The Bellefontaine Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to set the low air loss mattress (LAL mattress, a specialized medical bed mattress designed to prevent and treat pressure ulcers [localized damage to the skin and/or underlying tissue usually over a bony prominence] by constantly blowing a tiny amount of air through the tiny holes) in accordance with the weight for one (1) of three (3) sampled residents (Residents 117) reviewed for pressure ulcer. This deficient practice placed Resident 117 at risk for development of new pressure ulcers.Findings: During a review of Resident 117's admission Record, the admission Record indicated Resident 117 was admitted to the facility on [DATE] with diagnoses that included adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity) and protein calorie malnutrition (a condition that occurs when a person's body doesn't get the right amount of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the feet of one (1) of four (4) sampled residents (Residents 20) reviewed for accident were placed on the wheelchair's footrest during wheelchair transport.This deficient practice placed Resident 20 at risk of injury and serious harm.Findings: During a review of Resident 20's admission Record, the admission Record indicated Resident 20 was admitted to the facility on [DATE] with diagnoses that included lack of coordination, enthesopathy (any damage, disease or irritation at the exact spot where the tendons or ligaments attach to the bones) and bone density and structure disorder (thin and brittle bones [a physical state where bones become fragile, weak, and structurally compromised causing them to fracture or break much more easily than normal]. During a review of Resident 20's Minimum Data Set (MDS- a resident assessment tool), dated 5/7/2026, the MDS indicated Resident 20 had severe impairment in 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 observation, interview and record review, the facility failed to perform a trauma informed assessment (a structured clinical approach that evaluates how an individual's past and present trauma impacts their overall functioning, relationships, and well-being) for one (1) of two (2) sampled residents (Resident 134) who has a diagnosis of Post Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event). This deficient practice has the potential to affect Resident 134's psychological (relates to the mind, mental processes, and behavior) well-being and affects the resident's quality of life.Findings:During a review of Resident 134's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following but not limited to diagnoses of PTSD, anxiety (an emotion characterized by feelings of tension, worried thoughts, and physical changes like a rapid heartbeat), and depression (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident 84) observed during medication pass received Metformin Hydrochloride (drug used to lower and control blood sugar levels in people with type 2 diabetes mellitus [DM, a disorder characterized by difficulty in blood sugar control and poor wound healing)] ) with meals as indicated on the physician's order and facility's policy. This deficient practice placed Resident 84 at risk for gastrointestinal (GI, involves the mouth, esophagus, stomach, small and large intestines, rectum and anus) side effects which included nausea, diarrhea, and stomach cramping. Findings: During a review of Resident 84's admission Record, the admission Record indicated Resident 84 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included type 2 DM and gastro-esophageal reflux disease (GERD- when a valve between the stomach and food pipe does not close tightly, letting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 four (4) dumpsters (a movable waste container) and 1 trash can were covered and closed per facility policy and procedure (P&P). This failure had the potential to attract vermin (animals that are believed to be harmful, carry diseases such as rodents, parasitic worms, or insects), pests (any living thing that has a negative effect on humans), and wildlife (undomesticated animal species), increasing the risk of disease transmission and health issues for residents, staff, and the surrounding community.During an observation on 6/2/2026 at 7:35 AM outside to the left of the building next to the facility driveway, one gray trash can was observed overflowing with brown paper, plastic bags and a surgical mask with no cover or lid. One dumpster was also observed with the lid propped open with a cardboard box. During an interview on 6/3/2026 at 2:45 PM with Dietary Supervisor (DS), DS stated it is important that dumpster lids are not propped open because it is unsanitary. DS added that keeping 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 observe infection control measures for two (2) of 25 sampled residents (Residents 4 and 137) as indicated in the facility policy by failing to ensure:Treatment Nurse 2 (TN 2) changed gloves and performed hand hygiene (washing hands with soap and water for at least 20 seconds, or using alcohol-based sanitizer, to effectively eliminate germs and prevent disease spread) after touching the privacy curtain (a ceiling-suspended fabric partition used to temporarily section off patient beds, exam areas, or treatment spaces to protect patient dignity, ensure confidentiality, and create semi-private spaces) and before