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NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a charge against one (1) of 24 sampled residents (Resident 79) personal funds was not imposed during the resident's stay at the facility from 4/3/2025 to 6/14/2025. This deficient practice had a potential to result in emotional distress brought about by a financial loss due to Resident 79 not receiving the required reimbursement from the facility.Findings: During a review of Resident 79's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (a brain disorder caused by a chemical imbalance in the body) and sepsis (a life threatening medical emergency where the body has an overwhelming and extreme inflammatory [body's response to infection] response to an infection which can cause damage to its own tissues and organs). During a review of Resident 79'S Minimum Data Set (MDS - a resident assessment tool), dated 4/9/2025, the MDS indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a clean, comfortable, and home-like environment for one (1) of 24 sampled residents (Resident 25) by failing to ensure that Resident 25's room has no pool of water beside the resident's bed and the resident's electric fan by the resident's room was not dusty. These deficient practices caused an unsanitary environment and had potential for Resident 25 to be placed at risk for infection and injuryFindings: During a review of Resident 25'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 end stage renal disease (ESRD, irreversible kidney failure), dependence on renal (kidney) dialysis (process of removing waste products and excess fluid from the body), and paraplegia (loss of movement and/or sensation, to some degree, of the legs). During a review of Resident 25's Minimum Data Set (MDS- a resident assessment tool), dated…

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

Based on observation, interview, and record review, the facility failed to ensure the Low Air Loss mattress (LAL mattress, designed to prevent and treat pressure ulcer [localized damage to the skin and underlying soft tissue caused by prolonged pressure]) for one (1) of four (4) sampled residents (Resident 38) under pressure ulcer care area was set at the correct settings in accordance with the resident's weight. This deficient practice had the potential for Resident to develop new pressure injury. Findings: During a review of Resident 38's admission Record, the admission Record indicated the facility admitted Resident 38 on 10/11/2024. Resident 38's diagnoses included pressure ulcer of unspecified site , lack of coordination, and type 2 diabetes mellitus (a disease that occurs when there is a problem in the way the body regulates and uses sugar as fuel). During a review of Resident 38's Minimum Data Set (MDS, standardized care and screening tool), dated 10/17/2025, the MDS indicated Resident 38 was dependent (helper does all the effort) on toileting and needed substantial /maximal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 identify the environment for potential hazard for one of two sample residents (Resident 12) under accidents care area by failing to ensure the floor was dry. This deficient practice had the potential for Resident 12 to sustain injury in an event of a fall due to the wet floor. Findings:During a review of Resident 12'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 end stage renal disease (ESRD, irreversible kidney failure), dementia (a progressive state of decline in mental abilities), and generalized anxiety disorder (GAD, is a chronic condition characterized by excessive, persistent worry about everyday things that is difficult to control). During a review of Resident 12's Minimum Data Set (MDS- a resident assessment tool), dated 8/15/2025, the MDS indicated Resident 12's cognitive (ability to think and reason) skills for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide dialysis (process of removing waste products and excess fluid from the body) care and services by failing to assess the resident's left upper arm dialysis access site (surgical or medical creations that allow for blood to be cleaned by a dialysis machine and returned to the body) on 11/11/2025, 11/12/2025, and 11/18/2025 for one of two sampled residents (Resident 25) under dialysis care area, in accordance with the facility policy and physician's order. This deficient practice had the potential for complications such as bleeding or infection on Resident 25's left upper arm arteriovenous (AV) fistula (shunt, a surgically created connection between an artery and a vein, most commonly in the arm, that provides access for hemodialysis when kidneys fail) dialysis access. Findings: During a review of Resident 25's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was re admitted 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 ensure one (1) of three (3) sampled residents (Resident 17), under food care area, was provided with a meal tray that did not contain a food the resident was allergic to. This failure had the potential to result in Resident 17 experiencing an allergic reaction such as anaphylaxis (a severe, whole-body allergic reaction that happens quickly and is life-threatening).Findings:During a review of Resident 17's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of morbid (severe) obesity (a chronic condition characterized by an excessive accumulation of body fat that poses a risk to health) due to excess calories (the energy content of food and drink) and lack of coordination (the inability to control and organize the movement of different parts of the body, resulting in movements that are awkward, unsteady and clumsy). Resident 17's admission Record…

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

Based on observation, interview, and record review, the facility failed to dispose garbage and refuse (disposable material, which includes both recyclable and non-recyclable material) from the kitchen properly when the designated green kitchen dumpster (a movable waste container designed to be brought and taken away by a special collection vehicle) was observed overfilled with a lid covering it halfway. This failure had the potential to result in the attraction and spread of vermin (animals that are believed to be harmful, or that carry diseases, e.g., rodent's parasitic worms or insects) that could potentially infiltrate the facility, affect the resident care areas and pose a threat to residents of the facility.Findings: During a concurrent observation and interview on 9/30/2025 at 10:49 AM with dietary aide 1 (DA 1), a kitchen green dumpster was observed at the back of the facility. The kitchen green dumpster was observed to be overflowing, and the dumpster lid cover was halfway open. DA 1 stated the dumpster's lid was not and should be closed. DA 1 stated, The dumpster is full…

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

Based on observation, interview, and record review, the facility failed to ensure the ice machine drainage has an air gap (a vertical, unobstructed space between the ice machine's drain and the building's drainage system that prevents contaminated drain water from flowing back into the machine's clean water supply. It is a safety feature, often a simple pipe fitting or a dedicated device, that acts as a barrier, with the most common requirement being a 1-2 inch gap to comply with health and plumbing codes) to ensure no contact with outside contaminated (unfit for use, or unsafe) source as indicated in facility's policy and procedures (P&P). This deficient practice had the potential to result in backflow of contaminated water back to the ice machine and had the potential to result in pathogen (germ) exposure to residents, which could place the 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.During an…

