Providence St Elizabeth Care Center

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all drugs and biologicals to meet the needs of each resident during an inspection of one (1) out of two (2) medication carts, Medication Cart 1 (MC 1) reviewed under the Medication Storage and Labeling Task by: 1. Failing to accurately account for two doses of controlled medications (medications with a high potential for abuse) affecting Resident 23 in one (1) of two (2) inspected medication carts, Medication Cart (MC) 1. This deficient practice increased the risk of diversion (the transfer of a medication from a lawful to an unlawful channel of distribution or use) of controlled medications and the risk that Resident 23 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization. 2. Failing to ensure Resident 23 received the 5 p.m. dose of pregabalin per physician's order on 12/13/2025 and 12/17/2025.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 by: 1. Failing to ensure a bottle of salad dressing labeled with open date of 12/23/2025 was labeled with a best by date of 2/23/2026. 2. Failing to discard a bunch of parsley leaves inside a sealed plastic bag had brownish discoloration. 3. Failing to ensure a can of applesauce with dent was not placed in the shelf for dented cans. 4. Failing to ensure one (1) round shaped and 1 square shaped clean food containers were still wet and stacked in the clean and dried dishes/utensils section of the kitchen. 5. Failing to ensure eight (8) meal trays were stacked wet on the drying rack in the dishwashing room. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (transfer of bacteria from one object to another) in 33 out of 35 medically compromised residents who received food from the kitchen.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 enforce its policy of storing food brought in by family or visitors in a way that it was either separate or easily distinguishable from facility food when there was no designated refrigerator space for residents with leftover foods from home or outside sources. This failure had the potential to result in a decrease in the residents' food intake leading to unintentional (without trying) weight loss and frustrations among 33 of 35 facility residents. Findings: During a concurrent observation and interview during a brief kitchen tour on 12/29/2025 at 7:57 a.m. with the Dietary Supervisor (DS), observed a transparent bin with lid inside Refrigerator 2 labeled Resident Food. The DS stated the bin was for residents` food items that required refrigeration and the food item must be in a sealed container in its original packaging. During another follow up interview on 12/29/2025 at 12 p.m. inside the kitchen with DS, the DS stated that opened items…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 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: 1. Ensure Resident 73's personal bag was not stored on the ground during a tour of the Laundry Facilities on 12/30/2025. This deficient practice had the potential to spread communicable diseases among residents, staff, and visitors. 2. Ensure the Enhanced Barrier Precaution (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO, microorganisms, mainly bacteria, that are resistant to one or more classes of antibiotics] that uses targeted gown and glove use during high contact resident care activities) sign was posted by the door leading into the room of one (1) of one (1) sampled resident (Resident 21) reviewed under infection control. This deficient practice…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its policy for antibiotic (medication used to treat infection) stewardship (efforts in long-term care facilities to ensure that antibiotics are used only when necessary and appropriate [means prescribing the right drug at the right dose at the right time for the right duration]) program and infection prevention and control program for four of four sampled residents (Residents 12, 1, 33, and 41) reviewed for antibiotic use by failing to ensure:1. Failing to ensure Resident 12 meets the criteria for the use of sulfamethoxazole and trimethoprim double strength (also known as Bactrim DS, a combination of two antibiotics used to treat bacterial infections in the ear, sinus, throat, lungs, and skin) for urinary tract infection (UTI - an infection in the bladder/urinary tract). 2. Failing to ensure Resident 12 was monitored for adverse side effects (an unintended, negative health outcome or unwanted event that occurs as a result of a treatment,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the residents' right to privacy and confidentiality by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 2 did not leave an unattended computer screen in a public area displaying a resident`s personal clinical information and Medication Administration Record (MAR, a record of all medications taken by a resident on a day-to-day basis) for one randomly sampled resident (Resident 23). 2. Provide privacy when LVN 2 administered Resident 6's scheduled morning medications in the activity room. This deficient practice had resulted in unauthorized exposure of the resident's medical care and treatment resulting in violation of the resident's right to privacy with the potential to cause psychosocial harm. Findings: a. During a review of Resident 23's admission Record (AR), the AR indicated the facility admitted the resident on 12/12/2025, with diagnoses that included morbid obesity (a serious health condition that results from an abnormally high body mass), pulmonary fibrosis (a lung disease that occurs…

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

Based on observation, interview, and record review, the facility failed to ensure residents 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 one (1) of one (1) sampled resident (Resident 12) reviewed for physical restraints by failing to obtain a physician's order, informed consent, and complete a restraint assessment prior to placement of bed pad alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff). These deficient practices had the potential to result in the restriction of the resident's freedom of movement, a decline in physical functioning, psychosocial harm, physical harm from entrapment, and death of residents. Findings: During a review of Resident 12's admission Record (front page of the chart that contains a summary of basic information…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a baseline care plan for one of two sampled resident (Resident 44) reviewed for Pain Management by failing to develop a care plan that identified resident-centered interventions per facility policy and procedure (P&P) regarding Resident 44's use of as needed (PRN) hydrocodone - acetaminophen (an opioid [also called a narcotic - powerful pain-reducing medication). This deficient practice had the potential to result in miscommunication among facility staff and a delay in care or lack of delivery of care and services for the resident. Findings: During a review of Resident 44's admission Record (AR), the AR indicated the facility admitted the resident on 11/14/2025 with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial paralysis or weakness on one side of the body), metabolic encephalopathy a (general term that describes brain disease, damage, or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure necessary treatment and care was provided for one of three sampled residents (Resident 43). The facility failed to: 1. Ensure licensed nurse assessed and monitored Resident 43's change of condition (COC- a sudden, clinically important deviation from a patient's baseline in physical, cognitive [ability to think, and understand] behavioral, or functional status which without immediate intervention, may result in complications or death) when Resident 43 complained of urinary symptoms. 2. Ensure Licensed Nurses notify the physician of the change of condition and carry out physician order for laboratory test ordered on 12/28/2025. 3. Develop a care plan for symptoms of urinary tract infection (UTI - an infection in the bladder/urinary tract) These deficient practices has the potential for delay of care and services with the potential of worsening Resident 43's condition. Findings: During a review of Resident 43's admission Record, the admission…