continuing wound treatment for Resident 4.Certified Nursing Assistant 4 (CNA 4) doff (remove an item or clothing) and dispose of PPE and perform hand hygiene after providing peri-care (cleaning the genitals and anal area) to Resident 38.These failures had the potential to result in an increased risk for the spread of bacteria, viruses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an antibiotic surveillance (is the continuous tracking and analysis of how antibiotics (medicines used to treat bacterial infections by killing bacteria or inhibiting their growth] are used and how bacteria are becoming resistant to them) data collection form was completed for one (1) of two (2) sampled residents (Resident 134) who was receiving antibiotic therapy. This deficient practice had the potential for Resident 134 to be prescribed inappropriate antibiotic and increased the risk of developing antibiotic-resistant organisms (bacteria that are not controlled or killed by antibiotics).Findings:During a review of Resident 134's admission Record, the admission Record indicated the resident was admitted on [DATE] with the following but not limited to diagnoses of otitis media (middle ear infection or inflammation) of the right ear, bronchitis (an inflammation of the main airway/windpipe), and pneumonia (an infection/ inflammation in 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 DPS:Based on observation, interview and record review, the facility failed to administer an intravenous (IV -within a vein) medication at the prescribed infusion rate for one of two sampled residents (Resident 3). This failure resulted in Resident 3's Vancomycin (Vanco- a medication used to treat infections caused by bacteria) being administered slower than prescribed, with the potential to lead to ineffective treatment or bacterial resistance for Resident 3.Findings:During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included, but not limited to, urinary tract infection (UTI- an infection in the bladder/urinary tract), gout (a painful form of arthritis [joint pain or swelling, stiffness, and tenderness] caused by too much uric acid [a waste product left over from normal chemical processes in the body] in the blood) and fracture (a crack or break in a bone) of the right femur (thigh bone) neck. During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to maintain accurate documentation of the urine output for one (1) of 2 sampled residents (Residents 1) with indwelling catheter (a flexible tube that passes through the urethra [a tube through which the urine leaves the body] and into the bladder to drain urine) in the resident's Medication Administration Record (MAR) and urine output log in accordance with the facility's policy. This deficient practice had the potential to result in miscommunication among staff and resulted in the medical records inaccurate representation of care provided to Residents 1.Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis of urinary retention (inability to completely empty the bladder). During a review of Resident 1's order summary report dated 8/13/2025, the order summary report indicated an order to record indwelling catheter output in milliliter (ml - units of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the ampicillin (drug used to prevent and treat several bacterial infections) six (6) grams (gm - unit of measurement) every 12 hours intravenous piggyback (IVPB- a way to give a patient a dose of medicine directly into the vein through the existing line) was reconciled (formal process of creating the most accurate and complete list of resident's current medications from the previous health care facility or from home, and comparing that the list with the medications being prescribed by the physician of the receiving healthcare facility) and administered for one (1) of two (2) sampled residents (Resident 1) in accordance with the facility's policy and procedure. This deficient practice resulted in Resident 1 not receiving the ampicillin for the scheduled time frame while the resident is in the facility which potentially resulted in delayed healing of the resident's right knee periprosthetic joint infection (PJI- an infection 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 follow its Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions) policy to ensure the advance directive was in the chart for two (2) of four (4) sampled residents (Resident 30 and Resident 222). This deficient practice had the potential for Resident 30 and Resident 222 to not have their wishes met regarding life-sustaining treatment (any treatment that serves to prolong life without reversing the underlying medical condition) or health care. Findings: 1. During a review of Resident 30's admission Record, the admission Record indicated resident was originally admitted on [DATE] and was readmitted on [DATE] with the following diagnoses of End Stage Renal Disease (ESRD- irreversible kidney failure) and atherosclerotic heart disease (the buildup of fats, cholesterol and other substances in and on the artery walls). During a review of Resident 30'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: 1. Foods are stored in a manner that prevents foodborne illness (illness that comes from eating contaminated food) for residents. 