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

Based on observation, interview, and record review, the facility failed to ensure the food service area was maintained clean, sanitary, and in a functional manner while providing proper food handling in accordance with the facility's policy and procedure (P&P) by failing to ensure:1. Walk in freezer's temperature was checked on 8/4/2025 and 8/5/2025, Walk in refrigerator's (Refrigerator 1) temperature was checked on 8/4/2025 and 8/5/2025 and Standing refrigerator's (Refrigerator 2) temperature was checked on 8/2/2025, 8/3/2025, 8/4/2025 and 8/5/2025.2. Dishwasher machine's top surface was clean, without dust and crumbs. 3. [NAME] crispies were disposed after 6/30/2025 as labeled in the use by date sticker and flour with prepared date of 6/14/2025 was labeled with correct use by date.4. The dry food storage room's temperature was checked daily from 7/20/2025 to 8/5/2025. 5. 208 nutritional supplement drinks (designed to help individuals gain or maintain weight and used as meal replacements) were not stored in a room with temperature of 90 Fahrenheit (F, unit of measurement). 6. 52…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 readmit one (1) of two (2) sampled residents (Resident 1) back to the facility on 5/17/2025 after Resident 1 was discharged from General Acute Care Hospital (GACH) back to the facility in accordance with the facility's policy and procedure (P&P) titled Bed Holds and Returns. This deficient practice had the potential to violate the rights of Resident 1 and lengthen unnecessary stay in GACH. Findings: During a review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that including but not limit to spondylosis (gradual breakdown of the spine and related structures), anxiety disorder (persistent and excessive worry that interferes with daily activities), depression (a common mental health condition characterized by a persistent low mood, loss of interest or pleasure in activities, and other symptoms that can significantly interfere with daily life) and borderline personality disorder (a personality…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its protocol for Antibiotic Stewardship to reduce inappropriate antibiotic (medication used to kill bacteria and to treat infections) use by not administering antibiotic drug if the antibiotic drug use criteria (McGeer criteria, a set of standardized definitions used to identify healthcare-associated infections in long-term care facilities for surveillance, tracking outbreaks, and making informed decisions about antibiotic use) was not met for two (2) of 2 sampled residents (Residents 1 and 2). This deficient practice had the potential for Residents 1 and 2 to develop antibiotic resistance (when bacteria, viruses, fungi, and parasites no longer respond to antimicrobial medicine and become ineffective making infections difficult or impossible to treat increasing the risk of disease spread, severe illness, disability, and death) and suffer adverse side effects from unnecessary or inappropriate antibiotic use. Findings: 1. During a review of…

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

Based on interview and record review, the facility failed to ensure the facility employed a designated Infection Preventionist (IP) with specialized training. This failure had the potential to result in the prevention and control of infections among the residents and staff. Findings: During an interview on 5/6/2025 at 3:55 PM with Registered Nurse 1 (RN 1), RN 1 stated the facility had been without a designated IP for almost a month now. RN 1 stated RN 1 and the licensed nurses were covering the IP position. RN 1 stated RN 1 and licensed nurses were doing the IP job duties such as antibiotic stewardship for the residents. During an interview on 5/7/2025 at 5:20 PM with RN 1, RN 1 stated the staff covering the IP position did not and should have an IP certification. During a concurrent interview and record review on 5/7/2025 at 5:35 PM with Medical Records (MR) of the previous IP nurse's Notice to Employee as to Change in Relationship, MR stated the previous IP's last day worked was on 2/6/2025. During a record review of the facility's policy and procedure titled, Infection…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities), ombudsman (OMB) (advocates for residents of nursing homes, board and care homes and assisted living facilities) and local law enforcement within the two (2) hour time frame and thoroughly investigate an allegation of physical abuse (intentional act causing injury or trauma to another person or animal by way of bodily contact) of one (1) of two (2) sampled residents (Resident 1) that happened on 2/17/2025 [NAME] accordance with the facility policy. This failure may result in psychosocial harm (pertaining to the influence of social factors on an individual's mind or behavior, and to the interrelation of behavioral and social factors) to Resident 1 such as experiencing fear retaliation (an unpleasant emotion or thought that you have when you are frightened or worried by something dangerous, painful, or bad that is happening) and/ or anxiety…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an allegation of sexual abuse (any act of sexual contact that a person suffers, submits to, participates in, or performs as a result of force or violence, threats, fear, or deception or without having legally consented to the act) for one (1) of two (2) sampled residents (Resident 1) within 2-hour timeframe to the State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities) and the state ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities), in accordance with the facility's abuse policy. This deficient practice had the potential to compromise or impede the protection of Resident 1 from further abuse, which could result in emotional distress. 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 that included spondylosis (gradual breakdown of the spine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 honor the food preferences for one (1) of two (2) sampled resident's (Resident 1) in accordance with the facility's policy and procedure (P&P) titled, Resident Food Preferences and as indicated on the physician's order. This deficient practice had the potential to cause Resident 1 to feel disrespected and to feel stomach discomfort. 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 that included spondylosis (gradual breakdown of the spine and related structures), anxiety disorder (persistent and excessive worry that interferes with daily activities), depression (a common mental health condition characterized by a persistent low mood, loss of interest or pleasure in activities, and other symptoms that can significantly interfere with daily life) and borderline personality disorder (a personality disorder characterized by severe mood swings,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adequate assistance to prevent accidents for one (1) of two (2) residents (Resident 1). On 4/24/2024, Certified Nursing Assistant 2 (CNA 2) assisted Resident 1 back to bed from the resident's wheelchair without assistance of another facility staff. This failure resulted in Resident 1 having an assisted fall with CNA 2 and placed resident at risk of injury. 