resident 2 and Resident 3 after their roommate (Resident 1) expired (died) on [DATE] at 6 p.m. This deficient practice had the potential for Residents 2 and 3's stress and anxiety to increase. Cross-reference F584 Findings: A review of Resident 2's admission Record indicated the facility admitted Resident 2 on [DATE] and readmitted the resident on [DATE] with diagnoses that included unspecified psychosis (a mental disorder that causes people to lose touch with reality, resulting in a disruption of their thoughts and perceptions), dysphagia (swallowing difficulties), anxiety disorder (a…

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

Based on interview and record review, the facility failed to ensure the physician was notified timely for one of three sampled residents (Resident 1). On 5/30/2024 at 9:10 a.m., Resident 1 had a pulse rate (the number of times the heart beats per minute) of 126 and physician was not notified until 12:40 p.m. This deficient practice resulted in the delay of obtaining appropriate instructions from the physician for proper management. Findings: During a record review of Resident 1's admission Record indicated the facility admitted Resident 1 on 5/3/2024 with diagnoses that included pneumonia (infection of the lungs), unspecified (unconfirmed) chronic obstructive pulmonary disease (COPD- a common lung disease causing restricted airflow and breathing problems) and unspecified dementia (the loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities). During a record review of Resident 1's History and Physical dated 5/6/2024 indicated Resident 1 did not have the capacity to understand and make…

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

Based on interview and record review, the facility failed to develop a comprehensive care plan for one of three sampled residents (Resident 1) to address Resident 1's tachycardia (elevated pulse rate) on 5/30/2024. This deficient practice had the potential for delayed provision of necessary care and services. Findings: During a record review of Resident 1's admission Record indicated the facility admitted Resident 1 on 5/3/2024 with diagnoses that included pneumonia (infection of the lungs), unspecified (unconfirmed) chronic obstructive pulmonary disease (COPD- a common lung disease causing restricted airflow and breathing problems) and unspecified dementia (the loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities). During a record review of Resident 1's History and Physical dated 5/6/2024 indicated Resident 1 did not have the capacity to understand and make decisions. During a record review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening 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 provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Resident 1) by failing to ensure metoprolol tartrate (medication used to treat high blood pressure) was not given to Resident 1 on 6/2/2024 at 9 a.m., 6/3/2024 at 9 a.m. and 5 p.m., as per physician's order. This deficient practices had the potential to result in medication error and delay in necessary care and had the potential to result in ineffectively managed hypertension (uncontrolled elevated blood pressure) for Resident 1. Findings: During a record review of Resident 1's admission Record indicated the facility admitted Resident 1 on 5/3/2024 with diagnoses that included pneumonia (infection of the lungs), unspecified (unconfirmed) chronic obstructive pulmonary disease (COPD- a common lung disease causing restricted airflow and breathing problems) and unspecified dementia (the loss of cognitive functioning, 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.

Based on interview and record review, the facility failed to prepare and orient a resident to ensure a safe discharge for one of three sampled residents (Resident 1) by: 1. Failing to ensure Resident 1 was discharged to a board and care (a residential home that has been licensed by the California Department of Social services to house and provide non-medical care for six elderly residents) as per physicians' order. 2. Failing to document independent living facility's contact number in Resident 1's medical record. 3. Failing to ensure Placement Coordinator (PC- assist in locating facilities in your local area that will meet your caregiving needs) was informed that physician's order was to discharge Resident 1 to board and care. These deficient practices placed Resident 1 at risk for unsafe discharge. On 7/1/2024 Resident 1 was discharged to an independent living (unlicensed facility). Findings: During a review of Resident 1's admission Record, it indicated the facility admitted Resident 1 on 5/27/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an engaged governing body was responsible for establishing and implementing policies regarding the management of the facility for one of three sampled residents (Resident 2). On [DATE] at 6 p.m., Resident 2 expired in the facility and was not picked up by mortuary services until 911 (emergency services) was called the following day of [DATE] at 8:50 a.m. This deficient practice resulted to Resident 2's dead body stayed at the facility for more than 12 hours. Findings: A review of Resident 2's admission Record indicated the facility admitted Resident 2 on [DATE] with diagnoses that included metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), unspecified (unconfirmed) malignant neoplasm (cells grow and divide more than they should) of the major salivary gland (produce saliva and empty it into your mouth through ducts, or small openings, it lubricates your mouth and throat, aid in swallowing and digestion,…