2. All personnels in the kitchen, which includes outside maintenance, working on kitchen equipment, wore hair nets. These deficient practices have the potential to result in foodborne illness in a population of 103 residents who consume the food prepared by the facility every day. Findings: During an observation on 4/28/2025 at 8:05 a.m. in the walk-in refrigerator, the following items were found: 1. Sesame dressing received on 2/11/25 and opened at 2/25/25. 2. Multiple small cups of cranberry and orange juice on a large tray without a prepared date found on the cups or on the tray. During an interview on 4/28/2025 at 8:10 AM, [NAME] 1 (CK 1) stated the sesame dressing should only be good for one (1) month once opened and should be thrown after to prevent the residents from getting sick. During a concurrent interview and review of the facilities Dry Goods Storage from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to observe infection control measures for three of 22 sampled residents (Residents 175, 173 and 271) as indicated on the facility policy by failing to ensure: 1. Treatment Nurse 1 (TN 1) doff (take off) Personal Protective Equipment (PPE, protective clothing, goggles, or other garments to prevent or minimize exposure to and spread of infection or illness) and perform hand hygiene (cleaning hands to prevent germs) after repositioning Resident 175 and before continuing wound care treatment. 2. Licensed Vocational Nurse 5 (LVN 5) doff PPE after administering medications to Resident 173 and before touching the medication cart. This deficient practice has the potential to spread infection to staff and residents. 3. Resident 271's indwelling catheter drainage bag (Foley catheter- a tube that allows urine to drain from the bladder into a drainage bag) was not touching the floor. This deficient practice had the potential to expose Resident 271 to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 39) was treated with respect and dignity in accordance with the facility policy by failing to keep the resident's bed linen clean and free of food particles/ crumbs. This deficient practice had the potential to affect the resident's self-worth and self-esteem. Findings: During a review of Resident 39's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the following diagnoses of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and dementia (a progressive state of decline in mental abilities). During a review of Resident 39's Minimum Data Set (MDS - a resident assessment tool), dated 3/8/2025, the MDS indicated resident was severely impaired (never/ rarely make decisions) with cognitive (the ability to understand and make decisions)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 223 and 53) were provided with the following in accordance with the facility's policy: 1. Resident 223's call light (device used by residents to call staff) was not within arm's reach. This deficient practice had the potential for Resident 223 not to be able to call the facility staff for help or assistance, especially during an emergency. 2. Facility failed to ensure Resident 53's bed had a footboard (a flat board placed at the foot of a resident's bed to help maintain proper positioning and alignment, thereby preventing the feet from slipping off the bed). This deficient practice had the potential to negatively impact Resident 53's comfort and physical well-being due to improper positioning of the foot. Findings: 1. During a review of Resident 223's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis of post laminectomy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to provide privacy and confidentiality (safeguarding the content of information including video, audio, or other computer stored information from unauthorized disclosure without the consent of the resident and/or the individual's surrogate or representative) for one of 22 sampled residents (Resident 223) when Resident 223's medical records were left exposed by leaving the computer unattended and not turning off the computer screen on 5/1/2025. This deficient practice violated Resident 223's right to privacy and confidentiality. Findings: During a review of Resident 223's admission Record, the admission Record indicated Resident 223 was admitted to the facility on [DATE] with diagnoses that included post laminectomy syndrome (chronic pain that persist after a laminectomy [surgical removal of the roof of the spinal canal] or other back surgery), arthrodesis status (when a joint has been surgically fused or fixed to prevent movement,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurate assessment of resident's medication on the Minimum Data Set (MDS, a resident assessment tool) for one (1) of 22 sampled residents (Resident 50) as indicated on the facility policy. This deficient practice had the potential for the facility to not develop and implement a resident centered care plan for Resident 50 to receive necessary care and services. Findings: During a review of Resident 50's admission Record, the admission Record indicated Resident 50 was admitted to the facility on [DATE] with diagnoses that included unspecified dislocation of left hip (when the ball at the end of the thighbone is pushed out of its socket in the pelvis), abnormalities of gait (walking) and mobility, and hyperlipidemia (a condition in which there are high levels of fat particles in the blood). During a review of Resident 50's MDS, dated [DATE], the MDS indicated Resident 50 was assessed having intact memory and cognitive (mental action or process of…