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 [DATE] with diagnoses of atherosclerotic (a buildup of fats, cholesterol [waxy, fat-like substance found in the blood and cells] and other substances in and on the artery [a blood vessel that carries blood away from the heart and to the body's tissue and organs] walls) heart disease (a group of conditions that affect the heart and blood vessels) and intracranial injury (also known as traumatic brain injury [TBI] is a brain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 2) received food that accommodated resident intolerances and preferences. This failure placed Resident 2 at risk for experiencing feelings of sadness and distress and had the potential to result in Resident 2 having decreased meal intake which would lead to weight loss and malnutrition (a state of nutritional deficiency or imbalance that occurs when the body does not receive or absorb sufficient nutrients [calories, protein, vitamins, minerals] to maintain health and function properly). Findings: During a review of Resident 2's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of spondylosis (a condition in which there is abnormal wear on the cartilage [a touch, flexible tissue that lines joints and gives structure to parts of the body] and bones of the neck [cervical vertebrae]) 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 psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) were not used unnecessarily for two of two sampled residents (Resident 1 and 2) by failing to: 1. Document specific indications for Resident 1's targeted behavior of kicking the bed and pulling the gastrostomy tube (g-tube- a surgical opening fitted with a device to allow feeding to be administered directly to the stomach common for people with swallowing problems) for the use of quetiapine (Seroquel-an antipsychotic medication used to treat schizophrenia [a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness and social interactions] and lorazepam (Ativan-an anti-anxiety [characterized by feelings of worry, apprehension, or nervousness, often accompanied by physical symptoms like increased heart rate or sweating] medication) as indicated in the facility's policy and procedure (P&P).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to prevent an accident by failing to monitor one of two sampled residents (Resident 1) for constant kicking of leg when severely anxious or agitated in accordance with the facility's policy and procedure (P&P), titled, Safety and Supervision of Residents, This deficient practice placed Resident 1 at risk for fracture on the foot and had the potential to result in reoccurring foot injuries. Findings: During a review of Resident 1's Face Sheet (a document that compiles a resident's information, including name, address, date of birth , insurance details, and emergency contacts as well as medical history, allergies and current medications), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included fracture (break in the bone) of metatarsal bones (one or more of the five long bones that connect the ankle to the toes) left foot, Alzheimer's disease unspecified (a disease…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure the facility's consultant pharmacist's recommendation for the use of lorazepam (Ativan-an anti-anxiety [characterized by feelings of worry, apprehension, or nervousness, often accompanied by physical symptoms like increased heart rate or sweating] medication) and quetiapine (Seroquel-a psychoactive medication used to treat schizophrenia [a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness and social interactions], bipolar disorder [a mental health condition characterized by extreme shifts in mood ranging from intense highs to periods of intense lows], and depression [low mood, fatigue, and hopelessness]) in the Drug Regimen Review (DRR- a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing consequences and potential risks associated with medication) was communicated to the physician for one of two sampled residents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 appropriate pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) management for two of three sampled residents (Resident 2 and 3), by failing to ensure the Low Air Loss mattresses (LAL- a type of mattress used for residents who are at risk of developing pressure sores or already have pressure sores) were at the correct weight settings for the residents. This failure resulted in inadequate therapy from the LAL mattresses, with the potential to worsen Resident 2 and 3's current pressure ulcers. Findings: 1. During a review Resident 2's Face Sheet (admission record), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included pressure ulcer of sacral region (the area of the lower back, specifically encompassing the sacrum [triangular bone formed at the base of the spine]), unstageable (full-thickness skin and tissue loss in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to report an injury of unknown origin for one of one resident (Resident 1), who was observed with unexplained swelling (a raised/ enlarged, curved shape on the surface of your body which appears as a result of an injury or an illness) on the resident's right hand on 1/26/2025. This failure compromised Resident 1's safety and well-being by delaying appropriate medical evaluation and intervention. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of dementia (a progressive state of decline in mental abilities), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movement), and ataxia (a neurological condition that affects coordination, balance, and movement. It is caused by damage to the cerebellum, the part of the brain that controls these functions). 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 revise and update the Care Plan (CP- a tool that helps nurses and other care team members organize aspects of patient care according to a timeline, and allows them to think critically and holistically in a way that supports the patient's physical, psychological, social, and spiritual care) for one of one sampled resident (Resident 1), who had a fall incident on 2/11/2025. This failure resulted in a lack of new fall prevention interventions, placing Resident 1 at risk for another fall incident and/ or injury. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of dementia (a progressive state of decline in mental abilities), parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movement), and ataxia (a neurological condition that affects coordination, balance, 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 provide the necessary care and services in accordance with professional standards of practice (guidelines that outline the expectations and requirements for professionals) to attain or maintain the highest practicable physical well-being (highest possible level of functioning and well- being) for one of two sampled residents (Resident 1) by failing to: 1. Notify and coordinate with Resident 1's primary physician regarding Resident 1's neurologist ([NAME] -a medical doctor who is an expert in diagnosing and treating diseases and conditions of the brain, spinal cord, and nerves) order to continue Resident 1's lacosamide medication (Vimpat - a medication used to manage and control partial seizures [brief episodes of abnormal brain activity that can cause involuntary movements, loss of consciousness, or other symptoms]) on 11/5/2024. The facility did not notify [NAME] about Resident 1's lacosamide was stopped on 11/2/2024. 2. Notify and coordinate 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.