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 there was accurate documentation for one of three sampled residents (Resident 1) by failing to document the independent living facility's contact number in Resident 1's medical record. This deficient practice placed Resident 1 at risk for an unsafe discharge. On 7/1/2024 Resident 1 was discharged to an independent living (unlicensed facility). Findings: During a review of Resident 1's admission Record, it indicated the facility admitted Resident 1 on 5/27/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic inflammatory lung disease that causes obstructed airflow from the lungs), type 2 diabetes mellitus (a problem in the way the body regulates and uses sugar as a fuel) and adult failure to thrive (has a loss of appetite, eats and drinks less than usual, loses weight, and is less active). During a review of Resident 1's History and Physical, dated 5/28/2024, it indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set…

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 assess three of three sampled residents (Resident 1, 2, and 3) for risk of entrapment (an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail) from bed rails (adjustable metal or rigid plastic bars that attach to the bed that are available in a variety of types, shapes, and sizes ranging from full to one-half, one- quarter, or one-eighth lengths, i.e., grab bars, assist bars, side rails, safety rails, mobility bar) when Resident 1, 2, and 3 did not have an entrapment risk assessment performed prior to installation of a bed rail. This deficient practice had the potential to result in psychosocial harm, physical harm from entrapment (occurs when a resident is caught between the mattress and bed rail or within the bed rail itself) and death of residents. Findings: 1. A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 4/11/2024 with diagnoses including, but…

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 an environment that is free from accidents when one of three sampled residents (Resident 1) was not accurately evaluated for fall risk when Resident 1 ' s Fall Risk Assessment, dated 4/11/2024, indicated Resident 1 was not at risk for falls. This deficient practice had the potential for the facility to not develop and implement a plan of care to prevent falls and injuries in residents. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 4/11/2024 with diagnoses including, but not limited to, fusion of spine (surgical procedure that joins two or more parts of the spine) in the lumbar region (lower end of the spine) and thoracic region (middle section of the spine), generalized muscle weakness, and difficulty in walking. A review of Resident 1 ' s Minimum Data Set (MDS – a standardized assessment and care screening tool), dated 4/17/2024, indicated Resident 1 was able to understand and make decisions, required supervision or touching assistance with eating and oral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan by: 1. Failing to ensure Resident 27 had a care plan addressing the use of bolster pillows in the resident's bed for one of one sampled resident investigated during review of physical restraints use. Cross reference to F604 2. Failing to ensure Resident 345's dialysis care plan intervention of monitoring intake and output was implemented for one of one sampled resident investigated during review of dialysis care area. 3. Failing to ensure Resident 37 and Resident 68 had a care plan addressing the use of antibiotics (medication used to treat infections) for two of five sampled residents investigated during review of antibiotic stewardship. 4. Failing to ensure Resident 80 had a care plan addressing self-administration of medication. Cross reference to F554 These deficient practices had the potential to result in inconsistent implementation of the care plan that may lead to 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 one of three sampled resident (Resident 67) investigated during medication observation pass was free of any significant medication error when: 1. Licensed Vocational Nurses failed to administer metoprolol tartrate (medication that works by relaxing blood vessels and slowing heart rate to improve blood flow and decrease blood pressure [the pressure of blood pushing against the walls of your arteries]) to Resident 67 as prescribed for three out of 18 days. This deficient practice had the potential for Resident 67's blood pressure to be elevated. 2. Licensed Vocational Nurses failed to rotate injections sites for Enoxaparin (an anticoagulant known as a blood thinner used to prevent and treat blood clots) for 4 out of 18 days. This deficient practice had the potential for Resident 67's to have bruising and trauma to injection site. Findings: a. A review of Resident 67's admission Record indicated the facility admitted the resident 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: 1. Label a multi-dose container of multivitamin with minerals (a combination of different vitamins and minerals) with an open date for one of three sampled residents (Resident 67) residents observed during medication administration. 2. Ensure zolpidem oral tablets (controlled medication a [drug or chemical whose manufacturer, possession, or use is regulated by a government] used to treat insomnia [trouble sleeping]) were stored in the bubble pack (a packaging that have a preformed plastic pocket or shell where a product sits securely in place) with intact seal and not covered with tape affecting Resident 63 in one of two inspected carts (Station A Med Cart 1). 3. Ensure hydromorphone oral tablets (controlled medication used to treat severe pain) were stored in the bubble pack with intact seal and not covered with tape affecting Resident 87 in one of two inspected carts (Station A Med Cart 1). These deficient practices had the potential…

