Panorama Gardens Nursing And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a document that summarizes a resident's needs, goals, and care/treatment) for four of 28 sampled residents (Resident 13, 38, 86, and 154) by failing to: 1. Develop interventions for Resident 13 to prevent further range of motion ([ROM] full movement potential of a joint) limitations upon admission on [DATE], develop interventions upon identification of severe ROM limitation (0-25 percent [%] range intact) in the left hand on 6/2/2025, and include the provision of the Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) program in Resident 13's care plan. These failures resulted in Resident 13's left-hand contracture (a stiffening/shortening at any joint that reduces the joint's range of motion) in a closed fist position. 2. Develop and implement care plan interventions for Resident 38's Sign-In Sheet 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.

Based on interview and record review, the facility failed to update a resident`s care plan to include pain interventions for one of two sampled residents (Resident 69) reviewed under the pressure ulcer care area after Resident 69 developed Stage Two (2) (an open, shallow wound that has damaged the epidermis [top layer of the skin] and the dermis [middle layer of the skin], with the fluid-filled blister appearing as a ruptured or intact blister containing fluid) fluid-filled blister (a painful skin condition where fluid fills a space between layers of skin) on the left heel. This deficient practice had the potential to result in inadequate management of Resident 69's pain resulting in decreased quality of life. Findings: During a review of Resident 69's admission Record, the admission Record indicated the facility initially admitted Resident 69 on 1/15/2025 and re-admitted Resident 69 on 6/26/2025 with diagnoses including type two (2) diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), hemiplegia (paralysis [inability to move]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice by failing to: a. Implement the listed care plan intervention to raise the head of one of the sampled resident's (Resident 5) bed, while in bed, during 2 random observations. This deficient practice had the potential to result in Resident 5 having shortness of breath (difficulty breathing) and complications of congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently sometimes resulting in leg swelling).b. Follow the physician's order to notify the physician when the accucheck (blood sugar result) result was greater than (>) 200 milligrams per deciliter (mg/dL, a unit of measure for blood sugars) for one of three residents reviewed under the care area of insulin.This deficient practice had the potential to result in Resident 10 being at risk of suffering from hyperglycemia (high blood sugar…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 28 sampled residents (Resident 63) investigated for frequency of visits, was evaluated by a physician at the required intervals by failing to:1. Ensure Resident 63 was seen by the physician at least once every 60 days between the dates of 11/15/2024 and 3/01/2025. 2. Ensure Resident 63 was seen by the physician within the first 30 days after readmission, and then at 30-day intervals up until 90 days after readmission from a general acute care hospital (or simply hospital) on 4/25/2025.This had the potential for Resident 63's physician to miss addressing the beginning of Resident 63's elevated blood sugars.Findings:During a review of Resident 63's admission Record (or Face Sheet, the front page of the chart that contains a summary of basic information about the resident) the admission Record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including diabetes mellitus (DM, a disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to establish and implement policies with clear guidance in treating a resident with elevated blood sugar levels in the months of 7/2025 and 8/2025 for one (Resident 63) of 28 sample residents. Additionally, although attempts were made to contact Resident 63's primary care physician since 8/07/2025, the licensed nurses did not speak to the doctor by phone until 8/25/2025 after the survey team inquired regarding Resident 63's elevated blood sugars for the month of 8/2025.This had the potential for Resident 63 to suffer from complications related to hyperglycemia. Findings:During a review of Resident 63's admission Record, the admission record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) and stroke. During a review of Resident 63's Minimum Data Set (MDS, a standardized assessment…

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

Based on interviews and record review, the facility failed to ensure there was evidence to support the initiation of a psychotropic (drug that affects brain activities associated with mental processes and behavior, which includes but not limited to medications used to treat anxiety [a feeling of fear, dread, and uneasiness that is more intense and persistent than normal and can interfere with daily life]) for one of five sampled residents reviewed under the unnecessary medication, chemical restraints/psychotropic medications care area (Resident 12). This failure had the potential of unnecessary chemical restraint. Findings: During a review of Resident 12's admission Record, the record indicated the facility originally admitted Resident 12 to the facility on 4/14/2025 with diagnoses including psychosis (a state where a person experiences a loss of contact with reality) and post-traumatic stress disorder (PTSD, a mental health condition that can develop after experiencing or witnessing a traumatic event). During a review of Resident 12's Minimum Data Set (MDS- a federally mandated…

