Cedar Pine Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of two (2) of six (6) sampled residents (Resident 23 and 2) observed during medication administration as indicated on the physician's order and facility policy and procedure (P&P) when:1. Licensed Vocational Nurse 3 (LVN) 3 failed to administer Resident 23's levetiracetam (Keppra, medication used to prevent seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]), metformin (medication used to control blood sugar levels), and escitalopram (Lexapro; medication used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]) on time.This deficient practice had the potential to cause Resident 23's medical conditions to not be treated effectively.2. LVN 2 failed to administer Resident 2's metoprolol (medication to treat or prevent hypertension [high blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a Medication Regimen Review (MRR, also known as a Drug Regimen Review-is a structured, comprehensive evaluation of all medications a resident is taking, conducted typically by a pharmacist to ensure medications are appropriate, safe, effective, and used correctly) to identify and follow up on an irregularity (includes, but is not limited to, use of medications without adequate indication, without adequate monitoring, in excessive doses, and/or in the presence of adverse consequences, as well as the identification of conditions that may warrant initiation of medication therapy) for two (2) of five (5) sampled residents (Resident 22 and Resident 57) reviewed for unnecessary medications in accordance with the facility's policy and procedure (P&P) by failing to ensure: 1. Resident 22 was monitored for the use of montelukast (a medication to treat lung inflammation), including required monitoring for its black box warning (BBW, serious,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident 57) were free from unnecessary drug (any drug when used without adequate indications for its use by failing to have accurate indication for the use of donepezil hydrochloride (prescription medication used to treat the symptoms of dementia [a progressive state of decline in mental abilities]). This deficient practice had the potential to place Residents 57 at risk for significant adverse (harmful) consequences from the use of unnecessary drug.Findings: During a review of Resident 57's admission Record, the admission Record indicated Resident 57 was originally admitted to the facility on [DATE]. The admission record also indicated Resident 57's diagnoses included dementia, schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and anxiety disorder (a mental health condition characterized by excessive, persistent, and uncontrollable fear or worry). 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 observation, interview, and record review, the facility failed to ensure its medication error rate was less than five (5) percent (%). Four (4) medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/ manufacturer's specifications / accepted professional standards and principles) out of 27 total opportunities (observed administered medications) for error, to yield an overall medication error rate of 14.81 % for two (2) of six (6) sampled residents (Resident 2 and Resident 23) observed for medication administration.1. Licensed Vocational Nurse 3 (LVN) 3 failed to administer Resident 23's levetiracetam (Keppra, medication used to prevent seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]), metformin (medication used to control blood sugar levels), and escitalopram (Lexapro, medication used to treat…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow its policy and procedure (P&P) to ensure two (2) of six (6) sampled residents (Resident 23 and 2) observed during medication administration were free from significant medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/ manufacturer's specifications / accepted professional standards and principles, which may have cause the resident discomfort or jeopardize health and safety) when:1. Licensed Vocational Nurse 3 (LVN) 3 failed to administer Resident 23's levetiracetam (Keppra, medication used to prevent seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]), metformin (medication used to control blood sugar levels), and escitalopram (Lexapro, medication used to treat depression [a mood disorder that causes a persistent feeling 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 maintain an accurate and complete medical records for one (1) of 23 sampled residents (Resident 73) in accordance with the facility's policy and procedures (P&P) by failing to document Resident 73's use of low air loss mattress (LALM, designed to distribute the resident's body weight over a broad surface area and help prevent skin breakdown).This deficient practice has the potential to cause Resident 73 to receive inappropriate care. Findings:During a review of Resident 73's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included muscle weakness and stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of sacrum (lower end of the spinal area at the base of the spine). During a review of Resident 73's Minimum Data Set (MDS- a resident assessment tool) dated 5/26/2026, the MDS indicated Resident 73 had intact cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure infection prevention measures (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for two (2) of 23 sampled residents (Residents 9 and 43) by failing to:1. Ensure Certified Nurse Assistant 3 (CNA 3) performed hand hygiene (cleaning hands with the use of alcohol-based hand rubs containing 60%-95% alcohol or hand washing with soap and water) during meal assistance with Resident 43.2. Ensure Resident 9's gastrostomy tube (G-Tube- a surgical opening fitted with a tube to allow feedings to be administered directly to the stomach common for people with swallowing problems) feeding pump (an electronic or battery-powered medical device designed to deliver liquid nutrition, hydration, or medications directly into a resident's stomach) was clean and sanitary during feeding administration. These failures have the potential for Residents 9 and 43 to be at risk for preventable infections…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain clinical records in accordance professional standards and practices and facility's Policy and Procedure (P&P) for one (1) of six (6) sampled residents (Resident 1) by failing to accurately document the administration of narcotics (drug or controlled substance that affects the mood or behavior and if consumed for nonmedical purposes or not prescribed by the doctor can cause serious harm) count in the narcotic drug record (narcotic count sheet is a document used to document and track the administration of controlled substance to ensure accurate dispensing and administration of medications, as well as to provide a record of how much of a controlled substance has been used and when).This deficient practice had the negative impact on the delivery of services and lead to potential harm or irreversible harm to the residents.Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reconcile the General Acute Care Hospital's (GACH) Discharge Medications List and carry out a physician's order to administer long-acting insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) for one (1) of two (2) sampled residents (Resident 2) as indicated on the facility policy and procedure (P&P). This deficient practice resulted in Resident 2 experiencing hyperglycemia (a condition where there's too much glucose in the blood) placing Resident 2 at risk for various serious complications such as ketoacidosis (DKA, a complication of diabetes in which acids build up in the blood to levels that can be life-threatening), dehydration (a condition occurs when the body loses more fluids than it takes in, leading to an insufficient amount of water for normal bodily functions), confusion (a state of reduced awareness and impaired thinking), and coma (a state of prolonged…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the intravenous (IV, administering fluids or medications directly into a vein using a needle or tube, allowing for immediate entry into the bloodstream) hydration (the process of supplying water to maintain adequate fluid levels in the body) for one (1) of two (2) sampled residents (Resident 1) on 4/10/2026, in accordance with the physician's order, care plan, and facility policy. This failure had the potential to put Resident 1 at risk for dehydration (a condition occurs when the body loses more fluids than it takes in, leading to an insufficient amount of water for normal bodily functions) and complications that can lead to hospitalization and death. Findings: During a review of Resident 1's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses including malignant (harmful, or dangerous to health) neoplasm (an abnormal, new growth of tissue in the body) of lungs 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 maintain an accurate and complete record for two (2) of 2 sampled residents (Resident 1 and 2) as indicated in the facility's policy and procedure (P&P) when: The facility failed to complete and accurately document Resident 1's neurological evaluation flow sheet (a standardized clinical documentation tool used to frequently monitor, record, and assess a patient's neurological status).The facility failed to complete Resident 1's fall risk assessment on 4/8/2026.The facility failed to accurately document Resident 2's neurological evaluation flow sheet.This deficient practice had the potential to result in miscommunication and improper delivery of care and inaccurate information of the care provided to Resident 1 and 2.Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including but not limited to fibromyalgia (chronic disorder characterized by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide an accurate report detailing suspected presence of contraband (any item that is illegal to possess) for one (1) resident (Resident 1) as indicated in the facility's policy and procedure.This deficient practice had the potential to compromise or impede the protection of all the residents which could affect residents' physical, emotional, mental wellbeing and lead to irreversible results or death. Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including but not limited to fibromyalgia (chronic disorder characterized by widespread musculoskeletal pain, fatigue, sleep disturbances), cervical disc displacement (herniated disc in the neck, the soft, jelly-like center of a spinal disc pushes out through a tear in its outer ring), and hypertension (high blood pressure). During a review of Resident 1's General Acute Care Hospital's (GACH)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs for two (2) of 2 sampled residents (Resident 1 and Resident 2) in accordance with the facility policy by failing to:1. Administer Resident 1's morning medications timely on 12/23/25.2. Administer Resident 2's morning medications timely on 12/23/25.This deficient practice had the potential to result in ineffectively managing Resident 1 and Resident 2's medical condition, which could result to harm, hospitalization and death.3. Leaving Resident 2's Medication unattended at bedside.This deficient practice had the potential for other residents to take the medications, which could result in harm to the other residents if ingested.Findings:1. During a review of Resident 1's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent sexual abuse (non-consensual sexual contact of any type with a resident) for two (2) of 2 sampled residents (Resident 1 and 2) on 12 /18/2025 in the facility's hallway. On 12/18/2025, Orientee of Dietary (OD) and Certified Nursing Assistant (CNA 1) witnessed Resident 1 pulled down his (Resident 1) pants and pulled out his (Resident 1) penis. Resident 2 then performed oral sex (one partner uses the tongue, mouth or throat to excite the other partner's sex organs) to Resident 1. This failure resulted in Resident 1 and 2 to sexual abuse potentially risking emotional trauma (response to deeply distressing or disturbing event) or psychological trauma (damage to the mind that occurs as a result of a severely distressing event) placing other residents in the facility at risk for sexual abuse.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE]. 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 an interview and record review, the facility failed to ensure that the resident's anti-anxiety (medications that reduce feelings of fear, dread, and tension by calming the nervous system) medication ordered as needed (PRN- a medication or treatment to be administered only when the patient exhibits specific symptoms or the situation requires it, rather than on a fixed, routine schedule) had a stop date and was reevaluated by the physician after 14 days of the order date for the appropriateness of use in accordance with facility policy, for one (1) of one two sampled resident (Resident 1). This deficient practice had the potential to cause serious harm, such as severe confusion, falls, issues, and cognitive (mental action or process of acquiring knowledge and understanding) decline, which could lead to drug dependency (use of drugs that continues even when significant problems related to their use have developed), trauma, and an increased risk of death. Findings: During a review of Resident 1's admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one (1) of three (3) sampled residents (Resident 1) was free from physical abuse (any intentional act causing injury or trauma to another person through bodily contact). Resident 1 had a change of behavior of screaming towards Resident 3 on 11/11/2025 and the facility did not have documented evidence the behavior was addressed. This resulted in Resident 2 hitting Resident 1 on the face on 11/12/2025.and Resident 1 sustained a scratch under the resident's right eye and redness on the right side of the nose. Findings:During a review of Resident 1's admission Record, the admission record indicated the resident was admitted to the facility on [DATE] with the following but not limited to diagnoses of dementia (a progressive state of decline in mental abilities), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), depression (a serious mood disorder characterized by persistent sadness and loss of interest,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility staff failed to implement fall interventions in accordance with the care plan to frequently observe and place one of two Residents (Resident 1) who was assessed as high risk for fall in a supervised area while out of bed. This deficient practice resulted in a fall (unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force) on 5/10/2025, which placed Resident 1 at risk for serious injury like fractures (break in the bone) and head injury (injury that damages your head, including the skull [bony framework of the head, enclosing the brain and supporting the face] and brain), hospitalization and even death.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 10/25/2024 and readmitted on [DATE], with diagnoses including, but not limited to left sided hemiplegia (complete or severe paralysis of one side of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to create and implement a comprehensive person-centered care plan for one (1) of two (2) sampled residents (Resident 1) to address Resident's 1's diagnosis of alcohol dependence (also known as alcohol use disorder [[NAME]], a chronic disease characterized by a compulsive need to drink alcohol despite negative consequences).This failure resulted in Resident 1 going out on pass (OOP - a non-medical visit outside of the facility most commonly used for visits with family or friends) from the facility on 7/15/2025 at 11:45 AM and not returning. The facility was notified by the local police on 7/15/2025 at 10:51 PM that Resident 1 was found at the general acute care hospital (GACH) emergency department. Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of alcohol abuse (drinking in a manner, situation, amount, or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to promote dignity and respect for two of three sampled residents (Resident 35 and Resident 5) for dignity and respect as indicated on the facility's policy by failing to ensure: 1. Resident 35 wore the resident's personal clothing. 