Based on observation, interview, and record review the facility failed to follow the menu and did not meet nutritional needs for 63 of 67 sampled residents on regular (diet with no restriction) and therapeutic diets (diet that controls certain food and nutrients) when [NAME] 1 did not follow the recipe for sauce and Cajun country rice. This failure had the potential to result in decrease food and nutrient intake resulting in unintended (not done on purpose) weight loss and increase blood pressure. Findings: During a review of the facility ' s recipe titled Recipe: Cajun Country Rice, dated 10/25/2024, the recipe indicated, Ingredients: margarine, onions, celery, green or red pepper, thyme and cayenne. During a review of the facility ' s recipe titled Recipe: Fish with Tarragon Sauce dated 10/25/2024, the recipe indicated, Sauce ingredients: margarine, onions, tarragon, salt, low sodium chicken broth, corn starch in water. During a review of the facility ' s daily cook ' s spreadsheet (a list containing types and amount of foods of what each diet type would receive) titled Winter…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and appearance for breakfast when: Cook 1 did not follow the recipes for a. for tarragon sauce resulting to salty food product. b. Cajun rice affecting the flavors. These failures had a potential to result in 63 of 67 (including Resident 1 and Resident 2) unplanned weight loss. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated the facility admitted Resident 2 on 6/12/2023 with diagnoses including spinal stenosis (when space inside the backbone is too small), muscle wasting (thinning) and atrophy (loss of muscles) and chronic kidney disease (when the kidney becomes damaged overtime) During a review of Resident 2 ' s Physician Order Sheet, dated 6/12/2023, the Physician Order Sheet indicated a physician ' s order for regular diet (a diet with no restriction). During a review of Resident 2 ' s Minimum Data Set (MDS- a resident assessment tool), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Refrigerator racks had chips. 2. Three (3) plain Greek yogurts, two (2) low fat yogurts, 2 cottage cheeses, and 3 low fat cottage cheese passed their expiration date in the walk-in refrigerator. 3. Four (4) dented (a hollow made by a blow or by pressure) cans were stored along with non-dented cans. 4. [NAME] 1 did not wash his hands after wiping the food preparation sink and then immediately returned to work and touched the scoops for lunch trayline ' s (an area where foods were assembled on the trays), use. These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 63 of 67 medically compromised residents who received food 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 interviews and record review, the facility failed to provide adequate supervision to prevent accidents for two (2) out of the four (4) sampled residents (Resident 1 and 4) by: 1. Failing to monitor Resident 1 at least every two (2) hours and as needed in accordance with the resident's care plan for Resident noted of picking up things quickly and hides it. On 1/3/2025, Resident 1 was observed with a ring (not the resident's ring) on the resident's left hand's middle finger. This deficient practice has resulted in Resident 1 's left hand middle finger to get swollen and appeared to have pus (a thick, usually yellowish-white, fluid matter that is formed as part of an inflammatory response typically associated with an infection) due to the ring that does not fit the resident and staff was not able to remove. Resident 1 was transferred to the hospital on 1/3/2025 and received intravenous (IV- way of giving the drug or substance through a needle or tube inserted into a vein) antibiotics (medicine that fight…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pad/ call light (a device used by residents to call staff) was within reach for four of 17 sampled residents (Residents 6, 20, 171, and 34) in accordance with the facility policy. This failure had the potential for Residents 6, 20, 171, and 34 not to be able to call for help or assistance which could result to delay in the delivery of care and services, especially during an emergency, which could lead to illness and harm to the residents. Findings: 1. During a review of Resident 6's admission Record, the admission Record indicated the facility admitted Resident 6 on 11/13/2023 with diagnoses which included hyperlipidemia (an excess of lipids or fats in your blood), anemia (when you have low levels of healthy red blood cells to carry oxygen throughout your body), muscle atrophy (wasting or thinning of muscle mass). During a review of Resident 6's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to post precautionary and safety sign indicating use of oxygen (therapy a treatment that provides extra oxygen for people to breathe in) for two (2) of three (3) sampled residents (Residents 120 and 121) as indicated in the facility's oxygen administration policy. This deficient practice could potentially place Residents 120 and 121 at risk for injury and serious harm. Findings: 1. During a review of Resident 120's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included epilepsy (brain activity that cause sudden uncontrollable electrical disturbance in the brain and sometimes loss of awareness) and asthma ( a chronic lung disease caused by narrowing and swelling of the airways in the lungs that makes it difficult to breathe). During a review of Resident 120's Minimum Data Set (MDS- a federally mandated assessment tool), dated…

