The Rehabilitation Center Of North Hills

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to review and revise the comprehensive care plan (a document outlining a detailed approach to care customized to an individual resident's need) for two of 26 (Resident 8 and 112) sampled residents. This failure practice had the potential for Residents 8 and 112 not to receive the necessary care and services. Findings: a. During a review of Resident 8's admission Record, the admission Record indicated the facility originally admitted Resident 10 to the facility on [DATE] and readmitted on [DATE] with diagnoses that included gastro-esophageal reflux disease (a chronic digestive condition where stomach acid or bile repeatedly flows back into the esophagus) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 8' s Minimum Data Set (MDS, a resident assessment tool) dated 4/08/2026, the MDS indicated Resident 8 was cognitively (the process of acquiring knowledge 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 set a resident's low air loss mattress (LALM - designed to distribute a patient's body weight over a broad surface area and help prevent skin breakdown) in accordance with the physician's order for one out of one sampled resident (Resident 122) investigated for pressure ulcer/injury (also known as pressure sores and decubitus ulcers, localized damage to skin and/or underlying tissue caused by prolonged pressure or friction, often over bony areas a skin and soft tissue injury that occurs when skin is under pressure). This failure placed the resident at risk for discomfort and development of new and or worsening of pressure ulcers. Findings: During a review of Resident 122's admission Record, the admission Record indicated the facility originally the resident to the facility on 4/26/2026 with diagnoses that included sepsis (a life-threatening blood infection), anoxic brain damage (brain death), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that respiratory care supplies for two of two sampled residents (Resident 9 and Resident 67) reviewed under the respiratory care area, were changed in accordance with professional standards of practice and facility's policy and procedure. This failure had the potential to place the residents at increased risk of developing respiratory tract infections and distress. Findings: a. During a review of Resident 9's admission Record, the admission Record indicated the facility originally admitted the resident on 6/27/2024 and readmitted on [DATE] with diagnoses including but not limited to end stage renal disease (ESRD - irreversible kidney failure), and paraplegia (loss of movement and/or sensation, to some degree, of the legs). During a review of Resident 9's Order Summary revised 6/4/2026, the Order Summary indicated an order for oxygen at two liters per minute (LPM) via nasal cannula (a small plastic tube, which fits into the person's…

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

Based on observation, interview, and record review, the facility failed to document the administration of a dose of ciprofloxacin (an antibiotic medication used to treat infections) in the medication reconciliation log (a sheet used to compare medical orders with the medication given to a resident to prevent errors, omissions, duplication, and maintain medication count) for one of three sampled medication carts (Nurse Station 1 Medication Cart 1). This failure resulted in a medication count discrepancy of ciprofloxacin and had the potential to result in a double dosage administration to the resident which can lead to adverse reactions (undesired harmful effect resulting from a medication or other intervention).Findings: During a concurrent observation, interview, and record review on 7/16/2026 at 11:01 a.m., with Licensed Vocational Nurse 8 (LVN 8), observed the Nurse Station 1 Medication Cart 1. Observed the ciprofloxacin count in the medication bubble pack (a type of medication packaging in which each individual dose is sealed inside its own plastic bubble with a foil backing) was…

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

Based on interview and record review, the facility failed to ensure that all of a resident's active diagnoses were reflected in the admission Record under the Diagnosis Information section for one of one sampled resident (Resident 48). This failure resulted in Resident 48's admission Record containing incomplete information and had the potential to create confusion in the delivery of care and services.Findings: During a review of Resident 48's admission Record, the admission Record indicated the facility admitted the resident on 1/10/2026 with diagnoses including, but not limited to, seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), hypertension (HTN-high blood pressure), and dysphagia (difficulty swallowing). Resident 48's admission Record did not include diagnosis for depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), psychosis (severe mental disorder in which thought and emotions are so impaired that contact is lost with external…

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

Based on observation, interview, and record review, the facility failed to follow infection control practices and food handling practices by failing to ensure leftover milk is removed from the resident`s bedside after two hours for one of one resident (Resident 40). This deficient practice had the potential to place the resident at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). Findings: During a review of Resident 40's admission Record, the admission Record indicated the facility originally admitted the resident on 1/8/2026 and readmitted the resident on 3/11/2025 with diagnoses including gastro-esophageal reflux disease (stomach contents flow backward, up into the esophagus, the tube that carries food from your throat into stomach) and type two (2) diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 40's Minimum Data Set (MDS - a resident assessment tool) dated 6/10/2026, the MDS indicated Resident 40 had that ability to usually make…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper use of a low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure ulcer/injuries [PU/PIs - injuries that breakdown the skin and underlying tissue when an area of skin is placed under pressure]), for one of four sampled residents (Resident 2) by failing to set the LALM to the correct mode while the resident was lying in bed, and by placing multiple layers of linens on top of the LALM. These deficient practices had the potential to increase the resident's risk for skin breakdown and/or delay the healing of existing PU/PI.During a review of Resident 2's admission Record, the admission Record indicated that the facility originally admitted the resident (Resident 2) on 1/2/2026 and readmitted on [DATE] with diagnoses that included hemiplegia (total paralysis [complete or partial loss of muscle function in a part of the body, often accompanied by a loss of sensation] of the arm, leg,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 notify a resident's family/representative regarding a resident missing their doctor's appointment for one of five sampled residents (Resident 4). This deficient practice had the potential for Resident 4's family not to be involved in Resident 4's plan of care.Findings: During a review of Resident 4's admission Record, the admission Record indicated the facility admitted the resident on 7/16/2025 with diagnoses that include other specified polyneuropathies (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet), moderate protein-calorie malnutrition (a condition resulting from an imbalance between the nutrients your body needs to function and the nutrients it actually gets), and myelodysplastic syndrome (a group of diseases where the bone marrow does not make enough healthy blood cells). During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool) dated 1/15/2026, the MDS indicated that Resident 4 had intact cognition (the mental action or process of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain good grooming and personal hygiene for two of four sampled residents (Resident 1 and Resident 2) when the facility failed to trim and clean the residents' fingernails. This deficient practice resulted in Resident 1 and Resident 2 having long fingernails, placing the residents at increased risk for infection, skin breakdown and injury, and cross contamination; and had the potential to negatively affect the residents' comfort, self-esteem, and sense of dignity.Findings: a. During a review of Resident 1's admission Record, the admission Record indicated that the facility admitted the resident on 11/16/2025 with diagnoses including sepsis (a life-threatening blood infection), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and embolism (a blockage in a blood vessel) and thrombosis (the formation of a blood clot inside a blood vessel…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 no more than two layers of linen were placed on top of the low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure ulcer/injuries [PU/PI - injuries that breakdown the skin and underlying tissue when an area of skin is placed under pressure]) for one of four sampled residents (Resident 1). This deficient practice had the potential to increase the resident's risk of skin breakdown.Findings: During a review of Resident 1's admission Record, the admission Record indicated that the facility admitted the resident on 11/16/2025 with diagnoses including sepsis (a life-threatening blood infection), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), PU/PI stage III (full-thickness loss of skin, dead and black tissue may be visible) of sacral (the bony region at the very base of your spine and just above the tailbone) region, and dependence on respirator (a medical device to help support or replace…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a comprehensive, person-centered care plan (a written course of action that helps a resident achieve outcomes that improve their quality of life) for one (1) of three (3) sampled residents (Resident 1), that addressed Resident 1's use of continuous oxygen.This deficient practice had the potential to negatively affect the delivery of care and services to Resident 1.During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 9/17/2025 and readmitted the resident on 12/5/2025 with diagnoses that included pneumonia (an infection in the lungs), urinary tract infection (UTI - an infection in the bladder [muscular organ that stores urine] or urinary tract [refers to the system of organs that produce, store, and excrete urine]) and acute respiratory failure (when the lungs suddenly cannot release enough oxygen into the blood, which prevents the organs from properly functioning) with…

