Paramount Convalescent Hosp.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Infection Prevention Nurse (IPN) demonstrated competency in implementing infection control practices related to antibiotic usage for one of one sampled residents (Resident 2). The facility failed to:1.Monitor Resident 2 who was administered two antibiotics (medications used to treat an infection) since admission on [DATE] with no end date to stop treatment. This failure resulted in Resident 2 receiving two antibiotics for an extended period without appropriate monitoring or reassessment, placing the resident at risk for adverse effects, including potential worsening of chronic kidney disease ( condition in which the kidneys are damaged and gradually lose their ability to filter waste and excess fluids from the blood effectively), which could lead to fluid retention (condition where excess fluid accumulates in the body's tissues, leading to swelling), swelling, and cognitive (ability to think, understand, learn, and remember)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that expired enteral nutrition products (specialized liquid formulas used in tube feeding to provide essential nutrients to residents unable to eat by mouth) were removed from the medication storage room after their expiration date. This failure had the potential to result in adverse side effects, including gastrointestinal distress, infection, and loss of potency (strength of a drug or its effectiveness in achieving a desired result), compromising the health and safety of residents receiving enteral nutrition.Findings:During an observation on 12/3/2025 at 2:17 p.m. in Medication Storage room [ROOM NUMBER], one expired 1500 milliliter (mL-unit of measurement) container of Diabetes source ( enteral nutrition formula) was found in a red basket. The product had an expiration date of 11/24/2025.During a concurrent observation and interview on 12/3/2025 at 2:45p.m. with Registered Nurse (RN) 3 in the central supply room (where nurses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 consent to treatment documentation was completed with all required elements for one of 14 sampled residents (Resident 44).This deficient practice has the potential to result in residents receiving treatments or interventions without understanding the risks, benefits, or alternatives. Findings:During a review of Resident 44's admission Record (Face sheet), the admission Record indicated the facility admitted the patient on 10/26/2001 with diagnoses including chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), hypertension (HTN- high blood pressure), and major depressive disorder (feel very sad, empty or hopeless most days and interferes with daily life).A review of Resident 4's History and Physical (H&P) dated 8/16/2025, the H&P indicated Resident 4 has the capacity to understand and make decisions.During a record review on 12/03/2025 at 9:15 a.m. of Resident 44's medical record (chart), the documentation of consent to treatment was missing Resident 44's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess one of five residents (Resident 1) during a change of condition and notify the physician in a timely manner during multiple episodes of elevated blood pressure. This failure resulted in Resident 1 having a headache and had the potential to result in dizziness, cerebral infarction (part of the brain dies because it's not getting enough blood and oxygen) and re-hospitalization for Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 6/4/2022, and readmitted on [DATE] with diagnoses including hemiplegia (a condition where one side of your body is paralyzed or experiences weakness), cerebral infarction, atherosclerotic heart disease (thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery) and hypertension (HTN-high blood pressure). During a review of Resident 1's History and Physical (H&P) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one of two sampled residents (Resident 1) was treated with respect and dignity by failing to ensure Resident 1 ' s indwelling urinary catheter (medical device which helps drain urine from the bladder) drainage bag was covered with a privacy bag (a bag used to the cover and hold the catheter drainage/collection bag so it is not visible). This deficient practice had the potential for Resident 1 to feel embarrassed and have low self-esteem by not having his catheter drainage bag not covered. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including type 2 diabetes mellitus (DM – a disorder characterized by difficulty in blood sugar control and poor wound healing) and urinary retention (a condition which makes it difficult or impossible to empty the bladder). During a review of Resident 1 ' s History and Physical (H&P),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observe infection control measures. The facility failed to : a.Ensure Resident 1 and 48's tube feeding ( medical device used to provide nutrition to resident who cannot obtain nutrition by mouth ) and water bags were changed every 24 hours. These failures had the potential to result in cross contamination and place the residents at risk for the spread of infection. b. To practice handwashing during wound care treatment on Resident 18 who had a Stage 4 pressure injury (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) in the sacro coccyx (tail bone) area. c. To ensure dirty linens were handled and disposed in a sanitary way after providing personal care for Resident 33 who was treated with antibiotic because of Extended spectrum beta lactamase ([ESBL]-an enzyme that makes bacteria resistant to many antibiotics {medication to treat infection} which makes the infection difficult to treat). d. 