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 professional standards for food services safety and that food maintained its nutritive value and was not compromised by prolonged food storage when multiple items were noted without an open date or use by date. This deficient practice had the potential to result in 91 out of 95 residents receiving food items that are expired and placed residents at risk for developing foodborne illness symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization. Findings: During a concurrent observation and interview during the initial kitchen tour on 2/17/2024 at 8:02 a.m. with the Assistant Dietary Supervisor (ADS), observed the following: 1. Unopened Mozzarella cheese, 4 bags with delivery date of 2/12/2024 with no use by date. 2. Unopened Italian Vegetable blend, 2 bags with no delivery date, or use by date, 3. Opened Quaker Quick Creamy Wheat in dry storage with delivery date of 1/25/2024 and use by date of…

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

Based on observation, interview and record review, the facility failed to implement and maintain an infection control program by failing to: 1. Ensure LVN 2 performed hand hygiene to one of one sampled resident (Resident 66) observed during medication administration. 2. Ensure Resident 146's urinary catheter drainage bag (a bag designed to urine drained from the bladder via a catheter) was kept off the floor for one out two sampled residents investigated addressing the urinary catheter (a tube that is inserted into the bladder, allowing urine to drain freely) or urinary tract infection (UTI, an infection that affects part of the urinary tract-kidneys, ureters, urinary bladder and the urethra) care area. These deficient practices placed the resident at increased risk for acquiring infection from cross contamination (unintentional transfer of bacteria/germs or other contaminants from one surface or substance to another). 3. Ensure one of three sampled staff (Laundry Staff 1 [LS 1]) did not leave her plastic bag with food and two water bottles in contact with the clean linen inside 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 care in a manner that maintained or enhance a resident's dignity and respect in full recognition of their individuality during one (Resident 146) of one random observations by failing to ensure the resident's urinary catheter drainage bag (a bag designed to urine drained from the bladder via a catheter) was covered with a privacy bag. This deficient practice had the potential to affect the residents' sense of self-worth and self-esteem. Findings: A review of Resident 146's admission Record indicated the facility admitted the resident on 2/14/2024 with diagnoses including retention of urine, obstructive and reflux uropathy (a condition in which the flow of urine is blocked), and hydronephrosis (swelling of the kidneys due to a back-up of urine). A review of Resident 146's History and Physical (H&P) dated 2/17/2024, indicated the resident was able to make his needs known but did not have the capacity to make decisions. A review of Resident 146 's Admission/readmission Data Tool (a tool used by nurse 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 a resident's self-administration of medications was appropriate and safe for one of one sampled resident (Resident 80) investigated during a random observation by failing complete a Medication Self-Administration Assessment for Resident 80 before leaving medications at the resident's bedside. This deficient practice had the potential to result in unsafe medication management. Findings: A review of Resident 80's admission Record indicated the facility admitted the resident on 9/13/2023 and readmitted the resident on 12/14/2023 with diagnoses including end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis), hypertensive chronic kidney disease (high blood pressure caused by damage to the kidneys), and generalized muscle weakness. A review of Resident 80's History and Physical (H&P), dated 12/15/2023, indicated the resident had the capacity to understand and make medical decisions. A review of Resident 80's Minimum Data Set (MDS, a standardized…