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

Based on observation, interview, and record review, the facility failed to ensure the staff providing care and services to the resident who has a feeding tube (are soft plastic tubes through which liquid nutrition travels through the gastrointestinal tract [the series of organs that food and liquids pass through as they are digested, absorbed, and leave the body as feces]) are aware of, competent in, and utilize facility protocols regarding feeding tube nutrition and care for one of one sampled resident (Resident 1) reviewed for tube feeding by failing to ensure Resident 1's water flush bag was labeled with the resident's name, room number, rate of infusion, and initials of the licensed nurse who hung the water flush bag. This deficient practice had the potential to result in altered nutritional status that can lead to over or under hydration, gastrointestinal (GI, relating to stomach and intestines) infection to the resident. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted the resident on 12/2/2025, 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 observation, interview, and record review, the facility failed to ensure respiratory care provided to residents was consistent with professional standards of practice for one of one sampled resident (Resident 1) reviewed for respiratory care by failing to ensure Resident 1's suction canister (a container used in medical settings to collect bodily fluids [like mucus, blood, or other secretions] that have been drawn out of a patient's body using a medical suction machine) was labeled with the date it was last changed. The deficient practice had the potential for residents to develop complications such as shortness of breath, desaturation (low levels of oxygen in the blood), and respiratory infections. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted the resident on 12/2/2025, with diagnoses including gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), dysphagia (difficulty swallowing), and pneumonitis (inflammation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 employee files contained documentation of required performance evaluation for one of two sampled Certified Nursing Assistant (CNA) 2. This failure had the potential to negatively impact on the quality and safety of resident care delivery. Findings: During an interview on 12/30/2025 at 8:39 a.m. with CNA 2, CNA 2 stated she has been working in the facility two years. During a concurrent interview and employee records review for CNA 2 on 12/30/2025 at 9:30 a.m. with Director of Staff Development (DSD), the DSD stated CNA 2's original hire date was on 11/4/2024. DSD stated that CNA 2 does not have any performance evaluation on file. The DSD stated all employee files, including CNA 2, went missing after previous DSD left employment in September 2025. The DSD stated he is responsible for completing CNAs' performance evaluations as the current DSD effective 9/3/2025. The DSD stated performance evaluations are completed annually in the month the CNA was hired. The DSD stated CNA 2's hire date under new facility…