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

Based on observation, interview, and record review, the facility failed to ensure a resident who required assistance with nail trimming was provided care and services to maintain good personal hygiene for one of four sampled residents (Resident 11). This deficient practice had the potential to result in a negative impact on the resident`s self- esteem due to an unkempt appearance. Findings: During a review of Resident 11's admission Record, the admission Record indicated the facility originally admitted the resident on 12/17/2012 and readmitted the resident on 5/16/2024 with diagnoses that included but not limited to, hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]) and type two (2) diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]). During a review of Resident 11's Minimum Data Set (MDS - a resident assessment tool) dated 7/01/2025, the MDS indicated that the resident`s cognitive (the mental action or process of acquiring knowledge and understanding through thought,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accident hazards for two of seven residents (Resident 9 and 40) investigated under the Accidents care area by failing to:1. Ensure bedside rails were not used for a resident (Resident 9) that does not require such use to prevent risk of limb entrapment which could lead to injury.2. Ensure Resident 40's bedside rails were fully covered by padding per the physician's orders.These deficient practices had the potential to place Residents 9 and 40 at an increased risk of injury and harm. Findings: 1. During review of Resident 9's admission Record, the admission Record indicated the facility originally admitted the resident on 5/09/2025 and readmitted the resident on 7/19/2025, with diagnoses including unspecified dementia (a condition where a person experiences cognitive [the mental processes involved in gaining knowledge and comprehension] decline that cannot be definitively diagnosed as a specific type of dementia) and gastroesophageal reflux disease (a condition in which stomach…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 trauma-informed care (an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma) to one of two residents (Resident 12) investigated under the Behavioral-Emotional care area when the resident's triggers (a psychological stimulus that prompts recall of a previous traumatic event, even if the stimulus itself is not traumatic or frightening) for his diagnosed Post-Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) were not adequately assessed and the resident's care plan (a document that outlines a patient's healthcare needs, goals, and the interventions and treatments planned to achieve those goals, serving as a roadmap for their care and facilitating communication among the healthcare team) did not include person-centered specific interventions to address the resident's PTSD.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess a resident for risk of entrapment (when a resident is trapped in the spaces in between or around the bed rails [adjustable metal or rigid plastic bars that attach to the bed that are available in a variety of types, shapes, and sizes], mattress, or bed frame), obtain an informed consent and a physician order for the use of bedside rails for one of two of residents (Resident 9).This deficient practice had the potential to place the resident at risk of accidents such as a body part being caught between the rails which could lead to injury.Cross reference with F689.Findings:During a review of Resident 9's admission Record, the admission Record indicated the facility originally admitted the resident on 5/09/2025 and readmitted on [DATE], with diagnoses including unspecified dementia (a condition where a person experiences cognitive [the mental processes involved in gaining knowledge and comprehension] decline that cannot be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (1) of two sampled residents (Resident 52) observed received their medication on time when Resident 52 received Zenpep (a prescription medication used to treat exocrine [releasing substances through a duct to the outside of the body or into an organ] pancreatic insufficiency (EPI), a condition in which the pancreas does not produce enough enzymes to properly digest food. When taken with a meal or snack, it helps break down food and helps the body to properly absorb nutrients from food, which can relieve symptoms such as fatty stools, gas, and bloating) more than 2 hours after the scheduled time as prescribed to be taken with meals. This failure had the potential to worsen resident's health condition. Findings: During a review of Resident 52's admission Record, the record indicated Resident 52 was re-admitted on [DATE] with diagnoses including but not limited to: adrenocortical insufficiency (a condition where the adrenal glands…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately document in the medical record for one of 28 sampled resident (Resident 69) for the provision for Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) services on 8/26/2025. This failure resulted in inaccurate medical records for the provision of Resident 69's RNA services for sit-to-stand transfers. Findings: During a review of Resident 69's admission Record, the admission Record indicated the facility admitted Resident 69 on 6/26/2025 with diagnoses including Type 2 diabetes mellitus ([DM] disorder characterized by difficulty in blood sugar control and poor wound healing), unspecified fall, abnormalities of gait (manner of walking) and mobility, and hemiparesis (weakness of the arm, leg, and trunk on the same side of the body) following cerebral infarction (brain damage due to a loss of oxygen to the area) affecting the right dominant side. During a review of…

