Four Seasons Healthcare & Wellness Center, LP

Based on observation, interview and record review, the facility failed to ensure that one of three sampled residents (Resident 2) was free from the use of physical restraints when the resident's bed was positioned against the wall in a manner that restricted the resident's voluntary movement. This deficient practice had the potential to limit Resident 2's freedom of movement, interfere with the resident's right to be free from physical restraints, and compromise the resident's right to be treated with dignity and respect.Findings: During a review of Resident 2's undated, admission Record, the admission Record indicated the facility admitted the resident on 10/1/2025 with diagnoses including cerebral infarction (occurs when the blood flow to part of the brain was blocked), unstageable PU (a deep wound where the true depth cannot be determined because the base was covered by dead tissues) to right upper back, and presence of gastrostomy (a small tube placed directly into the stomach through a tiny surgical opening in the belly skin) tube. During a review of Resident 2's Minimum Data…

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

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) received care consistent with professional standards of practice to prevent pressure ulcers (PU, a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) by failing to ensure Resident 2's low air-loss mattress (LALM - a mattress composed of inflatable air cushions used to relieve pressure on body parts) was set to appropriate settings per Physician Orders. This deficient practice placed Resident 2 at risk for the development of pressure ulcers. Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) received care consistent with professional standards of practice to prevent pressure ulcers (PU, a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) by failing to ensure Resident 2's low air-loss mattress…

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

Based on observation, interview and record review, the facility failed to maintain an effective prevention and control program related to Enhanced Barrier Precautions (EBP-an infection control intervention designed to reduce transmission or multi[drug -resistant organisms through targeted gown and glove use during high-contact resident care activities) for one of three sampled residents ( Resident 2). This deficient practice placed Resident 2 at risks for potential exposure to transmission of infectious organisms. Findings:During a review of Resident 2's undated admission Record the admission Record indicated the facility admitted the resident on 10/1/2025 with diagnoses including cerebral infarction (occurs when the blood flow to part of the brain was blocked), unstageable (a deep wound where the true depth cannot be determined because the base is covered by dead tissues) pressure ulcer (PU, a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) of the right upper back, and presence 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 protect the resident's right to be free from physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) for one of four sampled residents (Resident 1) when on 12/22/2025 (time unknown) in the Station A hallway (near the smoking patio entrance and Station A dining room), Resident 2 used a wooden back scratcher (a handheld tool used to reach and relieve back itches) to hit the top of Resident 1's head. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. On 12/23/2025, Resident 1 sustained an acute (sudden or short-term) pain one out of 10 to Resident 1's top of scalp.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 7/12/2010 and readmitted the resident on 2/3/2022 with diagnoses…

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

Based on interview and record review, the facility failed to ensure the medical records of one of three sampled residents (Resident 1) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to ensure licensed nurses documented Resident 1's change of condition (COC) in Resident 1's medical records. This deficient practice resulted in incomplete and inaccurate information on Resident 1's medical records and had the potential for delayed medical interventions.Findings: During a review of Resident 1's admission Record (undated), the admission Record indicated the facility admitted the resident on 5/22/2019 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), other specified disorders of the brain, and convulsions (a medical event involving sudden, violent, involuntary muscle contractions and relaxations, causing uncontrollable shaking or stiffening of the body linked to unusual brain activity). 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.

Based on interview and record review the facility failed to exercise reasonable care for the protection of the resident's property from loss or theft for one of three sampled residents (Resident 1) when the facility failed to document Resident 1's lost or stolen coin purse containing her social security and identification card were documented in the facility's Theft and Loss log. This failure had the potential to prevent tracking of additional lost items and hinder the facility's ability to identify patterns or trends related to theft and loss of resident property.Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 2/3/2020 and readmitted the resident on 2/3/2022 with diagnoses including hypertension (HTN - high blood pressure), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of the left and right knee, and chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing).During a review of Resident 1's History and Physical…

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

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 one of three sampled residents (Residents 1) by failing to ensure the licensed nursing staff would not sign Resident 1's Medication Administration Record for antibiotic (a type of medication used to treat or prevent bacterial infections by killing bacteria or stopping their growth) therapy on three different dates (9/20/2025, 9/23/2025, and 9/25/2025) when the medication had not been delivered to the facility. This deficient practice resulted in the medical record inaccurately representing care Resident 1 did not receive and had the potential to place the resident at risk for worsening infection. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE] and readmitted on [DATE] with medical diagnosis including multiple sclerosis (a disease in which the immune system eats away at 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 maintain a clean and sanitary environment for one of three sampled residents (Resident 1) when on 12/2/2025 Resident 1's bathroom wall was noted with a rusty brown dry water streak. This deficient practice had the potential to negatively impact Resident 1's well-being.Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 2/4/2025 and readmitted the resident on 9/25/25 with diagnoses including chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), emphysema (is a chronic lung disease, part of COPD, where tiny air sacs in the lungs (alveoli) get damaged and lose their elasticity, creating large, inefficient air pockets instead of many small ones), and solitary pulmonary nodule (a single lung opacity smaller than 3 centimeters [a unit of measurement]). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/13/2025, the MDS indicated Resident 1 had the ability 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 keep the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) within reach of the resident for one of five sampled residents (Resident 1) reviewed under accommodation of needs. This deficient practice had the potential for Resident 1 to be unable to summon health care workers for help as needed.Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted the resident on 9/12/2017, with diagnoses including dementia (a progressive state of decline in mental abilities), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a condition that causes weakness on one side of the body), and parkinsonism (a group of movement disorders that cause slow, stiff, and shaky movements). During a review of Resident 1's History and Physical (H&P), dated 11/29/2024, the H&P indicated the resident does not have the capacity to understand and make decisions. During 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.

Based on observation, interview, and record review, the facility failed to ensure the resident's environment was free of accident hazards for one of five sampled residents (Resident 2) reviewed for accidents by failing to ensure Resident 2's fall/floor mats (a cushioned floor pad designed to help prevent injury should a person fall) did not have any furniture or medical equipment on top of them. The deficient practice increased the risk of accidents such as falls with injuries on residents.Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted the resident on 8/7/2020, with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (a condition that causes weakness or a partial loss of strength on one side of the body), and muscle weakness. During a review of Resident 2's History and Physical (H&P), dated 6/4/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident 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 that one of three sampled residents (Resident 1) and or conservator (appointed by a judge to act or make decisions for the person who needs help) was informed of Resident 1's change in condition on 10/22/2025.This failure had violated conservator's right to be informed.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 8/8/2025, with diagnoses that included metabolic encephalopathy (a condition where the brain's function is impaired due to disturbances in the body's metabolism [the process where your body converts food and drink into energy]), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life). The admission Record indicated Resident 1 had a conservator.During a review of Resident 1's History and Physical…

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

Based on interview and record review the facility failed to maintain an accurate and complete medical record for one of three sampled residents (Resident 2) by failing to ensure accurate time of notification was documented in Resident 2's medical record.This failure had the potential to cause confusion in care and the medical records containing inaccurate documentation.Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 2/6/2025, with diagnoses that included unspecified (unconfirmed) epilepsy (repeatedly uncontrolled electrical activity in the brain, which may produce a jerking movement of a part or the entire body), chronic pain syndrome (a condition where persistent pain lasts for at least three months) and unspecified depression (a serious mood disorder that goes beyond temporary sadness, causing a persistent feeling of emptiness, hopelessness, and loss of interest in life).During a review of Resident 2's History and Physical (H&P-a medical examination that involves a doctor taking a Resident's medical…

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

Based on interview and record review, the facility failed to provide laboratory (lab) services for one of four sampled residents (Resident 1) on 10/4/2023. On 10/4/2023, Resident 1 was discharged without the ordered labs being completed.This deficient practice had the potential for a delay in Resident 1's care. Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 9/16/2023 with diagnoses including anemia (a condition where the body does not have enough healthy red blood cells), dysphagia (difficulty swallowing), and cognitive communication deficit.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 9/23/2023, the MDS indicated Resident 1 had the ability to understand and be understood. The MDS indicated Resident 1 required extensive assistance (resident involved in activity, staff provide weight bearing support) with bed mobility, transfer, walking in room and in corridor, dressing, eating, toileting and personal hygiene.During a review of Resident 1's Physician Orders, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to set up the total amount for the gastrostomy tube (g-tube - is a feeding tube that delivers nutrition, fluids, and medicine directly to the stomach through a surgically created opening in the abdomen) machine for one of three sample resident (Resident 1).This facility deficient practice could lead to fluid overload, unintended weight gain, increase the risk of regurgitation and discomfort for Resident 1.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 4/14/2004, initially admitted the resident on 2/22/2022 and recently readmitted on [DATE] with a diagnosis of urinary tract infection in any part of the urinary system {waste disposal system}) and dysphagia (difficulty of swallowing).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/21/2025, the MDS indicated Resident 1 had intact thought process and required…

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

Based on interview and record review the facility failed to ensure that medication was administered according to the physician order for one of three sample resident (Resident 2).This deficient practice had the potential for Resident 2 to not receive the full benefit of the medication. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 2/4/2025 with a diagnosis of spondylosis with radiculopathy (age-related wear and tear in your spine is pinching a nerve, which causes pain, numbness, or weakness to spread from your back to your limbs) and chronic pain.During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 8/14/2025, the MDS indicated Resident 2's thought process was intact and required set-up assistance from staff to complete activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily).During a review of Resident 2's Physician's Orders, dated 8/12/2025, the Physician's Order indicated to give Paxlovid (oral antiviral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 have a documented process on tracking medical records requests for one of four sampled residents (Resident 1). Resident 1's legal representative sent a request to release Resident 1's medical records on 5/8/2025. This deficient practice violated the resident's rights to secure personal medical records.Findings: During a review of Resident 1's admission Record (undated), the admission Record indicated the facility admitted the resident on 8/2/2024 with diagnoses including cellulitis (a deep bacterial infection of the skin) of the left upper limb, chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]). During a review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/9/2024, the MDS indicated the resident's cognition (conscious mental activities including thinking, reasoning, understanding, learning,…