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

Based on observation, interview, and record review, the facility failed to follow the established and alternative menu per resident preferences and facility policy and procedure (P&P) to meet resident nutritional needs by failing to provide a resident's request for a salad or cauliflower on the lunch tray on 12/29/2026 for one of three sampled residents (Resident 44) reviewed under the Food care area. This deficient practice had the potential to result in resident dissatisfaction and malnutrition. Findings: During a review of Resident 44's admission Record (AR), the AR indicated the facility admitted the resident on 11/14/2025 with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial paralysis or weakness on one side of the body), metabolic encephalopathy (a general term that describes brain disease, damage, or malfunction usually related to inflammation within the body), type two (2) diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), 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 accurately update the 2025 Facility Assessment (an evaluation of the physical environment necessary to meet the needs of the residents) for two of three sampled residents (Residents 74 and 1) to reflect care, and competency (a combination of knowledge, skills, abilities, and behaviors that enable an individual to perform a task or role successfully) of staff for gastrostomy (g-tube-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) tube medication administration. These deficient practices had the potential for the facility to not provide needs of the residents with g-tube and delay necessary care and services. Findings: During a review of Resident 74's admission Record, the admission Record indicated the facility admitted Resident 74 on 6/1/2023, and readmitted on [DATE], with diagnoses that included encounter attention to gastrostomy, acute respiratory…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain accurate clinical records in accordance with accepted professional standards and practices for two of two sampled residents (Resident 44 and 21) reviewed for Pain Management by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 4 accurately documented in the medication administration record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) the assessed numeric pain rating scale (a standard pain scale with zero being no pain and ten [10] as the worst pain one can imagine) number for the administration of (PRN) hydrocodone - acetaminophen (an opioid [also called a narcotic - powerful pain-reducing medication) when the pain level was documented as zero on 12/17/2025 at 11 a.m. for Resident 44. 2. Ensure LVN 3 accurately documented in the MAR the resident's pain level on 12/18/2025 for Resident 21. This resulted in inaccurate documentation in Resident 44 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 one of two sampled Certified Nursing Assistant (CNA) 2 completed mandatory dementia (a progressive state of decline in mental abilities) management and abuse prevention training. This deficient practice has the potential to lead into insufficient staff training, posing significant risks for the residents, including potential injury, neglect, and abuse. Findings: During a concurrent interview and record review on 12/30/2025 at 9:30 a.m. with the Director of Staff Development (DSD), CNA 2's employee file was reviewed and the DSD stated CNA 2's original hire date was 11/02/2024. During a subsequent concurrent interview and record review on 12/31/2025 at 12:24 p.m. with the DSD, in-service attendance records were reviewed. The DSD stated there was no documentation showing that CNA 2 attended any in-service training on abuse or dementia management prior to June 2025. The DSD stated since June 2025, abuse in-service trainings were provided on 7/25/2025, 9/5/2025, 9/26/2025, 11/20/2025, and 12/29/2025 with each lasting one…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Remove 16 doses of morphine sulfate (a medication used to treat pain) 15 milligrams (mg - a unit of measure for mass) and 56 doses of oxycodone/APAP (a medication used to treat pain) 5/325 mg from the medication cart after the physician's orders were discontinued affecting two of three sampled residents (Residents 1 and 3.)2. Create a Controlled Drug Administration Record (a log signed by the nurse with the date and time each time a controlled substance is given to a resident) for one of two supplies of oxycodone (a medication used to treat pain) 5 mg affecting one of three sampled residents (Resident 2.) The deficient practices of failing to maintain accountability of controlled substances (medications with a high risk for abuse) increased the risk of diversion (any use other than that intended by the prescriber) and the risk that Residents 1, 2 and 3 could have received too much or too little medication possibly resulting in serious…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two sampled residents (Resident 1) received care in accordance with professional standards of practice to attain or maintain the highest practicable physical well-being, when Registered Nurse (RN 1) failed to: 1. Conduct an assessment after Certified Nursing Assistant (CNA 1) reported that she overheard Resident 1 state he was going to hurt himself if he was not allowed to leave the facility. 2. Timely notify the doctor regarding Resident 1's change of condition involving possible self-harm. These deficient practices had the potential to result in Resident 1 receiving inadequate care.Findings: a. During a review of Resident 1's admission Record, dated 11/21/2025, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE]. The admission Record indicated Resident 1's diagnoses included hepatic encephalopathy (a brain disorder caused by advanced liver disease that prevents the liver from filtering toxins from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 c. During a review of Resident 1's Record of Admission, the Record of admission indicated the facility admitted the resident on 5/22/2014 and most recently readmitted the resident on 10/19/2023. During a review of Resident 1's Client Diagnosis Report, undated, the Client Diagnosis Report indicated diagnoses that included unspecified dementia (a progressive state of decline in mental abilities), spinal stenosis (a narrowing of the spinal canal in your lower back that may cause pain or numbness in your legs) cervical region (the neck), encounter for gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and acquired absence of unspecified parts of the digestive tract. During a review of Resident 1's H&P, dated 11/8/2023, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 1's MDS, dated [DATE], the MDS indicated the resident was usually able to…