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

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 (PASARR-a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) recommendation to obtain a PASARR level II (a detailed assessment performed on individuals identified during a Level I PASSR screening as potentially having a serious mental illness [SMI], intellectual disability [ID], developmental disability [DD], or related condition [RC]) evaluation for one (Resident 84) of three sampled residents after receiving a Level II Notice of Attempted Evaluation Letter, dated 11/7/2024. This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 84. Findings: During a review of Resident 84's admission Record, the admission Record indicated the facility initially admitted Resident 84 on 9/3/2022 and readmitted on [DATE] with diagnoses including but not limited…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the fluid restriction for one (1) of three (3) sampled residents (Resident 102) as indicated on the physician's order. This deficient practice has the potential for Resident 102 to have fluid overload (a condition where the body has too much fluid which could lead to various symptoms, including swelling, shortness of breath, and weight gain). Findings: During a review of Resident 102's admission Record, the admission Record indicated the resident was admitted on [DATE] with diagnoses that included congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter as well as they should). During a review of Resident 102's Care Plan initiated on 2/12/2025, the Care Plan indicated Resident 102 was at risk for heart failure with an approach plan to encourage 1200 cc fluid restriction…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper application of resting hand splint (provide support and rest to the hand and wrist, particularly during periods of rest or sleep to help reduce pain, swelling, stiffness, and contractures [shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints]) and elbow splint (a support or brace that helps stabilize and protect the elbow joint) for one (1) of four (4) sampled residents (Resident 56) with limited range of motion (ROM - movement of the joints) as indicate on the physician's order. This deficient practice had the potential to cause complications such as pain, swelling, and contractures) to Resident 56's right arm, fingers and wrist. Findings: During a review of Resident 56's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses of contracture (a stiffening/shortening…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow its policy to post a No Smoking sign outside the room of one of two sampled residents (Resident 222) while the oxygen was in use. This deficient practice had the potential to cause fire which could harm the residents, staff, and visitors at the facility. Findings: During a review of Resident 222's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis of asthma (a condition in which a person's airways become inflamed, narrows, swells, and produces extra mucus, which makes it difficult to breathe). During a review of Resident 222's Minimum Data Set (MDS- a resident assessment tool), dated 4/15/2025, the MDS indicated Resident 222 had an intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 222 required substantial assistance (helper does more than half the effort) with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one of three sampled residents (Resident 62) in accordance with the facility policy by failing to administer cholecalciferol (a dietary supplement used to treat Vitamin D deficiency) and Miralax (a medication used to treat occasional constipation [difficult bowel movement]) as indicated on the physician's order. This deficient practice had the potential for Resident 62 to experience constipation, muscle weakness, and bone and joint pain. Findings: During a review of Resident 62's admission Record, the admission Record indicated Resident 62 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included encounter for attention to gastrostomy (the care and maintenance of an artificial opening into the stomach, typically a gastrostomy tube [G-tube]), respiratory failure (a condition where the lungs are unable to adequately deliver oxygen to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five (5) percent (%). Two (2) medication errors (the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order; manufacturers specifications / accepted professional standards and principles) out of 33 opportunities (observed administered medications) for error which yielded a facility medication error rate of 6.06 percent for one of three sampled residents (Resident 62) observed during medication administration (med pass). Licensed Vocational Nurse 8 (LVN 8) failed to administer cholecalciferol (a dietary supplement used to treat Vitamin D deficiency) and Miralax (a medication used to treat occasional constipation [difficult bowel movement) once daily as indicated in the Physician's order. This deficient practice had the potential to result in adverse reactions (an undesired harmful effect resulting from a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to promptly provide dental services for one of two sampled residents (Resident 46) as in accordance with the facility's Dental Services policy. This deficient practice resulted in Resident 46 having