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 call light was within reach for two of five sampled residents investigated during review of environment facility task Resident 27 and Resident 33). These deficient practices had the potential for delaying care and services requested by the residents and placing the residents at risk for falls and injuries. Findings: a. A review of Resident 27's admission Record indicated the facility admitted the resident on 01/10/2024, with diagnoses including difficulty walking, encephalopathy (damage or disease that affects the brain), and muscle weakness. A review of Resident 27's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/16/2024 indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding), had impairment on both side of the lower extremity and was dependent on helper with sit to lying, lying to sitting on side of the bed and toileting hygiene. A review of Resident 27's care plan dated 1/17/2024 indicated 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 to ensure a current copy of the advance directive (AD, written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) was in the resident's medical records for one of two sampled residents (Resident 144) investigated during review of advance directive care area. This deficient practice had the potential to cause conflict due to lack of communication regarding residents' wishes about their medical treatment. Findings: A review of Resident 144's admission Record indicated the facility admitted the resident on 2/7/2024 with diagnoses including retention of urine, UTI, sepsis (a life-threatening emergency that happens when your body's response to an infection damages vital organs and, often, causes death), and encounter for palliative care (a specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness). A review of Resident 144's History and Physical (H&P) dated 2/7/2024, 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 ensure a resident was free from physical restraint for one of one sampled resident (Resident 27) investigated during review of use of physical restraints when bilateral bolster pillows were tucked under the fitted sheet to prevent the resident from getting out of bed. This deficient practice placed Resident 27 at risk for being restricted with movement and had the potential to violate the resident's rights to be free from any restraints that are imposed for reasons other than the treatment of the resident's medical symptoms. Findings: A review of Resident 27's admission Record indicated the facility admitted the resident on 01/10/2024, with diagnoses including difficulty walking, encephalopathy (damage or disease that affects the brain), and muscle weakness. A review of Resident 27's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/16/2024 indicated the resident had severely impaired cognition (mental…

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 a baseline care plan (initial written guide that organizes information about the resident's care) addressing hospice care within 48 hours of admission for one out of two sampled residents (Resident 144) investigated during review of hospice and end of life care area. This deficient practice had the potential for Resident 144 not to receive the appropriate care and treatment specific to his needs. Findings: A review of Resident 144's admission Record indicated the facility admitted the resident on 2/7/2024 with diagnoses including retention of urine, sepsis (a life-threatening emergency that happens when your body's response to an infection damages vital organs and, often, causes death), and encounter for palliative care (a specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness). A review of Resident 144's History and Physical (H&P) dated 2/7/2024, indicated the resident was not alert and oriented. A review of Resident 144 's Admission/readmission Data Tool (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 provide the necessary treatment and services for one of three (Resident 52) sampled residents investigated during review of pressure ulcer/injury (a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) care area by failing to follow the manufacturer's guidelines for the use low air loss (LAL) mattress. This deficient practice had the potential to delay the healing of Resident 52's pressure injuries. Findings: A review of Resident 52's admission Record indicated the facility admitted the resident on 12/22/2023 with diagnosis including muscle weakness (generalized), type 2 diabetes mellitus (a chronic, metabolic disease characterized by elevated levels of blood glucose [or blood sugar], which leads over time to serious damage to the heart, blood vessels, eyes, kidneys and nerves), pressure ulcer of left heel unstageable (when the stage is not…

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

Based on observation, interview, and record review the facility failed to secure a resident's urinary catheter (a tube that is inserted into the bladder, allowing urine to drain freely) with a securement device for two of three sampled residents (Resident 144 and Resident 146) investigated during review of urinary catheter care area. This deficient practice had the potential for the residents' urinary catheters to be dislodged requiring reinsertion of the catheter tubing and increase the potential for the residents to obtain a urinary tract infection (UTI, an infection that affects part of the urinary tract-kidneys, ureters, urinary bladder, and the urethra). Findings: a. A review of Resident 144's admission Record indicated the facility admitted the resident on 2/7/2024 with diagnoses including retention of urine, UTI, sepsis (a life-threatening emergency that happens when your body's response to an infection damages vital organs and, often, causes death), and encounter for palliative care (a specialized medical care that focuses on providing relief from pain and other symptoms of…