2. Resident 5 was kept clean and without white colored food debris around the resident's mouth and a brown stain on the left upper should of the resident's gown. These deficient practices had the potential to negatively affect Resident 35 and Resident 5's self-worth, self-esteem and psychosocial (pertaining to the influence of social factors on an individual's mind or behavior) well-being. Findings: 1. During a review of Resident 35's admission Records, the admission Records indicated the Resident 35 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including hemiplegia (severe or complete loss of strength on one side of the body) and hemiparesis (loss of strength on one side of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a comprehensive resident centered care plan (a formal process that correctly identifies existing needs and recognizes a resident's potential needs or risks to achieve healthcare outcomes) in accordance with the facility's care plan policy for two (2) of 2 sampled resident (Residents 41 and 51) by failing to ensure: 1. Resident 41 had a care plan to address the resident's central venous catheter (a type of access used for hemodialysis [a procedure removing metabolic waste products or toxic substances from the bloodstream]). This deficient practice had the potential to not be able to provide the specific interventions such as monitoring Resident 41's access site for bleeding and infection, which could result in harm. 2. Resident 51 had a care plan to address use of a heart monitor. This deficient practice had the potential for Resident 51 not to receive specific interventions such as skin integrity check and monitoring…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 its medication error (the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order; manufacturers specifications / accepted professional standards and principles) rate was less than five (5) percent (%). Two (2) medication errors out of 30 total opportunities for error, to yield an overall medication error rate of 6.67 % for two (2) of seven (7) sampled residents (Residents 50 and 51) observed for medication administration. This deficient practice had the potential to result in Residents 50 and 51 experiencing adverse medication effects (unwanted, uncomfortable, or dangerous effects that a medication may have) that could negatively affect the residents' health and well-being. Findings: 1. During a review of Resident 50's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was re admitted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility's policy and procedure on disposal of discontinued medications when three (3) unidentified pills were observed on the floor of the medication storage room. This deficient practice increased the risk for residents to accidentally receive the medication that had become ineffective or toxic due to improper storage possibly leading to health complications, which may result to harm and hospitalization. Findings: During a concurrent observation on [DATE] at 9:38 AM, in the medication room, and interview with Infection Preventionist Nurse (IPN), IPN verified that there were 3 loose pills on the floor of the medication room. IPN described the following pills as: 1. Light purple in color, round. 2. Yellow in color, oblong. 3. White colored round pill. IPN was unable to determine what kind of pills were found on the floor. IPN stated the loose pills on the floor has the possibility of being kicked out of the medication room, 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 follow proper food handling practices in accordance with its policy and procedure by failing to label food items in the refrigerators, and freezers in the kitchen with item name, date opened and used by date and discard one (1) expired food items. These deficient practices had the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness (example food poisoning with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever) and can lead to other serious medical complications and hospitalization. Findings: During a concurrent observation and interview on 5/20/2025 at 8:01 AM with [NAME] 1, Refrigerator #2 had a 1-gallon (gal, unit of volume) container of Thousand Island dressing with no label of open date. [NAME] 1 stated, I just opened it yesterday, I just forgot to put the opened date. We need to write down the open date and used by date so we will know when it will be expired. During a concurrent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 up on a resident's request on [DATE] to formulate an Advance Directive (legal document that provide instructions for medical care and only go into effect if you cannot communicate your own wishes) for one of three sampled residents (Resident 16). This failure resulted in a delay of seven (7) years in addressing Resident 16's request and had the potential for the staff not to carry out the resident's wishes regarding health care decisions during an emergency. Findings: During a review of Resident 16's admission Record, the admission Record indicated Resident 16 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis malignant neoplasm (cancer) of right breast and blindness on one eye. During a review of Resident 16's Minimum Data Set (MDS- resident assessment tool), dated [DATE], indicated Resident 16 had intact cognitive skills (ability to reason, think, and make decisions) for daily decision…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the physician of significant changes in condition (a major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions) for one of two sampled resident (Resident 51), who experienced eight (8) episodes of hypotension (low blood pressure when blood pressure is much lower than normal and varies from one person to another. This condition occurs when a person's blood pressure drops as little as 20 mmHg (millimeters of mercury- a unit of measurement to quantify the pressure exerted by blood against the walls of the arteries) reducing blood flow to the heart, brain, and other parts of the body) related to the use of Losartan Potassium-HCTZ (medication to treat high blood pressure). This deficient practice resulted in delayed treatment for repeated hypotensive episodes for Resident 51 placing him at risk of adverse outcomes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an accurate range of motion (ROM, means how far and in what direction you can move a joint or muscle) assessment on the Minimum Data Set (MDS, a resident assessment tool) for one (1) of 2 sampled residents (Resident 50) as indicated in the facility's policy. This deficient practice had the potential to result in an incorrect plan of care which could negatively affect the delivery of necessary care and services to Resident 50. Findings: During a review of Resident 50's admission Record, the admission Record indicated Resident 50 was admitted to the facility on [DATE] and re-admitted on [DATE]. During a review of Resident 50 History and Physical (H&P), dated 3/1/2025, the H&P indicated Resident 50's diagnoses that included cerebrovascular accident (CVA, stroke, loss of blood flow to a part of the brain) with bilateral lower extremity contractures (stiffening/ shortening at any joint, that reduces the joint's range of motion) and left…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assist one of one sampled resident (Resident 46) who were unable to carry out activities of daily living (ADL) to maintain good grooming, and personal and oral hygiene by failing to assist Resident 46 with oral care. This failure placed Resident 46 at risk to develop dental caries (or tooth decay- a progressive destruction of bone or tooth), teeth and gum infections and/ or lung infection, that could lead to hospitalization. Findings: During a review of Resident 46's admission Records, the admission Records indicated Resident 46 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), mild, without behavioral disturbance; type 2 diabetes mellitus (a medication condition characterized by the body's inability to regulate blood sugar level); and gastroesophageal reflux disease…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of two (2) of seven (7) sampled residents (Resident 50 and 51) as indicated on the facility policy and physician's order by failing to: 1. Administer Resident 50's carvedilol (a medicine used to treat hypertension [high blood pressure]) with food on 5/23/2025. 2. Administer Resident 51's sevelamer (a medicine to treat hyperphosphatemia [too much phosphate in the blood]) with food on 5/23/2025. This deficient practice had the potential to result in Residents 50 and 51 not obtaining the therapeutic level (medicine levels in your blood are in a range that is medically helpful but not dangerous) of the medication, which could lead to complications and harm to the residents. Findings: 1. During a review of Resident 50's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was re admitted on [DATE], with diagnosis 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.