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

Based on interview and record review, the facility failed to ensure accurate documentation of the administration of medications for one (1) of three (3) sampled residents (Resident 1), by failing to document the administration of Resident 1's medication on the Medication Administration Record (MAR - a report detailing the medications administered to a resident by the licensed nurse in the facility).This deficient practice had the potential to result in medication errors and/or drug diversion (illegal distribution or abuse of prescription drug).During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 9/17/2025 and readmitted the resident on 12/5/2025 with diagnoses that included pneumonia (an infection in the lungs), urinary tract infection (UTI - an infection in the bladder [muscular organ that stores urine] or urinary tract [refers to the system of organs that produce, store, and excrete urine]) and acute respiratory failure (when the lungs suddenly cannot release enough oxygen into the blood, which prevents 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 ensure the resident assessment accurately reflected the residents' status for one (1) out of three (3) sampled residents (Resident 1).This deficient practice had the potential to lead to a delay or lack of delivery of care and services for Resident 1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD - a lung disease that causes obstructed airflow from the lungs, making it hard to breathe), type 2 diabetes mellitus (condition in which the body doesn't use insulin properly, resulting in unusual blood sugar levels), and urinary tract infection (UTI - an infection in the bladder [muscular organ that stores urine] or urinary tract [refers to the system of organs that produce, store, and excrete urine]). During a review of Resident 1's Skilled Nursing Facility admission History and Physical, dated 9/22/2025, the Skilled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a comprehensive person-centered care plan (a written course of action that helps a resident achieve outcomes that improve their quality of life) for one of three sampled residents (Resident 1) that addressed:1. Resident 1's hearing difficulty; 2. Resident 1's wounds; and 3. Resident 1's indwelling catheter (a thin, flexible tube inserted into the bladder to drain urine). This deficient practice had the potential to negatively affect the delivery of care and services to Resident 1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD - a lung disease that causes obstructed airflow from the lungs, making it hard to breathe), type 2 diabetes mellitus (condition in which the body doesn't use insulin properly, resulting in unusual blood sugar levels), and urinary tract infection (UTI - an infection in…

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

Based on observation, interview, and record review, the facility failed to implement infection control practices by failing to:1. Ensure Restorative Nursing Assistant 1 [RNA 1]) had not worn long artificial fingernails according to facility policy while providing direct resident care for one of five sampled residents (Resident 1).2. Ensure one of 12 sampled staff (Janitor 1) wore gloves while collecting and discarding trash bags and performed hand hygiene (cleaning hands by either washing with soap and water, or by using a hand sanitizing gel) after handling and discarding trash bags.3. Ensure two of 12 sampled staff (Certified Occupational Therapy Assistant 1 [COTA 1] and RNA 2) wore N95 masks (a disposable face mask that covers the user's nose and mouth which offers protection from small solid or liquid droplets found in the air) properly, covering their nose and mouth while in resident care areas during a Coronavirus disease-2019 (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection) outbreak (OB - when more people than usual get sick with 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 discharge planning process for one of three sampled residents (Resident 1) included an interdisciplinary team (IDT-a group of professionals including physicians, nursing, social services, therapy, and activities department who work together to achieve a shared goal for the resident) meeting prior to Resident 1 being transferred to a board and care facility (small, residential homes that provides personal care and support services for a limited number of residents) to ensure discharge readiness and/or appropriateness of the receiving board and care facility. This deficient practice placed Resident 1 at risk for unmet care needs, potential medication mismanagement, and overall functional decline in health status. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 2/7/2025 with diagnoses that include quadriplegia (paralysis [loss of ability to move] from the neck down, including legs, and arms, usually due to a spinal cord injury), sepsis (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 develop and implement a person-centered care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) for three of 27 sampled residents (Resident 75, 94, and 82) by failing to: 1. Develop a care plan addressing Resident 75's use of bed siderails. ? 2. Develop a care plan addressing Resident 94's preferred language for communication. 3. Develop a care plan addressing Resident 82's multiple joint contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and limited range of motion (ROM, full movement potential of a joint). These deficient practices had the potential to result in failure to deliver the necessary care and services. Findings: a. During review of Resident 75's admission Record, the admission Record indicated that the facility originally…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 10 sampled residents (Resident 82) received appropriate services to prevent a decline in range of motion (ROM, full movement potential of a joint) by failing to: 1. Provide sufficient physical therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) and occupational therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) services to safely assess and monitor Resident 82's use of a new left elbow splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint), new left hand splint, new right knee splint, new left knee splint, and new left ankle splint on 9/20/2024. 2. Provide Resident 82 with a left-hand splint three to four hours a day, seven times a week as ordered by a physician. These deficient practices had the potential to cause injury…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: a. Ensure that a licensed nurse did not leave 11 medications at a resident`s bedside who was assessed as not safe to self-administer oral medications for one of two residents (Resident 11). This deficient practice had the potential for the resident to choke on the medications upon oral ingestion while unsupervised. b. Provide bed rail padding for a resident with a history of epileptic seizures (a sudden surge of abnormal electrical activity in the brain, leading to a range of symptoms like muscle spasms, loss of consciousness) as ordered by the physician for one of one resident (Resident 54). This deficient practice placed Resident 54 at an increased risk for injuries. c. Provide a resident, who is at high risk for falls, with landing mats (cushioned mats placed on the floor, typically beside a bed or chair, to mitigate injury if a patient falls) as ordered by the physician for one (Resident 107) out of four sampled residents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: 1. Account for two (2) doses of Controlled Medication (also known as Controlled Drug and Controlled Substance [CM, CD, CS]- medications which have a potential for abuse and may also lead to physical or psychological dependence) for Resident 13 and 110 in one (1) of four (4) inspected medication carts (Medication Cart 1 Station 3.) 2. Identify and report CM discrepancy for June 2025 in one (1) of four (4) inspected medication carts (Medication Cart 2 Subacute.) 3. Reconcile (the process of comparing transactions and activity to supporting documentation) and account for one (1) medication emergency kit (eKIT) containing CMs for June 2025, in one (1) of two (2) inspected Medication Rooms (Medication Room Station 2.) These deficient practices increased the opportunity for CM diversion (the transfer of a controlled medication or other medication from a lawful to an unlawful channel of distribution or use,) and the risk that residents in the facility could…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Ensure a resident was free from significant medication error by failing to administer antihypertensive medication (used to treat high blood pressure [the force of the blood pushing on the blood vessel walls is too high]) timely for one of one resident (Resident 11) investigated under medication administration. This deficient practice had the potential to cause complications such as high blood pressure that could require hospitalization. 2. Ensure licensed nurses administered and/or held midodrine (medication used to treat low blood pressure [BP]) in accordance with the physician's prescribed parameters for one of two sampled residents (Resident 97) investigated under the care area of significant medications. This deficient practice had the potential for placing the resident at increased risk of experiencing adverse side effects. 3. Ensure residents were free of any significant medication errors by failing to not administer 31 doses 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: 1. Label one Timolol (a brand name medication used to treat glaucoma [a condition of increased pressure in the eyeball]) eye drop bottle for Resident 89, with an open date in accordance with facility requirements and manufacturer's requirements in one (1) of four (4) inspected medication carts (Medication Cart 2 Station 3.) 2. Remove and discard from use one (1) open, expired insulin (medication used to regulate blood sugar levels) Humulin N (an intermediate acting insulin) Kwikpen (an injection device containing insulin) stored at room temperature for Resident 101, in accordance with manufacturer's requirements and facility policy and procedures in one (1) of four (4) inspected medication carts (Medication Cart 1 Subacute.) 3. Label one (1) open insulin Humulin R (short-acting insulin) vial stored at room temperature for Resident 120, in accordance with manufacturer's requirements in one (1) of four (4) inspected medication carts (Medication Cart 1 Station 3.) These deficient practices increased the risk…