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

Based on observation, interview and record review, the facility failed to administer parenteral fluids (the intravenous administration of medication) consistent with professional standards of practice to one of one sampled resident (Resident 347) during random observation of residents with peripheral intravenous (IV) catheter (a thin, flexible tube that is inserted into a vein to draw blood and give treatments including IV fluids, drugs, or blood transfusions) by failing to: 1. Follow-up with the physician to obtain an order to discontinue the peripheral intravenous catheter after the physician ordered to discontinue monitoring the IV site for signs and symptoms of inflammation/infiltration (when some of the fluid leaks out into the tissues under the skin where the catheter has been put in to the vein) on 2/11/2024. 2. Assess the continued need for the IV catheter if not being used for IV fluids or medications. This deficient practice placed the resident at risk for infection or inflammation of the IV catheter site due to lack of assessment and monitoring of the site. Findings: A…

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

Based on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards for one of one sampled resident (Resident 144) during a random observation by failing to ensure Resident 144's nasal cannula (a lightweight tube which on one end splits into two prongs which are placed in the nostrils to provide supplemental oxygen to the body) was properly applied to ensure the resident receive the oxygen ordered by the physician. This deficient practice had the potential to affect Resident 144's comfort by not getting enough oxygen in the system causing shortness of breath leading to hypoxia (low levels of oxygen in the body). Findings: A review of Resident 144's admission Record indicated the facility admitted the resident on 2/7/2024 with diagnoses including retention of urine, UTI, sepsis (a life-threatening emergency that happens when your body's response to an infection damages vital organs and, often, causes death), and encounter for palliative care (a specialized medical care that focuses on providing relief from pain 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 one of seven sampled residents (Resident 2) investigated during review of dining observation task was provided food that accommodated the resident's preference when the resident was served food (pork) that was on the resident's list of food dislikes. This deficient practice placed the resident at risk for having poor appetite that could potentially result in weight loss. Findings: A review of Resident 2's admission Record indicated the facility admitted the resident on 12/28/2023 with diagnoses including type 2 diabetes (disease that occurs when the body's blood sugar is too high) with diabetic polyneuropathy (malfunction of many nerves in different parts of the body), muscle weakness, and anemia (a condition in which the blood does not have enough health red blood cells and hemoglobin [a protein in red blood cells that carry oxygen all through the body]). A review of Resident 2's History and Physical dated 12/29/2023, indicated the resident does not have the capacity to understand and make decisions. 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 interview and record review, the facility failed to maintain medical records that are complete and accurately documented for one of three (Resident 92) investigated during review of closed records by failing to ensure the licensed nurse documented in the resident's progress note the accurate time of when cardiopulmonary resuscitation (CPR, an emergency life-saving procedure that is done when someone's breathing, or heartbeat has stopped) was performed to Resident 92. This deficient practice had the potential to result in the resident's medical record containing inaccurate documentation. Findings: A review of Resident 92's admission Record indicated the facility originally admitted the resident on [DATE] and readmitted the resident on [DATE] with diagnoses including osteomyelitis (bone infection), altered mental status and chronic congested heart failure. A review of Resident 92's History and Physical dated [DATE], indicated the resident does not have the capacity to understand and make decisions. A…

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

Based on interview and record review, the facility failed to arrange provisions of hospice services (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill) in a consistent manner for one of one sampled resident (Resident 144) investigated during review of hospice services by failing to: 1. Ensure Hospice Provider 1 (HP 1), provided the facility a calendar of hospice aide schedule of visits. 2. Ensure there was documented evidence that the hospice aide visited the resident as indicated in the plan of care. These deficient practices had the potential to negatively affect the residents' physical comfort and psychosocial well-being and had the potential to result in the delay or lack of necessary hospice care and services. Findings: A review of Resident 144's admission Record indicated the facility admitted the resident on 2/7/2024 with diagnoses including retention of urine, sepsis (a life-threatening emergency that happens when your body's response to an infection damages vital organs and, often, causes death), and…