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

Based on observation, interview, and record review, the facility failed to ensure residents who need respiratory care are provided care consistent with professional standards of practice for one of one sampled residents (Resident 26) reviewed under the respiratory care area by failing to ensure supplemental oxygen (O2) was administered per physicians orders, was documented in the Medication Record (MAR, - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), and was monitored while in use. This deficient practice had the potential to result in undetected changes in the resident's respiratory status resulting in a delay in care and services. Findings: During a review of Resident 26's Record of Admission, the Record of admission indicated the facility admitted the resident on 8/13/2024. During a review of Resident 26's Client Diagnosis Report, undated, the Client Diagnosis Report indicated diagnoses that included heart failure (HF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 not: 1. administering two (2) doses on [DATE] at 9 a.m. and 5 p.m. of metoprolol (a medication used to for hypertension [a condition in which the blood vessels have persistently raised pressure]) to one of four residents (Resident 5) observed during the Medication Administration facility task. 2. administering 24 doses of expired insulin (a medication used to regular blood sugar levels) from [DATE] to [DATE] by six different licensed nursing staff (Licensed Vocational Nurse [LVN]- 2, 3, 4, 5, 6, and Director of Nursing [DON]) to Resident 19 in one of two observed medications carts (Medication Cart 2). 3. administering two (2) doses on [DATE] at 9 a.m. and 5…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Remove and discard from use one expired insulin (medication used to regulate blood sugar levels) Lispro (fast-acting insulin) Kwikpen (type of injection device) for Resident 19, in accordance with manufacturer's requirements in one of two inspected medication carts (Medication Cart 2). 2. Remove and discard from use one open Aplisol (medication used to diagnose tuberculosis [a contagious infection in the lungs that is usually spread through the air]) vial for facility stock, in accordance with manufacturer's requirements and facility policy and procedures in one of one inspected medication rooms (Medication room [ROOM NUMBER]). These deficient practices increased the risk that Resident 19 and other residents in the facility could receive medication that had become ineffective or toxic due to improper storage or labeling, possibly leading to health complications (like diabetic ketoacidosis [a condition that develops when the body…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 established menu to meet nutritional needs by failing to follow the 10/1/2024 lunch menu when corn bread was omitted, and green beans were substituted for seasoned peas for 42 of 45 facility residents including one of one sampled residents (Resident 10) reviewed under the Food care area. This deficient practice had the potential to result in unwanted resident weight loss. Findings: During a review of Resident 10's Record of Admission, the Record of admission indicated the facility admitted the resident on 5/24/2022 and most recently readmitted the resident on 6/16/2022. During a review of Resident 10's Client Diagnosis Report, undated, the Client Diagnosis Report indicated diagnoses that included sepsis (a life-threatening blood infection), metabolic encephalopathy (a general term that describes brain disease, damage, or malfunction usually related to inflammation within the body), dysphagia (difficulty swallowing), anxiety disorder (a mental health condition that may result in restlessness,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 for 42 of 45 facility residents by failing to ensure: 1. Food items in the kitchen refrigerator, in the dry storage area, and in the resident refrigerator were labeled according to facility policy. 2. Ensure two large, plastic food storage bin lids were secured in the dry storage area. 3. Ensure an open carton of almond milk, in the kitchen refrigerator, had a cap closure and was not left open. 4. Ensure a staff member's personal cup was not located in the kitchen prep area. 5. Ensure a zucchini with a mold-appearing substance was not readily available to be served in the outside Fridge #3. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (transfer of bacteria from one object to another) in 42 of 45 medically-compromised residents who received food from the kitchen. Findings: 1.During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to 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: 1.Implement Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO, microorganisms, mainly bacteria, that are resistant to one or more classes of antibiotics] that uses targeted gown and glove use during high contact resident care activities) when Licensed Vocational Nurse 7 (LVN 7) did not don (put on) a gown while providing gastrostomy (GT, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach, common for people with swallowing problems) care for one of one sampled residents (Resident 1) reviewed under the Tube Feeding care area. 2.Ensure the facility EBP policy and procedure 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 promote the resident rights to examine the results of the most recent survey (a survey to determine compliance with state and federal regulations) of the facility by failing to: 1. Ensure three of three (Residents 20, 26, and 24) residents knew where to locate the most recent survey results. 2. Post the most recent survey results in a place that are prominent and accessible (a place where individuals wishing to examine surveys results do not have to ask staff to see them) to residents, family members, and legal representatives of residents. These deficient practices had the potential to impede the resident's rights. Findings: During an interview on 10/1/2024 at 2:50 p.m., three of three resident council group attendees (Residents 20, 26, and 24), stated they do not know where to find the state inspection results. During an observation on 10/2/2024 at 10:43 a.m., observed a survey binder posted on a wall-mounted holder by the information board. During a concurrent interview and record review on 10/2/2024 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.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 97) was provided a homelike environment by failing to: 1. Properly secure the ceiling light's screen, leaving the screen not fully clipped in place. 2. Ensure that a chain/cord is attached to the wall light to enable Resident 97 to turn the light on and off. These deficient practices had the potential to violate the resident's right to living in a safe, comfortable, and homelike environment. Findings: During a review of Resident 97's Record of Admission, the Record of admission indicated the facility admitted the resident on 9/17/2024 with diagnoses including left hand acute (sudden onset) osteomyelitis (inflammation of bone or bone marrow, usually due to infection) and cellulitis (a skin infection that causes swelling and redness) of left finger. During a review of Resident 97's History and Physical (H&P) dated 9/21/2024, the H&P, indicated the resident has the capacity to understand and make decisions. During a review of Resident 97'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 send a copy of the notification of discharge to the ombudsman (a long-term care resident advocate) for one of three sampled residents reviewed under closed record review (Resident 46). This deficient practice had the potential for Resident 46 to have an unsafe discharge. Cross-reference F625 and F641 Findings: During a review of Resident 46's Record of Admission, the Record of admission indicated the facility admitted the resident on 8/15/2024 with diagnoses including, but not limited to, encounter for orthopedic (relating to the branch of medicine dealing with the correction of deformities of bones or muscles) after care and generalized weakness and was discharged to the hospital on 8/18/2024. During a review of Resident 46's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/18/2024, the MDS indicated Resident 46 was able to understand and make decisions, was independent with eating and required supervision to maximal assistance with activities of daily living including hygiene,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 made aware of the facility's bed-hold policy upon transfer to a general acute care hospital (GACH) for one of three sampled residents (Resident 46) investigated during closed record review when the facility failed to complete and provide the seven (7) day bed hold agreement to Resident 46. This deficient practice had the potential for the resident and/or the resident's resident representatives to not know if the resident have a room to return to after going to the GACH. Cross-reference F623 and F641. Findings: During a review of Resident 46's Record of Admission, the Record of admission indicated the facility admitted the resident on 8/15/2024 with diagnoses including, but not limited to, encounter for orthopedic (relating to the branch of medicine dealing with the correction of deformities of bones or muscles) after care and generalized weakness and was discharged to the hospital on 8/18/2024. During a review of Resident 46's Minimum Data Set (MDS, a federally mandated resident assessment 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.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of five sampled residents (Resident 3) investigated under the unnecessary medication care area and one of one sampled residents (Resident 148) investigated under the urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) or Urinary Tract Infection (UTI, an infection in the bladder/urinary tract) care area when: 1. The facility failed to develop a care plan for Resident 3's use of Eliquis (also known as apixaban, an anticoagulant medication used to prevent blood clots). 2. The facility failed to implement Resident 148's care plan for the resident's urinary catheter. These deficient practices had the potential cause a delay in care. Cross-reference F757 and F880. Findings: 1. During a review of Resident 3's Record of Admission, the Record of admission indicated the facility originally admitted Resident 3 on 3/11/2015 and readmitted the resident on 5/1/2024 with diagnoses including, but not limited to, acute…