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

Based on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs of residents when: 1. [NAME] 1 did not follow the recipe for garlic buttered rice 2. [NAME] 1 did not follow portion sizes for small and large portions by serving three (3) ounces (oz, a unit of measurement) instead of two (2) oz and four (4) oz respectively. This deficient practice had the potential to result in bland (lacking strong flavor or taste) food item resulting to decreased nutrient intake due to poor food intake of 78 of 120 resident who received garlic buttered rice and ineffective therapeutic diet (a meal plan that controls the intake of certain food and nutrients in the treatment or management of certain medical condition or illness) provisions of four (4) of six (6) residents on small portion diets and two (2) of three (3) residents on large portion diets getting food from the kitchen. Findings: 1. During a review of the facility's daily spreadsheet (a list of food, amount of food that each diet would receive) titled Menus, dated 6/16/2025, 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, flavor and appearance when: 1. The temperature of the foods were as follows: a. Pound cake with strawberries and whip cream was at 56.5 degrees Fahrenheit (°F, a scale of temperature) b. Zucchini 115°F, c. Puree (a texture modified diet that consists of smooth, moist foods that are easy to swallow, food with soft pudding like consistency) pound cake with strawberries and whip cream was at 60°F 2. Zucchini was soggy and overcooked. 3. Gravy drippings were on the side of the plate. This deficient practice placed 78 of 120 facility residents on regular, therapeutic diets (a meal plan that controls the intake of certain food and nutrients in the treatment or management of certain medical conditions or illness) and puree diets at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen. Findings: 1. During a review of the facility's menu spreadsheet (a list of food, amount of food that each diet would receive) titled Menus,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 foods in a form designed to meet individual needs when the pureed (a texture-modified diet composed of foods that have been ground, pressed, or strained to a soft, smooth consistency, similar to pudding) roast pork was runny and did not hold its shape on the plate and pureed bread lacked a smooth pudding like consistency, containing visible bread particles. These failures had the potential to result in difficulty in swallowing, chewing, decreased in food intake and nutrient intake to 10 of 10 residents on pureed diet, resulting in unintended (not planned) weight loss and choking (when food gets stuck in your airway, blocking the flow of air to your lungs). Findings: During a review of the facility's menu spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled Menus, dated 6/16/2025, the spreadsheet indicated residents on puree diet would include the following foods on the tray: - Puree braised pork shoulder ½ cup (c., household measurement) - Puree garlic buttered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, as evidenced by the following: 1. There was no thermometer inside the reach-in freezer (refers to a standard freezer that allows for easy access to the frozen items stored inside) for temperature monitoring. 2. Kitchen equipment and kitchen areas were observed to be unclean and not sanitized. a. Walk-in freezer (a large, refrigerated room designed for storing frozen food items) curtains were observed to have stickers, sticker residues and food spills. b. Walk-in refrigerator (refers to a large, walk-in storage space, used to store perishable food items) vent had dust build-up. c. Dry storage vent (used to ensure proper air circulation and humidity control within areas where non-perishable foods and supplies are stored at room temperature) had dust build-up. 3. Eight (8) of eight dented canned goods were stored alongside non-dented cans, posing a potential food safety risk. 4. Staff failed to perform hand hygiene (refers 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 dispose garbage and refuse properly (to dispose of waste materials [refuse] in a way that complies with regulations and best practices, minimizing environmental and health risks) when there were soiled gloves, empty plastic cups, liquid spills and other trash on the floor and surrounding areas of the dumpster bin (a movable waste container designed to be brought and taken away by a special collection vehicle, or to a bin that a specially designed garbage truck lifts). This deficient practice had potential to attract birds, flies, insects, and pests (any unwanted organism that can contaminate or interfere with food safety and hygiene), and possibly spread infection to 78 of 120 facility residents. Findings: During a concurrent observation and interview on 6/17/2025 at 12:54 p.m., with the Dietary Supervisor (DS), observed the dumpster and soiled gloves, wet spill under the dumpster bin and other dirt debris. The DS stated it was not okay to have liquid spills, soiled gloves and other dirt debris around the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain accurate and complete resident medical records for two of 10 sampled residents (Resident 82 and 48) when nursing staff failed to: 1. Document when nursing staff did not put on a left hand splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) on Resident 82 three to four hours a day, seven days a week as ordered by a physician. These deficient practices resulted in inaccurate medical documentation and had the potential for worsening of contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of the left wrist and hand in Resident 82. 2. Ensure there was a diagnosis of anxiety (intense, excessive, and persistent worry and fear about everyday situations) documented prior to starting a routine anti-anxiety medication, clonazepam (anti-anxiety medication) for Resident 48. This deficient practice resulted 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 (b.) During a review of Resident 16's admission Record, the admission Record indicated the facility originally admitted the resident on 5/12/2009 and readmitted the resident on 7/7/2015 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). During a review of Resident 16's Minimum Data Set (MDS - a resident assessment tool), dated 4/1/2025, the MDS indicated the resident had severely impaired cognition (thought processes) and was dependent for most activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 77's admission Record, the admission Record indicated the facility originally admitted the resident on 4/18/2023 and readmitted the resident on 1/16/2024 with diagnoses including dysphagia (difficulty swallowing). During a review of Resident 77's History and Physical (H&P - a comprehensive assessment of a patient's health status, combining a patient's reported medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide care in a manner that maintained a resident's dignity and respect for one of two sampled residents, reviewed under the care area of dignity by failing to ensure Treatment Nurse 1 (TN1) knock or request permission before entering Resident 82's room. This deficient practice violated the resident`s rights to be treated with respect and dignity and had the potential to affect the residents` sense of self-worth and self-esteem. Findings: During a review of Resident 82's admission Record, the admission Record indicated the facility originally admitted the resident on 09/13/2024 and readmitted on [DATE] with diagnoses including, chronic respiratory failure (can occur when your blood has too much carbon dioxide or not enough oxygen) and sepsis (a life-threatening complication of an infection). During a review of Resident 82's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 3/15/2025, the MDS indicated the resident had 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 provide the resident and the resident's representative information regarding formulating an 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 for one of six sampled residents investigated during review of advance directive care area (Resident 82). This deficient practice had the potential for Resident 82 and their representative to not be informed of their right to formulate an advance directive and not honor the resident's wishes regarding end-of-life care. Findings: During a review of Resident 82's admission Record, the admission Record indicated the facility originally admitted the resident on 09/13/2024 and readmitted on [DATE] with diagnoses including, chronic respiratory failure (can occur when your blood has too much carbon dioxide or not enough oxygen) and sepsis (a life-threatening complication of an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 notify the resident's physician for one of 10 sampled residents (Resident 82) when licensed nursing staff failed to put on a left hand splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) for three to four hours a day, seven days a week as ordered by a physician. This deficient practice had the potential to cause a decline in range of motion (ROM, full movement potential of a joint) and worsening of contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) in Resident 82. Findings: During a review of Resident 82's admission Record, the admission Record indicated the facility admitted the resident on 9/13/2024 and readmitted the resident on 3/6/2025 with diagnoses including but not limited to acute and chronic respiratory failure (any condition that affects breathing function and result in lungs not functioning properly) with hypoxia (low oxygen level in tissues), quadriplegia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 receiving risperidone (used to treat schizophrenia [mental disorder in which people interpret reality abnormally]) was monitored for a specific paranoid (intense anxious or fearful feelings and thoughts) behavior exhibited for one of three residents (Resident 75). This deficient practice had the potential to result in inaccurate evaluation of the efficacy of risperidone and placed the resident at risk of experiencing medication adverse effect (undesired harmful effect resulting from a medication or other intervention) such as hypotension (low blood pressure) which could lead to fall and injury. Findings: During review of Resident 75's admission Record, the admission Record indicated that the facility originally admitted the resident on 3/21/2024 and readmitted the resident on 5/31/2024 with diagnoses that included muscle weakness, schizophrenia, and type two (2) diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]). During a review of Resident 75'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 interview and record review, the facility failed to conduct a quarterly review of a resident's comprehensive care plans (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) for one of one resident (Resident 75). This deficient practice had the potential to result in failure to deliver the necessary care and services. Findings: During review of Resident 75's admission Record, the admission Record indicated that the facility originally admitted the resident on 3/21/2024 and readmitted the resident on 5/31/2024 with diagnoses that included muscle weakness, schizophrenia, and type two (2) diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]). During a review of Resident 75's Minimum Data Set (MDS - a resident assessment tool), dated 3/30/2025, the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: A. Ensure a resident's low air loss mattress (LALM - designed to distribute a resident's body weight over a broad surface area and help prevent skin breakdown) was set to the resident's weight per manufacturer's guidelines for one (Resident 82) out of five sampled residents investigated for pressure ulcer/injury (PI/PU, injuries to the skin and underlying tissue resulting from prolonged pressure). This deficient practice placed the resident at risk of discomfort and development of new pressure ulcers. B. Ensure residents received care consistent with professional standards of practice to prevent pressure injuries by failing to ensure the LALM had firmness adjustment knob to set and determine the firmness setting as ordered by the physician in one of two residents (Resident 103) reviewed under the pressure ulcer/injury care area. This deficient practice had the potential for the worsening of or the development of PI/Pus in Resident 103.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assess and document the location and characteristic of a resident's pain prior to pain medication administration for one of one sampled resident (Resident 110) investigated under the pain care area. This deficient practice had the potential for inadequate management of Resident 110's pain resulting in decreased quality of life. Findings: During a review of Resident 110's admission Record, the admission Record indicated the facility originally admitted the resident on 11/26/2024 and readmitted on [DATE] with diagnoses including aftercare following a joint replacement surgery, intracerebral hemorrhage (bleeding into the brain tissue), and right knee osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 110's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 5/5/2025, the MDS indicated the resident was cognitively intact (can think, learn, and remember clearly)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Licensed Vocational Nurse 8 (LVN 8) possessed the necessary knowledge and skills to properly assess and evaluate one of one sampled resident (Resident 630's) food allergy (when your body's immune system mistakenly identifies a food as harmful and triggers a reaction). This deficient practice placed Resident 630 at risk of being exposed to an allergen (substance that can cause an allergic reaction), which could have led to a serious allergic reaction (a condition that causes illness when someone eats certain foods or touches or breathes in certain substances). Findings: During a review of Resident 630's admission Record, the admission Record indicated the facility admitted Resident 630 on 6/6/2025 with diagnoses that included multiple sclerosis (a disease that causes breakdown of the protective covering of nerves in the brain and spinal cord), essential hypertension (high blood pressure), and diabetes mellitus (DM, a disease of inadequate control of blood sugar levels). During a review of the Allergy Report 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 a resident obtained needed dental services when one of two residents (Resident 13) did not have their dental services coordinated to provide dental extractions as recommended by the dentist. This deficient practice had the potential for Resident 13 to experience pain, infection, chewing problems, and weight loss. Findings: During a review of Resident 13's admission Record, the admission Record indicated the facility originally admitted the resident on 6/27/2024 and readmitted the resident on 10/9/2024 with diagnoses including but not limited to congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and end stage renal disease (ESRD-irreversible kidney failure). During a review of Resident 13's Minimum Data Set (MDS - a resident assessment tool), dated 4/1/2025, the MDS indicated Resident 13 was cognitively intact (can think, learn, and remember clearly) and was dependent on staff for toileting, bathing, dressing the…