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

Based on observation, interview, and record review, the facility failed to ensure an eye drop (liquid solutions you put on the surface of your eyes) was not left at bedside table and resident was assessed for self-administration of medication for one of three sampled residents (Resident 1). This deficient practice placed Resident 1 at risk for a negative outcome and the potential for another resident to take and misuse the medication (eye drop). Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 2/8/2025, with a diagnosis of diabetes mellitus (condition where blood sugar levels are too high) and chronic obstructive pulmonary disease (long-term lung disease that makes it hard to breathe). During a review of Resident 1' History and Physical, dated 6/10/2025, the History and Physical indicated that Resident 1 did not have capacity to made decisions at this time. During a review of Resident 1's Order Summary Report, with order date of 6/3/2025, the Order Summary report indicated to instill one drop in both eyes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical records of three of three sampled residents (Resident 1, Resident 2, and Resident 3) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to: 1. Ensure Certified Nursing Assistants (CNAs) documented Residents 1, 2, and 3 ' s percentage (% - per one hundred) of food eaten on the correct time. 2. Ensure CNA 1 accurately documented Resident 1 ' s bowel movement (defecation). 3. Ensure Registered Nurse (RN) 1 completed and signed Resident 1 ' s Change in Condition Evaluation (CIC). These deficient practices resulted in inaccurate information on Residents 1, 2, and 3 ' s medical records and had the potential for delayed and inaccurate medical interventions. Findings: During a review of Resident 1 ' s admission Record (undated), the admission Record indicated the facility admitted the resident on 5/21/2025, with diagnoses including type 2 diabetes mellitus (DM - 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 a resident was provided supervision to prevent elopement (the act of leaving a facility unsupervised and without prior authorization) for one of three sampled residents (Resident 1). On 6/7/2025, at 12:27 p.m., Resident 1, who was assessed as a high risk for elopement, walked out of the facility unassisted and without permission. Resident 1 exited the facility building through the main facility entrance door with the Receptionist (REC) 1 at the reception desk who stated he (REC 1) did not see Resident 1 go out of the facility main door. REC 1 stated the reception area had a list of residents on elopement risk and one of his responsibilities was to ensure the residents do not go out of the main facility door unassisted and without permission. This deficient practice resulted to Resident 1 ' s elopement and can potentially place Resident 1 at risk for serious health problems and accidents. Findings: During a review of Resident 1 ' s admission Record (undated), the admission Record indicated the facility admitted 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 keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach of the resident for four of four sampled residents (Residents 489, 390, 139, and 133) reviewed under the environment care area. This deficient practice had the potential for residents not being able to summon health care workers for help as needed. Findings: During a review of Resident 489 ' s admission Record, the admission Record indicated the facility admitted the resident on 4/17/2025, with diagnoses including epileptic seizures (abnormal electrical brain activity, also known as seizures, kind of like an electrical storm inside the head), muscle weakness, and difficulty in walking. During a review of Resident 489 ' s History and Physical (H&P), dated 4/19/2025, the H&P indicated the resident was unable to make decisions. During a review of Resident 489 ' s Fall Risk Evaluation, dated 4/17/2025, the Fall Risk…

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

Based on observation, interview, and record review, the facility failed to ensure the confidential personal information of 15 of 15 sampled residents were protected by failing to: 1. Ensure the diet type report for Resident 144, Resident 83, Resident 162, Resident 70, Resident 3, Resident 29, Resident 107, Resident 147, Resident 106, Resident 85, Resident 63, Resident 182, Resident 157 was not in the handwashing trash in the kitchen. 2. Ensure documents containing protected health information ([PHI]- any health information that can be used to identify a specific individual which must remain confidential to prevent harmful consequences) was shredded prior to disposing in the waste container for Resident 38 and Resident 129. These failures had the potential to violate Resident 144, Resident 83, Resident 162, Resident 70, Resident 3, Resident 29, Resident 107, Resident 147, Resident 106, Resident 85, Resident 63, Resident 182, Resident 157, Resident 38 and Resident 129's rights for privacy and confidentiality of personal and medical records. Findings: 1. During an observation, on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its Grievance and Complaint Policy and Procedure (P&P) by failing to: 1. Follow the Grievance and Complaint Policy and Procedure (P&P) when Resident 13 complained to Licensed Vocational Nurse (LVN) 4 that Certified Nursing Assistant (CNA) 3 refused to warm up Resident 130's meal for one of two sampled residents (Resident 130) reviewed during the Sufficient and Competent Staffing task. 2. Follow the Grievance and Complaint P&P when the Grievance Official failed to follow-up and inform Resident 157 of the findings of the investigation for one of seven sampled residents (Resident 157) reviewed during the Dining Observation task. This deficient practice had the potential to affect the residents' quality of life and provision of care of effective therapeutic diet (a meal plan that controls the intake of certain food and nutrients). 3. Take reasonable steps to protect the resident's personal property when LVN 2 failed to notify SSA 1 when Resident 188…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for six (6) of 6 sampled residents (Residents 16, 159, 73, 489, 97, and 72) reviewed for physical restraints care area by failing to: 1. Complete Resident 16's restraint assessment quarterly. 2. Ensure Resident 159 had a physician's order and care plan for the placement of bed against the wall. 3. Accurately complete Resident 73's restraint assessments for the use of restraint bed against the wall. 4. Ensure Resident 489's bed alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) had a restraint assessment. 5. Ensure Residents 97 and 52's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (is a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for: 1. Two of four sampled residents (Residents 489 and 42) reviewed for mood/behavior by failing to develop and implement a care plan on the use of antidepressants (Trazadone and Alprazolam, prescription medicines to treat depression). 2. One of two sampled residents (Resident 10) reviewed for antibiotic use by failing to develop and implement a care plan on the use of Cefepime HCl. 3. One of one sampled resident (Resident 152) reviewed under the Respiratory Care area by failing to develop and implement resident specific Care Plans (CP - a document outlining a detailed approach to care customized to an individual resident's need) for the use of continuous positive airway pressure (CPAP - a breathing machine designed to increase air pressure, keeping the airway open…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accordance with professional standards to three of three sampled residents (Residents 52, 390, and 159) reviewed for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites. The deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross reference F760 Findings: 1. During a review of Resident 52's admission Record, the admission Record indicated the facility admitted the resident on 4/6/2018, and readmitted the resident on 2/2/2023, with diagnoses including type 2 diabetes mellitus…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 services to two of 10 sampled residents (Residents 116 and 173) with limited range of motion (ROM - full movement potential of a joint [where two bones meet]) by failing to: 1. Ensure Resident 116 did not have a delay in start of Restorative Nursing Aide (RNA - nursing aide program that help residents to maintain their function and joint mobility) services for passive range of motion (PROM - movement at a given joint with full assistance from another person) for both upper extremities (BUE - shoulder, elbow, wrist, hand) and both lower extremities (BLE - hip, knee, ankle, foot) five times a week. 2. Ensure Resident 173 did not have a delay in the start of RNA services for PROM for the left lower extremity and right residual limb five times a week. These deficient practices had the potential to cause a decline in ROM and function for Residents 116 and 173. Findings: 1. During a review of Resident 116's admission Record (AR), the AR…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 environment was free of accident hazards for seven (7) of nine (9) sampled residents (Residents 390, 99, 8, 489, 97, 54, and 488) reviewed for accidents by: 1. Failing to ensure Resident 390's bed was not placed in a high position. 2. Failing to ensure Resident 8's bed pad alarm (a pressure-sensitive pad placed under the mattress or seat cushion that trigger an alarm or warning light when they detect a change in pressure) was functioning properly. These deficient practices placed the residents at risk for increased chances of incurring injury such as falls with fracture (a break or crack in a bone) and even death. 3. Failing to ensure Residents 489, 97, 99, and 54's bed remote control's (a device typically found near a resident's bed or within reach to adjust bed configuration) cord was free from exposed/frayed wires. This deficient practice had the potential to place Resident 489, 97, 99, and 54 at risk for 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 ensure residents with a urinary catheter (FC - also known as an indwelling catheter or Foley catheter, a hollow tube inserted into the bladder to drain or collect urine) received appropriate care and services to prevent urinary tract infections (UTI - an infection in the bladder/urinary tract) for three (3) of four (4) sampled resident (Residents 390, 99, and 8) reviewed for urinary catheter or UTI by: 1. Failing to ensure Residents 390's and 99's urinary catheter tubing did not have a kink or loop while hanging on the side of the bed. 2. Failing to ensure Resident 8's urinary catheter was anchored with a leg strap and change the leg bag with a regular urinary drainage bag while in bed. These deficient practices had the potential for the urine to not flow freely, the resident's FC to be pulled out, or move around, which may lead to the development of UTI, pain, trauma, and catheter blockage. Findings: a. During a review of Resident 390's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure respiratory care provided to residents was consistent with professional standards of practice for two of two sampled residents (Resident 152 and 42) reviewed for respiratory care by failing to: 1. Ensure oxygen was administered per physician's order, documented when administered or refused, and the physician was notified when Resident 152 refused the administration of continuous supplemental oxygen and remained on room air (RA). 2. Ensure the oxygen via nasal cannula (NC, a device that gives additional oxygen [supplemental oxygen or oxygen therapy] through the nose) was attached to the Resident 42's nostrils. These deficient practices had a potential for the residents to develop complications such as shortness of breath and desaturation (low levels of oxygen in the blood). Findings: a.During a review of Resident 152's admission Record, the admission Record indicated the facility admitted the resident on 7/23/2024, with diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to account for two (2) doses of Controlled Substances (also known as Narcotics, Controlled Drug and Controlled Medications [CS, N, CD, CM]- medications which have a potential for abuse and may also lead to physical or psychological dependence) for Residents 139 and 153 in one (1) of three (3) inspected medication carts (Medication Cart Station 2 Cart A.). As a result, control and accountability of medications and CS's did not follow state and federal regulations and facility policy and procedures. These deficient practices increased the opportunity for CS diversion (the transfer of a controlled medication or other medication from a lawful to an unlawful channel of distribution or use), the risk that Residents 139 and 153 and other residents in the facility could have accidental overdose (administering more than the prescribed dose causing adverse drug reactions [unwanted, uncomfortable, or dangerous effects that a medication may have, such as coma (a state…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free from the use of unnecessary psychotropic (any medication capable of affecting the mind, emotions, and behavior) medications in accordance with the facility policy and procedure (P&P) for one of two sampled residents (Residents 130) reviewed during the Sufficient and Competent Nurse Staffing task and three of five sampled residents (Resident 488, 390, and 42) reviewed during the Unnecessary Psychotropic Medication task, by failing to: 1. Obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for Resident 130's lorazepam (a psychotropic medication used to treat feelings of anxiousness). 2. Ensure psychotropic medications ordered to be administered as needed (PRN) were ordered with a 14 day stop date (indicates when the medication should be discontinued to ensure medications are not continued unnecessarily) 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 ensure that its medication error rate was less than five (5) percent (%). Two (2) medication errors out of 30 total opportunities contributed to an overall medication error rate of 6.67% affecting two (2) of five (5) residents observed for medication administration (Resident 30 and 181.) The medication errors were as follows: 1. Resident 30 did not receive ceftriaxone (an antibiotic [medication used to treat infections caused by bacteria]) as ordered by Resident 30's physician. 2. Resident 181 received docusate (a medication used for bowel [intestine] management) at a different time than ordered by Resident 181's physician. These failures had the potential to result in Resident 30 and 181 receiving suboptimal (less than standard) care and resulting in Residents 30's and 181's health and well-being negatively impacted. Findings: During a review of Resident 30's admission Record (a document containing demographic and diagnostic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) by failing to: 1. rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous ([SQ] - beneath the skin) insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) administration sites for three (3) of three (3) sampled residents (Residents 52, 159, 390) reviewed for insulin. 2. remove expired insulin from the medication cart and administering expired insulin by several Licensed Vocational Nurses (LVN)s to Resident 90 in one (1) of three (3) inspected medication carts (Medication Cart Station 2 Cart A). As a result, Resident 90 received four (4) doses of expired insulin between [DATE] and [DATE] not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1. Label one (1) artificial tears (a medication used for eye dryness) eye drop bottle for Resident 68, in accordance with facility policies, in one (1) of three (3) inspected medication carts (Medication Cart Station 3). 2. Remove and discard from use one (1) expired insulin (a medication used to regulate blood sugar levels) Lispro (fast-acting insulin) Kwikpen (type of injection pen) pen for Resident 90 from one (1) of three (3) inspected medication carts (Medication Cart Station 2 Cart A.) These deficient practices increased the risk that Residents 68 and 90 could have received medications that had become ineffective or toxic due to improper storage or labeling, and to experience serious complications such as eye infections and hyperglycemia (elevated blood sugar levels) diabetic coma (a life-threatening complication that can result from very high blood sugar or very low blood sugar levels) resulting in potential hospitalization and/or…