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 ensure two of three residents had clean and trimmed nails (Resident 17 and 45). This failure had the potential to negatively impact the resident's quality of care and self-esteem. Findings: 1.During a review of Resident 17's admission Record, the admission Record indicated Resident 10 was admitted on [DATE] with diagnoses that included Psoriatic Arthritis Mutilans (rare and painful condition that severely damages the hands, feet, and sometimes the spine) and atrial fibrillation (irregular and fast heartbeat). During a review of Resident 17's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 8/26/2024, the MDS indicated Resident 17 required partial/moderate assistance (helper does less than half the effort) with personal hygiene. During a review of Resident 17's care plan initiated 9/6/2024, the care plan focus was, Resident 17 was at risk for skin integrity with goals that included Resident 17 was to maintain and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure two of four sampled residents (Resident 39 and Resident 18) received the necessary treatment and services that will prevent development and promote healing of pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) by: a.Failing to monitor and assess Resident 39's skin areas where the nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was applied. b. Failing to ensure Resident 18 who had Stage 4 pressure injury on the Sacro coccyx area (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone on the tail bone) was repositioned to offload (method of reducing or removing pressure on the area to help prevent and heal pressure injury) was implemented. These failures resulted in the development of a Stage 1 pressure injury (intact skin with a localized area of redness and/or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure two of 14 sampled residents received effective pain management by: 1.Failing to assess and treat one of three resident's experiencing pain (Resident 11). 2.Failing to ensure Resident 18's pain level assessment is based on the cognitive level (mental process involved in knowing, learning, and understanding things) of the resident. These failures had the potential to put Resident 11 and Resident 18 at risk for pain to go unrecognized and untreated leading to delay of care and treatment. Findings: 1.During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure) and headaches. During a review of Resident 11's care plan initiated on 2/16/2024, the care plan focus was, Resident 11 had hypertension with goals that included Resident 11 was to remain free from signs and symptoms (s/s) of hypertension.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: a.Ensure five of five Restorative Nursing Assistants ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) had an annual competency evaluation (systematic process that evaluated an individual's skill and knowledge) for providing range of motion ([ROM] full movement potential of a joint [where two bones meet]) exercises, application of orthotics (also known as splints, material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion), and ambulation (the act of walking) to 13 residents receiving RNA services, including one of seven sampled residents (Resident 43) with limited ROM and mobility (ability to move). This failure had the potential for 13 residents receiving RNA services, including Resident 43, to experience a decline in ROM and mobility. b. Ensure Registered Nurse Supervisor (RNS) 1 and Licensed Vocational Nurse…

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

Deficiency Text Not Available

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review the facility failed to ensure it was free from a medication error rate of five percent or greater as evidenced by the identification of eleven medications errors out of thirty-three opportunities for error, to yield a total error rate of 33.33 percent for the two of four sampled residents (Residents 28 and 37). This failure had the potential for medications to not maintain a therapeutic dose level (maintain a certain level in your blood to work well) when not administer according to physician orders. Findings: During an observation on 10/1/2024 at 10:30 a.m., in Resident 37's room, observed Licensed Vocational Nurse (LVN) 4 administer Resident 37's 9:00 a.m. medications at 10 :30 a.m. During an observation on 10/1/2024 at 11:24 a.m. in Resident 28's room, observed LVN 4 administer Resident 28's 9:00 a.m. medications at 11:24 a.m. a.During a review of Resident 28's admission Record, the admission Record indicated Resident 28 was admitted to the facility 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 ensure sanitary conditions were maintained in the kitchen by failing to: a.Date and label open bag of peanut butter dough, bag of frozen fries and open bottles of salsa in the freezer and refrigerator. b.Practice hand washing during cooking, checking of temperatures of cooked food items and distribution of food during tray line. c.Use a beard net ( worn to contain facial hair)during food preparation and food distribution during lunch tray line. These failures had the potential to cause cross contamination ( unintentional transfer of harmful bacteria from one object to another)and food borne illnesses (any illness resulting from eating contaminated/ spoiled foods)among the residents. Findings: a.During an initial tour observation on 9/30/2024, at 8:10 a.m. with Dietary Aide (DA1) , an open bag of frozen fries and an open bag of peanut butter dough were open but was not labeled when they were opened by kitchen personnel in the freezer. During an observation and interview on 9/30/2024 with [NAME] (CK1), observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide therapy services, including Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function), Speech Therapy ([SLP] profession aimed in the prevention, assessment, and treatment of speech, language, communicative, and swallowing disorders), and Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) to one of seven sampled residents (Resident 5) with range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) concerns in accordance with Resident 5's physician signed care plans for OT, PT, and SLP. This failure resulted in Resident 5 not receiving any interventions to improve communication, mobility, and activities of daily living ([ADLs] tasks related to personal care including bathing, dressing, hygiene, eating, and mobility) to reach…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: a. Ensure accurate documentation for two of six sampled residents (Resident 43 and 32) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) concerns. This failure resulted in inaccuracies in the provision of care recorded in the clinical records of Resident 43 and 32. b. Ensure one out of three sampled residents (Resident 38) medication administration record (MAR) accurately reflect licensed nurse administered Resident 38's medication on 10/3/2024 at 9 a.m. This failure had the risk for medication errors or omission in medication administration. Findings: a. During a review of Resident 43's admission Record, the admission Record indicated Resident 43 was initially admitted to the facility on [DATE] with diagnoses including end stage renal disease ([ESRD] irreversible kidney failure), dependence on renal (kidney) dialysis (treatment to cleanse the blood of wastes and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 18) was free from physical restraint by not placing bilateral (both) 1/2 siderails on the bed without a physician's order or assessment. This failure had the potential to place Resident 18 at risk for unnecessary use of restraints that can lead to skin injuries , decline in mobility, and bed entrapment (an event in which a patient is caught, trapped, or entangled in the spaces in or about the bed rail, mattress, or bed frame). Findings: During a review of Resident 18's admission Record, the admission Record indicated the resident was initially admitted on [DATE] and was readmitted on [DATE] to the facility with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person focused care plan for two of 14 sampled residents (Resident 11 and Resident 18) by failing to: 1.Follow and implement interventions for Resident 11's management of pain. 2.Develop a comprehensive care plan that will address Resident 18's pain. These failures place Resident 11 and Resident 18 at risk for delay of care and treatment. Findings: 1.During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure) and headaches. During a review of Resident 11's care plan initiated on 10/2/2024, the care plan focus was Resident 11 complains of constant pain with goals that included Resident 11 will minimize complaints of pain. Interventions for Resident 11 included monitor pain every four hours. During a review of Resident 11's Medication Administration Record (MAR), the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of seven sampled residents (Resident 18) with limited range of motion [(ROM) full movement potential of a joint (where two bones meet)] and mobility (ability to move) had two staff members present while using a mechanical lift (a device that helps people who have difficulty moving on their own to be transferred or moved from one place to another) during a transfer from the bed to the shower bed. This failure placed Resident 18 at increased risk for accidents, including a fall from the mechanical lift which could have resulted in physical injury. Findings: During a review of Resident 18's admission Record, the admission Record indicated Resident 18 was admitted to the facility on [DATE] with diagnoses including parkinsonism (group of conditions with symptoms including slow movements, stiffness, tremors, and balance issues), autistic disorder (neurological and developmental disorder that affects how people interact with others,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, Licensed Vocational Nurse (LVN) 4 failed to keep one of one sampled resident (Resident 38) head of the bed elevated at a minimum 30 degrees at all times during the administration of feedings or medications to prevent aspiration (accidental inhalation of food, liquid, or other material into the lungs) and pneumonia (lung infection) per facility's policy and procedure (P&P). This failure had the potential to place Resident 38 at risk for aspiration and pneumonia. Findings: During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was admitted to the facility on [DATE] and readmitted on [DATE], with the diagnoses including gastrostomy ([g-tube] tube inserted in the stomach to assist with