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

Based on interview, and record review, the facility failed to ensure one of one sampled resident (Resident 630's) food allergy (when your body's immune system mistakenly identifies a food as harmful and triggers a reaction) was honored when the food allergy was not entered in Resident 630's medical records in a timely manner, and staff did not accurately enter the food allergy into the meal order system. The diet ticket (a slip of paper or digital record that specifies which meal a resident is supposed to have and when and used by the kitchen staff to ensure each resident receives the correct food at the correct time) indicated an allergy to bell peppers instead of all peppers. This deficient practice resulted in Resident 630 being served peppers which had the potential to result in an allergic reaction (a condition that causes illness when someone eats certain foods or touches or breathes in certain substances). Findings: During a review of Resident 630's admission Record, the admission Record indicated the facility admitted Resident 630 on 6/6/2025 with diagnoses that included…

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

Based on observation, interview, and record review, the facility failed to maintain one of six rehabilitation therapy (therapy given to restore an individual back to their highest possible level of physical, mental, and psychosocial well-being) equipment for resident use. This failure had the potential for injury and spreading of infections to residents using the therapy equipment. Findings: During an observation and interview on 6/17/2025 at 8:43 a.m., inside the therapy gym, with the Director of Rehabilitation (DOR), the DOR stated the facility maintenance staff completed maintenance on the therapy equipment. The DOR observed the therapy mat and confirmed there were five open tears along the middle and right side outer edge of the therapy mat and a black plastic protective border was falling off the left side of the outer edge of the therapy mat. The DOR stated the therapy staff did not inform the maintenance staff of the tears in the therapy mat or the black plastic protective border was falling off and not secured. The DOR stated staff should report the equipment issues to…

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

Based on observation, interview and record review the facility failed to provide one of one resident (Resident 103), reviewed under the privacy care area, full visual privacy (a resident has a means of completely withdrawing from public view, without staff assistance, while occupying their bed [for example, curtain, moveable screens]) by not ensuring that ceiling suspended curtains extended fully around the resident's bed. This deficient practice prevented Resident 103 from having full privacy from public view. Findings: During a review of Resident 103's admission Record, the admission Record indicated the facility admitted Resident 103 on 4/21/2025 with diagnoses including tracheostomy status (an opening in the windpipe to allow for breathing), gastrostomy status(the surgical creation of an opening (stoma) into the stomach, typically for the purpose of feeding or administering medications) and cachexia (unintentional weight loss, primarily muscle mass, due to an underlying illness, not intentional dieting). During a review of Resident 103's History and Physical (H&P), dated…