Based on interview and record review, the facility failed to assist one of one sampled resident (Resident 42) in obtaining dental services when the Social Service Director (SSD) did not follow up with the dental office regarding Resident 42 ' s eligibility for dental services. This failure resulted in Resident 42 feeling frustrated at not having his dental needs met and having difficulty chewing food. Findings: During a review of Resident 42 ' s admission Record, the admission Record indicated the facility admitted Resident 42 on 5/24/2024 and readmitted of 1/31/2025 with diagnoses including cerebral infarction (a condition where brain tissue dies due to lack of oxygen supplying the brain), anxiety disorder (a condition characterized by excessive and persistent worry, fear, and nervousness), and chronic pain syndrome (a condition where pain persist for a long time and can interfere with daily life activities). During a review of Resident 42 ' s Minimum Data Set (MDS - a resident assessment tool), dated 2/13/2025, the MDS indicated Resident 42 ' s cognitive (the ability to think 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 provide food that is palatable and attractive for one (1) out of 22 residents (Resident 19) based on the facility's policy. This deficiency has resulted Resident 19 being served his disliked foods which had the potential to negatively affect Resident 19's psychosocial (pertaining to the influence of social factors on an individual's mind or behavior) well-being. Findings: During a review of Resident 19's admission Record, the admission Record indicated Resident 19 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included morbid obesity (weight more than 100 pounds over your ideal body weight and experiencing severe health effects), Gastroesophageal reflux disease (GERD, happens when stomach acid flows back up into the esophagus and causes heartburn [a painful, burning feeling in the middle of your chest]) and major depressive disorder ( or also called clinical depression, it affects how you feel, think…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 22 sampled resident (Resident 1) who required adaptive feeding equipment (modified utensils, accessories, glasses, and plates to help improve residents' comfort and independence) utilize a weighted spoon (specialized utensil with built up handle designed to assist residents with limited or weakened grasping strength) and plate guard (unique spill guard which prevents food from accidentally being pushed off the plate) during meal, as indicated on the physician's order. This deficient practice placed Resident 1 at risk for further decline in physical functioning and decline to perform self-feeding skills. Findings: During a review of Resident 1's admission Record indicated the resident admitted to the facility on [DATE] and got readmitted on [DATE], with diagnoses including but not limited to dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), osteoarthritis (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement its policy and procedure on infection control for four (1) of 22 sampled residents (Resident 30) when staff did not use personal protective equipment (PPE, used to prevent or minimize exposure and to protect from potential transmission of biological agents that can be transferred from person to person by direct and indirect contact) while rendering wound care to Resident 30 who was on enhanced barrier precaution (EBP, use of PPE beyond anticipated blood and body fluid exposures) on 5/23/2025. This deficient practice had the potential to result in a widespread infection in the facility that could compromise the health of the residents, visitors, and staff. Findings: During a review of Resident 30's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was re admitted on [DATE], with diagnosis of hypertension (high blood pressure), pain, and epilepsy (a brain disease…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 22 sampled residents (Resident 42) had a call light (a device used to call for assistance) within reach. This failure had the potential to result in Resident 42 being unable to call for assistance resulting to unmet needs and possibly being injured when trying to reach the call light. Findings: During a review of Resident 42's admission Record, the admission Record indicated the facility admitted Resident 42 on 5/24/2024 and readmitted on [DATE] with diagnoses including cerebral infarction (a condition where brain tissue dies due to lack of oxygen supplying the brain), anxiety disorder (a condition characterized by excessive and persistent worry, fear, and nervousness), and chronic pain syndrome (a condition where pain persist for a long time and can interfere with daily life activities). During a review of Resident 42's Minimum Data Set (MDS - a resident assessment tool), dated 2/13/2025, the MDS indicated Resident 42's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of two samples residents (Resident 1) received appropriate treatment and services to correct the assessed problem and provided behavioral health services for Resident 1, whose primary diagnosis includes alcohol use, unspecified with unspecified alcohol-induced disorder (alcohol use without specific details about the extent or nature of the related disorder), other psychoactive (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) substance abuse, uncomplicated (many illegal drugs and substances including alcohol, caffeine, nicotine, marijuana, and certain pain medicines), imprisonment and other incarceration (confinement to a jail, prison or other penal institution or correctional facility) by failing to: 1. Ensure to refer Resident 1 to a psychologist (a professional who practices psychology [the scientific study of human mind and its functions, especially those…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three sampled residents (Resident 2) were free from physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish), when Resident 1 allegedly scratched Resident 2's face on 3/18/2025. This deficient practice resulted in Resident 1 had a scratch to his nose and had the potential to negatively affect Resident 1's comfort and psychosocial (having to do with the mental, emotional, social, and spiritual effects of a disease) well-being which can lead to hospitalization and/ or death. Findings: During a review of Resident 1's admission Record, indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), and lack of coordination. During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed in accordance with the facility's Enhanced Barrier Precaution (EBP- infection control practices in nursing homes that focuses on reducing the spread of multi drug resistant organisms [MDRO - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria] by using targeted gown and gloves use during high-contact resident care activities [activities involving a lot of physical touching or close interaction with the resident, potentially increasing the risk of spreading germs or infections], rather than isolating residents) policy when: 1. Certified Nurse Assistant 1 (CNA 1) did not wear an isolation gown while changing the diaper on one (1) of two (2) sampled residents on EBP (Resident 1). 2.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (Facility 1) failed to maintain complete and accurate medical records in accordance with the accepted professional standards (a set of guidelines and expectations that define the competent level of care a healthcare professional should deliver) and practices and follow facility's Policy and Procedures (P&P) for one of one sampled resident (Resident 1) by failing to document resident-initiated discharge (when a nursing home resident or their representative gives notice that they want to leave the facility) coordination of Resident 1 to Facility 3 on 1/20/2025. This deficient practice had the potential to confuse members of the health care team and negatively impact the delivery of services. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/1/2024 with diagnoses that included but not limited to atrial fibrillation (irregular heart beat that occurs when the upper chambers of the heart…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to report an allegation of abuse (any intentional or unintentional actions that cause harm or distress to a patient or person in their care) within two hours to local police department, state survey agency and ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) after the allegation of physical abuse (inflicting physical injury such as hitting and slapping) was made by one of one sampled resident (Resident 1). This deficient practice resulted in delayed reporting which could have resulted in ongoing abuse, leading to worsening physical, emotional, or psychological (mental or emotional) harm for Resident 1. Findings: During a review of Resident 1's admission Record dated 2/5/2025, indicated Resident 1, was admitted to the facility on [DATE] with diagnosis of functional quadriplegia (inability to move due to severe disability frailty caused by another medical condition without physical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure accurate assessment of oxygen (O2) use for three of three sampled residents (Residents 4, 5 and 6) on the Minimum Data Set (MDS- a resident assessment tool) as indicated on the facility policy. This deficient practice had the