feeding), hypertensive heart disease ((heart problems that occur because of high blood pressure), depression (a low mood or loss of pleasure or interest in activities for long periods of time), diabetes mellitus type 2 (the body has trouble…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 four sampled residents (Resident 18) was free from unnecessary medication by: 1.Ensuring non-pharmacological interventions (intervention that does not primarily use medicine) was ordered for Resident 18 who was prescribed with psychotropic medicine ( any drug or substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, and behavior). This failure had the potential to result in the use of unnecessary psychotropic medication to Resident 18. Findings: During a review of Resident 18's admission Record, the admission Record indicated the resident was initially admitted on [DATE] and was readmitted on [DATE] to the facility with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide one of two sampled Residents (Resident 43) with meals that accommodated resident's food preferences. This failure had the potential to result in decreased meal intake and can lead to weight loss. Findings: During a review of Resident 43's admission Record, the admission Record indicated the resident was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses that included end stage renal disease (ESRD-irreversible kidney failure), diabetes mellitus(DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and dependence on renal dialysis (procedure to remove waste products and excess fluids from the blood when the kidneys stop properly). During a review of Resident 43's History and Physical(H&P) dated 6/1/2024, the H &P indicated the resident had a fluctuating capacity to understand and make decisions. During a review of Resident 43'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Resident 3 was aware of what she was signing when she signed the arbitration agreement (AA- a contract in which you give up your right to being certain claims to court). This failure had the potential to result in Resident 3 not having her right to limit opportunity to initiate judicial proceedings that challenge unfavorable decisions. Findings: During a review of Resident 3's admission record, the admission record indicated Resident 3 was admitted [DATE] with diagnoses including Diabetes Mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and legal blindness (severely impaired vision). During a review of Resident 3's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 8/29/2024, the MDS indicated Resident 3 had a Brief Interview for Mental Status (BIMS- a tool used to assess a patient's cognitive function) score of 15 which indicates that a person's cognition is intact.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Quality Assessment Assurance (QAA) Committee failed to implement corrective action from the previous re-certification survey regarding the provision of Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) services for range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move). This failure resulted in repeated deficient practices for Quality of Care related to the RNA program during the current re-certification survey. Findings: During a review of the Federal Statement of Deficiencies from the facility's last re-certification survey, dated 10/6/2023, Federal Statement of Deficiencies indicated the facility failed to ensure the Restorative Nursing Assistant (RNA) service provided passive range of motion ([PROM] movement of joint through the ROM from an external force with no effort from the person) exercises and applied a splint…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 wall in one of 19 rooms (Room A) was properly maintained without any holes. This failure had the potential to expose one of 52 residents (Resident 27) to hazards located in the walls, including water, fire, and pests. Findings: During a review of Resident 27's admission Record, the admission Record indicated Resident 27 was admitted to the facility on [DATE] with diagnoses including morbid obesity (condition where a person has an extremely high amount of body fat which can lead to serious health problems), hypertensive heart disease (condition where the heart has to work harder than normal because of high blood pressure), congestive heart failure (heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), type 2 diabetes mellitus (disorder characterized by difficulty in blood sugar control and poor wound healing), and reduced mobility (ability to move). 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and/or implement a care plan for one of three sampled residents (Resident 1) who was assessed at risk for elopement (leaving an institution without notice or permission). This deficient practice resulted in Resident 1 attempting to elope from the facility by climbing out of the facility s bathroom window and breaking her right leg when she fell to the ground outside that bathroom. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia (progressive loss of memory), anxiety (extreme worry), depression (feeling unhappy and without hope) and a history of falling. During a review of Resident 1's Minimum Data Set ([MDS]) a standard assessment and care screening tool), dated 11/21/2023 Resident 1's cognitive (the ability to think, reason, and understood) skills for daily decision-making were moderately impaired. 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.