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

Based on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with its policy and procedure by failing to ensure: 1. Food containers were completely sealed and intact. 2. A can opener was clean and free of gunk (unpleasantly sticky or messy substance) and rust (a reddish-brown substance that forms on the surface of iron and steel as a result of reacting with air and water) 3. Resident 16's breakfast tray was replaced with a clean tray and plate prior to being delivered back to the resident. 4. The kitchen trashcan was not overflowing and was not touching the rack of clean plate cover. 5. The dietary aid (DA1) did not use a dirty potholder while preparing food on 10/30/2024. These deficient practices have 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:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to observe infection control measures as indicated on the facility policy and procedure (P&P) when the facility failed to: 1. Ensure Certified Nursing Assistant 2 (CNA 2), Licensed Vocational Nurse 1 (LVN 1) and LVN 3 donned (put on) personal protective equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) prior to entering Resident 26's room, which was an enhanced barrier precautions room (EBP; gown and glove use during high-contact resident care activities for residents who are at increased risk of multidrug-resistant organism [MDRO; a microorganism that is resistant to multiple classes of antibiotics and antifungals] acquisition or who are known to be colonized [when one has the germs on or in their body but does not have symptoms of an infection] or infected with an MDRO). 2. Ensure CNA 2 wore gloves when handling a plastic bag full of dirty linen after changing Resident 26. 3.…

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

Based on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect for one (1) of one sampled resident (Resident 20). The facility staff was observed standing over the resident while assisting the resident during a meal. This deficient practice had the potential to affect Resident 20's self-esteem and self-worth. Findings: During a review of Resident 20's admission Record, the admission Record indicated the facility admitted Resident 20 on 8/10/2024 with the diagnoses that included lack of coordination, hyperlipidemia (excess of lipids or fats in your blood), chronic kidney disease (a long-term condition where the kidneys do not work as well as they should). During a review of Resident 20's History and Physical Examination (H&P), dated 8/23/2024, the H&P indicated Resident 20 does not have the capacity to understand and make decisions. During a review of Resident 20's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 6/7/2024, the MDS indicated Resident 20 was…

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

Based on interview and record review the facility failed to ensure the Advance Health Care Directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them) was readily retrievable by any facility staff for one (1) of two (2) sampled residents (Resident 53). This failure had the potential to result in nursing staff not knowing if Residents 53 had specific resident wishes to follow in case of an emergency. Findings: During a review of Resident 53's admission Record, the admission Record indicated the facility admitted Resident 53 on 10/22/2023 with diagnoses which include hypertension (when the pressure in your blood vessels is too high), Parkinson (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance), dyskinesia (uncontrolled, involuntary muscle movements ranging from shakes, tics, and tremors to full-body movements) During a review of Resident 53's History and Physical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to protect the resident's right to be free from verbal abuse (a range of words or behaviors use to manipulate, intimidate, and maintain power and control over someone) by staff for one (1) of 17 sampled residents (Resident 123) when Licensed Vocational Nurse 4 (LVN 4) used inappropriate language with Resident 123. This failure resulted in Resident 123 experiencing feelings of disappointment in the facility staff caring for her and had the potential to result in mental and emotional distress. Findings: During a review of Resident 123's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of spondylosis (a condition in which there is abnormal wear on the cartilage [a touch, flexible tissue that lines joints and gives structure to parts of the body] and bones of the neck [cervical vertebrae]) and anxiety disorder (a condition that causes excessive feelings of fear, dread, and uneasiness,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 12) was provided assistance while eating as indicated in the care plan and facility's policy and procedure. This deficient practice had the potential for decline and not to maximize Resident 12's functional ability to perform Activities of Daily Living (ADL, basic tasks that people need to do to live independently) which can affect the resident's physical and mental wellbeing. This failure also had the potential not to meet Resident 12's nutritional needs which could lead to further malnutrition (a condition that occurs when a person's body doesn't get the right amount of nutrients it needs to function properly) and hospitalization. Findings: During a review of Resident 12's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included mild protein calorie malnutrition and adult…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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) regarding respiratory infection control for one (1) of four (4) residents (Resident 220) by not ensuring Resident 220's nebulizer (an electrically powered machine that turns liquid medication into a mist so that it could be breathed directly into the lungs through a face mask) tubing was stored in a plastic bag with a label indicating the date the tubing was changed and name of the resident. This failure had the potential to put Resident 220 at risk for infection. Findings: During a review of Resident 220's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of atrial fibrillation (a type of irregular heartbeat that occurs when the upper chambers of the heart, called the atria, beat rapidly and out of sync) and pleural effusion (a condition where fluid builds up in the pleural space, the thin cavity between the lung and the…