pain when wearing dentures, poor food intake from inability to effectively chew food and had the potential to result in weight loss, lack of energy, and loss of muscle mass. Findings: During a review of Resident 46's admission Record, the admission Record indicated the facility initially admitted Resident 46 on 6/17/2020 and readmitted on [DATE] with diagnoses including, but not limited to, hypertension (high blood pressure), dysphagia (difficulty swallowing), protein-calorie malnutrition (state of inadequate intake of food as a source of protein[builds, maintains, and replaces the tissues in the body], calories [unit of measurement for the energy contained n food], and other essential nutrients [chemical compounds in food that are used by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure food brought in by family met the prescribed diet and ensure food safety requirements for one (Resident 66) of three sampled residents. This deficient practice had the potential to result in electrolyte (crucial for various bodily functions, including maintaining fluid balance, regulating muscle and nerve function, and supporting heart health) imbalances, fluid overload (medical condition where there is too much fluid in the body), and food borne illnesses (food poisoning) to Resident 66 that can lead to other serious complications and hospitalization. Findings: During a review of Resident 66's admission Record, the admission Record indicated the facility initially admitted the resident on 1/29/2024 and readmitted on [DATE] with diagnoses including, but not limited to, chronic kidney disease stage five (final stage of kidney failure, also known as end stage renal disease [ESRD]), dependence on hemodialysis (a treatment to cleanse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 bed was in locked position for one (1) of two (2) sampled residents (Resident 1) who fell on 4/4/2025 around 9 am and was high risk for fall (to drop or descend under the force of gravity, as to a lower place through loss or lack of support) as indicated on the resident ' s care plan. This deficient practice had the potential to result in serious injuries or death in an event of another fall. 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 but not limit tomuscle weakness, osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D) and high blood pressure. During a review of Resident 1 ' s Minimum Data Set (MDS- a resident assessment tool), dated 3/13/2025, the MDS indicated Resident 1 had severe…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call light device (one of the major communication technologies that link nursing home staff to the needs of residents) was within reach (an arm's length) for two (2) of three (3) sampled residents (Resident 2 and 3). This had the potential to result in a delay in care for Resident 2 and 3 and not receive the necessary care and services which can lead to illness or serious injury. Findings: 1. During a review of Resident 2's admission record indicated the facility admitted Resident 2 on 8/2/24 with diagnosis which include fall on the same level, dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), hypertension (when the pressure in your blood vessels is too high). During a review of Resident 2's Minimum Data Set (MDS, standardized care and screening tool), dated 07/28/24, indicated Resident 2 was severely impaired with cognitive (processes of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain safe, clean, comfortable sanitary and home like environment for one (2) of four (4) sampled residents (Resident 3 and 4) by not ensuring that Resident 3 and 4's trash can was not overflowing, and there were no clutters on the floor. These deficient practices caused an unsanitary and had a potential for residents to be placed at risk for injury. Findings: 1. During a review of Resident 3's admission record indicated the facility admitted Resident 3 on 10/26/2023 with diagnosis which include quadriplegia (a condition where all four limbs experience paralysis), respiratory failure, and hyperlipidemia (an excess of lipids or fats in your blood). During a review of Resident 3's Fall Assessment (checks your risk of falling) dated 1/6/2024 score was 17 which means Resident 3 was at risk for fall. During a review of Resident 3's Minimum Data Set (MDS, standardized care and screening tool), dated 6/21/2024, indicated Resident 3 was…

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

Based on observation, interview, and record review, the facility failed to 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 three (3) sampled residents (Resident 1) was switched on. This deficient practice had the potential for Resident 1's pressure ulcer to worsen and for the resident to develop new pressure injury. Findings: During a review of Resident 1's admission Record indicated the facility admitted Resident 1 on 8/22/2023. Resident 1's diagnoses lack of coordination, muscle weakness, and dementia (the loss of the ability to think, remember, and reason to levels that affect daily life and activities). During a review of Resident 1's Order Summary Report order date 2/23/2024 indicated: Treatment: LAL mattress for pressure distribution and skin integrity management every shift. During a review of Resident 1's Minimum Data Set (MDS, standardized care and screening tool), dated 5/20/2024 indicated Resident 1 was severely impaired