Based on observation, interview, and record review, the facility failed to ensure food was stored and distributed under food safety requirements by failing to: 1. Ensure ice machine was maintained in a clean and sanitary way. 2. Ensure canned food stored in dry storage pantry had a received date label. These failures had the potential to cause food borne illness (food poisoning) for 49 out of the 49 residents in the facility. Findings: During an initial kitchen tour on 10/05/2023 at 8:00 a.m. with the Dietary Manager (DM), observed ice machine with brown reddish spots inside the border of the ice machine when wiped with a white paper towel and the inside of the ice machine sliding door was observed with rusty dark spots. During a concurrent observation and interview with DM on 10/5/2023 at 8:00 am., the DM stated the ice machine was cleaned once a month by the maintenance staff but should be cleaned daily. During an observation on 10/05/2023 at 8:15 a.m. in the presence of DM in the dry food storage pantry, observed Campbells soup can was not labelled with the date and time it was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to implement infection control practices to prevent the development and transmission of communicable diseases and infections. The facility failed to: 1.Ensure visitors wore Personal Protective Equipment (PPE: equipment to protect self and others from spreading infectious bacteria and virus) when entering Resident 26's room who were on contact isolation (when a patient has an infectious disease that may be spread by touching either the patient or objects the patient has handled), took a chair and brought it inside Resident 105's room and failed to do hand hygiene (cleaning one's hands that substantially reduces potential pathogens (harmful microorganisms) on the hands). 2. Ensure certified nurse assistant (CNA) 9 donned (put on )PPE inside the room of a resident who was on contact isolation while rendering care. 3. Ensure CNA 8, donned PPE prior to entering resident room on contact isolation. This failure had the potential for cross…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide prompt efforts to resolve the grievances the residents voiced to the facility through the grievance reporting form and resident council (organized group of residents who meet regularly to discuss and address concerns about their rights, and care in the facility) meetings for three of seven residents (Resident 14, Resident 39, Resident 105) who attended the resident council meeting during the recertification survey. This failure has violated the residents' right to have grievances filed by residents in the facility during the resident council meeting was addressed and resolved. Findings: During a review of Resident 14's admission record (face sheet) the face sheet indicated Resident 14 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a progressive disorder of the nervous system that affects movement), diabetes mellitus (a group of diseases that affect how the body uses blood sugar) and pneumonia (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 ensure correct dosage of medications were administered per physician order to two of two sampled residents (Resident 50 and 32). This failure had the potential for harm to Resident 50 and Resident 32 receiving a medication dosage not ordered by the physician. Findings: A. During an observation and record review on 10/5/2023 at 8:57 a.m. of Resident 50's morning medication administration (med pass) observed Licensed Vocational Nurse (LVN) 1 dispensed Vitamin B12 (vitamin supplement) 500 micrograms (mcg-strength in microgram unit) to Resident 50. LVN 1 stated the order for Resident 50's was Vitamin B12 50 mcg by mouth daily. LVN 1 stated he gave the 500-mcg dose because Vitamin B12 does not come in 50 mcg. LVN 1 stated the licensed nurses just give Resident 50 the 500mcg dose because Vitamin B12 50 mcg was not available. LVN 1 stated Resident 50 should not receive the Vitamin B 12 500 mcg dose because it was not ordered by the physician.…

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

Based on interview and record review the facility failed to ensure one of four Residents (Resident 17) with limited mobility received assistance to improve, maintain and prevent avoidable decline in range of motion and mobility by failing to implement Physical Therapy ([PT] the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery) recommendations to start Restorative Nursing Assistive Services ([RNAS] nursing interventions that promote the residents ability to adapt and adjust to living) ordered on 9/18/2023 for Passive Range of Motion (PROM) for the bilateral (both) lower legs for joint integrity (inspection, palpation, active and passive range of motion, and the assessment of supporting structures and special testing). This failure had the potential to limit Resident 17's range of motion to all extremities, gradual loss of strength and