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

Based on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when two (2) of 2 staff (Cook 1 and [NAME] 2) were not able to verbalize the correct cool-down process (a method to safely reduce the temperature of cooked food and prevent bacterial growth) of food. This failure resulted in improper cooling of roast turkey and roast beef which had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 164 of 176 medically compromised residents who received food from the kitchen. Findings: 1. During an interview on 4/22/2025 at 11:18 a.m. with [NAME] 1, [NAME] 1 stated she started cooking the roast turkey this morning. During a concurrent interview and record review on 4/23/2025 at 8:46 p.m. with [NAME] 1, the cooling log dated 4/2025 was reviewed. The cooling log indicated there was a record…

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

Based on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs of residents when [NAME] 1 did not follow the recipe for gravy on 4/22/2024 for lunch. This failure had the potential to result in salty food item resulting to excessive nutrient intake of sodium (a nutrient naturally found in salt), ineffective therapeutic diet provisions, increased blood pressure, water retention, and poor food intake to 50 of 176 residents on consistent carbohydrate diet (CCHO, a diet with the same amount or servings of carbohydrates in each meal for blood sugar control) and CCHO, renal diet (a diet low in salt, potassium, phosphorus and limited in protein) residents including Resident 157 getting food from the kitchen. Findings: During a review of Resident 157's admission Record, the admission Record indicated the facility initially admitted Resident 157 on 10/23/2024 and readmitted the resident on 1/8/2025 with diagnoses that included type two (2) diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved temperature, flavor and appearance when: a. The temperature of the roast turkey was at 125 degrees Fahrenheit (°F, a scale of temperature), apple sauce at 51°F, vanilla mousse at 46°F and grape juice was at 46°F. b. Roast Turkey for renal (a diet low in salt, potassium, phosphorus and limited in protein) consistent carbohydrate (CCHO, a diet with the same amount or servings of carbohydrates in each meal for blood sugar control) diets was salty. c. Puree mashed potatoes and puree roast turkey did not hold its shape on the plate. This deficient practice placed 164 of 176 facility residents including Residents 173 and 157 who are on regular, therapeutic diets (a meal plan that controls the intake of certain food and nutrients) and puree diets (food with soft pudding like consistency) at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen. Cross Reference F803…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 puree (foods that are smooth with pudding like consistency) roast turkey and puree mashed potato did not hold their shapes and were flat on the plates. These failures had the potential to result in difficulty in swallowing, chewing, decreased in food intake and nutrient intake to 12 of 176 residents on puree diet, resulting to unintended (not planned) weight loss and chocking (when food gets stuck in your airway, blocking the flow of air to the 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 Spring Cycle Menus, dated 4/22/2025, the spreadsheet indicated residents on puree diet would include the following foods on the tray: Puree roast turkey half (1/2) number 8 scoop (1/2 cup [c] a household measurement) Puree cranberry-ginger-citrus sauce 1ounces (oz, a unit of measurement) Puree bread dressing number 12 scoop (1/3 c) Puree three bean salad 1/3 c…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Kitchen equipment and utensils were not maintained in their proper condition (smooth and easy to clean). a. The shelves in the reach-in refrigerator by the supervisor's office had chips and cracks b. The shelves in the reach-in refrigerator by the exit door had amber discoloration, cracks, chips and rust. c. Fifty (50) of 50 residents cracked trays. 2. A broken thermometer was found in the vegetable freezer. 3. A tub of cottage cheese was at 51.8 degrees Fahrenheit (°F, a scale of temperature), mocha mix was at 48°F inside the milk reach-in refrigerator. 4. Improper cooling was observed for the following food items: a. 4/13/2025 roast turkey was cooled for a total of eight (8) hours. b. 4/21/2025 roast turkey was cooled for a total of 8 hours c. 4/22/2025 roast beef was cooled for more than four hours without reaching 40°F. 5. Staff wiped the preparation table during salad preparation and left the green wiping cloth…

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

Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained a resident's dignity for one (1) of 1 sampled resident (Resident 16) reviewed for dignity by failing to ensure Certified Nursing Assistant (CNA) 7 was sitting at eye level when assisting the resident while eating. This deficient practice had the potential to negatively affect the residents' psychosocial wellbeing. Findings: During a review of Resident 16's admission Record, the admission Record indicated the facility originally admitted the resident on 6/5/2012 and readmitted the resident on 8/22/2023, with diagnoses including adult failure to thrive (a gradual decline in a person's physical and emotional well-being), dementia (a progressive state of decline in mental abilities), and generalized muscle weakness. During a review of Resident 16's History and Physical (H&P), dated 8/29/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 16's Minimum Data Set (MDS - a resident assessment tool), dated…

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

Based on interview and record review, the facility failed to ensure residents were free from the use of unnecessary psychotropic (any medication capable of affecting the mind, emotions, and behavior) medications in accordance with the facility policy and procedure for one of two sampled residents (Resident 130) reviewed during the Sufficient and Competent Nurse Staffing task, by failing to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for lorazepam (a psychotropic medication use to treat feelings of anxiousness). This deficient practice had the potential to result in the use of unnecessary psychotropic drugs resulting in adverse effects (an undesired and harmful result of a treatment or intervention, such as a medication or surgery) of the medication and a violation of the resident's right to make medical decisions regarding the use of psychotropic medications. Cross reference F758 Findings: During a review of Resident 130's admission Record, the admission Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that the discharge information is documented in the resident's medical record and is communicated to the resident for one of three sampled residents (Resident 188) reviewed under Discharge care area by: 1. Failing to ensure the inventory belonging's list for Resident 188 was signed when it was released to the resident. 2. Failing to document on the resident's medication list the complete information to include the quantity of medications supplied and the last administration times (the time the resident was given the medications) to Resident 188. These deficient practices had the potential to result in discontinuity of the resident's care and an unsafe transition of care. Findings: During a review of Resident 188's admission Record, the admission Record indicated the facility admitted the resident on 2/27/2025 with diagnoses including congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently), atrial…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 baseline care plan for each resident for one of six sampled residents (Resident 489) reviewed for physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) on the use of side rails (bars attached to the sides of a bed) and bed alarms (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff). The deficient practice had the potential for delay in the provision of essential healthcare services affecting the resident's well-being. Findings: During a review of Resident 489's admission Record, the admission Record indicated the facility admitted the resident on 4/17/2025, with diagnoses that included epileptic seizures (abnormal electrical brain activity, kind of like an electrical storm inside the head), dementia (a progressive state of decline in mental…

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

Based on observation, interview, and record review, the facility failed to assure that each resident receives care and services for the provision of parenteral fluids (formulated liquids that are injected into a vein to prevent or treat dehydration [a condition caused by the loss of too much fluid from the body]) consistent with professional standards of practice to one out of two sampled residents (Resident 10) reviewed for antibiotic (medicines that stop bacteria from growing) use by failing to ensure Resident 10's: 1. Midline catheter (a long, thin, flexible tube that is inserted into a large vein in the upper arm) dressing was changed every 48 hours per physician's order. 2. Infusion port (a device used to draw blood and give treatments, including intravenous fluids, blood transfusions, or antibiotics) was swabbed with an antiseptic solution (a chemical agent that slows or stops the growth of microorganisms on external surfaces of the body and helps to prevent infection) before flushing the port with 10 milliliters (ml, a unit of volume) normal saline solution (NS, a mixture 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 ensure licensed nurses had the specific competencies (measurable pattern of training, skills, experience, and knowledge in order to perform occupational tasks successfully) and skill sets necessary to care for residents' needs for one of five sampled staff reviewed for sufficient and competent nurse staffing by failing to ensure Registered Nurse (RN) 1 had a skills competency on administering intravenous (IV, within a vein) antibiotics (medicines that fight bacterial infections) through a midline/peripheral catheter (thin, soft tube that is placed into a vein, usually in the arm). The deficient practice had the potential to induce bloodstream infections such as sepsis (a serious condition in which the body responds improperly to an infection) to residents. Findings: During a concurrent observation and interview on 4/22/2025, at 10:43 a.m., with RN 1, inside Resident 10's room, observed RN 1 hung Cefepime IV (antibiotic) to Resident 10. RN 1 disconnected the old IV tubing line and attached the 10 milliliters…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 each resident's drug regimen are free from unnecessary drugs for one of two sampled residents (Resident 10) reviewed for antibiotic use by failing to ensure the antibiotic (Cefepime HCl) had monitoring for adverse effect (unwanted undesirable effects that are possibly related to a drug). This deficient practice placed the residents at risk for unnecessary medication and undetected adverse/side effects. Findings: During a review of Resident 10's admission Record, the admission Record indicated the facility admitted the resident on 12/30/2024, with diagnoses including local infection of the skin and subcutaneous tissue (the layer of tissue that underlies the skin) and type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) with other skin ulcer (open sores caused by poor blood circulation). During a review of Resident 10's History and Physical (H&P), dated 12/30/2024, the H&P indicated the resident was alert, oriented to person, place, time, and communicated…

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

Based on observation, interview, and record review, the facility failed to ensure one (1) of 1 sampled resident (Resident 182) received and consumed foods in the appropriate nutritive content as prescribed by a physician when staff did not update the diet for Resident 182. Resident 182, who was on renal (a diet low in salt, potassium, phosphorus and limited in protein) diabetic diet ([consistent carbohydrate diet] CCHO, a diet with the same amount or servings of carbohydrates in each meal for blood sugar control) regular portion, received diabetic, renal large portion diet instead. This deficient failure had the potential to cause unplanned weight gain and ineffective therapeutic diet (a meal plan that controls the intake of certain food and nutrients) for Resident 182. Findings: During a review of Resident 182's admission Record, the admission Record indicated the facility admitted Resident 182 on 10/23/2024 with diagnoses that included type two (2) diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), end stage renal disease…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: A. Document a change of condition (COC, is a sudden, clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains) for two of two sampled residents (Residents 40 and 98) reviewed for hospitalizations for: 1. Resident 40, who went to General Acute Care Hospital (GACH) 1 for gastrostomy tube (GT, a tube inserted through the belly that brings nutrition directly to the stomach) placement on 12/16/2024. 2. Resident 98, who went to GACH 2 for seizure (a sudden, temporary disruption of the brain's normal electrical activity, often causing changes in awareness, movement, or behavior) on 2/24/2025. The deficient practice had potential for delays in the provision of care and services to the residents and failure to accurately account for events that triggered the residents' change in condition. B. Maintain accurate documentation of wounds for one of one sampled resident (Resident 166) reviewed under…