with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. A review of Resident 84's admission Record indicated the facility admitted Resident 84 on 3/18/2021 with diagnoses which include muscle weakness, lack of coordination, hypertension (when the pressure in the resident ' s blood vessels is too high). A review of Resident 84's MDS, dated [DATE], indicated Resident 84 was moderately impaired with cognitive skills for daily decision making. The MDS indicated Resident 84 substantial/ maximum assistance (helper does more than half the effort. Helper lifts or hold trunks or limbs and provide more than half the effort) on toilet hygiene, shower /bathe self, personal hygiene. A review of Resident 84's Order Summary Report, dated 2/25/2024, indicated Low bed to decrease potential for injury. A review of Resident 84's Care Plan, revised 11/21/23, indicated Resident 84 was high risk for falling related to poor safety awareness, decrease strength endurance, unsteady gait, visual deficit, and history of fall. The care plan intervention included was for the facility staff to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide the necessary care for two (2) of 2 sampled residents (Residents 79 and 85) who are on oxygen therapy (supplemental oxygen, a treatment that provides you with extra oxygen to breath) by: 1. Facility failed to ensure Resident 79's nasal cannula (NC; a device that delivers extra oxygen through a tube and into your nose) oxygen tubing connected to their oxygen tank was stored in a bag and not sprawled out along the Resident 79 ' s wheelchair seat and touching the wheelchair wheels and failed to ensure that the resident ' s humidified (increased moisture) oxygen nasal cannula tubing was not touching the floor when in use. 2. Facility failed to ensure Resident 85's continuous positive airway pressure (CPAP, a machine that uses mild air pressure to keep breathing airways open while you sleep) has an order, and CPAP mask was stored in a bag when not in used on 5/13/2024 and 5/16/2024. This failure had the potential to result in Resident's…

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

Based on interview and record review, the facility failed to ensure control and accountability of Controlled Substance (CS- medications which have a potential for abuse and may also lead to physical or psychological dependence) awaiting final disposition (process of returning and/or destroying unused medications) when the facility's Narcotic and Hypnotic Record (also known as CS) accountability logs for March 2024 and May 2024 did not include the verifying signatures of either the Director of Nursing (DON) or a Registered Nurse (RN) along with the Licensed Vocational Nurse (LVN), as indicated on the facility policy and procedures. This deficient practice increased the opportunity for CS diversion (the transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use) and accidental exposure of residents to harmful medications, potentially negatively impacting their health and wellbeing. Findings: A record review on 5/15/2024 at 1:58 PM, with the DON, the Narcotic and Hypnotic Record accountability logs for March and May 2024 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 Cross referenced with 656 Based on interview and record review, the facility failed to include appropriate monitoring to ensure resident's drug regimen was free from unnecessary medications (any medication in excessive dose, excessive duration, without adequate monitoring) for one of five sampled residents (Resident 119) by failing to monitor Resident 119 for sign and symptoms of bleeding for the use of Eliquis (a medication used for atrial fibrillation [a condition with irregular, fast heart rate caused by poor blood flow,]) for 15 days. This deficient practice had the potential to cause Residents 119 to receive suboptimal (less than the highest standard or quality) care, experience serious adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have) possibly resulting in bleeding, hospitalization, or death. Findings: A review of Resident 119's admission Record (a document containing demographic and diagnostic information) indicated Resident 119 was admitted to the facility on…

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

Based on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with their policy and procedure by failing to ensure: 1. Food in the kitchen were labeled with item name, date opened and expiration date. 2. Prepared food are dated correctly. 3. Various food containers are sealed properly. 4. Expired food was removed from the shelves and discarded. 5. Juice machine log was updated. These deficient practices had the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness ([food poisoning] with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever) and can lead to other serious medical complications and hospitalization. Findings: During concurrent observation in the facility's kitchen on 5/13/2024 at 7:46 AM with the Dietary Supervisor (DS), the DS stated the bag of chocolate cookies was not labeled with best by date. The DS stated the milk container was dirty and was not labeled with open date and expiration…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow its policy and procedure titled, Advance Directive (a written statement of a resident's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the resident be unable to communicate) for two of seven (7) sampled residents (Residents 102 and 324) by not ensuring a copy of the resident's Advance Directive was readily accessible in their medical chart. This failure had the potential to cause conflict with the residents' wishes regarding health care and nursing staff not knowing if Resident 102 had specific wishes to follow in case of an emergency. Findings: 1. A review of Resident 102's admission Record, indicated the resident was initially admitted to the facility on [DATE] with diagnoses of cerebral ischemia (acute [sudden onset] brain injury that results from impaired blood flow to the brain) and sepsis (a life-threatening condition that occurs when the body damages its own tissues and…