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

Based on interview and record review, the facility failed to ensure the interdisciplinary team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of the residents' care plan) was involved in determining whether the self-administrations was clinically appropriate for one of four sampled residents (Resident 1) who was not assessed for self-administration for the use of Imodium (used to control and relieve diarrhea) oral tablets and probiotic (a pill containing live good bacteria that can help promote a healthy balance of bacteria in the body) oral tablets that were stored at the resident's bedside.This deficient practice had the potential to result in Resident 1 unsafely administering medications and unsafely access medications stored at bedside.During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 5/24/2025 with diagnoses including right foot fracture (broken bone), age-related cognitive (the 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 interview and record review, the facility failed to develop a comprehensive person-centered care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) for one of four sampled residents (Resident 1) addressing Resident 1's self-administration of Imodium (used to control and relieve diarrhea) oral tablets and probiotic (a pill containing live good bacteria that can help promote a healthy balance of bacteria in the body) oral tablets that were stored at the resident's bedside.This deficient practice had the potential to negatively affect the delivery of care and services.During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 5/24/2025 with diagnoses including right foot fracture (broken bone), age-related cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses) decline, and constipation (problem with passing stool).During a review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 treated with dignity and respect by not confirming if Resident 1 wanted to have a shower completed on 1/29/2025. This deficient practice had the potential to affect Resident 1's sense of self-worth and self-esteem. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 12/22/2024 with diagnoses including bipolar disorder (mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (intense, excessive, and persistent worry and fear about everyday situation), and need for assistance with personal care. During a review of Resident 1's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of 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 follow its own policy and procedure (P&P) titled Change of Condition Reporting dated March 2024, by not reporting to the physician that the nursing staff did not obtain urine for a urinalysis (UA- test that checks your urine for signs of health issues like infections, kidney problems, and liver disease) ordered on 9/21/2024 for one of three sampled residents (Resident 1). This deficient had the potential for Resident 1 not being provided treatment based on the results of the UA, which could lead to a worsening infection, decreased quality of life and possibly death. Findings: During a review of Resident 1's admission Record dated indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), sepsis (a life-threatening condition that occurs when the body's response to an infection injures its own tissues 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 resident's responsible party (RP) 1 was informed about dental treatment recommendations for one of two sampled residents (Resident 85). This deficient practice violated the resident's and RP 1's right to make an informed decision regarding dental treatment. Findings: A review of Resident 85's admission Record indicated the facility admitted the resident on 4/17/2020 with diagnoses including Type II diabetes mellitus (a disease in which your body does not produce enough insulin needed to control sugar levels in the blood), need for assistance with personal care, difficulty walking, major depressive disorder (causes severe symptoms that affect how you feel, think, and handle daily activities, such as sleeping, eating, or working), and schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves). The admission Record indicated RP 1 was the responsible party for Resident 85. A review of Resident 85's History and Physical (H&P) dated 5/17/2023 indicated the resident did…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 call light device was within reach for one of two sampled residents (Resident 87). This deficient practice resulted in Resident 87 being unable to call a health care worker for help as needed. Findings: A review of Resident 87's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including, Type II diabetes mellitus (a disease in which your body does not produce enough insulin needed to control sugar levels in the blood), need for assistance with personal care, and contracture unspecified joint (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness). A review of Resident 87's Minimum Data Set (MDS - a standardized resident assessment and care screening tool) dated 8/7/2024, indicated the resident had moderate cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to review and update the care plan after a change of condition (an improvement or worsening of a patient's condition which was not anticipated) for one of three sampled residents (Resident 71 ). This deficient practice had the potential to result in Resident 71 receiving inadequate care and supervision at the facility. Findings: A review of Resident 71's admission Record (Face Sheet) indicated the resident was admitted to the facility on [DATE], with diagnoses including diabetes mellitus Type II (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and end stage renal disease (when the kidneys permanently fail to work). A review of Resident 71's Care Plan revised on 11/27/2023, indicated the resident had risk for episodes of hyperglycemia and hypoglycemia (when the blood sugar level is lower than normal) related to diabetes. The care plan goal for the resident was to be free from sign and symptoms of…