development of pressure injury ( damaged to the skin due to prolonged pressure on the skin) due to immobility ( inability to move). Findings: 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure necessary care and services needed were provided to one of two sample residents (Resident 5). Facility failed to: 1.Ensure Resident 5 oxygen tubing was connected to oxygen machine and the nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) was on Resident 5 nostril. This failure had the potential for complications associated with lack of proper oxygen therapy for Resident 5. Findings: During a review of Resident 5's admission Record (face sheet) indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including aphasia (a language disorder that affects a person's ability to communicate), type 2 diabetes mellitus (a condition in which the body fails to metabolize (process) glucose (sugar) correctly ), chronic obstructive pulmonary disease ([COPD-progressive disease that makes it hard to breath). During a review of Resident 5's Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 17 sampled resident (Resident 205) medication was not left unattended at bedside without a physician order for self-administration. This failure had the potential for Resident 205 at risk for medication errors and had the potential for unsafe medication administration to an incorrect resident. Findings: During an observation on 10/4/2023 at 10:48 a.m. during the initial tour of a recertification survey with the Registered Nurse (RN) 1, Oral B throat lozenges (medication used for sore throat) was found on Resident 205's bedside table without a physician order for self -administration (able to take medications on their own without the nurse being present). During a review of Resident 205's admission Record (face sheet) the face sheet indicated Resident 205 was admitted to the facility on [DATE], with diagnoses including spinal stenosis (narrowing of the spine), sepsis (infection in the blood) and acute respiratory failure (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to permit one of one resident (Resident 1) to return to the facility after hospitalization when Resident 1 was ready to be readmitted too the facility on 9/5/2023 and on 9/12/2023. This deficient practice resulted in Resident 1 having to remain in acute care hospital and unable to go back home (facility)and had the potential to negatively affect Resident 1's wellbeing. Findings: During a review of Resident 1 ' s admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included epilepsy (brain disorder that causes recurring seizures), gastrostomy (surgical opening into the stomach from the abdominal wall for introduction of food via tube ) , hemiparesis (muscle weakness or partial paralysis on one side of the body), and dysphagia (difficulty of swallowing). During a review of Resident 1 ' s Minimum Data Set( [MDS] a standardized assessment and care screening tool), dated 7/22/2023, 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 provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of their individuality for one of three sampled residents (Resident 1) by: 1. Failing to provide Notice of Medicare Non-Coverage (NOMNC- a notice that indicates when resident's care is set to end) and Physician Orders for Life Sustaining Treatment (POLST- a written medical order from a physician specifying the types of medical treatment residents want to receive during serious illness) in Spanish and Spanish translating service as requested by Resident 1 to understand NOMNC and POLST before signing the documents. 2. Failing to obtain Resident 1's dentures. This failure resulted in Resident 1 feeling lack of self-determination to make decisions, loss of dignity, and loss of self-esteem. Findings: 1. During a review of Resident 1's admission record, the admission record indicated Resident 1 was admitted to the facility initially on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop person centered care plans for one of three sampled residents (Resident 1) by: 1 Failing to follow up and to obtain Resident 1's dentures by Social Service Director (SSD). 2.Failing to provide and explain the Physician Orders for Life Sustaining Treatment (POLST- a written medical order from a physician) in a language that Resident 1 could understand.This failure has the potential to result in Resident 1's care needs not being addressed, and the lack of ability to identify the resident's ongoing needs. Findings: During a review of Resident 1's admission record, the admission record indicated Resident 1 was admitted to the facility initially on 11/7/2019 and last readmission on [DATE]. Resident 1's diagnosis included end stage renal disease (kidneys can no longer support body's needs and unable to filter waste), diabetes mellitus (a group of diseases that affect how the body uses blood sugar), abnormal gait (a change of walking…

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