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

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to ensure Resident 389 was placed on enhanced barrier precautions (EBP - targeted steps taken by healthcare staff in nursing homes to prevent the spread of multidrug resistant organisms [MDROs - resistant germs] during high-contact care activities) who had a urinary catheter (FC - also known as an indwelling catheter, a hollow tube inserted into the bladder to drain or collect urine). This deficient practice had the potential to spread infections and illnesses among residents. Findings: During a review of Resident 389's admission Record, the admission Record indicated the facility admitted the resident on 2/27/2025 with diagnoses including urinary tract infection (UTI- an infection in the bladder/urinary tract), obstructive (blockage in the urinary tract) and reflux (urine flows backward…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility's Antibiotic Stewardship Program (ASP - a set of commitments and actions designed to improve the use of antibiotics [a medication used to treat bacterial infections]) for one of five sampled residents (Resident 99) reviewed during the Infection Control task by failing to monitor and include Resident 99's use of methenamine hippurate (a type of antibiotic) in the ASP infection surveillance data. This deficient practice had the potential to place the resident at risk for microbial resistance and reduced resident outcomes. Findings: During a review of Resident 99's admission Record, the admission Record indicated the facility admitted the resident on 9/17/2024, with diagnoses including urinary tract infection (UTI - an infection in the bladder/urinary tract), extended spectrum beta lactamase (ESBL - an enzyme that makes bacteria resistant to a broad range of antibiotics) resistance, resistance to multiple antibiotics, and overactive bladder. During a review of Resident 99's Minimum Data Set (MDS - 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 one of three sampled resident ' s (Resident 1) comprehensive, person-centered care plan interventions were created and accurately documented. This deficient practice had the potential for confusion amongst Resident 1 ' s care team and delayed provision of necessary care and services. Findings: During a record review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted the resident on 12/5/2024 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), displaced fracture (a broken bone where the broken ends were no longer aligned and had a gap between the bones) of the olecranon (tip of the elbow), and muscle weakness. During a record review of Resident 1 ' s History and Physical (H&P- a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 12/13/2024, the H&P indicated Resident 1 had the capacity to understand 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 the medical records of one of three sampled residents (Resident 1) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to: 1. Ensure Licensed Nurses documented Resident 1 ' s accurate bowel (a long tube in the body which digested food passes from the stomach to the anus)and bladder (a hallow organ that stores urine in the body) status. 2. Ensure Licensed Nurses documented the level of care provided to Resident 1 after the resident ' s change of condition (COC). These deficient practices resulted in inaccurate information on Resident 1 ' s medical records and had the potential for delayed and inaccurate medical interventions. Findings: During a record review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted the resident on 12/5/2024 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), displaced fracture (a broken bone where…

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

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Resident 1) by: 1. Failing to ensure Licensed Vocational Nurse 2 (LVN 2) and LVN 3 administer a medication following a physician ' s order. 2. Failing to ensure LVN 1 obtain a physician order for Resident 1 to self-administer a medication (when a person can take their own medicines). 3. Failing to ensure LVN 1 followed facility ' s policy for medication administration. These deficient practices had the potential to result in medication error. Findings: a. During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 12/4/2021, with diagnoses that included hypokalemia (low blood potassium, occurs when potassium levels in the blood are below normal, potentially leading to muscle weakness, fatigue, and in severe cases, abnormal heart rhythms), cervical spinal stenosis (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 a resident's right for communication and access to persons and services inside and outside the facility for one of three sampled residents (Resident 1) was accommodated. Resident 1 did not receive an outside incoming call. This failure had the potential to negatively impact the psychosocial well-being of the resident. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 12/4/2021, with diagnoses that included hypokalemia (low blood potassium, occurs when potassium levels in the blood are below normal, potentially leading to muscle weakness, fatigue, and in severe cases, abnormal heart rhythms), cervical spinal stenosis (a condition where the spinal canal in the neck narrows, putting pressure on the spinal cord and nerve roots) and chronic pain syndrome (a condition where pain persists for more than three months and interferes with daily life). During a review of Resident 1's History and Physical (H&P-a medical examination that involves 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 one of three sampled residents (Resident 1) who was assessed as not safe to self-administer a medication and did not have a physician order to self-administer was given one tablet of Percocet (controlled medication [a drug or substance that is regulated by the government due to its potential for addiction] used to treat pain) 7.5-325 milligram (mg - metric unit of measurement, used for medication dosage and/or amount), to take outside the facility when Resident 1 went out to church. This failure had the potential to result in unsafe medication administration for Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 12/4/2021, with diagnoses that included hypokalemia (low blood potassium, occurs when potassium levels in the blood are below normal, potentially leading to muscle weakness, fatigue, and in severe cases, abnormal heart rhythms), cervical spinal stenosis (a condition where the spinal canal in the neck narrows, putting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 with his requested medical records. This failure resulted to Resident 1's delay in receiving requested medical records. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 12/4/2021, with diagnoses that included hypokalemia (low blood potassium, occurs when potassium levels in the blood are below normal, potentially leading to muscle weakness, fatigue, and in severe cases, abnormal heart rhythms), cervical spinal stenosis (a condition where the spinal canal in the neck narrows, putting pressure on the spinal cord and nerve roots), and chronic pain syndrome (a condition where pain persists for more than three months and interferes with daily life). During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 9/29/2024, the H&P 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 interview and record review, the facility failed to develop a comprehensive care plan for one of three sampled residents (Resident 1) by failing to ensure a care plan was develop on Resident 1 ' s refusal of Lidoderm external patch ( medicated adhesive material applied to skin to treat pain) and Lasix (also known as water pill, a medication used to prevents your body from absorbing too much salt, causing it to be passed in your urine). This deficient practice had the potential for delayed provision of necessary 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 12/4/2021, with diagnoses that included hypokalemia (low blood potassium, occurs when potassium levels in the blood are below normal, potentially leading to muscle weakness, fatigue, and in severe cases, abnormal heart rhythms), cervical spinal stenosis (a condition where the spinal canal in the neck narrows, putting pressure on the spinal cord and nerve roots) and chronic pain syndrome (a condition where…

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

Based on interview and record review, the facility failed to maintain accurate and complete medical record for one of three sampled residents (Resident 1) by: 1. Failing to document complete blood pressure as ordered by the physician to monitor for orthostatic hypotension (a condition in which blood pressure drops significantly when a person stands up from a sitting or lying position) 2. Failing to document attempts to call the physician to obtain a refill of a medication. These deficient practices had the potential to cause confusion in Resident 1's care and medical records containing inaccurate documentation. Findings: a. During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 12/4/2021, with diagnoses that included hypokalemia (low blood potassium, occurs when potassium levels in the blood are below normal, potentially leading to muscle weakness, fatigue, and in severe cases, abnormal heart rhythms), cervical spinal stenosis (a condition where the spinal canal in the neck narrows, putting pressure on the spinal cord…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 four of five sampled residents (Resident 1, Resident 4, Resident 5, and Resident 6) received care consistent with professional standards of practice to prevent pressure ulcers (PU, a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) by failing to: 1. Ensure Residents 1, 4, and 6 were turned and repositioned as indicated on the residents' care plan. 2. Ensure Resident 5's care plan intervention included the resident to be turned and repositioned. Resident 5 had a PU on the sacral region (area at the base of the spine, near the hips). These deficient practices had the potential for Residents 1, 4, 5, and 6's PUs to worsen and had the potential for the development of more PUs. Findings: During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 1/10/2025 with diagnoses including…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical records were complete and accurately documented for one of three sampled residents (Resident 1) by failing to: 1. Ensure Licensed Vocational Nurse 1 (LVN 1) documented timely Resident 1's change of condition (COC) in the resident's medical records. 2. Ensure LVN 1 documented the level of care provided to Resident 1 after the resident's change of condition. 3. Ensure Registered Nurse 1 (RN 1) documented timely Resident 1's COC in the resident's medical records. 4. Ensure RN 1 documented the time Resident 1's attending physician and resident representative were notified of the resident's COC. 5. Ensure LVN 5 documented the care provided to a resident on the correct resident's medical record. These deficient practices resulted in inaccurate information on Resident 1's medical records and had the potential for delayed and inaccurate medical interventions. Findings: During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 1/6/2025 with diagnoses…

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

Based on interview and record review, the facility failed to follow professional standards of practice for one of three sampled residents (Resident 1) by failing to: 1. Ensure Licensed Vocational Nurse 1 (LVN 1) monitored Resident 1's blood sugar after the resident's change of condition (COC). 2. Ensure Resident 1's vital signs (measurements of the body's most basic functions that includes blood pressure [the force of your blood pushing against the walls of your arteries], heartrate, respiratory rate [the number of breaths a person takes per minute], oxygen saturation [amount of oxygen level of the blood], and temperature) were checked when Resident 1 had a COC on 1/9//2025. These deficient practices had the potential to place Resident 1 at risk for undetected elevated high blood sugar, heart rate, respiration, and temperature which could negatively impact the resident's health and safety. Findings: During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 1/6/2025 with diagnoses including chronic obstructive…

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

Based on interview and record review, the facility failed to follow professional standards of practice for one of five facility staff when Certified Nursing Assistant 5 (CNA 5) slept while on duty. This deficient practice had the potential for services and care to not be provided to the residents that had the potential to cause harm to the residents such as falls and elopement. Findings: During an interview on 12/12/2024 at 4:46 p.m. with the Director of Nursing (DON) and a concurrent review of the facility video, the DON stated he observed CNA 5 sleeping in the hallway while CNA 5 was on duty. The video on the DON's cellphone indicated CNA 5 was sitting on a chair in the hallway with head down and eyes closed. The video indicated the DON recorded CNA 5 sleeping on 12/12/2024 at 2:06 a.m. for two minutes. The DON stated facility staff sleeping while on duty had the potential for resident calls and resident needs to not be attended to. The DON stated CNA 5 sleeping on duty was a violation of the facility's policy that indicated facility staff cannot sleep during working hours. During…

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

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 abuse for one of seven sampled residents (Resident 1), when on 11/4/2024, Certified Nursing Assistant 1 (CNA 1) witnessed Resident 2 slap Resident 1 across the face. CNA 1 also confirmed Resident 2 was cursing towards Resident 1 using profanities (type of language that includes dirty words and ideas). This deficient practice resulted in Resident 1 being subjected to verbal (a type of abuse that uses language) and physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) resulting in an abrasion (skin scrape) on the upper left side of cheek bone while under the care of the facility. Findings a.1. During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1on 10/20/2023 with diagnoses that included bilateral primary osteoarthritis of the knee (joint disease affecting both knees), adult failure to thrive (a decline in 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 develop and implement comprehensive, person-centered care plan (contains relevant information about a resident's health conditions, goals of treatment, specific actions that must be performed, and a plan for evaluation) with measurable objectives and interventions for one of six sampled residents (Resident 2) by failing to indicate specific interventions for Resident 2's risk for falls. This deficient practice placed Resident 2 at risk for not receiving the necessary services and assistance that can result in serious injuries. Findings: During a record review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 7/20/2024 with diagnoses including essential hypertension (an abnormally high blood pressure that was not a result of a medical condition), aphasia (a language disorder that affects a person's ability to communicate), and hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction ( damage to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medical records were complete and accurately documented for two of six sampled residents (Resident 1 and Resident 2) by failing to: a. Ensure Social Service Assistant 1 (SSA 1) documented timely Resident 1's condition in the resident's clinical records after an alleged sexual abuse. b. Ensure SSA 2 documented the level of care provided to Resident 2 based on the resident's level of care assessment. These deficient practices resulted in inaccurate information on Resident 1 and Resident 2's clinical records and had the potential for delayed and inaccurate medical interventions. Findings: a. During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 7/23/2024 with diagnoses including chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor airflow), paraplegia (a chronic condition that describes the loss of muscle function in the lower half of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Fall Risk Evaluation (used to find out if you have a low, moderate, or high risk of falling) was accurately documented to reflect the fall risk of one of three sampled residents (Resident 1). This deficient practice had the potential to negatively affect Resident 1's plan of care and delivery of necessary care and services. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 7/28/2023 and readmitted on [DATE] with diagnoses including history of falling, unspecified convulsions (a condition in which muscles contract and relax quickly and cause uncontrolled shaking of the body), and chronic obstructive pulmonary disease (COPD- a lung disease that makes it hard to breathe because it damages the airways and air sacs in the lungs). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 7/26/2024, indicated Resident 1 had 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.