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

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 communication devices in the language that the residents were able to understand for two of two sampled residents (Resident 105 and Resident 107). These deficient practices prevented the residents from being able to communicate with the staff and had a potential to delay receiving appropriate care and treatment the residents needed. Findings: A review of Resident 105's admission Record (Face Sheet) indicated the facility originally admitted Resident 105 on 12/27/2021, and readmitted on [DATE], with diagnoses including unspecified dementia (loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that the loss interferes with a person's daily life and activities), and adult failure to thrive (a decline in older adults that manifests as a downward spiral of health and ability). A review of Resident 105's Minimum Data Set (MDS- standardized assessment and care planning 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately assess one of three sampled residents (Resident 144) with an indwelling catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) upon admission and readmission to the facility. This deficient practice had the potential to lead to the inadequate care of Resident 144. Findings: A review of Resident 144's admission Record (Face Sheet) indicated the facility originally admitted the resident on 8/5/2024, and readmitted on [DATE], with diagnoses including calculus (stone) in bladder (organ in the lower part of the abdomen that stores urine before it leaves the body), and obstructive and reflux uropathy (when the urine instead of flowing from your kidneys to your bladder, flows backward, or refluxes, into your kidneys because of an obstruction). A review of Resident 144's Licensed Nurse-Initial admission Record dated 8/5/2024, indicated the resident did not have urinary retention 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 ensure the Social Services department completed their admission assessment for two of two sampled residents (Resident 29 and Resident 301). This deficient practice had the potential for delay in the delivery of care and services. Findings: a. A review of the admission record for Resident 301, it indicated the was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a problem in the brain), COVID-19 (acute disease caused by a coronavirus), pneumonia (lung inflammation cause by a bacterial or viral infection), need for assistance with personal care, difficulty in walking, dysphagia (difficulty swallowing), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 8/19/2024 indicated Resident 301 had moderate cognitive impairment, had minimal difficulty hearing in…