potential for the facility to not develop and implement an individualized care plan for Residents 4, 5, and 6, which could negatively affect the resident's overall wellbeing. Findings: 1. During a review of Resident 4's admission Record, the admission Record indicated the facility initially admitted the resident on 9/2/2024 and was readmitted on [DATE] with diagnoses that included, but not limited to end stage renal disease (ESRD-irreversible kidney failure) requiring hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed), type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary respiratory care services for three (3) of 3 sampled residents (Residents 4, 5, and 6) by failing to: a. Ensure oxygen (O2, a colorless, odorless gas necessary for most living organisms to breathe and function properly) was administered to the residents via nasal cannula (NC- a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) according to the physician's orders. b. Label the humidifier (medical devices that increase the humidity in your oxygen while using supplemental oxygen. These devices look like water bottles and have a special cap with a wing nut on top used for attaching the humidifier to an oxygen concentrator.) with resident's name and date as indicated in the facility's oxygen policy and procedure (P&P). These deficient practices placed Resident 4, 5, and 6 at risk for experiencing complications such as respiratory distress (a condition that occurs when the body…

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

Based on interview and record review, the facility failed to maintain an accurate resident medical records for one of two sampled Residents (Resident 1) by failing to ensure vital signs (measurements of the body's most basic functions that include body temperature, blood pressure, pulse rate, breaths per minute, and the amount of oxygen circulating in blood, also known as oxygen saturation [level of oxygen in the blood]) were not documented on 12/22/2024, 12/23/2024, 12/24/2024 and 12/25/2024 while Resident 1 was in the General Acute Hospital (GACH, a health facility having a duly constituted governing body with overall administrative and professional responsibility and an organized medical staff that provides 24-hour inpatient care.) This deficient practice had the potential for staff to not know the resident's actual condition resulting to necessary services and care not provided to the resident. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 9/30/2021. Resident 1's diagnoses included epilepsy (happens…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not ensure staff followed the facility's isolation (separation of residents with an infection from residents without an infection) and enhanced barrier precautions (EBP- refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] that employs targeted gown and glove use during high contact resident care activities) policies for two of two sampled residents (Residents 4 and 7) and four of eight rooms (Rooms 3, 7, 9, and 11) with residents on EBP by: 1. Resident 4 did not have isolation signage posted outside the room door or wall. 2. Staff did not wear personal protective equipment (PPE-equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses. PPEs may include gloves, safety glasses and shoes, gowns, or coveralls) when providing care to Resident 7 who has a gastrostomy (a surgical opening fitted with a device to allow feedings, fluids, 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 provide padded side rails (metal or plastic bars positioned along the side of a bed) as indicated on the physician's order for one of two sampled Residents (Resident 3) who has a diagnosis of seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). This failure had the potential for Resident 3 to sustain an injury or harm in an event of a seizure episode. Findings: During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 1/31/2003. Resident 3's diagnoses included seizure, schizophrenia (a mental illness that is characterized by disturbances in thought), and repeated falls. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool) dated 12/11/2024, the MDS indicated Resident 3 was moderately impaired (decisions poor; cues/supervision required) with cognitive (processes of thinking and reasoning) skills for daily decision making. 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 provide Occupational Therapy (OT, improving the patient's ability to perform activities of daily living) and Physical therapy (PT, treatment that helps you improve how your body performs physical movements) for one (1) of two (2) sampled residents (Resident 2) as indicated on the Physician's order, care plan, and facility assessment tool. This deficient practice placed Resident 2 at risk for decline in physical functions and developing contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), which could negatively affect the resident's overall wellbeing. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 11/7/2024. Resident 2's diagnoses included muscle weakness, gastrostomy a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reasonable accommodation to meet the choices of two of two sampled residents (Resident 37 and Resident 38) by failing to assign female Certified Nursing Assistants (CNA) as per the residents' request. This deficient practice had the potential to affect Resident 37 and Resident 38's quality of life and negatively impact their psychosocial well-being. Findings: 1. A review of Resident 37's admission Record indicated Resident 37 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included benign lipomatous neoplasm (a non-cancerous lump that forms due to an overgrowth of fat cells), type 2 diabetes mellitus (a disease that occurs when the blood sugar is too high), and hemiplegia (paralysis on one side of the body) and hemiparesis (weakness or the inability to move one side of the body) following unspecified cerebrovascular disease affecting left non-dominant side (a group of disorders that affect the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a safe and homelike environment (having qualities associated with home; comfortable, familiar, cozy) for two (2) of 23 sampled resident (Resident 31 and 64) by: 1. Facility failed to provide protection of Resident 64's personal property from theft or loss, when Resident 64's responsible party (RP) reported missing personal belongings. 2. Facility failed to provide a bathroom to Resident 31 that did not have four missing tiles on the wall. These deficient practices resulted in the violation of the Resident 64 and 31's right of having a safe and clean environment and had the potential to cause emotional distress to the resident. Findings: 1. A review of Resident 64's admission Record indicated Resident 64 was admitted to the facility 5/7/2024, with diagnoses of malignant (cancerous) neoplasm (abnormal growth of cells in the body) of unspecified part of unspecified bronchus (one of the two tubes that carry air into the lungs from the trachea) or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility failed to develop care plans (a document that outlines the facility's plan to provide personalized care to a resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs) for three of four residents (Resident 21, 32, and 52) per facility policy, facility failed to: 1. Develop a care plan for Resident 21 after having 4 incidents of falling. 2. Develop a care plan for Resident 32's compromised oral condition. 3. Resident 52 did not have an individualized care plan for limited range of motion on the resident's left side of body. These failures resulted in Residents 21, 3, and 52 receiving care that was not comprehensive and personalized to meet the specific needs identified above, with the potential to result in decreased quality of care and quality of life for Residents 21,32 and 52. Findings: 1. A review of Resident 21's admission Record indicated Resident 21 was readmitted into 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to update and revise the care plans for two of 23 sampled residents in accordance with the facility policy by failing to ensure: 1. Resident 64's care plan was revised when the diet was changed. 2. Resident 63's dialysis (a lifesaving treatment for residents with kidney failure) care plan was updated and revised to address intake and output (I & O) monitoring. These deficient practices have the potential to negatively affect the provisions of care and services for the residents. Findings: 1. A review of Resident 64's admission Record indicated Resident 64 was admitted to the facility 5/7/2024, with diagnoses of malignant (cancerous) neoplasm (abnormal growth of cells in the body) of unspecified part of unspecified bronchus (one of the two tubes that carry air into the lungs from the trachea) or lung, pleural effusion (fluid buildup in the space between the lung and the chest wall), and atelectasis (collapse of a lung or part of a lung due 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 three of four sampled residents (Resident 37, 48, and 60) were provided necessary treatment and services to prevent formation of and promote healing of pressure injury (pressure ulcers- injury to the skin and underlying tissue resulting from prolonged pressure on the skin) in accordance with the facility's policy and procedure (P&P) and physician's order by: 1. Facility failed to ensure Resident 37's low air loss mattress (LALM/ LAL mattress- an air mattress covered in tiny holes designed to let out air very slowly which helps keep the skin dry and [NAME] away any moisture) was set up according to the resident's weight. Resident 37 was observed with the LALM set at approximately 200 pounds ([lbs]- unit of measurement) and Resident 37 weighed 121 lbs. This deficient practice placed Resident 37 at risk to develop pressure injury. 