Based on observation, interview, and record review, the facility failed to properly prevent coronavirus disease 2019 (COVID-19, a viral infection that is highly contagious and easily transmits from person to person, causing respiratory problems and may cause death) by failing to: a. Ensure Registered Nurse 1 (RN 1) and RN 2 wore the N95 mask (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) properly. RN 1 and RN 2 ' s N95 mask did not cover their nose and mouth while at nurse station 1. b. Ensure the transportation company personnel wore personal protective equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) before entering the facility and prior to assisting Resident 4 with transport. These deficient practices increases the risk of spreading COVID-19 to residents and staff. Findings: a. During an observation and concurrent interview on 7/29/2024 at 8:25 a.m., observed RN 1 and RN 2 wearing the N95 mask under the chin with their nose and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to discuss or assist Resident 1 in formulating an Advance Directive (are legal documents that provide instructions for medical care) for one of three sampled residents (Resident 1). This deficient practice had a potential in not honoring Resident 1's preferences for medical treatment. Findings: A record review of Resident 1's admission Record indicated the resident was admitted on [DATE] with medical history including encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition), dysphagia (inability to swallow), hypertension (elevated blood pressure), hyperlipidemia (elevated cholesterol), dysphagia (inability to swallow), muscle weakness, and transient ischemic attack (a brief stroke like attack). A record review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/27/2024, indicated Resident 1 had severe impaired cognition (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.

Based on interview and record review the facility failed to provide professional standard of care for one of four (Resident 2) residents when Resident 2 was given enteral nutrition (any method of feeding that uses the gastrointestinal [GI] tract to deliver nutrition and calories) through Residents 2 ' s gastrostomy (a surgical procedure used to insert a tube, often referred to as a G-tube [GT], through the abdomen and into the stomach) using a urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) from 5/10/2024 until 6/9/2024. This deficient practice place Resident 2 at risk for complications including repeated rupture (bursting) of catheter balloon tubing, lumen (space inside the catheter) blockage, and catheter migration (when a catheter moves from its intended position to another part of the body). Findings: A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 5/10/2024 with diagnoses including dysphagia (swallowing difficulties), gastrostomy, and muscle weakness. A review of Resident 2 ' s History…

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

Based on observation, interview, and record review, the facility failed to implement infection control measures for one of three sampled residents (Resident 3) by failing to ensure Certified Nursing Assistant 1 (CNA 1) wore protective gown when changing Residents 3's linen who was on enhanced barrier precaution (expand the use of personal protective equipment and refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug resistant organisms [MDRO- are germs that are difficult to treat because they are resistant to many antibiotics]). This deficient practice had the potential for cross contamination (unintentional transfer of bacteria/germs or other contaminant from one surface to another) of infection among residents. Findings: A review of Resident 3's admission Record indicated the facility admitted the resident on 12/21/2023 with diagnoses that included unspecified (unconfirmed) cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply…

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

Based on interview and record review, the facility failed to offer the resident or the resident's representative assistance with formulating an Advance Directive (AD - a legal document telling the doctor one's wishes about their healthcare in the event they cannot make the decision for themselves) on admission to two out of two sampled residents (Residents 324 and 57) investigated during review of advance directive care area. This deficient practice violated the resident or their representative the right to be fully informed of the option to formulate an AD and had the potential to delay emergency treatment or the potential to force emergency, life-sustaining procedures against the resident's personal preferences. Findings: a. A review of Resident 324's admission Record indicated the facility admitted the resident on 4/22/2024 with diagnoses including sepsis (a serious condition that happens when your body's response to an infection damages vital organs and, often, causes death), peripheral vascular disease (a progressive disorder that restricts blood flow to the arms, legs, or…

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

Based on interview and record review the facility failed to: 1. Notify a resident's representative of a change in condition of one of one sampled resident (Resident 149) investigated during a review of a complaint when Resident 149's wound on the right heel was reclassified from deep tissue pressure injury (DTPI, purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) to diabetic ulcer (a slow-healing wound that commonly appears on the feet) on 2/16/2024. This deficient practice violated the resident's rights and/or the representative's right to be fully informed of Resident 149's change of condition. 2. Notify the physician of one of three sampled residents (Resident 321) investigated during review of closed record when Licensed Vocational Nurse 5 (LVN 5) and Registered Nurse 1 (RN 1) did not administer lactulose (a type of laxative [medicine that loosen stools and increase bowel movements] used to treat or prevent certain brain conditions related to liver failure) to Resident 321, who has…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure licensed nurses provide care in accordance with professional standards to three of four sampled residents (Residents 149, 36, and 78) investigated during review of insulin (a hormone that lowers the level of blood sugar in the blood) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin (a drug used to control the amount of sugar in the blood) injection sites. The deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs). Findings: 1. A review of Resident 149's admission Record indicated the facility admitted the resident on 12/21/2023, with diagnoses including cerebral infarction (damage to tissues in the brain due to a 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers (or pressure injury, localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) receive the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing to three of three sampled residents investigated during review of pressure ulcers (Resident 74, 15, and 223), when the facility failed to set Resident 74, 15, and 223's low air loss mattresses (LALM - a pressure reducing device) to the resident's weight per manufacturer's guidelines. These deficient practices had the potential for development and worsening of pressure ulcers/injuries to residents. Findings: a. A review of Resident 74's admission Record indicated the facility admitted the resident on 1/19/2024, with diagnoses including multiple sclerosis (a potentially disabling…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2. A review of Resident 37's Face Sheet (admission Record) indicated the facility admitted the resident on 8/29/2020 with the following diagnoses, but not limited to acute kidney disease (define), hypertension (a condition in which the force of the blood against the artery wall is too high), diabetes,( a disease that results in too much sugar in the blood) myocardial infarction ( a blockage of blood flow to the heart muscle) peripheral vascular disease ( a circulation condition in which narrowed blood vessels reduce blood flow to the limb ) A review of Resident 37's Minimum Data Set (MDS - an assessment and screening tool) dated 5/2/2024, it indicated the resident was originally admitted to the facility on [DATE] and was able to understand others make herself understood, and not appropriate to self-medicate. A review Resident 37's Care Plan (CP) titled, Cognitive / vision / falls / activities of daily living (ADLs) / ., dated 5/2/2024, it indicated the resident was alert with some forgetfulness. During a…

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

Based on observation, interview, and record review, the facility failed to ensure a residents who experienced urinary retention (inability to completely empty the urinary bladder by urinating) was assessed and provided appropriate treatment and services to maintain as much normal bladder function as possible and to prevent catheter (flexible hollow tube inserted into the urethra [tube that transports urine from the bladder to the exterior of the body] to drain the bladder of urine) associated urinary tract infections (CAUTI or UTI, condition that occurs when bacteria enters the urinary tract by way of a catheter resulting in an infection) for one of one residents (Resident 39) investigated during the Urinary Catheter care area by failing to: 1.Obtain an order for intermittent self-catheterization (procedure that involves inserting a catheter into the bladder to empty it) for Resident 39 who was identified as self-catheterizing (provide straight catheterization for oneself). 2. Obtain the resident's Urology Progress Notes between 5/9/2023 and 5/11/2024 after resident's appointments…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. A review of Resident 94's admission Record indicated the facility admitted the resident on 8/7/2020, with diagnoses including schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions) and bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs [mania or hypomania] or lows [depression]). A review of Resident 94's H&P, 7/1/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 94's MDS, dated [DATE], indicated the resident usually had the ability to make self-understood and understand others. The MDS indicated the resident was on a high-risk drug class antipsychotic medication (a type of drug used to treat symptoms of psychosis). A review of Resident 94's Order Summary Report indicated an order for: -4/9/2024 Seroquel tablet 25 milligrams (mg, a unit of mass or weight) (Quetiapine Fumarate). Give 1 tablet by mouth at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Four medication errors out of 28 total opportunities contributed to an overall medication error rate of 14.29% affecting two of four residents observed for medication administration (Resident 37 and 41.) The medication errors were as follows: 1. Resident 37 did not receive aspirin (a medication used to prevent cerebrovascular accidents [CVA] - an interruption in the flow of blood to cells in the brain] by thinning the blood) as ordered by Resident 37's physician, and received a dose of calcium with vitamin D3 (a combination medication used as a dietary supplement to provide support to bones) and a form of multivitamin (a medication used as a dietary supplement to provide essential vitamins, minerals, and other nutritional elements) that was different than the one ordered by Resident 37's physician. 2. Resident 41 did not receive vitamin D3 (a form of vitamin D called…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents are free of any significant medication by failing to: 1. Rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin (a hormone that lowers the level of blood sugar in the blood) insulin injection sites to three out of four sampled residents (Residents 149, 36, and 78) investigated during review of insulin use. The deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs). Cross Reference F658 2. Ensure to administer aspirin (a medication used to prevent cerebrovascular accidents [CVA] - an interruption in the flow of blood to cells in the brain] by thinning the blood) to one of four residents (Residents 37) observed for medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1. Label one insulin (medication used to regulate blood sugar levels) glargine (long-acting insulin) prefilled pen (an injection device containing insulin) for Resident 57 at room temperature, in accordance with manufacturer's requirements in one of three inspected medication carts (Medication Cart Station 2A.) 2. Store or label one insulin Humulin R (short-acting insulin) vial for Resident 78, in accordance with manufacturer's requirements in one of three inspected medication carts (Medication Cart Station 3.) These practices increased the risk that Residents 57 and 78 could have received medication that had become ineffective or toxic due to improper storage or labeling, possibly leading to health complications resulting in hospitalization or death. Findings: During an observation on [DATE] at 02:26 PM, in Medication Cart Station 3, in the presence of Licensed Vocational Nurse (LVN) 3, the following medications were found either stored…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 19 of 124 residents on puree diet (diet that contains food with smooth like pudding consistency) and five (5) of 124 residents on regular texture by: a. Not following standardized recipes for puree bread and puree scrambled eggs. b. Not following portion sizes for gravy based on facility spreadsheet. This deficient practice had the potential to cause difficulty in eating, chewing, and swallowing to the residents and decrease food intake resulting to unintended (not done on purpose) weight loss. Findings: a. During an observation of the lunch trayline (an area where resident's food was assembled) on 4/30/2024 at 7:33 a.m., puree bread had small particles and eggs looked like regular, firm egg consistency. During a test tray (a process for taste testing food) evaluation with the Dietary Supervisor 1 (DS 1) on 4/30/2024 at 7:55 a.m., puree bread had little particles and eggs were firm. DS 1 stated puree bread was runny because it had been out; however, it was…