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

Based on observation, interview, and record review, the facility failed to ensure staffing information of the actual hours worked by licensed and unlicensed nursing staffing directly responsible for resident care per shift was posted daily on 8/23/2024. This deficient practice had the potential to keep residents and visitors unaware of the total number of staff and the actual hours worked by the staff in the facility. Findings: During an observation on 8/23/2024 at 9:05 a.m., observed posted in nurses' station 2 and subsequently at nurses' station 3, an untitled facility document indicating the facility's name dated 8/23/2024. The document posted indicated the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: 1. Night Shift (11:00 p.m. to 7:00 a.m.) a. Registered Nurses (RNs) - one RN, eight (8), scheduled total hours of work, b. Licensed Vocational Nurses (LVNs) - three LVNs, 24 scheduled total hours of work c. Certified Nursing Assistants (CNAs) - nine CNAs, 72 scheduled total hours of work 2. Morning (AM) Shift (7:00…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to administer medications within one (1) hour of the due scheduled time (either one hour before or one hour after) for one of three sampled residents (Resident 1). This deficient practice had the potential to result in ineffective management of Resident 1 ' s neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet) and anxiety (intense, excessive, and persistent worry and fear about everyday situations). Findings: A review of Resident 1 ' s admission record indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses that include osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time), major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), anxiety and type 2 diabetes (a condition that happens because of a problem in the way the body regulates and uses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 notify a resident ' s responsible party (RP) of a room change for one of three sampled residents (Resident 2). This deficient practice violated the resident ' s and resident ' s RP ' s right to be informed in advance of a room change. Findings: A review of Resident 2's admission Record indicated the facility admitted Resident 2 on 2/23/2024 with metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), dysphagia (difficulty swallowing), and cognitive communication deficit (difficulty with thinking and how someone uses language). The admission Record listed Resident 1 ' s RP as Family Member 1 (FM1 ). A review of Resident 2 ' s history and physical dated 2/25/2024 indicated Resident 2 did not have the capacity to make their own decisions. A review of Resident 2's Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 2/27/2024,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care and services to maintain good grooming and personal hygiene for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 having long, untrimmed toenails that had the potential to result in a negative impact on the resident`s self-esteem and self-worth. Findings: A review of Resident 1's admission Record indicated the resident was readmitted on [DATE] with diagnoses that included unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and type 2 diabetes mellitus (a disease that occurs when blood glucose [blood sugar] is too high). A review of Resident 1's History and Physical Examination dated 9/27/2023 indicted Resident 1 has the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 12/22/2023 indicated Resident 1's cognition (the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care and services to maintain good grooming and personal hygiene for two of three sampled residents (Resident 1 and Resident 2). This deficient practice resulted in Resident 1 and Resident 2 having long, untrimmed toenails with sharp edges that had the potential to result in a negative impact on the resident`s self-esteem and self-worth. Findings: a. A review of Resident 1's admission Record indicated the facility readmitted Resident 1 on 1/23/2019 with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), idiopathic progressive neuropathy (refers to damage of the peripheral nerves where cause cannot be determined), and osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time). A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 1/16/2024, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident ' s rights to a dignified existence and self-determination was met for one of four sampled residents (Resident 1) when the Certified Nursing Assistant 1 (CNA 1) checked the inside of Resident 1 ' s incontinence (loss of bladder control) briefs while the resident was asleep. This deficient practice resulted in Resident 1 ' s rights being violated when the resident was not provided the opportunity to make the decision as to whether or not have her incontinence briefs checked. Findings: A review of Resident 1 ' s admission Record, indicated the resident was originally admitted to the facility on [DATE] with a readmission date of 7/23/2023; with a diagnosis of metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood). A review of Resident 1 ' s Minimum Data Set (MDS- a standardized assessment and screening tool), dated 8/8/2023, indicated the resident had the ability to usually understand others and 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.

Based on interview and record review, the facility failed to develop a person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) for one of five sampled residents (Resident 1), who was diagnosed with chronic renal failure (CRF - a condition involving a decrease in the kidneys' ability to filter waste and fluid from the blood). This deficient practice had the potential to result in a delay in or lack of delivery of care and services. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 6/2/2023 with diagnoses including kidney disease (involves a gradual loss of kidney function) . A review of Resident 1 ' s Initial History and Physical (H&P) dated 6/14/2023 indicated, CRF was included in Resident 1 ' s history. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and screening tool) dated 6/7/2023, indicated the resident usually understood others and was usually understood by others. The MDS further indicated Resident 1 required extensive assistance for activities 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 interview and record review, the facility failed to ensure one of five residents (Resident 1) was provided with a discharge summary that included a diagnosis of chronic renal failure (CRF - a condition in which the kidneys are damaged and cannot filter blood as well as they should). This deficient practice had the potential to result in unsafe discharge, incomplete documentation and communication of Resident 1 ' s stay in the facility. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 6/2/2023 with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning), anxiety disorder (persistent and excessive worry that interferes with daily activities), and kidney failure (a condition in which the kidneys lose the ability to remove waste and balance fluids). A review of Resident 1 ' s Initial History and Physical (H&P) dated 6/14/2023 indicated, CRF was included in Resident 1 ' s history. A review of 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 ensure 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 documented and communicated to staff responsible for care, for six of 10 sampled residents (Resident 132, 43, 94, 77, 45, and 44). 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. A review of the admission Record indicated Resident 94 was admitted to the facility on [DATE] with a readmission date of 2/24/2021 with diagnoses that included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), chronic obstructive pulmonary disease (progressive lung disease), and hypertension (high blood pressure). A review of the 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: 1. Failed to consistently monitor laboratory values tied to the use of Retacrit (a medication used to increase the number of red blood cells) between 6/24/2021 and 7/19/2021 in one of five sampled residents (Residents 121). This deficient practice increased the risk that Resident 121 did not receive Retacrit per the physician's orders which could have led to health complications possibly resulting in hospitalization or death. 2. Failed to ensure Resident 8 was monitored for the side effects of Norco (Acetaminophen and Hydrocodone -an opioid combination medicine used to relieve moderate to severe pain) 10-325 mg (milligrams-unit of measurement), for one of one resident (Resident 8) investigated under the care area. This deficient practice had the potential for Resident 8 to have harmful side effects such as constipation and drug overdose. Findings: a. A review of the admission Record indicated Resident 121 was admitted to the facility on [DATE] and…