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

Based on interview and record review, the facility failed to revise one of three sampled residents investigated under the nutrition care area when Resident 34's care plan was not updated to reflect current nutritional interventions addressing the resident's risk for further weight loss. This deficient practice had the potential to result in inconsistent implementation of the care plan that may lead to a delay in or lack of delivery of care and services. Cross reference F692 Findings: During a review of Resident 34's Record of Admission, the Record of admission indicated the facility admitted the resident on 8/20/2024 with diagnoses including unilateral primary osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) and gastro-esophageal reflux disease (GERD - a common condition in which the stomach contents move up into the esophagus). During a review of Resident 34's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 8/30/2024, the MDS indicated the resident made self-understood and understood others. The MDS indicated…

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

Based on observation, interview, and record review, the facility failed to provide an environment free from accidents and hazards for one of one sampled residents (Resident 10) reviewed under the Accidents care area by failing to ensure Resident 10 did not have a bottle of Refresh eyedrops (a medication to relieve dry, burning, irritated eyes) and a bottle of clindamycin phosphate topical solution (an antibiotic, a medication that stops the growth of bacteria) readily available for self-administration and accessible by other residents while in the dining room. This deficient practice had the potential to result in resident's self-administering medications without staff knowledge potentially resulting in resident illness. Findings: During a review of Resident 10's Record of Admission, the Record of admission indicated the facility admitted the resident on 5/24/2022 and most recently readmitted the resident on 6/16/2022. During a review of Resident 10's Client Diagnosis Report, undated, the Client Diagnosis Report indicated diagnoses that included sepsis (a life-threatening 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 observation, interview, and record review, the facility failed to provide nutritional care and services consistent with resident's nutritional assessment and care plan for one of three sampled residents (Resident 34) by: 1. Failing to continue obtaining the resident's weight weekly as ordered by the physician. 2. Failing to revise the resident's care plan to address the resident's weight loss. 3. Failing to complete an SBAR (Situation, Background, Assessment, Recommendation - an assessment used to facilitate prompt and appropriate communication) form for weight loss on 8/28/2024 and 9/17/2024. 4. Failing to ensure the Interdisciplinary (IDT-group of experts from various disciplines working together to treat ailment, injury, or chronic health conditions) care plan meeting was done to address the resident's weight loss. These deficient practices had the potential to result in further risk of weight loss for Resident 34. Findings: During a review of Resident 34's Record of Admission, the Record of…

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

Based on interview and record review, the facility failed to ensure a resident's drug regimen was free from unnecessary drugs for one of five sampled residents (Resident 3) investigated under the unnecessary medication care area when the facility failed to ensure Resident 3's order for Eliquis (also known as apixaban, an anticoagulant [blood thinner] medication used to prevent blood clots) did not specify an indication (valid reason) for use. This deficient practice had the potential for Resident 3 to experience errors in treatment. Findings: During a review of Resident 3's Record of Admission, the Record of admission indicated the facility originally admitted Resident 3 on 3/11/2015 and readmitted the resident on 5/1/2024 with diagnoses including acute respiratory failure with hypoxia (a condition when the body does not have enough oxygen in the tissues in the body) and generalized muscle weakness. During a review of Resident 3's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/14/2024, the MDS indicated Resident 3 did not have the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, comfortable, and homelike environment to two of four sampled residents (Residents 1 and 2) by failing to ensure Resident 1 and 2 ' s room temperature was not above 81 degrees Fahrenheit (a unit of measure). This deficient practice had the potential to affect the comfort of residents and placed the residents at risk for dehydration. Findings: a. During a review of Resident 1 ' s admission Record, the Admidion Record indicated the facility admitted the resident on 8/9/2024 with diagnoses including aftercare following joint replacement and lack of coordination. During a review of Resident 1 ' s History and Physical (H&P), dated 8/10/2024, the H&P indicated the resident has the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/13/2024, the MDS indicated resident with intact cognitive status 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 maintain written grievance documentation and outcome of investigation/course of action taken for one of three sampled residents (Resident 1) by failing to address Resident 1 ' s grievances related to room being hot and increased noise levels at night. This deficient practice had the potential for Resident 1 ' s grievances to go unnoticed causing frustration and distress to the resident; and had the potential to result in a delay of care and services. Findings: During review of Resident 1 ' s admission Record, indicated the facility admitted the resident on 8/9/2024 with diagnoses including aftercare following joint replacement and lack of coordination. During a review of Resident 1 ' s History and Physical (H&P), dated 8/10/2024, the H&P indicated resident has the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set (MDS), a standardized assessment and care screening tool), dated 8/13/2024, the MDS indicated the resident with intact cognitive status and required partial/moderate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 obtain a physician order for oxygen therapy for one of three sampled residents (Resident 1), who was receiving oxygen therapy. This deficient practice placed the resident at risk for adverse effects due to unnecessary oxygen administration. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted the resident on 8/9/2024 with diagnoses including aftercare following joint replacement and lack of coordination. During a review of Resident 1 ' s History and Physical (H&P), dated 8/10/2024, the H&P indicated the resident has the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/13/2024, the MDS indicated the resident with intact cognitive status and required partial/moderate assistance (helper does less than half the effort) with sit to stand, lying to sitting on the edge of bed, sit to lying, and roll left and right. 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.