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

Based on interview and record review, the facility failed to ensure a licensed nurse documented the administration of levetiracetam (a medication used to treat seizures [a sudden, temporary disruption in brain electrical activity that can cause involuntary changes in body movement, behavior, sensation, or awareness]) on the Medication Administration Record (MAR- a report detailing the medications administered to a resident by a healthcare professional) after administering the medication to one of one sampled resident (Resident 1). This deficient practice had the potential to result in medication errors and had the potential to result in confusion on the delivery of care and services. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 5/27/2021 and readmitted the resident on 5/12/2025 with diagnoses including intracerebral (within the brain) hemorrhage (the dramatic and sudden loss of blood), seizure, and gastrostomy (the creation of an artificial external opening into the stomach for nutritional support)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 materials to facilitate communication for a resident with speech disabilities for one of four sampled residents (Resident 1). This deficient practice had the potential to prevent the resident from communicating with the staff and had the potential to delay receiving care/treatment the resident needed. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 5/27/2021 and readmitted the resident on 5/12/2025 with diagnoses including intracerebral (within the brain) hemorrhage (the dramatic and sudden loss of blood), seizure (a sudden, temporary disruption in brain electrical activity that can cause involuntary changes in body movement, behavior, sensation, or awareness), and gastrostomy (the creation of an artificial external opening into the stomach for nutritional support) with dysphagia (difficulty swallowing). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 3/10/2025, the MDS indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a written course of action that helps a resident achieve outcomes that improve their quality of life) for one of four sampled residents (Resident 1), to address Resident 1's noncompliance with his physician ordered diet. This deficient practice had the potential to negatively affect the delivery of care and services to Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE] with diagnoses that included acute kidney failure (occurs when the kidneys suddenly become unable to filter waste products from the blood), chronic kidney disease (gradual loss of kidney function) - stage 4 (severe), type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 1/20/2025, the MDS indicated 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 implement infection control practices to prevent the spread of Coronavirus Disease 2019 (COVID 19 - a highly contagious respiratory illness in humans capable of producing severe symptoms) by failing to ensure two of two sampled staff (Respiratory Therapist 1 [RT 1] and Licensed Vocational Nurse 1 [LVN 1]) wore an N95 (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) while in the facility during a COVID 19 outbreak (a sudden increase in the number of COVID 19 positive cases). This deficient practice had the potential to result in an increase of COVID 19 positive cases and had the potential to result in the spread of infection placing residents, staff, and visitors at risk to be infected with COVID 19. Findings: During an observation on 4/2/2025 at 12:36 p.m., observed RT 1 walking out of Room A, a room that had a red contact precautions signage near the door indicating that the room had COVID 19 positive residents. RT 1 was observed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility's bed-hold (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) policy by failing to provide residents and/or the residents' responsible party with a notice of bed-hold upon transferring the residents to the general acute care hospital (GACH) for three of three sampled residents (Resident 1, Resident 2, and Resident 3). This deficient practice had the potential to deprive the residents and/or the residents' responsible party, the right to be informed of their rights regarding bed-holds. Findings: a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 2/7/2025 with diagnoses that included sepsis (a life-threatening complication of an infection), injury at C5 level of cervical spinal cord (the upper portion of the spinal cord, located in the neck region), paraplegia (loss of movement and/or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for three of three sampled residents (Resident 1, Resident 2, and Resident 3) by failing to document residents ' name, date of birth , and admission date as indicated on the facility ' s Bedhold Information Consent form. This deficient practice has the potential to result in residents ' medical records not being identifiable due to the incomplete information on Resident 1, Resident 2, and Resident 3 ' s Bedhold Information Consent form. Findings: a. During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 2/7/2025 with diagnoses that included sepsis (blood infection), injury at C5 level of cervical spinal cord (the upper portion of the spinal cord, located in the neck region), paraplegia (loss of movement and/or sensation, to some degree, of the legs), and pressure ulcer localized,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) by Resident 2 for one of two sampled residents (Resident 1). On 2/2/2025, Certified Nursing Assistant 1 (CNA 1) witnessed Resident 2 punch Resident 1 with a closed fist, three times on the left side of Resident 1's chest. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 1/9/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood), and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss…

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

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a written course of action that helps a resident achieve outcomes that improve their quality of life) for one of two sampled residents (Resident 1), who had a new onset of pain on 2/2/2025. This deficient practice had the potential to negatively affect the delivery of care and services to Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 1/9/2024 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), chronic respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in the body), unspecified severe protein-calorie malnutrition, major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). During a review of Resident 1's Minimum Data Set (MDS – a federally…

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

Based on interview and record review, the facility failed to monitor a resident for 72 hours after a Change of Condition (COC- sudden deviation from a resident ' s baseline in physical, cognitive [involving the processes of thinking and reasoning], behavioral, or functional domains) for one of two sampled residents (Resident 1) as indicated in the facility policy. This deficient practice had the potential to place the resident at risk of not receiving appropriate care due to the lack of monitoring and had the potential to negatively affect the resident ' s psychosocial (the mental, emotional, social, and spiritual effects of a disease) well-being and delay in attaining the resident ' s highest practicable mental and psychosocial well-being. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 1/9/2024 with diagnoses that including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), chronic respiratory failure (a condition where there's not enough oxygen or too…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility's policy on pain assessments as evidenced by failing to ensure a pain assessment was completed quarterly (every three months) and for new onset of pain on 2/2/2025 for one of two sampled residents (Resident 1). This deficient practice had the potential to result in Resident 1 not maintaining Resident 1's highest possible level of comfort. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 1/9/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood), and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 1/8/2025, the MDS indicated…