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

Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor, appearance, and temperatures when: a. Twenty (20) of 138 residents' food on Styrofoam plates and bowls for breakfast trayline. b. Sixty-five (65) of 138 resident's tray were not garnished for breakfast. c. Fifty-nine (59) of 59 eggs were bland in taste for regular diet (diet with no restriction) residents. d. Registered Dietitian 1 (RD 1) was not aware of the menu substitution for breakfast. e. One of two sampled residents investigated under the Food care area (Resident 69) was served cold and bland scrambled eggs. These deficient practices had the potential to cause unplanned weight loss, a consequence of poor food intake facility residents who getting food from the kitchen. Findings: a. During a breakfast trayline (an area where resident's food was assembled) observation on 4/30/2024 at 7:20 a.m., staff served fruit in a Styrofoam container, and some were served in bowls. During a breakfast trayline observation on 4/30/2024 at 7:45 a.m., staff served 20…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Proper food handling a. English muffins were on top of the preparation table near the toaster. b. Residents' food from home was expired and not labeled with name. 2. Hygiene a. Staff were wearing jewelries while cooking hamburgers and food preparation. b. Staff failed to handwash when changing from one task to another. 3. Cross-contamination a. Three (3) dented cans were found in the dry storage area. b. Water gallons were stored on the floor. c. Eighty three (83) of 130 trays used for lunch service were chipped and cracked. d. Expired Quaternary (Quat, a group of chemicals used to disinfect surfaces and equipment) Ammonium compound sanitizer test strips. e. Staff did not check Quat concentration according to test strips manufacturer's guidelines. f. Pots and pans were not air dried. 4. Equipment and kitchen cleanliness a. Kitchen hood had dirt…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 by not completely covering two (2) of four (4) black dumpster (a large trash container designed to be emptied into a truck) for unknown amount of time. This deficient practice had a potential to attract flies, insects, cats, and other animals to the dumpster area placing 124 of 138 facility residents getting food from the kitchen cross-contamination (a transfer of harmful bacteria from one place to another). Findings: During a concurrent observation of the garbage area located outside the facility and interview with Assistant Dietary Supervisor (ADS) at 4/30/2024 2:20 p.m., two (2) of four (4) black trash bins were not completely closed. ADS stated the 2 garbage bins were full and not completely closed. ADS stated the trash bins needed to be completely closed as it was part of their infection control and trash could fall out to the floor attracting flies, rats, and racoons. ADS stated potential outcome for this practice would be residents could get infection. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to maintain accurate clinical records in accordance with accepted professional standards and practices by failing to: 1. Ensure Treatment Nurse 1 (TN 1), Vocational Nurse 1 (LVN 1), and Licensed Vocational Nurse 5 (LVN 5) did not willfully falsify entries in the Treatment Administration Record (TAR, a flow sheet where nursing documents treatments provided to a resident daily) by documenting the resident was intermittently catheterized by licensed nurses for one of one residents (Resident 39) investigated under the Catheter (flexible hollow tube inserted into the urethra [tube that transports urine from the bladder to the exterior of the body] to drain the bladder of urine) care area. 2. Ensure Licensed Vocational Nurse 1 (LVN 1) accurately documented on 5/1/2024 that entries in the TAR were late entries (delayed entries not made within a reasonable time frame usually 24 to 48 hours) for one of one resident (Resident 39) investigated under the catheter care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infection control practices for seven out of seven sampled residents (Residents 333, 101 56, 94, 330, and 40) during a random observation by: 1. Failing to ensure the resident's urinal bottles (a container for receiving urine) were labeled with Resident 333's name. 2. Failing to ensure Certified Nursing Assistant 11 (CNA 11) washed Resident 333's urine bottles after emptying. 3. Failing to ensure Resident 101's nasal cannula tubing (a lightweight tube which on one end splits into two prongs which are placed in the nostrils to provide supplemental oxygen to the body) was not touching the floor. These deficient practices had the potential for cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) and placed the residents at risk for acquiring infection. 4. Staff failing to label the urinal bottles of Residents 56 and 94. 5. Certified Nursing Assistant 1 (CNA 1)…

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

Based on interview and record review, the facility failed to implement its policy and procedures for antimicrobial stewardship (AMS- a coordinated program that promotes the appropriate use of antimicrobials [including antibiotics, drugs used to treat infections caused by bacteria and other microorganisms], improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms) for one of six sampled residents (Resident 2) when clindamycin (an antibiotic) was ordered on 1/29/2024 as indefinite and the facility failed to monitor the antibiotic use for 77 days. This deficient practice had the potential for the resident to receive an inappropriate antibiotic and develop antibiotic resistance (when bacteria/germs change in some way that reduces or eliminates the effectiveness of drugs, chemicals, or other agents designed to cure or prevent infections). Findings: A review of Resident 2's admission Record indicated the facility admitted the resident on 12/28/2023. Resident 2's diagnoses included history of multidrug resistant…

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

Based on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) was within reach for one of two sampled residents (Resident 8) investigated under the Environment task. This deficient practice had the potential to result in the delay of care and services and possible injury to Residents when they are unable to summon health care workers. Findings: A review of Resident 8's admission Record indicated the facility admitted the resident on 7/29/2022 and readmitted the resident on 12/1/2022 with diagnoses that included malignant neoplasm of colon (a disease in which abnormal cells divide and grow uncontrollably ), anxiety disorder (a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear ), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with one's daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 54)'s clothes were not lost when sent to the laundry room. This failure resulted in Resident 54 being distressed. Findings: A review of Resident 54's admission Record indicated the facility admitted the resident on 2/6/2023 with diagnoses - of but not limited to diabetes (a chronic condition that affects the way the body processes blood sugar), anxiety disorder (mental health disorder characterized by feelings of worry, nervousness or unease), hypertension (a condition in which the force of the blood against the artery wall is too high ) and pneumonia (infection that inflames air sac in one or both lungs which may fill with fluid). A review of Resident 54's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 5/2/2024, indicated the resident understood others and was able to make himself understood. The MDS further indicated that Resident 54's cognitive (relating to the 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.

Based on interview and record review, the facility failed to resolve a grievance for one of one sampled resident (Resident 54) regarding their lost clothing. The failure resulted in Resident 54 being upset. Findings: A review of Resident 54's admission Record, it indicated the facility admitted the resident on 2/6/2023 with the diagnoses of but not limited to diabetes (a chronic condition that affects the way the body processes blood sugar) anxiety disorder (mental health disorder characterized by feelings of worry, nervousness or unease), and hypertension (high blood pressure) A review of Resident 54's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 5/2/2024, it indicated the resident understood others and was able to make himself understood. The MDS also indicated that Resident 54's cognitive (relating to the process of acquiring knowledge and understanding) status and decision-making skills were intact. During an interview on 4/30/2024 at 11:43 a.m., Resident 54 stated his clothes have been getting lost for the past eight months. The resident stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) to two of two sampled residents (Residents 94 and 18) investigated during review of physical restraints care area by failing to: 1. Ensure Resident 94's bed was not placed against the wall without assessing the need for use and assessing for risk of entrapment prior to use. 2. Ensure Resident 18's bed was not placed against the wall, without assessing the need for use, assessing for risk for entrapment prior to use, obtaining informed consent prior to use, and obtaining an order from the physician. 3. Ensure the use of left upper half side rails (a device that attaches to the side of the hospital bed) 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 interview and record review, the facility failed to implement its abuse prevention policy to one of three sampled residents reviewed during an investigation of a facility reported incident (FRI) involving an allegation of staff to resident abuse, by failing to immediately report, but not later than 2 hours after the allegation was made, to the State Survey Agency (SSA), the Ombudsman (assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences), and local law enforcement agency. This deficient practice had the potential to result in an unidentified abuse in the facility and had the potential for the residents to experience further abuse. Findings: A review of Resident 149's admission Record indicated the facility admitted the resident on 12/21/2023, with diagnoses including cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), aphasia (a language disorder caused by damage in a specific area of the brain that controls language expression and comprehension), and depression.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 thoroughly investigate an allegation of staff to resident abuse and failed to report the results of the investigation to the administrator and the State Survey Agency (SSA), within five working days of the incident. This deficient practice had the potential to result in an unidentified abuse in the facility and had the potential for the residents to experience further abuse. Findings: A review of Resident 149's admission Record indicated the facility admitted the resident on 12/21/2023, with diagnoses including cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), aphasia (a language disorder caused by damage in a specific area of the brain that controls language expression and comprehension), and depression. A Review of Resident 149's History and Physical (H&P), dated 12/22/2023, indicated the resident does not have the capacity to understand and make decisions. A review of Resident 149's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/28/2024,…

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

Based on interview and record review the facility failed to ensure safe and orderly discharge to one out of three sampled residents (Resident 170) investigated during closed record review by failing to provide documentation that the resident was provided complete information (including phone numbers) of the home health agency prior to discharge. This deficient practice placed the resident at risk for not receiving the necessary care and services related to the resident's discharge goals and needs. Findings: A review of Resident 170's admission Record indicated the facility admitted the resident on 1/29/2024, with diagnoses including end stage renal disease (a life-threatening condition when the kidneys fail to filter the blood), dependence on renal dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly), and kidney transplant status (a surgery done to replace a disease or inured kidney with a healthy kidney from a donor). A review of Resident 170's Change in Condition Evaluation (COC), dated 2/2/2024, 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: 1. To develop and implement a care plan addressing placement of bed against the wall for two of two sampled residents (Resident 94 and 18) investigated during review of physical restraints (the use of manual hold to restrict freedom of movement of all or part of a resident's body, or to restrict normal access to the resident's body). This deficient practice had the potential for residents to not receive the proper and necessary care related to use of restraints. 2. To develop and implement a care plan for one of one sampled resident (Resident 86) for refusing activities and range of motion (ROM-movement of the joints) treatments. This failure had the potential to place Resident 86 at risk for physical and psychosocial decline. Findings: 1. a. A review of Resident 94's admission Record indicated the facility admitted the resident on 8/7/2020, with diagnoses including hemiplegia (paralysis that affects only one side of the body) and hemiparesis (weakness or…

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

Based on observation, interview, and record review the facility failed to ensure the resident's comprehensive care plan was reviewed and revised by the interdisciplinary team to one out of four sampled residents (Resident 74) investigated during review of pressure injury/ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) care area when the resident refused to have the low air loss mattress (LALM, a mattress designed to prevent and treat pressure wounds) be set according to resident's weight. The deficient practice had a potential for worsening of the pressure injury (the breakdown of skin integrity due to pressure) of the resident. Findings: A review of Resident 74's admission Record indicated the facility admitted the resident on 1/19/2024, with diagnoses including multiple sclerosis (a potentially disabling disease of the brain and spinal cord), type 2 diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, is too high), and muscle weakness. A review of Resident 74'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 residents receive treatment and services to maintain vision to one out of one sampled resident (Resident 104) investigated during review of communication/sensory care area by failing to assist the resident in scheduling an ophthalmology (eye care specialist) appointment. The deficient practice had the potential to result in worsening of the resident's vision and could negatively affect the resident's overall well-being. Findings: A review of Resident 104's admission Record indicated the facility admitted the resident on 8/3/2021 and readmitted the resident on 7/28/2022, with diagnoses including depression and pleural effusion (occurs when fluid builds up in the space between the lung and the chest wall). A review of Resident 104's History and Physical (H&P), dated 10/16/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 104's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/7/2024, indicated the resident had the ability to make…