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

Based on observation, interview and record review, the facility failed to provide care and services to one of two sampled residents (Resident 172) who is on hemodialysis (dialysis, a process of filtering the blood of a person whose kidneys are not working normally) by failing to ensure: 1. A dialysis emergency kit (dialysis e-kit, kit that contains emergency supplies that will be needed in case dialysis site got dislodged and/ or is bleeding) accessible at Resident 172 bedside. 2. A warning signage visible to warn facility staff not to use Resident 172's left arm for blood pressure (BP, pressure of blood on the wall your arteries as your heart pumps blood around your body) check, laboratory test/ blood draw, and no finger stick (pricking the skin of a finger to obtain blood usually done during blood sugar check). This failure may result in the inability to manage/ control the bleeding from hemodialysis access site and increases the risk of accidental use of Resident 172's left arm that can cause bleeding and damage to Resident 172's arteriovenous shunt (AV, a connection that's made…

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

Based on observation, interview, and record review, the facility failed to maintain an effective pest (a general term for organisms which may cause illnesses) control program in accordance with the facility's policy and procedure (P&P) by failing to ensure the facility was free from ants. This deficient practice had the potential for residents to get sick if the residents consume food that were contaminated by ants. Findings: During an observation on 10/29/2024 at 11:43 AM, more than 10 black ants were crawling along the door frames of Resident 3 and Resident 18. During an observation on 10/29/2024 at 4:10 PM, more than 10 black ants were crawling on Resident 3 and Resident 18 door frame. During observation on 10/30/2024 at 9:31 AM, two black ants were crawling along the door frame of Resident 3. During a concurrent observation and interview on 10/31/2024 at 4:24 PM, with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated there were three (3) ants crawling along Resident 28's doorway. During a concurrent observation and interview on 10/31/2024 at 4:30 PM, with Maintenance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician visited residents at least once every thirty days for the first ninety days after admission, and at least once every sixty days thereafter for two (2) of 2 sampled residents (Residents 1 & 4). This deficient practice had the potential to negatively affect the residents' quality of care and delay of treatment. Findings: 1. During a review of Resident 1's admission Record, the record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnosis of muscle wasting and atrophy (muscle shrinking), polyneuropathy (damage or disease affecting multiple nerves of the body, causing weakness, numbness, and burning pain), and anxiety disorder (persistent and excessive worry that interferes with daily activities). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 8/5/2024, the record indicated Resident 1's cognitive (mental action 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 provide treatments and services to minimize decline in mobility and joint range of motion (ROM, full movement potential of a joint) for one of three sampled residents (Resident 1) who had limited range of motion and functional mobility when the facility failed to ensure Resident 1's Restorative nursing aide (RNA) program (nursing aide program to help residents maintain their function and joint mobility) treatments were not delayed after the discontinuation of physical therapy services (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function). This failure had the potential to cause further decline in Resident 1's range of motion, functional mobility, and ability to participate in activities of daily living. Findings: During a review of Resident 1's Face Sheet dated 9/25/24, the Face Sheet indicated Resident 1 initially admitted to the facility on [DATE] with diagnosis including, but not limited to lumbago (back…

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

Based on observation, interview, and record review, the facility failed to implement appropriate infection control when facility failed to ensure they have process in place and followed by facility staff on how to properly disinfect cloth gait belts (safety device worn around the waist that can be used help safely transfer a person from one surface to another) after each resident use. This deficient practice had the potential to transmit infections among residents and staff. Findings: During an observation on 9/25/24 at 11:32 AM, Restorative Nursing Aide (RNA 1) was walking with a resident down the hallway with a walker. The resident had a cloth gait belt around the waist. During an interview on 9/25/24 at 12:05 PM, the Director of Rehabilitation (DOR) stated, all therapy and RNA staff used cloth gait belts when working with residents. DOR stated staff used disinfectant wipes to wipe the cloth gait belts after each resident use. DOR stated cloth gait belts were a porous surface. DOR stated staff did not launder the cloth gait belts in between resident use and used the cloth gait…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 initiate an individualized resident-centered care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident)for one (1) of two (2) sampled residents (Residents 1) to address the resident's need to have abduction pillow (stabilizes the legs and helps maintain proper leg positioning while recovering after surgery) in between his bilateral legs to prevent hip dislocation (medical emergency that occurs when the head of the thighbone separates from the hip socket) after a surgery. Resident 1 was observed not wearing the abduction pillow in between his bilateral legs on 9/23/2024. This deficient practice has the potential to result to Resident 1's delay in recovery and/ or having complication after a surgery. Findings: During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 1 's diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow physician orders for the use of an abduction pillow (stabilizes the legs and helps maintain proper leg positioning while recovering after surgery) for one of two residents (Resident 1). Resident 1 underwent a right hip hemiarthroplasty on 9/1/2024 (a surgical procedure that replaces the femoral head of the hip with a prosthetic component) due to a left hip fracture (a partial or complete break in the upper part of the thigh bone [femur] where it meets the pelvic bone) This deficient practice had the potential to result in right hip dislocation (an injury in which the hipbone is moved out of place) to Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 1's diagnoses included a right hip hemiarthroplasty (a surgical procedure that replaces the femoral head of the hip with a prosthetic component),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document monitoring for one of 2 sampled residents (Resident 1), for 72 hours after an alleged abuse. This deficient practice had the potential to place Resident 1 at risk for unmonitored mental, emotional changes that could negatively impact Resident 1 ' s well-being. Findings: During a review of Resident 1 ' s Face Sheet, the face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included dementia (decline in mental ability severe enough to interfere with daily functioning/life), muscle wasting (deterioration of muscle tissue) and atrophy (decrease in size of an organ or tissue) and 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) with psychotic features (delusions and hallucinations) . During a review of Resident 1 ' s History & Physical (H&P), dated 1/26/2024, the H&P indicated…

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

Based on observation, interview, and record review, the facility failed to ensure the call light (one of the major communication technologies that link nursing home staff to the needs of residents) was accessible and addressed in a timely manner for four of six residents (Resident 2, Resident 3, Resident 4, and Resident 5). This deficient practice had the potential to result in a delay in care and services for Resident 2,3,4 and 5. Findings: 1. During a review of Resident 2 ' s admission record indicated the facility admitted Resident 2 on 3/24/2024 with diagnosis which include muscle weakness, hypertension (high blood pressure), dysphagia (difficulty swallowing). During a review of Resident 2 ' s care plan for at risk for an unavoidable fall, future fall, or injury, dated 3/24/2024 indicated interventions that included call light or alternative call light within resident reach (close enough to be touched). During a review of Resident 2 ' s Minimum Data Set (MDS, standardized care and screening tool), dated 6/19/2024, indicated Resident 2 had severely impaired with 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.