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

Based on observation, interview, and record review, the facility failed to ensure safe handling of medications and maintain a safe and secure storage of all medications for six of six residents (Residents 23, 57, 43, 61, 34, and 20), by: 1. Failing to ensure unopened insulin (hormone made by the pancreas that helps blood glucose to enter cells in the muscle, fat, and liver, where it is used for energy) medications for Residents 23, 57, and 43 were stored in the refrigerator, and when placed in room temperature have observed a storage period of 28 days per facility's policy. 2. Failing to ensure expired medications were removed immediately from the Medication Cart Nursing Station 2 for Residents 61, 34, and 20. These deficient practices placed the residents at risk of receiving expired and ineffective medications. Findings: During a concurrent interview and observation of the Medication Cart Nursing Station 1 with Licensed Vocational Nurse 1 (LVN 1) on 07/27/2021 at 2:12 p.m., LVN 1 confirmed the following medications: 1. Resident 23's Novolin insulin flexpen R 100, filled 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to draw a complete blood count (CBC, a laboratory blood test) every Wednesday per the physician's orders between 7/2/2021 and 7/19/2021 for one of five sampled residents (Resident 121). This deficient practice had the potential to negatively affect Resident 121's safety and well-being. Cross-reference with F757 Findings: A review of the admission Record indicated Resident 121 was admitted to the facility on [DATE] and was re-admitted on [DATE], with diagnoses that included anemia (low red blood cells) and hepatic failure (liver failure). A review of Resident 121's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 6/26/2021, indicated Resident 121 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact in daily decision making skills and needed one-person limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs 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 implement infection control policy and procedure by failing to: 1. Ensure that Licensed Vocational Nurse 6 (LVN 6) performed hand hygiene immediately upon leaving Resident 56's room and before using the computer in the medication cart and failing to perform hand hygiene again after using the computer and reentering Resident 56's room to proceed with setting up the tube feeding for one of one sampled resident (Resident 56). 2. Ensure staff were screened completely for signs and symptoms of Coronavirus-19 (COVID-19, an illness caused by a virus that can spread from person to person) prior to the start of their shift for two of 186 staff members as evidenced by three incomplete entries in the employee screening log on 7/26/2021, 7/27/2021, and 7/28/2021. 3. Ensure the Certified Nursing Assistant 2 (CNA 2) performed hand hygiene before moving from a contaminated body site to a clean body site during perineal care for one of one resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement the baseline care plan for one of one sampled resident (Resident 124) who had a baseline care plan that identified resident-specific interventions in regards to resident's bowel and bladder incontinence care. This deficient practice had the potential for Resident 124's wound to her coccyx (tail bone) area to worsen when facility staff was unable to provide a thorough perineal care. Findings: A review of Resident 124's admission Record indicated the resident was admitted on [DATE] with diagnoses included sepsis (an inflammation throughout the body due to bloodstream infection), urinary tract infection (UTI-infection that affects part of the urinary tract [kidneys, ureters, urinary bladder and the urethra]), hemiplegia (total or partial paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper pressure ulcer preventative measures were in place by not following the manufacturer's instructions for an alternating pressure mattress (alternating pressure therapy uses pressure redistribution to stimulate blood flow, blood nourishes the skin in which air cells on the mattress slowly inflate and deflate under the patient at a predetermined or adjustable cycle time. This allows time for blood flow to reach the skin healing and skin breakdown or bedsores) for one (Resident 78) of three residents investigated for pressure ulcers. This deficient practice placed the resident at risk for discomfort, development of pressure injuries, and delayed wound healing. Findings: A review of the admission Record indicated Resident 78 was admitted to the facility on [DATE] and was re-admitted on [DATE], with diagnoses that included diabetes mellitus (high blood sugar) and sacral region (a triangular bone in the lower back formed from fused…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pad alarm (sensor that alerted