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

Based on interview and record review, the facility failed to ensure a resident's attending physician documented a resident's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings) annually for one of two sampled residents (Resident 2). This deficient practice had the potential for inconsistent care coordination due to incomplete records for Resident 2. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 5/13/2022 and re-admitted the resident on 8/5/2023 with diagnoses that included bipolar disorder (mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks), paranoid personality disorder (mental health condition marked by a long-term pattern of distrust and suspicion of others without adequate reason), and schizoaffective disorder (a mental health condition that includes features of both schizophrenia [serious mental illness that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to account for 16 tablets of hydromorphone hydrocholoride (Dilaudid- controlled medication [medications with a high potential for abuse] used to treat severe levels of pain) for one of three sampled residents (Resident 1). This deficient practice increased the risk of diversion (any use other than that intended by the prescriber) of the controlled medication and had the potential for Resident 1 to have increased discomfort, increased pain levels and decreased quality of life. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility originally admitted Resident 1 on 9/2/2021, and readmitted on [DATE] with diagnoses including pelvic fracture (break in the bone), fracture of the lumbar vertebra (bones located in the lower back), septic shock (a life-threatening blood infection), chronic kidney disease (decreased kidney function), and chronic pain syndrome. During a review of Resident 1 ' s Minimum Data Set (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 maintain complete and accurate medical records in accordance with accepted professional standards for two of four sampled residents by failing to: 1. Document Resident 1 and Resident 3 ' s blood sugar readings and or insulin administered in the Medication Administration Records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident). 2. Document Resident 1's blood sugar (BS) reading accurately in the resident's blood sugar summary records. This deficient practice resulted in incomplete resident medical care information for Resident 1 and Resident 3 and placed the residents at risk for not receiving the appropriate care and treatment related to management of diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing). Findings: 1.a. During a review of Resident 1 ' s admission Record, the admission Record indicated the facility originally…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident ' s call light (a devices used by a resident to signal his/her need for assistance from staff) was answered promptly for one of four sampled residents (Resident 3). This deficient practice had the potential to delay the provision of services and residents' needs not being met. Findings: During a review of Resident 3 ' s admission Record, the admission Record indicated the facility originally admitted the resident on 4/29/2016 and readmitted on [DATE] with diagnoses including angina pectoris (a severe acute attack of cardiac pain), acute respiratory failure (lungs suddenly cannot provide enough oxygen to your blood, making it difficult to breathe and potentially causing your organs to not function properly due to lack of oxygen), and chronic pain syndrome. During a review of Resident 3 ' s Minimum Data Set (MDS - a resident assessment tool) dated 12/1/2024, the MDS indicated the resident ' s cognitive (the mental action…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a document that summarizes a resident's needs, goals, and care/treatment) for one of three sampled residents (Resident 1), who was identified to have an amputation (the action of surgically cutting off a limb). This deficient practice had the potential to negatively affect the delivery of care and services to Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 6/10/2024 and readmitted the resident on 9/5/2024 with diagnoses that included partial traumatic amputation of right mid foot and peripheral vascular disease (PVD - a disorder that reduces blood flow to a body part outside of the brain or heart). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 9/12/2024, the MDS indicated Resident 1's cognitive skills (the mental action or process of acquiring…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility's policy on skin assessment as evidenced by failing to ensure reassessments were done timely using the Braden Scale (a standardized tool used to assess a resident's risk for developing pressure ulcer [injury to skin and underlying tissue resulting from prolonged pressure on the skin]) for two of three sampled residents (Resident 2 and Resident 3). This deficient practice had the potential to negatively affect the delivery of care and services to Resident 2 and Resident 3. Findings: a. During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted Resident 2 on 11/1/2023 with diagnoses that included chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood), human immunodeficiency virus (HIV- a virus that attacks and weakens the body's immune system), and personal history of sudden cardiac arrest (sudden, unexpected loss of heart…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 monitor a resident for 72 hours after a Change of Condition (COC- sudden deviation from a resident's baseline in physical, cognitive [involving the processes of thinking and reasoning], behavioral, or functional domains) was completed for an abuse allegation for one of two sampled residents (Resident 1). This deficient practice had the potential to place the resident at risk of not receiving appropriate care due to the lack of monitoring and had the potential to negatively affect the resident's psychosocial (the mental, emotional, social, and spiritual effects of a disease) well-being and delay in attaining the resident's highest practicable mental and psychosocial well-being. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 11/10/2024 with diagnoses that included spinal stenosis (spaces inside the bones of the spine get too small), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care consistent with the professional standards of practice to help prevent pressure ulcer (also known as pressure injury, an injury to skin and underlying tissue resulting from prolonged pressure on the skin) for one of seven sampled residents (Resident 3) by failing to ensure weekly wound monitoring assessments for pressure ulcer were done on a weekly basis. This deficient practice had the potential for development and worsening of pressure ulcer to Resident 3. Findings: During a review of Resident 3's admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included nontraumatic intracerebral hemorrhage (a subtype of stroke that occurs when blood pools in the brain without trauma or surgery), hypertensive emergency (a sudden, severe increase in blood pressure along with signs of organ damage), and sepsis (a life-threatening condition that occurs when the body's response to an infection…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow its policy and procedure (P&P) titled Fall Management Program for one of three sampled residents (Resident 1), when on 7/22/2024, Certified Nurse Assistant (CNA 1) did not utilize a geriatric-shower chair (Geri-chair- a large, padded wheeled chair that can be used in the shower that is designed to assist residents with limited mobility) while providing shower assistance to Resident 1. This deficient practice resulted in Resident 1 having an assisted fall (when a resident falls and a staff member is present to help the resident to the ground or break the fall) while in the shower, and placed Resident 1 at risk for injury and decreased quality of life. Findings: During a review of Resident 1's admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included parkinsonism (a progressive disease of the nervous system marked by tremor [involuntary quivering movement],…

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

Based on interview and record review, the facility failed to ensure monitoring for changes in urine characteristics and signs and symptoms of a urinary tract infection (UTI - an infection in any part of the urinary system) for a resident with an indwelling catheter (a flexible tube that drains urine from the bladder) was done for one of five sampled residents (Resident 1). This deficient practice had the potential for a delay in care and services and potential for Resident 1 to develop an unrecognized UTI. Findings: During a review of Resident 1's admission Record, the document indicated the facility originally admitted the resident on 9/21/2022 and readmitted the resident on 7/14/2024 with diagnoses including but not limited to sepsis (a life-threatening complication of an infection), multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), and functional quadriplegia (a partial to complete paralysis [complete or partial loss of muscle function] of the upper and lower limbs). During 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a person-centered care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) for four of 34 sampled residents (Resident 115, 67, 103, and 427) by failing to: 1. Develop a care plan addressing Resident 115's visual impairment. 2. Develop a care plan addressing Resident 67, Resident 103, and Resident 427's use of a low air loss mattress (LAL - a specialty bed that alternates pressure to help heal and prevent pressure ulcers [an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure]). Findings: 1. A review of Resident 115's admission Record indicated the facility readmitted the resident on 5/23/2024 with diagnoses that included muscle weakness, type 2 diabetes mellitus, and primary open-angle glaucoma (occurs when resistance builds up in your eye's drainage canals).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Ensure the low air loss mattress (LAL - a specialty bed that alternates pressure to help heal and prevent pressure ulcers [an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure]) or alternating pressure mattress (APP - uses air to redistribute pressure across a sleeping surface) was set correctly for two of 34 sampled residents (Resident 35 and 117). 2. Ensure there was a physician's order for use of a LAL mattress for two of 34 sampled residents (Resident 427 and 40) These deficient practices had the potential to increase the resident's risk of skin breakdown or delay the treatment of pressure ulcers. Findings: 1.a. A review of Resident 35's admission Record indicated the facility originally admitted the resident on 1/2/2019 and readmitted the resident on 3/9/2024 with diagnoses including Parkinson's disease (a chronic, degenerative brain disorder that affects the nervous system 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 accurate documentation of the administration of a medication order for Netarsudil Dimesylate Ophthalmic Solution (generic name for Rhopressa Ophthalmic Solution , an eye drop medication used to lower eye pressure in people with glaucoma [a condition in which increased pressure in the eye can lead to gradual loss of vision] or ocular hypertension [a condition where the pressure inside the eye is higher than normal]) by transcribing twice (generic name and brand name) in the electronic Medication Administration Record (MAR- the report that serves as a legal record of the medications administered to a resident of a facility by a health care professional) for one of one resident (Resident 115) reviewed under Quality of Care. This deficient practice placed Resident 115 at risk for receiving the eye drop medication twice which could lead to adverse effects (an undesired effect of a drug) such as eye redness, severe eye pain, and blurred vision). Findings: A review of Resident 115's admission Record indicated the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility staff knocked and asked permission prior to going inside a resident's room for one of two rooms (Room A) observed during a facility tour. This deficient practice violated the resident's rights to be treated with respect and dignity which had the potential to affect the resident's sense of self-worth and self-esteem. Findings: During a concurrent observation and interview on 7/8/2024 at 10:30 a.m., observed Certified Nurse Assistant 2 (CNA 2) enter Room A with three resident occupants without knocking and asking permission to enter the room. CNA 3 then proceeded to the third bed and provided patient care. Upon exiting Room A, CNA 3 was asked why she did not knock prior to entering the residents' room. CNA 3 stated that she forgot and explained that she should have knocked prior to entering as a show of respect to the residents. CNA 3 stated that this facility is the resident's home and their privacy should be respected and upheld their dignity by respecting their personal space. 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 ensure an informed consent (a process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment) was obtained from a resident and/or the resident's responsible party (person, usually a family member who makes medical decisions for a resident) for one of two sampled residents (Resident 114) regarding the use of an antipsychotic medication (a medication used to treat psychosis [a mental condition in which thought, and emotions are so affected that contact is lost with external reality]). This deficient practice had the potential for the resident and/or the resident's responsible party to not be informed on medication therapy decisions that may affect a resident's health conditions. Findings: A review of Resident 114's admission Record indicated the facility originally admitted the resident on 4/28/2024 and readmitted the resident on 5/23/2024 with diagnoses including muscle weakness and unspecified dementia (decline in memory or other thinking skills…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 call light (a device used by a resident to signal his/her need for assistance from staff) was within reach for one of one sampled resident (Resident 62). This deficient practice had the potential to cause a delay in resident care and for the resident's needs to remain unmet. Findings: A review of Resident 62's admission Record indicated the facility admitted the resident on 9/1/2020 with diagnosis of head and skull injury and liver failure (loss of liver function). A review of Resident 62's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool) dated 5/31/2024, indicated Resident 62 had severe cognitive (mental action or process of acquiring knowledge and understanding) impairment. The MDS indicated Resident 62 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) on staff for activities of daily living (ADLs - activities related to personal care). During an interview on 7/8/2024 at 11:41 a.m., with Resident 62,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Restorative Nursing Assistant 1 (RNA 1) provided privacy to a resident while the resident received exercises for one of 34 sampled residents (Resident 35). This deficient practice violated the resident's right to privacy. Findings: A review of Resident 35's admission Record indicated the facility originally admitted the resident on 1/2/2019 and readmitted the resident on 3/9/2024 with diagnoses including Parkinson's disease (a chronic, degenerative brain disorder that affects the nervous system and muscle control), quadriplegia (a type of paralysis that results from a spinal cord injury that affects the body from the neck down), contracture (a permanent tightening of muscles, tendons, ligaments, skin, or other tissues that can cause joints to shorten and become stiff) of the right and left hand, and generalized muscle weakness. A review of Resident 35's History and Physical (H&P - a physician's examination of a resident that includes a medical history and a physical exam), dated 5/2/2024, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to permit one of one sampled resident (Resident 71) to return to the facility after hospitalization. Resident 71 was permitted to the facility on 7/10/2024. This deficient practice subjected Resident 71 to an unnecessary prolonged hospitalization. Findings: During a review of Resident 71's Face Sheet, the face sheet indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included acute (sudden) and chronic (on-going) respiratory failure with hypoxia (condition in which one does not have enough oxygen for their body tissues), and dependence on a ventilator (a machine used to support or replace breathing of one who cannot breathe on their own). During a review of Resident 71's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/22/2024, the MDS indicated that Resident 71 was severely impaired in cognition (the process of acquiring knowledge and understanding…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, who was assessed as unsafe to self-administer medications, was not left unattended with a bottle of antacid (a medication that relieves heartburn in the stomach by reducing the amount of acid in the stomach) at the bedside for another resident to take for one of one sampled resident (Resident 44). This deficient practice had the potential for other residents to enter the room and take the medication. Findings: A review of Resident 44's admission Record indicated the facility admitted the resident on 11/20/2017 and re-admitted the resident on 9/5/2022 with diagnoses that included gastric ulcer (a sore that develops on the lining of the stomach). A review of Resident 44's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/10/2024, indicated Resident 44 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact with skills required for daily decision making. The MDS indicated Resident 44 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: 1. Ensure that Licensed Vocational Nurse 4 (LVN 4) checked the placement of the gastrostomy tube (G-tube - a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration) before administering medications for one of two sampled residents (Resident 81) observed during the medication pass (the process through which medication is administered to a resident) observation. This deficient practice placed Resident 81 at risk for injury if medications were administered into a displaced (outside the stomach) G-tube. 2. Ensure the G-tube feeding bottle was labeled for one of 34 residents (Resident 80) who were prescribed with G-tube feeding. This deficient practice placed Resident 80 at risk for infection from spoiled G-tube feeding formula since it was unknown when the G-tube feeding bottle was changed or started. Findings: 1. A review of Resident 81's admission Record 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 failed to ensure a resident's as needed (PRN) lorazepam (medication used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations]) had a specific duration for one of 34 sampled residents (Resident 35). This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention). Findings: A review of Resident 35's admission Record indicated the facility originally admitted the resident on 1/2/2019 and readmitted the resident on 3/9/2024 with diagnoses that included epileptic seizures (brief, involuntary episodes of electric activity in the brain that can affect a person's movements, feelings, and consciousness). A review of Resident 35's History and Physical (H&P - a physician's examination of a resident that includes a medical history and a physical exam), dated 5/2/2024, indicated the resident does not have the capacity to understand and make decisions. 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.