Based on observation, interview, and record review the facility failed to ensure one (1) of five (5) sampled residents (Residents 1) was provided privacy during perineal care (the practice of washing the genital and rectal areas of the body). This deficient practice had the potential to result in Resident 1 ' s feelings of decreased self-esteem and self-worth. Findings: Druing a review of Resident 1 ' s admission record indicated the facility admitted Resident 1 on 7/5/2024 with diagnosis which include dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), depression (mood disorder that causes a persistent feeling of sadness and loss of interest), history of falling. During a review of Resident 1 ' s Minimum Data Set (MDS, standardized care and screening tool), dated 7/11/2024, indicated Resident 1 ' s cognition was intact (processes of thinking and reasoning skills) for daily decision making. The MDS indicated Resident 1 was partial /moderate assistance (helper does less than half the effort) on oral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Coronavirus disease 2019 (COVID-19 - a highly contagious infectious disease caused by severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) infection control according to the facility ' s policy and procedure. 1. The facility failed to ensure a COVID-19 designated room had appropriate signage indicating droplet isolation (measures to prevent transmission when infection can be spread to others by speaking, sneezing, or coughing) 2. Facility staff did not wear all required personal protective equipment (PPE - worn to prevent or minimize exposure to hazards) while assisting Resident 2 who was COVID-19 positive. 3. There were no face shields (aims to protect the wearer's entire face) readily available in Resident 2 ' s isolation cart (store and transport your facility's personal protective equipment). 4. Ensure Resident 2 ' s door remained closed according to the facility ' s policy and procedure. These failures had 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 follow the diet order for one of two sampled residents (Resident 2) in accordance with their policy. This deficient practice had the potential for Resident 2 not to receive his nutritional requirements which can lead to medical complications. Findings: A review of Resident 2's Face Sheet (admission Record) indicated resident was originally admitted on [DATE] and was readmitted on [DATE] with the following diagnoses of diabetes (a group of diseases that result in too much sugar in the blood) and hyperlipidemia (an elevated level of lipids - like cholesterol and triglycerides- in the blood). A review of Resident 2's History and Physical, dated 7/13/2024, indicated the resident does not have the capacity to understand and make decisions. A review of Resident 2's Minimum Data Set (MDS; a standardized care screening and assessment tool), dated 7/8/2024, indicated the resident is independent in cognitive (the functions your brain uses to 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 follow proper food handling practices for one of two sampled residents (Resident 1) in accordance with its policy and procedure by: 1. Failed to ensure Resident 1's corn bread muffin was free from non-edible item such as wire (unknown what type of wire) on 5/16/2024. 2. Failed to ensure Resident 1's cup, bowls, and forks were free from residue. These deficient practices had the potential to result in residents developing foodborne illness and injury which can lead to other serious medical complications and hospitalization. Findings: 1. A review of Resident 1's Face Sheet (admission Record) indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with the following diagnoses of anxiety (a feeling of fear, dread, and uneasiness) disorder and spinal stenosis (a narrowing of the spinal canal in the lower part of the back). A review of Resident 1's Minimum Data Set (MDS; a standardized care screening and assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents' (Resident 1) indwelling urinary catheter (tube that drains urine from the bladder into a drainage bag) was changed monthly as indicated in the physician's order. This deficient practice resulted in Resident 1 experiencing extreme pain when the indwelling catheter was changed on 3/15/24, five and half months after an order to change monthly was placed. Findings: A review of Resident 1's admission Record indicated Resident 1 was initially admitted to the facility on [DATE], with diagnoses of benign prostatic hyperplasia (age-associated prostate gland enlargement that can cause urination difficulty) with lower urinary tract symptoms (include voiding obstructive symptoms such as hesitance, poor and/or intermittent stream, straining, feeling of incomplete bladder emptying, dribbling, and storage or irritative symptoms such as frequency, urgency, urge incontinence [inability to control], and nocturia [waking up at night…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical doctor (MD) per physician ' s order after a change in condition for one of two sampled residents (Resident 1): 1 Licensed nurses did not notify the MD regarding Resident 1 ' s blood sugar (sugar located in the blood) below 120. 2. Licensed nurses did not notify the MD regarding Resident 1 not requiring medication administration of Humalog insulin (a medication that regulates the amount of sugar in the blood) for blood sugar below 120. This failure resulted in Resident 1 ' s MD not being notified of Resident 1 ' s blood sugar below 120 and not requiring insulin, which had the potential to negatively affect Resident 1 ' s treatment. Findings: During a review of Resident 1 ' s Face Sheet, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that include type 2 diabetes mellitus (DM2 - condition that results in too much sugar circulating in the blood), multiple sclerosis (MS – disease of the brain and spinal cord…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to withhold Humalog insulin (a medication that regulates the amount of sugar in the blood) doses as indicated on the physician ' s order for blood sugar levels (amount of sugar in the blood) less than 120 for one of two sampled residents (Resident 1). This failure had the potential for Resident 1 to become hypoglycemic (abnormally low levels of sugar in the blood) possibly leading to loss of consciousness (state of being awake, aware of and responding to one's surroundings) and death. Findings: During a review of Resident 1 ' s Face Sheet, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that include type 2 diabetes mellitus (DM2 - condition that results in too much sugar circulating in the blood), multiple sclerosis (MS – disease of the brain and spinal cord that causes the nerves to deteriorate or become permanently damaged, characterized by generalized muscle weakness and muscle wasting), bacteremia (the presence of bacteria…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow through with the Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) recommendation to obtain a PASRR level II evaluation (a comprehensive evaluation by the appropriate state-designated authority and determines whether the individual has mental illness, intellectual disability, or a related condition, determines the appropriate setting for the individual and recommends what, if any, specialized services and/or rehabilitative services the individual needs) for two of three sampled residents (Residents 1 and 22). This failure had the potential to result in Residents 1 and 22 not receiving the appropriate care, treatment, and services for their needs. Findings: 1. A review of Resident 1's Face Sheet indicated Resident 1 was admitted to the facility 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 3. A review of Resident 57's admission Record indicated the facility admitted the resident on 8/18/2023 with diagnoses that included fracture (break in the bone) of left femur (uppermost part of thighbone) and atherosclerosis of aorta (fat and calcium has built up in the inside wall of a large blood vessel). A review of the Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 8/22/2023, indicate Resident 57 had moderate cognitive impairment (ability to think and reason). A review of the undated History and Physical Examination indicated Resident 57 did not have the capacity to understand and make decisions. A record review of Physician Order Sheet for October 2023, indicated Resident 57 was ordered oxygen (O2) at 2 liters per minute via nasal cannula as needed for hypoxemia (low oxygen that need supplemental oxygen administered). During an observation on 10/23/2023 at 9:37 AM in Resident 57's room, Resident 57 was lying in bed with the head of bed slightly elevated. Resident 57 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement treatment for the prevention of pressure ulcer (painful wound caused as a result of pressure or friction) for three (3) of three sampled Residents (Resident 25, 27 and 22) in accordance with the facility's policy and procedure by failing to ensure: 1. and 2. The low air loss mattress (LAL, mattress used for residents who are at risk for developing sores or already have pressure ulcer designed to circulate a constant flow of air for the management of pressure sores) was on the correct settings for Residents 25 and 27. 3. Heel protectors were applied to Resident 22's bilateral heels as indicated on the Physician orders. These deficient practices have the potential to place the residents at risk for skin integrity complications and pressure injury. Findings: 1. A review of Resident 25's admission Record indicated the resident was admitted to the facility on [DATE] and re admitted on [DATE]. with diagnoses which included Alzheimer's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide oxygen therapy (treatment that provides supplemental, or extra oxygen) and necessary respiratory care services for four (4) of 4 sampled residents (Resident 5, 7, 30, and 48) in accordance with the facility's policy and procedure when: 1. Resident 5's oxygen tubing (a tubing that connects to the oxygen source used to deliver oxygen) connected to the oxygen humidifier (a device designed to increase the moisture in the air) was kinked from the top of the oxygen concentrator (a medical device that gives extra oxygen by taking and filtering air from the surroundings) and the end of nasal cannula tubing was disconnected from the oxygen humidifier. This deficient practice had the potential to place Resident 5 at risk for shortness of breath and/or hypoxia (low levels of oxygen in the body tissues) which could lead to serious injury or death. 2. Resident 30's oxygen humidifier jar was empty and did not have sterile water (water that is…