caregivers when a resident was getting up from bed or chair) was placed on the wheelchair per physician order, for one of one sampled residents (Resident 127). This deficient practice placed Resident 127 at risk for falls and serious injuries that included possible fractures (break in the bones) and bleeding. Findings: A review of the admission Record indicated Resident 127 was admitted to the facility, on 9/12/2018 and readmitted on [DATE], with diagnoses that included, but not limited to, dementia (group of symptoms affecting memory, language, problem-solving, and other thinking abilities) with behavioral disturbance, falls, abnormalities of gait (pattern of walking or moving on foot) and mobility. A review of the History and Physical, dated 7/13/2021, indicated Resident 127 did not have the capacity to understand and make decisions. A review of the Physician's Order, dated 7/13/2021, indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow professional standards of practice for suprapubic catheter (device that is inserted into the bladder to drain urine through a small cut made in the lower abdomen) care for one of one sampled resident (Resident 77) by failing to: 1. Ensure cloudy urine full of sediments (gritty particles in urine) and leakage in the urinary drainage bag was treated appropriately. 2. Secure the catheter (flexible tube inserted into the bladder to drain urine) tubing to Resident 77's thigh for stabilization as ordered by physician. These deficient practices had the potential to result in a urinary tract infection (UTI - an infection in any part of the urinary system) for Resident 77. Findings: A review of the admission Record (Face Sheet) indicated Resident 77 was admitted into the facility on 5/22/2002 and readmitted on [DATE] with diagnoses that included, but not limited to, UTI and neuropathic bladder (loss of bladder control caused by neurologic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Vocational Nurse 8 (LVN 8) did not administer one dose of Retacrit (a medication used to treat blood problems) on 7/12/2021 per the physician's hold (do not administer) orders for one of five sampled residents (Resident 121). By administering Retacrit (a medication used to increase the number of red blood cells), when the hemoglobin (Hgb, a red blood cell protein responsible for transporting oxygen in the blood) indicated it was to be held, had the potential to place a resident at risk for cardiovascular problems (heart problems, such as stroke or heart attack). Findings: A review of the admission Record indicated Resident 121 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that anemia (low red blood cells), and hepatic failure (liver failure), and acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood). A review of Resident 121'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 observation, interview, and record review, the facility failed to ensure two steel bins of beef and pork, stored in the freezer were cooled down appropriately following storage in the freezer. This had the potential for foodborne illnesses (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) to occur when being rewarmed to be served to residents. Findings: During the initial kitchen observation, a concurrent interview with the Dietary Supervisor (DS), and concurrent record review, on 7/27/2021 at 8:30 a.m., observed a steel bin labeled, Pork 7/25/21 and a steel bin labeled, Beef 7/24/21. The meats in the steel bins were covered with a light frost and the steel bins were cold to touch. The DS stated both were cooked on the labeled days and then put in the freezer. The DS was unable to state how the meats were cooled or how long they took to cool. The DS showed the 07/2021 Cool Down Log but the meats were not listed on the log. The DS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation for Resident 56's pre and post dialysis (process of removing waste products and excess fluid from the body) assessment for one of one resident. This deficient practice had the potential for unidentified communication to other healthcare members before and after dialysis treatment. Findings: A review of the admission Record indicated Resident 56 was admitted to the facility, on 6/16/2020, with diagnoses that included, but not limited to, end stage renal disease (ESRD - medical condition in which a person's kidneys cease functioning on a permanent basis), diabetes mellitus type 2 (chronic condition characterized by high blood sugar), and dependence on renal dialysis. A review of the Minimum Data Set (MDS - an assessment and care screening tool), dated 5/28/2021, indicated Resident 56 had the ability to usually make self-understood and to understand others. A review of Resident 56's Physician Order, dated 6/16/2020, indicated to monitor right upper chest permacath (dialysis…

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