2. Failed to reposition Resident 48 every two (2) hours as per physician order and plan of care. This…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two of two sampled residents (Resident 63 and 60) safe and appropriate care for the provision of dialysis (a lifesaving treatment for residents with kidney failure) consistent with professional standards of practice by: 1.a. Facility failed to assess Resident 60's left upper chest dialysis catheter (a catheter [thin tube] that is placed under the skin in a vein, allowing long-term access to the vein) on 5/14/2024 and 6/1/2024, in accordance with the facility's policy. 1.b. Facility failed to revise Resident 60's dialysis care plan when the resident's left upper arm Antero ventricular shunt (AV shunt, (vascular access in patients receiving regular hemodialysis) vascular access in patients receiving regular hemodialysis) was placed on 5/29/2024. These deficient practices had the potential for unnoticed or missed excessive bleeding and infection on the Resident 60's dialysis access sites. 2. Facility failed to ensure the following…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 risk for entrapment (an event in which a resident is caught, trapped, or entangled in the space in or about) and attempt alternatives prior to the use of side rails (adjustable metal or rigid plastic bars that attach to the bed) for two (2) of three (3) sampled Residents (Resident 32 & 61) as indicated on the facility policy. 1. Resident 32 did not have a reassessment for the use of side rails 2. Resident 61 did not have an assessment for the use of side rails. This failure had the potential to result in the inappropriate use of side rails for Resident 32 and 61, which could pose a safety risk and result in injury or harm. Findings: 1. A review of Resident 32's admission Record indicated Resident 32 was readmitted to the facility on [DATE], with diagnoses that included seizures (a sudden disruption of the brain's normal electrical activity accompanied by altered consciousness and/or other neurological and behavioral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Cross reference F759 Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one of seven sampled residents (Resident 50) in accordance with the facility policy by: 1. Failing to administer Dexamethasone (medication that provides relief for inflamed areas of the body) two milligrams (mg, unit of measurement) tablet timely as ordered on 6/14/2024. 2. Failing to administer the following 9 AM due medications on 6/14/2024: a. Cozaar (medication to lower blood pressure) oral tablet 50 mg b. Lasix (medication to treat fluid retention and swelling) oral tablet 20 mg c. Norvasc (medication to lower blood pressure) oral tablet 5 mg d. Docusate Sodium (stool softener) oral Capsule 100 mg e. Levetiracetam (medication to treat seizures [a sudden, uncontrolled burst of electrical activity in the brain]) oral tablet 750 mg f. Lidocaine Patch 4 percent (medication, a patch to relieve pain) These deficient practices had the potential for Resident 50 to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report to the resident's primary physician the irregularities (includes, but is not limited to, use of medications without adequate indication, without adequate monitoring, in excessive doses, and/or in the presence of adverse consequences, as well as the identification of conditions that may warrant initiation of medication therapy) on the medication regimen review (MRR, or Drug Regimen Review, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication), dated 5/28/2024, for two (2) of five (5) sampled residents (Resident 12 and Resident 61) in accordance with the facility policy. 1. Recommendation to evaluate whether taking Vascazen (helps reduce the risk of heart disease) 1 gram (g, unit of measurement) every night and Vascepa (medicine used to reduce the risk of heart attack, and certain types of heart issues requiring…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Cross reference: F755 Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). There were seven (7) medication errors out of 25 total opportunities for error, to yield an overall medication error rate of 28 % for one (1) of seven (7) residents observed for medication administration (Residents 50). The medication errors were as follows: 1. During a Medication Pass observation, Licensed Vocational Nurse 1 (LVN 1) failed to administer Dexamethasone (medication that provides relief for inflamed areas of the body) two milligrams (mg, unit of measurement) tablet timely as ordered on 6/14/2024. 2. During a Medication Pass observation, LVN 1 failed to administer the following 9 AM due medications on 6/14/2024: a. Cozaar (medication to lower blood pressure) oral tablet 50 mg b. Lasix (medication to treat fluid retention and swelling) oral tablet 20 mg c. Norvasc (medication to lower blood pressure) oral tablet 5 mg d. Docusate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 its Medication Storage policy by failing to: 1. Remove a box of expired eye gel from medication storage room [ROOM NUMBER] (MSR 1). 2. Remove a box of expired eye drops from MSR 1 This deficient practice increased the risk for Residents on insulin to receive medication that had become ineffective or toxic due to improper storage possibly leading to health complications, which may result to harm and hospitalization. 3. Store four (4) unopened Basaglar Kwik Pen (a medication used to control high blood sugar) in the refrigerator. 4. Store 4 unopened Trulicity (a medication used to lower blood sugar) in the refrigerator. This deficient practice caused the residents to be exposed to adverse side effects of using expired eye gel and eye drops such as signs of an allergic reaction, like rash, itching, severe dizziness, trouble breathing and blindness if it was used. 5. Defrost (become free of accumulated ice) Refrigerator 1. This deficient…

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

Based on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with its policy and procedure by failing to: a. Label foods in the kitchen with item 'use by' date (the last date recommended for the use of the product) or open date. b. Discard expired food in the kitchen. c. Store dishes in the kitchen in a sanitary manner. d. Ensure water filter line had an air gap and did not touch the drain on the floor. e. Ensure plunger was stored in accordance with professional standards. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization. Findings: During a concurrent observation in the kitchen and interview with the Dietary Supervisor (DS) on 6/11/2024 at 8:36 AM, the following were observed: a. resident's personal container with a used napkin 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 follow its policy to monitor the refrigerator and freezer's temperature containing residents' food brought from home to ensure that it was within acceptable temperatures for four of five sampled residents (Residents 18, 31, 47, and 50). This deficient practice had the potential to result in food-borne illnesses (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea and fever, other serious medical complications, and hospitalization. Findings: A review of Resident 18's admission Record indicated Resident 18 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of malignant (cancerous) neoplasm (abnormal growth of cells in the body) of unspecified site of right female breast. A review of Resident 31's admission Record indicated Resident 31 was initially admitted to the facility on [DATE], with diagnosis of Type 2 Diabetes Mellitus (a disease that occurs when…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility failed to ensure the arbitration agreement (a contract in which the right to bring certain claims to court for resolution is given up) included for the selection of a venue that is convenient (a location in which to carry out arbitration proceedings which should be agreed upon and suitable to both parties (facility and residents) for two of three sampled residents (Resident 3 and 21). This failure resulted in violation of Residents 3 and 21's right to be informed of all information related to an arbitration agreement. Findings: A review of an Arbitration Agreement signed by Resident 3 on 3/25/2019, failed to indicate information to address the selection of a venue convenient to both parties. A review of an Arbitration Agreement signed by Resident 21 on 5/29/2024, failed to indicate information to address the selection of a venue convenient to both parties. During a concurrent record review of the facility's Resident - Facility Arbitration Agreement and interview on 6/13/2024 at 11:48 AM with the Admissions Coordinator (AC), AC stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a coordination of care between the facility and hospice (care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure) staff for three of three sampled residents (Residents 61, 52, and 64) in accordance with the facility's hospice policy and hospice agreement by failing to ensure: 1. Hospice staff visited Resident 61 per Hospice calendar. 