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

Based on interview and record review, the facility failed to implement their protocol for antibiotic (medication used to treat infection) stewardship (efforts in doctors' offices, hospitals, long-term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate. That means prescribing the right drug at the right dose at the right time for the right duration) for one of five sampled residents (Resident 68) by: 1. Failing to document the completion date of ciprofloxacin (medication used to treat infection) eye drop in the Infection Prevention and Control Surveillance Log dated 2/2024. 2. Failed to provide documented evidence that Surveillance Data Collection forms were completed and matched the Infection Prevention and Control Surveillance Log for the month of 2/2024 for Resident 68. These deficient practices had the potential to increase antibiotic (medication used to treat infection) resistance (don't respond to a drug) from unnecessary or inappropriate antibiotic use. Findings: 1. A review of Resident 68's admission Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to administer pneumococcal vaccine (helps protect children and adults from various types of pneumococcal bacteria causing lung infection) to three of five sampled residents (Resident 37, 38 and 68) after the three resident had provided their consents to receiving the vaccine. This deficient practice placed Residents 37, 38 and 68 at a higher risk of acquiring and transmitting pneumonia to other residents in the facility. Findings: a. A review of Resident 37's admission Record (Face Sheet) indicated the facility admitted the resident on 1/30/2024 with diagnoses that included acute (you have active symptoms of heart failure with a new diagnosis or a long-term condition) on chronic (you have a history of heart failure, but are relatively stable) systolic heart failure (the left side of your heart, which pumps most of the blood, has become weak), essential hypertension (high blood pressure that doesn't have a known cause), and gout (a type of inflammatory…

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

Based on observation, interview, and record review, the facility failed to maintain mechanical, electrical, and resident care equipment in safe operating condition for one of five sampled residents investigated during review of environment task (Resident 54) by failing to: 1. Ensure Resident 54's bed controller was in working order (device used to change the height and angle of the bed). 2. Ensure Resident 54's bed mattress provided support to keep him comfortable. These deficient practices had the potential to affect Resident 54's comfort and places the resident at risk for injury. Findings: A review of Resident 54's admission Record indicated the facility admitted the resident on 1/9/2020 with diagnoses including generalized muscle weakness, lack of coordination, and contracture (a fixed tightening of muscle, tendons, ligaments, or skin) of right and left knee. A review of Resident 54's History and Physical (H&P) dated 7/19/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 54's Minimum Data Set (MDS - a standardized assessment and…

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

Based on interview and record review, the facility failed to maintain accurate and complete medical record for one of three sampled resident (Resident 1) by: 1. Failing to accurately document time physician was called on 12/13/2023 when Resident 1 had coughed out blood. 2. Failing to completely document assessment and interventions provided to Resident 1 when he had an episode of shortness of breath (sob) and hematemesis (vomiting of blood) on 12/14/2023. 3. Failing to monitor, document and report changes in lung sounds on auscultation (the action of listening to sounds from the heart, lungs, or other organs) as per Resident 1 ' s care plan. These deficient practices had the potential to result in confusion in the care and services rendered to Resident 1 and resulted in inaccurate and incomplete information entered into Resident 1 ' s medical record. Findings: a. A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 11/29/2023 with diagnoses that included Coronavirus Disease 2019 (COVID-19- highly contagious respiratory disease is thought 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 meet professional standards of quality for one of three sampled residents (Resident 1) by: 1. Failing to notify the attending physician timely when Resident 1 had an episode of shortness of breath (sob) and hematemesis (vomiting of blood) on 12/14/2023 at 7:30 a.m. The Change of Condition (COC) form dated 12/14/1023 indicated the attending physician was notified at 8:30 a.m. 2. Failing to immediately call the paramedics (are allied health professionals whose primary focus is to provide advanced emergency medical care for critical and emergent patients who access the emergency medical system) when Resident 1 ' s attending physician order to transfer the resident to General Acute Care Hospital (GACH) on 12/14/2023 at 8:30 a.m., via emergency number 911. The Paramedics record dated 12/14/2023 indicated dispatched was notified at 9:15 a.m. These deficient practices had the potential for delayed emergency lifesaving services. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on…