Based on observation, interview, and record review, the facility failed to implement its infection control policy by failing to ensure nasal cannula (oxygen [a colorless, odorless, and tasteless gas] tubing - a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) and humidifier (medical devices used to humidify supplemental oxygen) was changed and labeled with the date of change for one of four sampled residents (Resident 1). This deficient practice had placed Resident 1 at risk for infection. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 4/22/2021 with diagnoses including hemiplegia (paralysis that affects only one side of your body), sequelae (an aftereffect of a disease, condition, or injury) of cerebral infarction (occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it), and difficulty in walking. A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care-planning tool), dated 1/3/2024, indicated Resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure the resident's medical record was updated to show documentation the resident and/or their responsible party was provided with written information regarding the right to formulate an advance directive (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for one (Resident 34) of five sampled residents. 2. Ensure a current copy of the advance directive was in the resident's medical record for three (Resident 18, 199 and 200) of five sampled residents. These deficient practices violated the residents' and/or their representatives' right to be fully informed of the option to formulate advanced directives and had the potential to cause conflict with health care wishes for Resident 18, 34, 199 and 200. Findings: 1. A review of Resident 34's admission Record indicated the facility admitted the resident on 12/21/2022 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 observation, interview and record review, the facility failed to ensure the resident care plans (a document or agreement that lays out a resident's individual care needs and how these will be met) are implemented for three out of four (Resident 33, 23, and 6) by failing to: 1. Ensure Resident 33 and Resident 6's fingernails' free edges were free of dirt. 2. Ensure Resident 23 was provided with a communication board at bedside to facilitate ease of communication. These deficient practices resulted in failure to deliver the necessary care and services which had the potential to affect the resident`s sense of self-worth and self-esteem. Findings: a. A review of Resident 33's admission Record indicated the facility admitted the resident on 07/22/2021, with diagnoses including anxiety disorder (persistent and excessive worry that interferes with daily activities), cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), and hypertension (high blood pressure). A review of the Minimum Data Set (MDS - a standardized…

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

Based on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices by: 1. Failing to ensure food items not in their original containers were labeled and dated. 2. Failing to clean and disinfect a can opener after use. 3. Failing to document on the facility's dish machine temperature and sanitizing log for 10/13/2023 at lunch. 4. Failing to ensure refrigerator and freezer temperatures were documented for the months of August 2023, September 2023, and October 2023 for Refrigerator 1 (R#1), Refrigerator 2 (R#2), and Freezer 1 (FR#1). These deficient practices had the potential to place 42 out of 46 residents living in the facility at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). Findings: a. During an observation of the kitchen and a concurrent interview with the Dietary Supervisor (DS), on 10/13/2023 at 5:51 p.m., the DS stated there were eight cups of milk, seven cups of juice, and five cups of lactaid (dietary supplement) on a metal baking dish. The DS 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 interview and record review, the facility failed to follow its policy and procedure regarding antibiotic (medication to fight infection) stewardship (program to ensure that antibiotics are used only when necessary and appropriate to prevent unnecessary antibiotic use and combat antibiotic resistance [not effective to treat infection]) protocol for three of four sampled residents (Resident 12, 24 and 27) by failing to: 1. Ensure to complete the McGreer's (the criteria used by the facility to count true infections) criteria form once antibiotic was ordered. 2. Ensure the antibiotic stewardship surveillance form was easily and readily accessible. These deficient practices had the potential for residents to develop antibiotic resistance from unnecessary or inappropriate antibiotic use. Cross reference F842 Findings: A review of Resident 12's admission record indicated that facility admitted resident on 1/18/2018, with diagnoses including dysphagia (difficulty swallowing), atrial fibrillation (irregular…

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

Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhance a resident's dignity and respect by failing to ensure Certified Nurse Assistant 3 (CNA 3) knocked and asked permission from the resident before entering the room for one (Resident 6) of one sampled resident reviewed for dignity. This deficient practice had the potential to affect the resident`s sense of self-worth and self-esteem. Findings: A review of Resident 6's admission Record indicated the facility admitted the resident on 05/02/2023, with diagnoses including muscle weakness, cerebral infarction (disrupted blood flow to the brain), and metabolic encephalopathy (a general term that describes brain disease, damage, or malfunction usually related to inflammation [the body's natural reaction against injury and infection] within the body). A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 08/03/2023, indicated Resident 6 had the ability to make self-understood and had the ability to understand others. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a medication was not left with a resident who was not capable of self-administering eye medication for one of three sampled residents (Resident 18). This deficient practice placed the resident at risk for unsafe medication administration and or receiving unnecessary medications. Findings: A review of Resident 18's admission Record indicated the facility admitted the resident on 8/12/2023 with diagnoses including COVID 19 (a severe respiratory infection), congestive heart failure (heart does not pump blood as well as it should) and atrial fibrillation (irregular heart rate). A review of Resident 18's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 8/24/2023, indicated resident's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. A review of Resident 18's self-administration of medication assessment dated [DATE],…

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

Based on interview and record review, the facility failed to notify the resident's physician (MD 1) and their representative (RP 1) when the resident had a significant weight loss of 11% within six months for one (Resident 34) of three residents reviewed under the nutrition care area. On 03/03/2023, Resident 34 weighed 126 pounds (lbs.) On 09/28/2023, the resident weighed 112 pounds which is a -11.11 % weight loss. This deficient practice violated the resident's rights and/or representative's right to be fully informed of Resident 34's weight loss and had the potential for delay in care to address the resident's weight loss. Findings: A review of Resident 34's admission Record indicated the facility admitted the resident on 12/21/2022 with diagnoses including Parkinson's disease (a disorder of the central nervous system that affects movement), muscle weakness and hearing loss. A review of Resident 34's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 9/28/2023, indicated the resident had severely impaired cognition (the mental action or process of…