Based on observation, interview and record review, the facility failed to maintain accurate medical records for one of 34 sampled resident (Resident 478) by failing to ensure Licensed Vocational Nurse 2 (LVN 2) document the correct location of Resident 478's body part where the blood pressure (BP- the pressure of blood on the walls of your arteries as your heart pumps blood around your body) reading was obtained. This deficient practice had the potential to result in confusion regarding Resident 478's condition and what care and services were provided to Resident 478. Findings: A review of Resident 478's admission Record indicated the facility admitted Resident 478 on 6/27/2024 with diagnoses that included end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis [a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly] or a kidney transplant [surgery to place a healthy kidney] to maintain life). 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.

Based on observation, interview, and record review, the facility failed to: 1. Ensure Licensed Vocational Nurse 8 (LVN 8) donned (to put on) a gown prior to administering medications via gastrostomy tube (G-tube - a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration) for one of 34 sampled residents (Resident 77). 2. Ensure a resident, who had a g-tube, was placed on enhanced barrier precautions (EBP - an infection control method that uses targeted gown and gloves to reduce the spread of multidrug-resistant organisms [MDROs - microorganisms, mainly bacteria, that are resistant to one or more classes of antimicrobial [a substance that kills microorganisms such as bacteria or mold, or stops them from growing and causing disease agents]) for one of 34 sampled residents (Resident 278). These deficient practices placed the residents at increased risk of developing an infection. Findings: 1. A review of Resident 77's admission Record indicated the facility originally admitted the resident on 7/15/2022 and readmitted the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained residents' dignity by failing to ensure the urinary drainage bag (a bag that collects the urine drained from the bladder via a catheter [a tube inserted into the bladder to allow urine to drain freely]) was covered with a privacy bag for two of three sampled residents. (Resident 2 and Resident 3) This deficient practice had the potential to negatively affect residents' psychosocial wellbeing and loss of dignity. Findings: A review of Resident 2's admission Record indicated the facility readmitted the resident on 4/14//2024 with diagnoses that included acute (very serious, extreme, or severe) and chronic (persisting for a long time) respiratory failure (a serious condition that makes it difficult to breathe on your own) and benign prostatic hyperplasia (condition in which the prostate gland [a gland in the male reproductive system] is larger than normal). A review of Resident 2'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 observation, interview, and record review, the facility failed to ensure staffing information of the actual hours worked by licensed and unlicensed nursing staffing directly responsible for resident care per shift was posted daily as indicated in the facility's policy and procedure (P&P) on Nurse Staffing Information. This deficient practice had the potential to keep residents and visitors unaware of the total number of staff and the actual hours worked by the staff in the facility. Findings: During an observation on 6/3/2024 at 3:30 p.m., observed in front of the Admission's Office, a facility document titled Daily Nurse Staffing Information, dated 6/3/2024. During an observation on 6/4/2024 at 12:30 p.m., observed in front of the Admission's Office, a facility document titled Daily Nurse Staffing Information, dated 6/4/2024. During a concurrent observation, interview, and record review with the Nursing Staffing Coordinator (NSC) on 6/4/2024 at 12:47 p.m., the NSC observed the facility's document titled Daily Nurse Staffing Information, dated 6/4/2024 posted and framed 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 implement infection control practices by failing to ensure two of three sampled resident's (Resident 2 and Resident 3) urinary drainage bags were not touching the floor. This deficient practice had the potential for contamination (unintentional transfer of bacteria/germs or other contaminants from one surface to another) of the urinary bag which may in turn cause infection. Findings: A review of Resident 2's admission Record indicated the facility readmitted the resident on 4/14/2024 with diagnoses that included acute (very serious, extreme, or severe) and chronic (persisting for a long time ) respiratory failure (a serious condition that makes it difficult to breathe on your own) and benign prostatic hyperplasia (condition in which the prostate gland [a gland in the male reproductive system] is larger than normal). A review of Resident 2's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 4/21/2024, 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 interview and record review, the facility failed to ensure that three of three sampled residents (Resident 2, Resident 3, and Resident 4) were not prescribed permethrin cream (a medication used to treat scabies [a condition caused by tiny insects called mites] that infest and irritate a person's skin) and ivermectin (a medication that treats infections caused by roundworms, threadworms, and other parasites [organism that lives on or in a host organism and gets its food from or at the expense of its host]); medications used to treat scabies, to treat the residents' diagnosis of pruritus (itchiness). This deficient practice had the potential to result in the use of unnecessary medication and cause adverse side effects (an undesired harmful effect resulting from a medication or other intervention). Findings: a. A review of Resident 2's admission Record indicated the facility readmitted Resident 2 on 2/21/2024 with diagnoses that included pneumonia (an infection that involves one or both lungs, which may…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care and services to maintain good grooming and personal hygiene for two of three sampled residents (Resident 2 and Resident 4). This deficient practice resulted in Resident 2 and Resident 4 having long, untrimmed fingernails that had the potential to result in a negative impact on the resident's self-esteem and self-worth. Findings: a. A review of Resident 2's admission Record indicated the facility readmitted Resident 2 on 2/21/2024 with diagnoses that included pneumonia (an infection that involves one or both lungs, which may fill with fluid), chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood), encounter for attention to tracheostomy (provides an air passage to help you breathe when the usual route for breathing is somehow blocked or reduced), and unspecified intellectual disabilities (term used when there are limits to a person's ability to learn at an expected level…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 peripheral (the arms, hands, legs, and feet) intravenous (IV- into the vein) catheter (a thin plastic tube inserted into a vein using a needle) policy was implemented to provide safe care to prevent complications for one of three sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 at risk for developing complications such as inflammation of the vein and infection. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 12/13/2023 with diagnoses that included with acute respiratory failure (ARF - occurs when your lungs cannot release enough oxygen into your blood, which prevents your organs from properly functioning and affects your breathing) with hypoxia (low levels of oxygen in your body tissues) and tracheostomy (a surgically created hole in your windpipe [air passage from the throat to the lungs] that provides an alternative airway for breathing). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment…