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

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biological) for one of three sampled resident (Resident 1) by failing to ensure resident was not administered Bystolic (medication used to treat high blood pressure) on 12/13/2023 at 9 a.m., when the resident ' s systolic blood pressure was less than 110 as ordered by physician. This deficient practice placed Resident 1 at risk for hypotension (low blood pressure). Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 11/29/2023 with diagnoses that included Coronavirus Disease 2019 (COVID-19- highly contagious respiratory disease is thought to spread from person to person through droplets released when an infected person coughs, sneezes or talks), essential hypertension (high blood pressure that doesn't have a known cause) and unspecified (unconfirmed) atrial fibrillation (irregular heart beat). A review of Resident 1 ' s History…

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 resident received care consistent with professional standards of practice, by preventing pressure ulcers (injury to the skin and underlying tissues resulting from prolonged pressure on the skin by the bone) from worsening, for one of four residents (Resident 1) by failing to implement an intervention in the care plan to reposition Resident 1. This deficient practice resulted in failure to deliver necessary care and services, and the potential to result in Resident 1 ' s pressure ulcers worsening. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 7/20/2023, with diagnoses including fracture (broken bone) of superior rim of left pubis (bones that make up part of the pelvis), pressure-induced deep tissue damage (injury to the skin and underlying tissues resulting from prolonged pressure on the skin) of the sacral regions (area of the body between lower back and tailbone), and pressure-induced deep tissue damage of left heel. A review of Resident 1 ' s Minimum…

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

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program regarding Coronavirus disease 2019 (COVID-19, a viral infection that is highly contagious and easily transmits from person to person, causing respiratory problems and may cause death) for one of four sampled residents (Residents 4), by failing to: a. Ensure Case Manager (CM) perform hand hygiene (hand washing with soap and water or use of alcohol-based hand sanitizer) after touching Resident 4 ' s bathroom doorknob and after exiting Resident 4 ' s room. b. Ensure Restorative Nursing Assistant 1 (RNA 1) wore the N95 mask (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) properly with both elastic straps on. These deficient practices placed other residents and staff at risk for exposure and contracting COVID-19. Findings: a. A review of Resident 4 ' s admission Record indicated the facility admitted the resident on 11/13/2023 with diagnoses including COVID – 19, benign prostatic…

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 residents received care consistent with the facility ' s policy and procedures (P&P), plan of care, and physician ' s orders to promote healing of pressure ulcers (PU, a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) and to promote PU healing and prevent infections for two of three sampled residents (Residents 4 and 5). The facility failed to: 1. Set the low air-loss mattress (LALM - a mattress composed of inflatable air cushions that is used to relieve pressure on body parts) to the appropriate setting per manufacturer ' s recommendation for Residents 4 and 5. 2. Ensure Resident 4 ' s PU dressing (a type of bandage used to cover wounds) was kept clean and dry. 3. Ensure Resident 4 was turned and repositioned every two hours as indicated in the plan of care. These deficient practices resulted in: a. Resident 4 ' s PU increasing 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 4) was treated with respect and dignity in a manner that promotes maintenance or enhancement of the quality of life by failing to ensure the urinary catheter drainage bag was fully covered by the dignity bag (a dark colored bag that conceals the front and back of the urine drainage bag). This deficient practice had the potential to affect Resident 4 ' s sense of self-worth and self-esteem. Findings: A review of Resident 4 ' s admission Record indicated the facility admitted the resident on 4/22/2023 and readmitted on [DATE] with diagnoses including osteomyelitis (inflammation or swelling that occurs in the bone), type two diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, was too high), and pressure ulcer on the sacral region (bottom of the spine). A review of Resident 4 ' s Bowel and Bladder Program Screener, dated 9/1/2023, indicated the resident had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement its policy and procedure (P&P) on Residents Call System, Residents, for one of three sampled residents (Resident 1), when Resident 1 activated his call light (device used by residents to signal staff for assistance) and was not responded to until 15 minutes after the call light was activated. This deficient practice had the potential to for residents to feel frustrated and to not be attended to during an emergent situation, such as a fall or respiratory distress. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including contracture of muscle (stiffening of muscles due to disease or lack of use), generalized muscle weakness, and lack of coordination. A review of Resident 1 ' s Minimum Data Set (MDS – a standardized assessment and care-screening tool), dated 7/27/2023, indicated Resident 1 was able to understand and make decisions, and required…