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

Based on observation, interview, and record review, the facility failed to ensure one (Resident 28) of three sampled residents was provided a homelike environment when Resident 28's low air loss (LAL-specialty mattress) was secured to the foot of the bed with duct tape. This deficient practice had the potential to violate residents' right to living in a safe, comfortable, and homelike environment. Findings: A review of the Resident 28's Record of admission indicated the facility readmitted the resident on 7/14/2023 with diagnoses including sepsis (a life-threatening complication of an infection), pneumonitis (inflammation of lung tissue), muscle weakness, and dysphagia (difficulty swallowing). A review of Resident 28's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 7/19/2023 indicated the resident had clear speech, usually makes self-understood, and usually understand others. The MDS indicated Resident 28 required extensive assistance with bed mobility, dressing, and personal hygiene. The MDS also indicated Resident 28 was totally dependent 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 complete the Minimum Data Set (MDS- an assessment and care screening tool) within 14 days of the Assessment Reference Date (ARD) for two (Resident 10 and 31) of two sampled residents. This deficient practice had the potential to negatively affect the residents' plan of care and the delivery of necessary care and services. Findings: a. A review of Resident 10's Face Sheet (Record of Admission) indicated that the facility admitted the resident on 05/09/2023, with diagnoses including muscle weakness and fracture of shaft (break of the thigh bone between the hip and the knee). A review of Resident 10's MDS dated [DATE], indicated the resident had the ability to make self-understood and the ability to understand others. During a concurrent interview and record review on 10/15/2023 at 01:35 p.m., reviewed Resident 10's Discharge MDS dated [DATE] (type of MDS) with the MDS Nurse Coordinator (MDS NC). The MDS NC stated that the resident's MDS had an 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 update and or revise a resident's comprehensive care plan for two (Resident 28 and Resident 34) of three sampled residents by: 1. Failing to update Resident 28's care plan related to dementia (A group of thinking and social symptoms that interferes with daily functioning) 2. Failing to update and revise Resident 34's care plan with specific interventions after the resident had a significant weight loss. These deficient practices had the potential to result in inconsistent implementation of the care plan that may lead to a delay in or lack of delivery of care and services. Findings: a. A review of the Resident 28's Record of admission indicated the facility readmitted the resident on 7/14/2023 with diagnosis including sepsis (a life-threatening complication of an infection), pneumonitis (inflammation of lung tissue), muscle weakness, and dysphagia (difficulty swallowing). A review of Resident 28's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 7/19/2023 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 ensure residents were provided a communication device to allow communication between staff and residents for two of two (Resident 23 and Resident 30) sampled residents. This deficient practice had the potential to delay Resident 23 and Resident 30's delivery of care and services due the residents not being able to communicate their needs. Findings: a. A review of Resident 23's admission Record indicated the facility admitted the resident on 09/01/2023, with diagnoses including muscle weakness and intertrochanteric fracture (a type of hip fracture or broken hip). A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 09/13/2023, indicated Resident 23`s preferred language was not English and needed an interpreter to communicate with a doctor or health care staff. The MDS indicated Resident 23 had the ability to make self-understood and had the ability to understand others. The MDS indicated Resident…

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

Based on observation, interview and record review, the facility failed to provide nutritional and care and services for one of three sampled residents (Resident 34), consistent with resident's nutritional assessment and care plan by: 1. Failing to obtain the resident's the resident's weight weekly as ordered by the physician. 2. Failing to revise the resident's care plan to address the resident's weight loss. 3. Failing to ensure an accurate nutrition screening was done on 9/28/2023. 4. Failing to complete an SBAR (situation, background, assessment, recommendation; a technique that can be used to facilitate prompt and appropriate communication) form for weight loss on 7/7/2023 and 10/5/2023. 5. Failing to ensure the Interdisciplinary (IDT-group of experts from various disciplines working together to treat ailment, injury, or chronic health conditions) Care meeting was done on 10/7/2023 to address the resident's weight loss. Findings: A review of Resident 34's admission Record indicated the facility admitted the resident on 12/21/2022 with diagnoses including Parkinson's disease (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: 1. Ensure the Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Records (MAR) for one of three sampled residents (Resident 45). This deficient practice had the potential to result in medication error and/or drug diversion. 2. Ensure the Xarelto (can treat and prevent blood clots) 20 milligrams (mg - unit of measurement) was available during the medication administration observation on 10/04/2023 for one of seven sampled residents (Resident 200). This deficient practice had the potential to result in unintended complications related to the management of atrial fibrillation (an irregular and often very rapid heart rhythm) such as increased risk of stroke and death. Cross reference to F760 Findings: a. A review of Resident 45's admission Record (face sheet) indicated the facility admitted the resident on 9/20/2023 with diagnoses including cellulitis (skin infection) of the right lower leg and…