2. and 3. Residents 52 and 64 had a hospice comprehensive assessment to include the frequency of hospice staff visits This deficient practice had the potential for Resident's 61, 52, and 64 not to receive the hospice care and services necessary to promote comfort and quality of life. Findings: 1. A review of Resident 61's admission Record indicated Resident 61 was originally admitted to the facility on [DATE]. Resident 61's diagnoses included end stage heart failure (heart's inability to pump an adequate supply of blood),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement appropriate infection control practices for one of two sampled residents (Resident 62) as indicated on the facility's policy and procedure (P&P) by failing to ensure availability and use of EPA (Environmental Protection Agency) approved disinfectant solution in cleaning a contact isolation (used when a resident has an infectious disease that may be spread by touching either the resident of other objects the resident has handled) room with Clostridium difficile (C. diff- a bacteria that causes diarrhea), This deficient practice placed the residents, staff, and visitors at higher risk for cross-contamination, and increased spread of C. diff infection in the facility and the community. Findings: A review of resident 62's admission Record indicated Resident 62 was admitted to the facility on [DATE] with diagnoses that included acute (severe and sudden onset) and chronic (long lasting) respiratory failure with hypoxia (a condition…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and interview, the facility staff failed to provide a safe environment in the kitchen by failing to: 1. Ensure the portable air conditioner unit was safely plugged into the wall outlet. 2. Ensure the wall outlet was free of tape covering the plug and outlet when the generator was plugged into the wall outlet. This deficient practice had the potential to result in a fire which placed residents, staff, and visitors at risk. Findings: During on observation on 6/11/2024 at 8:52 AM in the kitchen, there was a double gang box switch and outlet combo (device that combines a switch and an electrical outlet in the same enclosure box) between the kitchen sink and towel dispenser. The bottom of outlet combo had an extension cable plugged in. The extension cable had a bug zapper, a phone charger, a large black portable air conditioning unit Portacool plugged in (about the height of the sink). Approximately a foot below the double gang box switch and outlet combo was a wall outlet with two outlets. The wall outlet had multiple layers of blue tape covering the bottom outlet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility failed to treat one of three sampled residents (Resident 8) dignity and respect by failing to secure the privacy curtain during resident care as indicated in facility's policy and procedure (P&P). This failure resulted in the violation of Resident 8's rights, with the potential for Resident 8 to experience negative feelings (including disrespect). Findings: A review of Resident 8's admission Record indicated Resident 8 was readmitted to the facility on [DATE], with diagnoses that included fracture (a break) of left humerus (upper arm bone), major depressive disorder (MDD - a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), chronic pain syndrome, and contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). A review of Resident 8's Minimum Data Set (MDS - a standardized…

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

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 (a device used by a resident to signal his or her need for assistance) was within reach for one of 23 sampled residents (Resident 56) who had a history of cerebrovascular accident (CVA, stroke- loss of blood flow to a part of the brain) and left-side hemiparesis (weakness or the inability to move on one side of the body), in accordance with the facility policy. This deficient practice had the potential to result in delayed provision of care and services for Resident 56. Findings: A review of Resident 56's admission Record indicated Resident 56 was admitted on [DATE] with diagnoses that included occlusion and stenosis of right carotid artery (condition that happens when the large artery on either side of the neck becomes blocked), anxiety disorder (persistent and excessive worry that interferes with daily activities), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness 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 residents' medical records were updated to show documentation that advance directives (legal written instructions 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 discussed and written information were provided to the residents and/or responsible parties (RP) for three of the seven sampled residents (Resident 5, 47 and 43). This deficient practice violated the Residents 5, 47 and 43 and/or the representatives' right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding health care. Findings: 1. A review of Resident 5's admission Record indicated Resident 5 was readmitted to the facility on [DATE], under full code status (full life saving support which includes cardiopulmonary resuscitation (CPR), if there is no heartbeat or breathing), with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the preadmission screening and annual resident review assessment (PASARR, preventing individuals with mental illness, developmental disability, intellectual disability, or related conditions from being inappropriately placed in nursing homes for long term care) form was accurately completed for a resident who had a mental illness for one of four sampled residents (Resident 52). This deficient practice led Resident 52 to not receive the necessary and appropriate psychiatric level of treatment and evaluation in the facility. Findings: A review of the Resident 52's admission Record indicated Resident 52 was admitted to the facility on [DATE], with diagnoses of schizoaffective disorder (a mental illness that causes loss of contact with reality) bipolar type (mental disorder characterized by episodes of mania [extreme highs] and depression [extreme lows]), and anxiety disorder (persistent and excessive worry that interferes with daily activities). A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an activity based on resident's preference and activity assessment for two of two sampled residents (Residents 52 and 29) in accordance with the facility policy. This deficient practice had the potential not to meet Residents 52 and 29's interests and activity needs, which could affect the physical, mental, and psychosocial well-being of each resident. Findings: 1. A review of Resident 52's admission Record indicated Resident 52 was admitted to the facility on [DATE], with diagnoses of schizoaffective disorder (a mental illness that causes loss of contact with reality) bipolar type (mental disorder characterized by episodes of mania [extreme highs] and depression [extreme lows]), anxiety disorder (persistent and excessive worry that interferes with daily activities), and hemiplegia (a condition caused by brain damage or spinal cord injury that leads to paralysis [loss of motor function in one or more muscles] on one side of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assist one (1) of two sampled residents (Resident 12) in making appointment of vision services as ordered by the physician. This deficient practice resulted in Resident 12 not having his vision examined to maintain and/or improve his vision. Findings: A review of Resident 12's admission Record indicated Resident 12 was admitted to the facility on [DATE] with diagnoses that included unspecified cataract (a cloudy area in the clear part of the eye that helps to focus light)and unspecified glaucoma (the result of pressure of the eye that damages the nerve that carries messages from the retina to the brain which can lead to permanent vision loss or blindness). A review of Resident 12's History and Physical Examination (H&P), dated 2/7/2024, indicated Resident 12 had fluctuating capacity to understand and make decisions. A review of Resident 12's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 5/21/2024, indicated Resident 12…

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