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

Based on observation, interview, and record review the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding (EF - a form of nutrition that is delivered into the digestive system as a liquid) to one of three random observations (Resident 80) by labeling the feeding formula bottle with an incorrect gastrostomy (GT, tube inserted through the wall of the abdomen directly into the stomach) feeding rate. This deficient practice had the potential to result in weight loss or gain and altered nutritional status that can lead to complications. Findings: A review of Resident 80's admission Record indicated the facility admitted the resident on 5/21/2019, and readmitted the resident on 10/2/2019, with diagnoses including gastrostomy (a tube inserted through the wall of the abdomen directly into the stomach), dysphagia (swallowing difficulties), and adult failure to thrive (a syndrome of weight loss, decreased appetite and poor nutrition, and inactivity). A review of Resident 80's History & Physical (H&P), dated 7/1/2023, 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 observation, interview and record review, the facility failed to administer parenteral fluids (the intravenous administration of medication) consistent with professional standards of practice for two (2) out of 2 sampled resident (Residents 324 and 57) during random observation of residents with intravenous (IV) catheter (a thin, flexible tube that is inserted into a vein to draw blood and give treatments including IV fluids, drugs, or blood transfusions) by: 1. Failing to label the IV dressing with the date when the peripheral intravenous line (PIV - a soft, flexible tube placed inside a vein, usually in the hand or arm to give a person medicine or fluids) dressing was last changed for Resident 324. 2. Failing to label the IV bag with the time the infusion of IV antibiotic was administered and the initials of the Registered Nurse (RN) who administered the IV medication for Resident 57. 3. Failing to place a sterile injection cap over the injection port of the double lumen central line (CL - also known as central venous catheter - a thin, flexible tube that is inserted into…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interviews, and record review the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills as followed: a. Staff failed to verbalize proper air-drying procedures when washing dishes. b. Staff failed to verbalize and follow the manufacturer's guidelines of J512 test paper (a type of test strip) when checking the Quaternary Ammonium Compounds (Quats, a group of chemicals used to disinfect surfaces and equipment) sanitizer concentration. These failures had a potential to result to cross-contamination (a transfer of bacteria from one object to another), unsanitized food preparation areas and bacterial growth to food that could lead to food borne illness (an illness caused by contaminated food and beverages) in 124 of 138 medically compromised residents who received food and ice from the kitchen. Cross Refernce F812 Findings: a. During an observation of the dishwashing process on 5/1/2024 at 8:39 a.m., the clear containers were stacked wet on 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 meet resident's (Resident 152) food preferences when there were missing items on the resident's tray. This deficient practice had the potential to cause frustrations and decrease food intake resulting to unintended (not done on purpose) weight loss. Findings: During an interview with Resident 152 on 4/30/2024 at 8:55 a.m., Resident 152 stated her food preferences were not honored as she was not getting what she requested. Resident 152 stated she filled up a sheet for food preferences for 4/30/2024 and 5/1/2024 and requested fruit plate and two (2) eggs. Resident 152 stated she only received fruit plate and regular tray but not the eggs. Resident 152 stated this was not the first time it happened, and it has been going on. A review of Resident 152's admission Record, indicated Resident 152 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (a condition when the heart does not pump enough blood for 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 inform the responsible party for one of six sampled residents (Resident 1). After encountering a change in health condition with injury, Resident 1's responsible party (RP) was not contacted or provided an update to Resident 1's change in health condition. This deficient practice denies Resident 1's RP the information required to make informed decisions for Resident 1's health related care and needs. Findings: A review of Resident 1's admission Record indicated an admit date of 4/14/2004 with the diagnoses of metabolic encephalopathy (chemical imbalance causing problems in the brain), other specified disorders of the brain, and adult failure to thrive (a decline in the elderly population affecting weight loss and inactivity). Further review of Resident 1's admission Record indicated four (4) emergency contact phone numbers listed. A record review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and screening tool), dated 1/9/2024, indicated that Resident 1 is severely impaired with thought process and…

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

Based on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1) who was unable to carry out activities of daily living (ADL-such as personal hygiene, bathing, bed mobility, dressing and transfers) received the necessary services to maintain good grooming and personal hygiene. This deficient practice had the potential to negatively affect Resident 1's self-esteem and well-being. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 11/25/2023 with diagnoses that included unspecified (unconfirmed) benign (those that stay in their primary location without invading other sites of the body) neoplasm (also known as tumor is an abnormal mass of cells in the body) of the meninges (protect the brain and spinal cord), type two diabetes mellitus (uncontrolled elevated blood sugar), unspecified dementia (not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and unspecified kidney failure.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 necessary respiratory care and services for one of four sampled residents (Resident 3) by failing to ensure oxygen tubing was dated on when it was changed. This deficient practice had the potential for Resident 3 to develop respiratory diseases. Findings: A review of Resident 3's admission Record indicated the facility admitted the resident on 8/31/2023 with diagnoses that included other toxic encephalopathy (exposure to natural or manmade toxic substances that alters the normal activity of the nervous system, disrupts or even kills neurons [key cells that transmit and process signals in the brain and other parts of the nervous system]), malignant neoplasm (a cancerous tumor that develops when abnormal cells grow, multiply and spread to other parts of your body) of the liver (the largest solid organ in the body that removes toxins from the body's blood supply, maintains healthy blood sugar levels, regulates blood clotting, and performs hundreds of other vital functions), essential hypertension…

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

Based on interview and record review, the facility failed to maintain a complete and accurate medical records in accordance with accepted professional standards for one of four sampled residents (Resident 1). This deficient practice had resulted to inaccurate information entered in Resident 1's medical record. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 11/25/2023 with diagnoses that included unspecified (unconfirmed) benign (those that stay in their primary location without invading other sites of the body) neoplasm (also known as tumor is an abnormal mass of cells in the body) of the meninges (protect the brain and spinal cord), type two diabetes mellitus (uncontrolled elevated blood sugar), unspecified dementia (not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and unspecified kidney failure. A review of Resident 1's History and Physical, dated 11/26/2024, indicated the resident had fluctuating capacity 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 observed infection control measures for one of four sampled residents (Resident 3) by failing to ensure oxygen tubing was not touching the floor. This deficient practice resulted in the contamination (the process of making something dirty) of the resident's care equipment and placed Resident 3 at risk for infection. Findings: A review of Resident 3's admission Record indicated the facility admitted the resident on 8/31/2023 with diagnoses that included other toxic encephalopathy (exposure to natural or manmade toxic substances that alters the normal activity of the nervous system, disrupts or even kills neurons [key cells that transmit and process signals in the brain and other parts of the nervous system]), malignant neoplasm (a cancerous tumor that develops when abnormal cells grow, multiply and spread to other parts of your body) of the liver (the largest solid organ in the body that removes toxins from the body's blood supply, maintains healthy blood sugar levels, regulates blood clotting, and performs…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 respect the rights and dignity for one of six sampled residents (Resident 1) by failing to provide Activities of Daily Living (ADL) grooming needs. This deficient practice prevents Resident 1 from reaching the highest potential for mental, emotional, and/or psychosocial well-being. Findings A review of Resident 1's admission Record noted an original admission date of 10/23/2023 with the following diagnoses of hypertensive heart disease (chronic or prolonged high blood pressure) with heart failure (decreased ability of the heart to pump blood for the body's needs), muscle weakness, and dementia (having impairments with thought process and decision making). A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 10/30/2023, indicated that Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making tasks were partially impaired. The MDS further indicated that Resident 1 required partial assistance with toileting…

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

Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for one of three sampled residents (Resident 6) to address residents ' refusal for nail care. On 11/17/2023, Resident 6 had long and dirty fingernails. This deficient practice had the potential to negatively affect Resident 6's self-esteem and placed her at risk for infection. Findings: A review of Resident 6 ' s admission Record indicated the facility admitted the resident on 7/22/2023 with diagnoses that included spinal stenosis (a narrowing of the spinal canal in the lower part of your back), hypertension (uncontrolled elevated blood pressure), and anxiety (a feeling of fear, dread, and uneasiness). A review of Resident 6 ' s History and Physical, dated 3/29/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 6 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/29/2023, indicated resident ' s cognitive (mental action or 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 one of three sampled residents (Resident 6) who was unable to carry out activities of daily living (ADL ' s such as bathing, dressing and personal hygiene) received the necessary services to maintain good grooming. On 11/17/2023, Resident 6 had long and dirty fingernails. This deficient practice had the potential to negatively affect Resident 6 ' s self-esteem and placed her at risk for infection. Findings: A review of Resident 6 ' s admission Record indicated the facility admitted the resident on 7/22/2023 with diagnoses that included spinal stenosis (a narrowing of the spinal canal in the lower part of your back), hypertension (uncontrolled elevated blood pressure) and anxiety (a feeling of fear, dread, and uneasiness). A review of Resident 6 ' s History and Physical, dated 3/29/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 6 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/29/2023, indicated resident ' 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 esure it has policies and procedures on the use of a wander guard (a monitoring bracelet that alarms once the bracelet crosses sensors on an exit door) and resident supervision affecting all residents. The facility also failed to implement its policy on the use of security and surveillance cameras (video cameras that record images in or outside a building or in a public place) to be monitored since per policy, the video surveillance cameras were monitored for the safety and benefit of its residents and video footages were stored. As a result, on 10/4/2023, Resident 1 eloped and was last seen at 6 a.m. inside the facility building in the hallway near Nursing Station 3 by the Director of Staff Development (DSD), who was walking in the hallway going to Nursing Station 4. Resident 1 was at risk for exposure to environmental elements including extreme temperatures (heat during the day and cold during the night) and increased probability of encountering an accident that can lead to serious injury, serious harm,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 employ a qualified social worker on a full-time basis for a facility that has more than 120 beds. This deficient practice had a potential for the residents not being assisted and receiving medically related social services to attain the highest practicable well-being. Findings: On 10/9/2023 at 11:15 a.m., during an interview with the Director of Nursing (DON) and concurrent review of the Census of the day, The DON stated the census was 180 residents and the bed capacity was 201. During an interview on 10/9/2023 at 12:56 p.m., Social Services Assistant 1 (SSA 1) stated the facility did not have a full time Social Services Director. During an interview on 10/9/2023 at 3:14 p.m., the Administrator (ADM) stated the facility did not have a qualified Social Services Director since 2/2023. The ADM stated they were looking for one. A review of facility ' s job description for Social Service coordinator indicated the social services qualifications in centers with 120 beds or more were to have a bachelor ' s degree in social work or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to allow a resident to return to the facility after a hospitalization for a change in condition for 1 of 3 residents (Resident 1) reviewed for admission/ transfer/ discharge. This deficient practice resulted in Resident 1 remaining in the hospital for one extra day and had the potential to result in the resident ' s Family Member (FM) being unaware of the facility ' s responsibility to accept Resident 1 back after transfer. Findings: A review of the Record of admission indicated Resident 1 was admitted to the facility on [DATE] and discharged to General Acute Care Hospital (GACH) on 7/24/2023 with diagnoses which included, but were not limited to urinary tract infection (UTI- an infection in any part of the urinary system, the kidneys, bladder or urethra), metabolic encephalopathy (is commonly defined as an alteration in consciousness caused due to brain dysfunction), acute respiratory failure (loss of the ability to breathe adequately or to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assess and monitor resident's urinary discomfort and burning sensation for potential symptoms of a urinary tract infection (UTI, infection that affects part of the urinary tract-kidneys, ureters, urinary bladder, and the urethra) for one of three sample residents (Resident 93) investigated under the Urinary Catheter or UTI care area. This deficient practice had the potential to negatively affect the resident's physical comfort and psychosocial well-being. Findings: A review of Resident 93's Face Sheet indicated the resident was admitted on [DATE] with diagnoses including urinary tract infection (UTI, infection that affects part of the urinary tract-kidneys, ureters, urinary bladder, and the urethra) and polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body). A review of Resident 93's Physician's Orders indicated an order of urinalysis (UA, a test used to examine the content of a urine sample) and culture (a test 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 accurately account for 10 doses of controlled substances (medications with a high potential for abuse) affecting nine residents (Residents 11, 50, 52, 65, 69, 93, 98, 130, and 141) in one of four inspected medication carts (Medication Cart 4A). This deficient practice increased the risk that Residents 11, 50, 52, 65, 69, 93, 98, 130, and 141 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization. Findings: During an inspection of Medication Cart 4A, on 8/10/2021 at 2:17 p.m., the following discrepancies were found between the Narcotic and Hypnotic Record (a log signed by the nurse with the date and time each time a controlled substance is given to a resident) and the medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication): 1. Resident 69's Narcotic and Hypnotic Record for lorazepam (a medication used to treat…