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

Based on observation, interview, and record review, the facility failed to ensure the resident is free from significant medication error by failing to administer Xarelto (can treat and prevent blood clots) during the medication administration observation on 10/14/2023 for one of seven sampled residents (Resident 200). Xarelto was not delivered timely resulting in Resident 200 missing the dose. This deficient practice had the potential to result in unintended complications related to the management of atrial fibrillation (an irregular and often very rapid heart rhythm) such as increased risk of stroke (occurs when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or bursts) and death. Cross reference to F755 Findings: A review of Resident 200`s Record of admission (face sheet) indicated the facility admitted the resident on 01/06/2022 and readmitted the resident on 10/06/2023, with diagnoses that included muscle weakness, congestive heart failure ( a serious condition in which the heart doesn't pump blood as efficiently as it should) and acute…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 laboratory results were communicated with the medical doctor (MD) timely for one of three sampled residents (Resident 30). This deficient practice had the potential to delay necessary care and services for Resident 30. Findings: A review of Resident 30's Record of admission indicated the facility admitted the resident on 9/11/20203 and readmitted the resident on 9/19/2023 with diagnoses that included sequelae of cerebral infarction (obstruction in blood flow to the brain can lead to permanent damage) and urinary tract infection (an infection in any part of the urinary system [the purpose of the urinary system is to eliminate waste from the body]). A review of Resident 30's Minimum Data Set (MDS-a standardized assessment and screening tool) dated 9/29/2023, indicated the resident's cognition (mental action or process of acquiring knowledge and understanding) was severely impaired. The resident had unclear speech (slurred or mumbled words), sometimes makes self-understood (ability is limited to making concrete…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 left over food brought from outside was stored in the refrigerator or discarded for one of one sampled resident (Resident 99). The same left-over food observed on 10/13/2023 at 7:25 p.m. was observed again on 10/14/2023 at 9:30 a.m. This deficient practice had the potential to result in foodborne illness (also called food poisoning, illness caused by eating contaminated food) for Resident 99. Findings: A review of Resident 99`s Record of admission indicated the facility admitted the resident on 10/09/2022 with diagnoses that included muscle weakness, urinary tract infection (an infection in any part of the urinary system, the kidneys, bladder, or urethra), and acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood). A review of Resident 99's History and Physical (H&P- a term used to describe a physician's examination of a patient obtained by doing a thorough medical history from the patient, performing a physical examination, and documenting findings), 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 interview and record review, the facility failed to ensure three of four sampled (Resident 12, 24, and 27) residents' medical records were readily accessible. This deficient practice had the potential to result in confusion among interdisciplinary team IDT-a group of experts from various disciplines working together to treat a resident's ailment, injury or chronic health condition) regarding the residents' condition and what care and services were provided to the residents. Cross reference F881. Findings: A review of Resident 12's admission record indicated that facility admitted resident on 1/18/2018, with diagnoses including dysphagia (difficulty swallowing), atrial fibrillation (irregular heart rate) and depression (mental health disorder characterized by persistently depressed mood or loss of interest in activities causing significant impairment in daily life). A review of Resident 12's Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 9/1/2023, 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 observe infection control measures for one of three sampled residents (Resident 200) by failing to ensure oxygen nasal cannula tubing (device used to deliver supplemental oxygen placed directly on a resident's nostrils) was not touching the floor. This deficient practice had the potential to result in contamination of Resident 200's care equipment and risk of transmission of bacteria that can lead to infection. Findings: A review of Resident 200 admission Record indicated the facility admitted the resident on 10/6/2023 with diagnoses including heart failure (heart does not pump blood as well as it should), acute respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in the body), and atrial fibrillation (irregular heart rate). A review of Resident 200's history and physical, dated 10/7/2023, indicated resident had the capacity to understand and make decisions. A review of Resident 200's physician orders, dated 10/6/2023, indicated resident had an order for continuous…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a Registered Nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week on the following dates: 6/3/2023, 6/4/2023, 6/11/2023, 6/17/2023, and 6/25/2023. This deficient practice had the potential for residents to not be provided with the adequate nursing services that only a RN could perform. Findings: A review of the facility ' s RN and Licensed Vocational Nurse (LVN) monthly schedule, dated June 2023, indicated that the facility did not have RN coverage for at least 8 hours a day on 6/3/2023, 6/4/2023, 6/11/2023, 6/17/2023, and 6/25/2023. A review of the facility ' s Nursing Staffing Assignment and Sign-In Sheet, dated 6/1/2023 to 6/30/2023, indicated that there were no RNs signed-in on 6/11/2023, 6/17/2023, 6/20/2023, and 6/25/2023. The sign-in sheet indicated that RN 1 ' s shift started at 11:45 a.m. and ended at 4:05 p.m. on 6/3/2023. The sign-in sheet indicated that RN 1 ' s shift started at 2 p.m. and there was no end of shift time indicated on 6/4/2023. There were no sign-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 ensure the facility assessment (an examination of the resident population to determine the resources necessary to care for its residents competently during day-to-day operations and emergencies) included the number of qualified facility staff to meet the residents ' needs. This deficient practice had the potential to place residents at risk for functional, physical, mental, and psychosocial needs to not be met. Findings: A review of the facility ' s Facility Assessment, dated 10/2022, did not indicate the overall staff needed to meet the residents ' needs. On 8/21/2023 at 3:28 p.m., during a concurrent interview and record review, the Facility Assessment were reviewed with the Administrator (ADM), and he stated that the facility assessment did not include the facility staffing information needed to provide care to the residents. The facility-provided document titled, Facility Assessment: From Start to Finish were reviewed with the ADM, indicated the regulation requirement for creating a facility assessment which included…

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