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

Based on interview and record review, the facility failed to ensure Registered Nurse 1 (RN 1) administered medication as ordered by the physician for one of six sampled residents (Resident 1). This deficient practice had the potential to result in a delay of necessary care and treatment and could lead to adverse health outcome for Resident 1. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 12/13/2023 with diagnoses that included with acute respiratory failure (ARF - occurs when your lungs cannot release enough oxygen into your blood, which prevents your organs from properly functioning and affects your breathing) with hypoxia (low levels of oxygen in your body tissues) and tracheostomy (a surgically created hole in your windpipe [air passage from the throat to the lungs] that provides an alternative airway for breathing). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 12/26/2023, indicated the resident was able to understand others and understood by others. The MDS further…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 its policy and procedure on abuse (willful infliction of injury with resulting physical harm, pain or mental anguish) for one of three sampled residents (Resident 5) when on 12/8/2023 at approximately 10:45 a.m. Resident 5 reported an allegation of verbal abuse that occurred on 12/7/2023. The facility failed to: 1. provide documented evidence that a Situation, Background, Assessment and Recommendation (SBAR - a communication tool that helps provide essential, concise information about the condition of a resident) Form was completed. 2. ensure Resident 5 was monitored every shift for 72 hours for emotional distress or negative outcome as a result of the alleged verbal abuse. These deficient practices could have resulted in Resident 2 needing care or emotional support which was not provided. Findings: 1. A review of Resident 5's admission Record indicated the facility admitted the resident on 9/1/2020 with diagnoses that included traumatic (results from a violent blow or jolt to the head or body) subdural…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (a written course of action that helps a resident achieve outcomes that improve their quality of life) to address the use of a long arm splint (device applied for elbow and forearm injuries to limit movement of the elbow) for one of three sampled residents (Resident 3). This deficient practice had the potential outcome to have a negative effect on Resident 3's quality of life, as well as the quality of care and services received. Findings: A review of Resident 3's admission Record indicated the facility admitted the resident on 10/31/2023 with diagnoses that included fibromyalgia (chronic [long-lasting] disorder that causes pain and tenderness throughout the body), fracture (broken bone) of shaft of humerus (a break of the upper arm bone), left arm, and fracture of shaft of humerus, right arm. A review of Resident 3's Minimum Data Set (MDS - an assessment and care screening tool) dated 11/7/2023 indicated the resident sometimes had the ability to make self-understood and sometimes 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.

Based on interview and record review, the facility failed to ensure that one of two sampled residents (Resident 3) received prescribed pain medication as ordered by the physician. This deficient practice of not administering pain medications as prescribed may lead to inadequate management of resident's pain. Findings: A review of Resident 3's admission Record indicated the facility admitted the resident on 10/31/2023 with diagnoses that included fibromyalgia (chronic [long-lasting] disorder that causes pain and tenderness throughout the body), fracture (broken bone) of shaft of humerus (a break of the upper arm bone), left arm, and fracture of shaft of humerus, right arm. A review of Resident 3's Minimum Data Set (MDS - an assessment and care screening tool) dated 11/7/2023 indicated the resident sometimes had the ability to make self-understood and sometimes had the ability to understand others. The MDS further indicated that Resident 1 had severely impaired cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). A…

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

Based on observation, interview and record review, the facility failed to ensure the call light system (a tool that allows residents to communicate with nurses that they need assistance) was in good working condition for one of three sampled residents (Resident 1). This deficient practice had the potential to result in a delay in nursing care and service for Resident 1. Findings: A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 8/4/2023 with diagnosis that included respiratory failure (a serious condition that makes it difficult to breathe on your own), tracheostomy (procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe]), and dependence on renal dialysis (treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to). A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 11/11/2023, indicated Resident 1 has no speech, rarely/never makes himself understood, rarely/never has the ability 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents' call lights were placed within reach for two of five sampled residents (Resident 1 and Resident 2). This deficient practice placed the residents at risk of inability to summon health care workers as needed to receive assistance that may include urgent care. Findings: a. A review of Resident 1's admission Record indicated the facility admitted the resident on 8/7/2023 with diagnoses including cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) and left arm fracture (broken bone). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 8/14/2023, indicated the resident was able to sometimes understand others and was able to sometimes make self-understood. The MDS further indicated that Resident 1 required total assistance from staff with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. b. 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.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) was provided Restorative Nursing Assistant (RNA- specially trained Certified Nursing Assistant who use specialized techniques to maintain and improve each resident's abilities and functions) services as ordered. This deficient practice had the potential to result in a decline in range of motion (ROM) for Resident 1. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 8/7/2023 with diagnoses including cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) and left arm fracture (broken bone). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 8/14/2023, indicated the resident was able to sometimes understand others and was able to sometimes make self-understood. The MDS further indicated that Resident 1 required total assistance from staff with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. 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.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided the correct x-ray (imaging study that takes pictures of bones and tissues inside the body) as order by the physician. Resident 1 had an order for a left hip x-ray on 9/1/2023, however a chest x-ray was competed. This deficient practice had the potential in a delay in necessary care and services. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 8/7/2023 with diagnoses including cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) and left arm fracture (broken bone). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 8/14/2023, indicated the resident was able to sometimes understand others and was able to sometimes make self-understood. The MDS further indicated that Resident 1 required total assistance from staff with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. A review of Resident 1's…

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