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

Based on observation, interview, and record review, the facility failed to ensure proper food handling practices by: 1. Failing to ensure that two boxes of apple juice were not stored on the floor in dry storage room. 2. Failing to ensure that three prepared milk trays in Fridge #2 (refrigerator #2) were dated. 3. Failing to ensure Resident 2's food brought in by family and stored in staff refrigerator was labeled with storage date. These deficient practices had the potential to result in foodborne illness (an infection or irritation of the gastrointestinal tract [including the stomach and intestines] caused by food or beverages that contain harmful bacteria/germs, chemicals, or other organisms) for 127 out of 127 residents who receive and consume food from the facility kitchen and the resident designated refrigerator. Findings: a. During an observation tour of the dry storage room, on 08/10/2021 at 8:50 a.m., with the Dietary Supervisor (DS), observed two boxes of apple juice on the floor of the dry storage room. During an interview, on 8/10/2021 at 8:50 a.m., the DS stated 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 b. A review of Resident 20's Face Sheet indicated the resident was readmitted on [DATE] with diagnoses including Parkinson's disease (a progressive nervous system disorder that affects movement) and resistance to other specified beta lactam antibiotics (management and treatment of bacterial infections). During a concurrent observation and interview, on 08/12/2021 at 9:29 a.m., observed Certified Nurse Assistant 3 (CNA 3) put on gown and gloves before entering Resident 20's room. CNA 3 provided bed bath to Resident 20. CNA 3 washed the resident's upper body with wash cloth soaked with soap and water and rinsed off with wash cloth and pat dry with towel. Using the same gloves, CNA 3 washed resident's perineal area and proceeded to resident's lower extremities and back area. Using the same gloves, CNA 3 placed new sheets and repositioned resident lying on his left side. During an interview, on 08/12/2021 at 9:48 a.m., CNA 3 confirmed the bed bath for Resident 20 was completed. CNA 3 confirmed he did not change his…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the call light was within reach for one out of one resident (Resident 91) investigated under the care area of accommodation of needs. This deficient practice had the potential for the resident's needs not being met as resident was unable to call for this assistance. Findings: A review of Resident 91's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (a disorder of the central nervous system that affects movement, often includes tremors), anemia (a condition resulting from a lack of red blood cells or dysfunctional red blood cells in the body leading to reduced oxygen flow) and muscle weakness. A review of Resident 91's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 06/30/2021 indicated the resident rarely made self understood and rarely understood others. The MDS also indicated Resident 91 had severely impaired cognitive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, the facility failed to ensure the resident's advance directives (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) were readily accessible in the physical chart for one of four sampled residents (Resident 105). This deficient practice had the potential to delay emergency treatment or the potential to force emergency, life-sustaining procedures against the resident's personal preferences. Findings: A review of Resident 105's Face Sheet indicated Resident 105 was admitted into the facility on [DATE] with diagnoses that included displaced fracture (when a bone breaks into two or more pieces and moves out of alignment) of sixth and seventh cervical vertebra (seven bony rings that form from the base of the skull down to the top of the shoulders), atrial fibrillation (rapid and irregular heart rhythm that can lead to blood clots), and hypertension (elevated blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an individualized plan of care for activities for one of one resident (Resident 129) investigated under the care area of care planning. This deficient practice resulted to failure in the delivery of necessary care and services for Resident 129. Findings: A review of Resident 129's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included age related osteoporosis (a condition where the bones become weak and brittle), fracture of right femur (right thigh bone break) and hypertension (high blood pressure). A review of Resident 129's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 07/15/2021 indicated the resident had clear speech, understood others, and was able to be understood by others. The MDS indicated the resident had moderate cognitive conscious mental activities including thinking, reasoning, understanding, learning, and remembering) impairment. 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 ensure that two of two sampled residents (Resident 16 and 129) investigated under the care area of activities were engaged in preferred activities as evidenced by: a. Resident 129 was not assessed for activities nor was offered activities. b. Failing to conduct an activities assessment for Resident 16. These deficient practices had the potential to affect the resident's sense of self-worth and psychosocial well-being through feelings of usefulness, self-respect, and self-satisfaction. Findings: a. A review of Resident 129's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included age related osteoporosis (a condition where the bones become weak and brittle), fracture of right femur (right thigh bone break) and hypertension (high blood pressure). A review of Resident 129's Minimum Data Set (MDS -a standardized assessment and care screening tool) dated 07/15/2021 indicated the resident had clear…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 treat a resident's contractures (muscles or tendons that have remained too tight for too long, thus becoming shorter) by not applying hand rolls as ordered for one of one sampled residents (Resident 61). This deficient practice had the potential to further affect the resident's limited range of motion and further worsening of the contracures. Findings: A review of Resident 61's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), contracture (muscles or tendons that have remained too tight for too long, thus becoming shorter) of muscle, and functional quadriplegia (complete inability to move due to severe disability or frailty caused by another medical condition without physical injury or damage to the spinal cord). A review of Resident 61's Minimum Data Set (MDS-an assessment and care screening tool)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a resident requiring a Foley catheter (indwelling catheter - a flexible tube that passes through the urethra [tube that leads from the bladder and transports and discharges urine outside the body] to drain urine) was connected and draining urine for one of one resident (Resident 73) investigated under the care area of urinary catheter. This deficient practice led to unnecessary resident abdominal pain and discomfort. Findings: A review of Resident 73's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), hypertension (high blood pressure) and muscle weakness. A review of Resident 73's Minimum Data Set, dated (MDS-a standardized assessment and care screening tool) dated 06/23/2021 indicated the resident had severe cognitive (conscious mental activities including thinking, reasoning,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 fully assess and effectively manage pain for one of one sampled resident (Resident 105), by failing to: 1. Perform a pain assessment after Resident 105 reported pain to Licensed Vocational Nurse 7 (LVN 7). 2. Assess Resident 105's pain intensity before and after pain medication administration on 8/6/2021. These deficient practices had the potential to result in ineffective pain control and Resident 105 experiencing unnecessary pain. Findings: A review of Resident 105's Face Sheet indicated the resident was admitted on [DATE] with diagnoses that included displaced fracture (when a bone breaks into two or more pieces and moves out of alignment) of sixth and seventh cervical vertebra (seven bony rings that form from the base of the skull down to the top of the shoulders), fracture of T5 - T6 vertebra (fifth and sixth thoracic vertebra [group of twelve small bones that form the middle section of the spine]), and nondisplaced fracture (broken…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 act upon in a timely manner on the Consultant Pharmacist's Medication Regimen Review recommendations including the documented rationale (underlying reason) for the ongoing need for routine use of Voltaren (diclofenac, used to relieve pain and swelling) and continuous use of Restoril (hypnotic used to treat insomnia [trouble sleeping]) for one of five sampled residents (Resident 65) investigated under the Unnecessary Medications, Psychotropic Medications, and Medication Regimen Review care area. This deficient practice had the potential to result in unnecessary medications placing the resident at risk for potential adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have). Findings: A review of Resident 65's Face Sheet Record indicated the resident was admitted on [DATE] with diagnoses including multiple sclerosis (a brain and spinal cord disease) and chronic pain syndrome. A review of Resident 65's Physician's Orders…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 signs and symptoms of bleeding were monitored for the use of Eliquis (a medication used to prevent blood clots) for one of five sampled residents (Resident 7.) The deficient practice of failing to monitor for signs and symptoms of bleeding during Eliquis therapy increased the risk that Resident 7 could have experienced adverse effects (unwanted and dangerous side effects of medication) such as bleeding and bruising leading to health complications requiring hospitalization. Findings: During a review of Resident 7's Face Sheet, dated 8/12/2021, indicated she was admitted to the facility on [DATE] with diagnoses including difficulty walking and muscle weakness. During a review of Resident 7's Physician Order Summary, dated 8/2021, the Order Summary indicated on 5/4/2021 the physician prescribed Eliquis 5 milligrams (mg - a unit of measure for mass) by mouth twice daily for DVT prophylaxis (prevention of the formation of blood clots that form in the…

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

Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Two medication errors out of 26 total opportunities contributed to an overall medication error rate of 7.69 % affecting one of four residents observed for medication administration (Resident 131.) The deficient practice of failing to administer medications in accordance with the attending physician's orders increased the risk that Resident 131 may have experienced health complications related to incorrect medication administration which could have negatively impacted her health and well-being. Findings: During an observation on 8/10/2021 at 8:56 a.m., in Nursing Station 1, the Licensed Vocational Nurse (LVN) 1 was observed administering one enteric coated (a special coating on a tablet used to prevent stomach irritation) tablet of aspirin (a medication used to prevent blood clots) 81 milligrams (mg - a unit of measure for mass) and two 1000 International Units (IU - a unit of measure for vitamins) capsules of vitamin D (a supplement) by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one bottle of bromfenac ophthalmic solution (a medication use to treat eye conditions) for Resident 9 was removed from the medication cart once expired for one of three inspected medication carts (Medication Cart 4B.) This deficient practice increased the risk that Resident 9 could have received medication that had become ineffective or toxic due to improper storage or labeling possibly leading to health complications resulting in hospitalization. Findings: During a concurrent observation and interview, on [DATE] at 2:17 p.m., with the Licensed Vocational Nurse (LVN) 2, in Medication Cart 4B, one bottle of bromfenac ophthalmic solution for Resident 9 was found labeled with an open date of [DATE]. LVN 2 stated the medication would be considered expired as the facility policy was to replace open eye drops 28 days after they were opened. LVN 2 stated this medication had also been discontinued for Resident 9 and should have been…

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