Based on observation, interview, and record review, the facility failed to provide necessary respiratory care services for one of two sampled resident (Resident 26) by failing to ensure Resident 26's nebulizer mask (a drug delivery device used to deliver drugs in the form of atomized inhalation into the lungs) and tubing were changed weekly per facility's policy. This deficient practice had the potential for Resident 26 to develop a respiratory infection. Findings: A review of Resident 26's admission Record indicated Resident 26 was admitted to the facility 5/3/2024, with diagnoses of atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), hypothyroidism (condition in which the thyroid gland does not produce enough thyroid hormone), and anxiety disorder (persistent and excessive worry that interferes with daily activities). A review of Resident 26's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 5/16/2024, indicated Resident 26's cognitive (mental action or process of acquiring knowledge and understanding)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident 61) was free from an unnecessary psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility policy and procedure by failing to ensure Resident 61 had a specific target behavior for the use of Zyprexa (medication used to treat certain mental/mood disorders). This deficient practice had the potential to place Resident 61 at risk for significant adverse (harmful) consequences from the use of unnecessary psychotropic drug. Findings: A review of Resident 61's admission Record indicated Resident 61 was originally admitted to the facility on [DATE]. Resident 61's diagnoses included anxiety disorder (persistent and excessive worry that interferes with daily activities), major depressive disorder (depression, is a mood disorder that causes a persistent feeling of sadness and loss of interest), and insomnia (a common sleep disorder that can make…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 23 sampled resident (Resident 22) who required adaptive feeding equipment (modified utensils, accessories, glasses, and plates to help improve residents' comfort and independence) utilize a plate guard (unique spill guard which prevents food from accidentally being pushed off the plate) during meal, as indicated on the physician's order. This deficient practice placed Resident 22 at risk for further decline in physical functioning and decline to perform self-feeding skills. Findings: A review of Resident 22's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including but not limited to aphasia (loss of ability to understand or express speech, caused by brain damage) following cerebral infarction (stroke, a loss of blood flow to part of the brain), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility failed to conduct a monthly Quality Assessment and Assurance (QAA, process to evaluate activities under the Quality Assurance and Performance Improvement [QAPI, process used to ensure services are meeting quality standards and assuring care reaches a certain level) program, such as identifying issues with respect to which QAA activities, including PI projects required under the QAPI program, are necessary) meeting as indicated in the facility policy and procedure (P&P). This failure had the potential to result in inadequate, incomplete provision of care and services provided to residents throughout the facility, decreasing their quality of life. Findings: During an interview on 6/14/2024 at 5:47 PM with Infection Preventionist Nurse (IPN), IPN stated every department in the facility makes a report to identify what needs to be improved and the QAPI meetings are for all departments to come together to present what areas need to be improved and to discuss solutions that can be implemented after the meeting. IPN stated QAPI has not had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adequate supervision to a resident assessed as high risk for fall by not providing a one-to-one sitter (1:1, staff who provides constant observation to ensure the safety of a resident who may be suffering from cognitive [thought process and ability to reason or make decisions] impairment or may be at risk for falls or of causing harm to themselves or others) for one of three sampled residents (Resident 1), in accordance with the resident ' s physician ' s order. This deficient practice resulted in Resident 1 ' s unwitnessed fall on 12/22/23 and resulted in the following: 1. A six (6) centimeter (cm, unit of measurement) laceration (a deep cut or tear in the skin) to Resident 1 ' s posterior occiput (back of the head) requiring 12 staples 2. Acute (severe and sudden in onset) Thoracic (T) 2 vertebral (the second bone in the spinal column) body fracture (broken bone) 3. Acute mild to moderate anterior (front) compression fracture…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observation, interview, and record review, the facility failed to accurately assess the resident's functional abilities for one (1) of five (5) sampled residents (Resident 1) on the Minimum Data Set (MDS- an assessment and care screening tool) as indicated on the facility policy. This deficient practice had the potential to not develop and implement an individualized care plan for Resident 1, which could result in injury/harm and negatively affect the resident's overall wellbeing. Findings: A review of the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses of osteoarthritis (disease that causes the joints to become very painful and stiff), atrial fibrillation (irregular heart beat), and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). A review of Resident 1's MDS, dated [DATE], indicated the resident was severely impaired with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based observation, interview, and record review, the facility failed to develop a resident centered care plan for one (1) of five (5) sampled residents (Resident 1) to address resident's specific functional abilities during activities of daily living as indicated on the facility policy. This deficient practice had the potential to not develop and implement an individualized care plan for Resident 1, which could result in injury/harm and negatively affect the resident's overall wellbeing. Findings: A review of the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses of osteoarthritis (disease that causes the joints to become very painful and stiff), atrial fibrillation (irregular heart beat), and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). A review of Resident 1's MDS, dated [DATE], indicated the resident was severely impaired with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to promote dignity and respect for one of five sampled residents (Resident 2) as indicated on the facility policy. This deficient practice had the potential to cause a decline in Resident 2's individuality, self-esteem, and self-worth. Findings: A review of the admission Record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included cerebral infarction (area of dead tissue in the brain resulting from blockage or narrowing in the arteries supplying blood and oxygen to the brain), hypertension (chronic elevated blood pressure), and hypothyroidism (abnormally low activity of the thyroid gland, resulting in retardation of growth and mental development in children and adults). A review of the History and Physical, dated, 10/16/23, indicated Resident 2 has fluctuating capacity to understand. H&P indicated diagnosis included dementia (long term and often gradual decrease in the ability to think and remember severe enough to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one out of one sampled resident (Resident 1) received proper services to maintain the resident's vision by failing to arrange the resident's appointment with an ophthalmologist (are eye doctors who perform medical and surgical treatments for eye condition). This deficient practice resulted in Resident 1 not receiving his vision services by not making his ophthalmologist appointment to maintain his vision. Findings: A review of an admission Records indicated resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including glaucoma (a diseases that damage the nerve at the back of your eye) and schizoaffective disorder (a mental illness that causes loss of contact with reality.) A Review of Physician Order, date 6/28/23 indicated Resident 1 may have eye consult with ophthalmologist. A review of the Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 8/25/23, 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 provide supervision to prevent accidents for three of five sampled smoking residents (Resident 1, 2, and 3) in accordance with the facility's Smoking Policy and guidelines. a. Residents 1, 2 and 3 had a lighter and cigarette in their possession and not kept at the designated locked storage cabinet for smoking paraphernalia. b. Resident 3 was observed smoking outside the designated smoking area without staff supervision and threw a lighted cigarette butt (end of cigarette) on the regular trash can on 10/24/2023. This deficient practice had the potential to result in an accidental fire in the facility, which could lead to harm and injury to the residents and staff. Findings: a. During a review of Resident 1's admission Record (face-sheet) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of post-traumatic stress disorder (PTSD is a disorder that develops in some people who have experienced a shocking, scary, or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent misappropriation of resident property by not having a signed inventory list (Resident Belonging List) for one of three sampled residents (Resident 1). This deficient practice had the potential to result in a loss of Resident 1's and other residents' personal belongings. Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis that included malignant neoplasm of the rectum (cancer of the rectum) and encephalopathy (a brain disease, disorder, or damage). A review of Resident 1's History and Physical (H&P), dated [DATE], indicated Resident 1 does not have the capacity to understand and make decisions. A review of Resident 1's Progress Notes indicated the resident expired on [DATE] under hospice care (care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort 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.