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

Based on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services by failing to store received medications in the medication room as indicated on the facility policy. This deficient practice had the potential for adverse reaction if these improper stored medications were administered to the residents. Findings: During an observation in Medication Storage Room on 10/25/2023 at 4:12 PM, with Licensed Vocational (LVN)7, the following were observed: 1. There were two medications: Humulin R (used to help manage blood sugar levels on adults with diabetes [high blood sugar level]) 100 units (unit of measure) vial delivered on 10/25/2023, and Latanoprost (treats high pressure inside the eye) 0.005% eye drops delivered on 10/24/2023, were placed inside a plastic bag with a melted, room temperature ice pack that was placed inside the medication box with other medications inside the bubble packs placed on top of the counter. 2. Medication Refrigerator have an ice built up in the freezer. During an interview with LVN 7 on 10/25/2023 at…

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

Based on observation, interview, and record review, the facility failed to: 1. Properly label foods and remove expired food items in the resident refrigerator, kitchen refrigerator, kitchen freezer and dry goods storage 2. Record refrigerator temperatures for the resident's communal refrigerator These failures had the potential to expose the residents to a food borne illness. Findings: 1. During a concurrent observation in the kitchen and interview on 10/23/23 at 8:43 AM with Dietary Service Supervisor (DSS), DSS stated a carton of soy milk in the refrigerator did not have a label indicating the opened date. DSS stated that it needed to be labeled with the date when it was opened because if the residents drink old milk, they can get sick. During a concurrent observation in the kitchen walk-in freezer and interview on 10/23/23 at 8:56 AM with DSS, a full tray of bacon was inside a partially uncovered metal container. DSS stated that it was supposed to be covered and that if it is left uncovered it could potentially contaminate other foods. During an observation in the dry goods…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 failed to ensure the lids to the trash dumpster were fully closed and trash was disposed of properly. This failure had the potential to lead to an infestation (the presence of an unusually large number of insects or animals) that could enter the facility and spread diseases to the residents. Findings: During an observation on 10/25/23 at 12:17 PM at the back of the facility grounds, there were two trash dumpster bins partially open with many bags of trash visible underneath the lids. Two lids were observed on one dumpster container. There was a bag of garbage resting in between both lids obstructing any possibility of closing. Small pieces of garbage were also seen on the floor near the dumpster bins. During a concurrent observation and interview on 10/25/23 at 12:18 PM near the trash dumpster area, housekeeper (HK) was observed placing a clear bag of garbage next to the dumpster bin on the ground. HK stated that they did not place it in the bin because it was already full. During an interview on 10/25/23 at 2:20 PM with Maintenance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy and procedure when: 1. Resident 5's oxygen humidifier (a device designed to increase the moisture in the air) was found sitting on the floor. 2. The facility staff failed to wear gloves while handling soiled re-usable gowns. 3. The facility failed to restock Personal Protective Equipment (PPE, is specialized clothing or equipment worn by an employee for protection against infectious materials, such as gowns, gloves, masks, and goggles) Cart of two Enhanced Standard Precaution (infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO, bacteria that resist treatment with more than one antibiotic] in nursing homes which involves gown and glove use during high-contact resident care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two (2) of 22 sampled residents (Resident 3 and 30) were informed of the risks and benefits of psychoactive medication (a drug that changes brain function and results in alterations in perception, mood, consciousness, or behavior). 1. Resident 30 was not provided a psychoactive medication consent form for the use of Lorazepam (a medication used to treat anxiety). 2. Resident 3 was not provided a psychoactive medication consent form for the use of Lorazepam, divalproex (a medication used to treat bipolar disorder), and Quetiapine (a medication used to treat bipolar disorder). These deficient practices resulted in Resident 30 and Resident 3 not being informed of their care and making an uninformed decision regarding the use of psychoactive medications. Findings: 1. A review of Resident 30's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis of major depressive disorder (a mood disorder that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the physician was notified of a significant weight loss (loss of more than five [5] percent of usual body weight over six [6] to 12 months) for one of 22 sampled residents (Resident 366). This failure had the potential to result in the decline of the resident's health due to delays in interventions to prevent further weight loss. Findings: During a review of Resident 366's admission Record Face Sheet dated 10/9/2023, the admission Record Face Sheet indicated the resident was admitted on [DATE], with a diagnoses of dysphagia (difficulty swallowing), gastro-esophageal reflux disease (GERD - a digestive disease in which stomach acid or contents irritates the food pipe lining), and dementia (impaired ability to remember, think, or make decision that interferes with doing everyday activities). During a review of Resident 366's History and Physical (H&P) dated 10/3/2023, the H&P indicated Resident 366 does not have the mental capacity to make medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on an observation, interview, and record review the facility failed to provide a safe, clean, and homelike environment for two (2) of 22 sampled residents (Resident 35 and Resident 167). This deficient practice had the potential to affect the resident's mental and psychosocial well-being. Findings: 1. A review of Resident 35's admission Record indicated the Resident 35 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) and trigeminal neuralgia (a type of nerve pain that affects the facial area). A review of the History and Physical Examination dated 9/23/2022, indicated Resident 35 had the capacity to understand and make decisions. A review of the Minimum Data Set (MDS) assessment, dated 9/25/2023, indicated Resident 35 usually made self-understood and understood others, and had moderately impaired cognitive skills (ability to make daily decision). The MDS indicated Resident 35…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 while ambulating to prevent accidents for one of three sampled residents (Resident 24) based on the resident's care plans. This deficient practice has resulted to Resident 24 had an assisted fall (suddenly go down onto the ground or towards the ground unintentionally or accidentally) incident on 10/23/2023 which may lead to serious injury to the resident. Findings: A review of Resident 24's admission Record indicated resident was originally admitted at the facility on 1/26/2023 and was readmitted on [DATE] with the diagnosis of Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) , lumbar spinal stenosis (a narrowing of the spinal canal in your lower back that may cause pain or numbness in your legs) and osteoarthritis (a type of arthritis [inflammation or swelling of one or more joints] that only…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Residents (Resident 366) maintained ideal body weight by failing to inform the doctor of resident's change of condition resulting in significant weight loss (loss of more than 5 percent of usual body weight over 6 to 12 months). This failure has the potential to result in serious injury, harm, impairment, or death to the resident. Findings: A review of Resident 366's physician progress note (from the hospital prior to admission) dated 10/2/2023, the Physician Progress Note indicated Resident 366's appetite ranged from poor to fair and refers to Resident 366 having anorexia (eating disorder that causes people to weigh less than considered healthy for their age and height, usually by excessive weight loss) due to not liking the food. A review of Resident 366's admission Record indicated the resident was admitted on [DATE], with a diagnosis of dysphagia (difficulty swallowing), gastro-esophageal reflux disease (GERD - a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the attending physician reviewed and signed the POLST (Physician Orders for Life-Sustaining Treatment - medical order form that informs medical staff what to do during a medical emergency and Resident is unable to speak for themselves) for one of one resident (Resident 366). This failure has the potential to result in psychological and physical harm if the resident's wishes during a medical emergency were not met. Findings: During a review of Resident 366's admission Record Face Sheet, the admission Record Face Sheet indicated the resident was admitted on [DATE], with a diagnoses of dysphagia (difficulty swallowing), gastro-esophageal reflux disease (GERD - a digestive disease in which stomach acid or contents irritates the food pipe lining), and dementia (impaired ability to remember, think, or make decision that interferes with doing everyday activities). During a review of Resident 366's History and Physical (H&P), dated 10/3/23, the H&P…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide pharmaceutical services to meet the needs of residents as indicated on the facility policy by failing to: a. Ensure the Change of Shift Narcotics (drug that produces analgesia [pain relief], narcosis [state of stupor or sleep], and addiction [physical dependence on the drug]) Reconciliation Records contained two Licensed Nurses' signatures for one (1) of two (2) carts. This deficient practice had the potential for harm to the resident due to an inaccurate record of narcotic medication use, and the loss of accountability, which could affect the controls against drug loss, diversion (abuse of prescription drugs), or theft. b. Clean and dry affected area as instructed by the manufacture's instruction, prior to applying lidocaine patch (a medication used to treat pain) to Resident's breast for 1 of 2 sampled residents (Resident 1). This deficient practice had the potential to decreased absorption of medication, which could result 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 appropriately monitor adverse side effects for one of five sampled residents (Resident 30) who was taking Lorazepam (medication used to treat anxiety) 1 milligram (mg) and verify the order with the physician as indicated in the facility's policy and procedure. These deficient practices had the potential for Resident 30 to experience adverse side effects without adequate monitoring. Findings: 1. A review of Resident 30's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 30's MDS, dated [DATE], indicated Resident 30 had moderately impaired cognitive skills. The MDS also indicated Resident 30 required extensive assistance in bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. A review of Resident 30's Physician Order Sheet dated October 2023, 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 ensure call light (used in healthcare facilities as an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for two out of 22 sampled residents (Resident 29 and Resident 7) as indicated in the facility's policy and procedure. These deficient practices had the potential not to meet the residents' needs and preference. Findings: 1. A review of Resident 29's admission Record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE]. The admission Record indicated, Resident 2's with diagnoses which included Diabetes Mellitus (DM, a condition that happens when your blood sugar [glucose] is too high), left hemiplegia (paralysis of one side of the body) and hypertension (HTN, high blood pressure) A review of Resident 29's MDS dated [DATE], indicated Resident 29 has moderately impaired cognitive skills (mental action or process of acquiring knowledge 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 provide interventions to prevent a fall (to move unintentionally or unexpectedly onto or toward the ground from a higher place) for two of two sampled residents (Resident 1 and 7) by failing to ensure the residents' bed was kept in low bed position (bed closer to the ground). These deficient practices resulted in Resident 1 suffering a fall on 9/29/23 and was transferred to the general acute care hospital (GACH). It also placed Resident 7 at risk of falling from the bed on 10/3/23. Findings: A review of the facility's face sheet indicated Resident 1 was admitted on [DATE] at 4:30 p.m. to the facility with diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), unspecified dementia (symptoms affecting memory, thinking and social abilities), Coronavirus 2019 (Covid-19, an infectious respiratory disease that is very contagious). A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to promote dignity and respect for one of three sampled residents (Resident 1) by failing to comply with the resident's request to not interact with one of the facility staff. This deficient practice had resulted in Resident 1 feeling disrespected and angry, which had the potential to affect Resident 1's psychosocial well-being. Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE]. Resident 1's diagnoses included Colon Cancer (a cancer of the large intestine, which may affect the colon or rectum), diabetes mellitus (a condition that happens when your blood sugar [glucose] is too high) and hypertension (high blood pressure) A review of Resident 1's History and Physical (H&P), dated 7/1/2023, indicated Resident 1 has the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 7/19/2023, indicated Resident…

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