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 confidential personal information for one of five sampled residents (Resident 4) was protected. The clinical records of Resident 4 were left unattended on the treatment cart computer. This deficient practice had the potential to violate Resident 4 ' s rights for privacy and confidentiality of personal and medical records. Findings: A review of Resident 4 ' s admission Record indicated the facility admitted the resident on 4/22/2023 with a readmission dated 9/24/2023. Resident 4 ' s diagnoses included osteomyelitis (inflammation or swelling that occurs in the bone) and type two diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, was too high). A review of Resident 4 ' s Minimum Date Set (MDS – a standardized assessment and care-screening tool), dated 9/8/2023, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding). On 10/12/2023 at 10:30 a.m., during an observation at Nursing Station A, LVN 1 walked…

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 communicate necessary information related to discharge for one of three sampled residents (Resident 3) when Resident 3 ' s Discharge Instructions Form/Recapitulation of Stay, dated 8/14/2023, did not indicate the following: - Reason for Discharge - Primary Physician - Medical Equipment Arrangements - In Home Care or Services - Emergency This deficient practice had the potential for Resident 3 ' s responsible person (RP) to not know who to contact regarding post-discharge care. Findings: A review of Resident 3 ' s admission Record (Face Sheet) indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including encounter for orthopedic (branch of medicine dealing with the correction of deformities of bones or muscles) aftercare, pressure-induced deep tissue damage (also known as a pressure injury or pressure ulcer – injury to skin and underlying tissue resulting from prolonged pressure on the skin) of the sacral region (area of the lower…

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 post the current daily nursing staffing information in two of two nursing stations (Station A and Station B). This deficient practice resulted in the current total number of staff and the actual hours worked by the staff not readily accessible to residents and visitors. Findings: During a concurrent observation and interview at Station B with Registered Nurse 1 (RN 1), on 8/24/2023 at 8:07 a.m., RN 1 stated the staffing information dated 8/22/2023 should have been changed yesterday and would have the date 8/23/2023. RN 1 stated the Director of Staff Development (DSD) is in-charge of posted the daily staffing information. During a concurrent observation and interview at Station A with the Business Developer (BD), on 8/24/2023 at 8:13 a.m., the BD stated the staffing information for Station A was dated 8/22/2023. The BD stated the staffing information is posted to inform residents and visitors of the current census, nursing staff working every shift, and estimated hours worked. The BD stated it also part 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 ensure the safety of one of five sampled residents (Resident 1) by failing to provide a facility staff to accompany the resident to a scheduled appointment. This deficient practice had the potential to negatively impact Resident 1 ' s safety and prevent the residents from attaining or maintaining their highest practicable physical, mental, and psychosocial well-being. Findings: A review of Resident 1 ' s admission Record indicated the facility initially admitted the resident on 6/10/2021 and readmitted the resident on 4/7/2023, with diagnoses including type two diabetes mellitus (a disease that occurs when the blood sugar is too high) with diabetic neuropathy (occurs when diabetes causes damage to the nerves), pressure-induced deep tissue damage (an injury to the underlying tissue below the skin surface that results from prolonged pressure on an area of the body) of the sacral region (the bottom of the spine located above the tailbone), acquired absence of right leg above the knee, and peripheral vascular disease (PVD –…

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 the requested posted nurse staffing data to one of five (Resident 4) sampled resident ' s legal representative. This deficient practice had the potential to keep residents and the public unaware of the total number of staff and the actual hours worked by staff in the facility. Findings: A review of Resident 4 ' s admission Record indicated the facility initially admitted the resident on 7/15/2023 and readmitted on [DATE] with diagnoses including sepsis (a serious condition in which the body responds improperly to an infection) and Alzheimer ' s disease (a brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple tasks. A review of Resident 4 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/8/2023, indicated the resident ' s cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was severely impaired. 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.