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

Based on observation, interview, and record review the facility failed to provide a clean comfortable, sanitary, and home like environment for one (1) of nine (9) sampled residents (Resident 47) by not ensuring that Resident 47 ' s bathroom toilet was free of fecal matter. This deficient practice caused an unsanitary environment and had a potential for Resident 27 to be placed at risk for infection injury. Findings: A review of Resident 47 ' s admission Record indicated the facility admitted Resident 47 on 9/11/2017 with the diagnoses that included muscle weakness, abnormal posture, hypertension (when the pressure in your blood vessels is too high). A review of Resident 47 ' s Minimum Data Set (MDS, standardized care and screening tool), dated 3/30/2024, indicated Resident 47 was assessed to need substantial maximal assistance (helper does more than half the effort) on toileting, and personal hygiene. The MDS indicated Resident 47 was dependent (helper does all the effort) on toilet transfer (ability to get on and off the toilet or commode. During concurrent observation in Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Cross referenced with F656 and F758 Based on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS, a standardized assessment and care planning tool) by including a diagnosis of schizophrenia (a mental disorder characterized by disordered thinking, behaviors, and emotions that impairs daily functioning) for one of two residents sampled (Resident 119) without evidence to support this as an established diagnosis in the resident's clinical record. The deficient practice increased the risk for Resident 119 not to receive the care and treatment according to resident's needs possibly leading to a decline in overall health and well-being of the resident. Findings: A review of Resident 119's admission Record (a document containing demographic and diagnostic information) indicated Resident 119 was admitted to the facility on [DATE] with a diagnosis including schizophrenia. A review of Resident 119's Medication Administration Record (MAR - a record of mediations administered 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 develop and implement a comprehensive resident centered care plan for two of 23 sampled residents (Residents 103 and 119) as indicated on the facility policy and procedure by failing to ensure: 1. Resident 103 had a care plan to address Resident 103's use of Donepezil (medication used to treat dementia [a brain disorder that affects the ability to remember, think clearly, communicate, and perform daily activities]) and monitoring of cerebrovascular accidents (CVA, an interruption in the flow of blood to cells in the brain by thinning the blood) prophylaxis (PPX, action taken to prevent disease) use of plavix (medication used to prevent CVA and Deep Vein thrombosis [DVT, a condition when a blood clot forms in one or more of the deep veins in the body]) 2. Resident 119 had a care plan which included measurable goals and outcomes for monitoring atrial fibrillation (a condition with irregular, fast heart rate caused by poor blood flow), use of Eliquis (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide services for two (2) out of three (3) sampled residents (Residents 323 and 53) in accordance with the facility ' s policy and procedure when: 1. Facility did not inform the primary physician of Resident 323 ' s rashes on both arms and back on 5/12/2024 and was not referred to dermatology (involves the study, research, diagnosis, and management of any health conditions that may affect the skin, fat hair, nails, and membranes) for further treatment as indicated in the care plan. 2. The facility failed to inform Resident 53 ' s primary physician (MD) that Resident 53 has been refusing to elevate his right leg on a pillow and to verify with the MD if resident needs an order for Thrombo-Embolic Deterrent (TED hose, specially designed knee-high, thigh-high, or waist-high stockings that help prevent blood clots and swelling in your legs). This deficient practice had the potential to result in a delay in reducing the swelling in 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 Physician Order and implement care plan interventions to provide care and services for one (1) of four sampled residents (Resident 68) by failing to ensure: Resident 68's head of bed (HOB) was elevated to at least 30 degrees while receiving g-tube (gastrostomy tube-a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) feedings. This failure had the potential for Resident 68 to be at risk for aspiration (a condition in which food, liquids, saliva, or vomit enters the airway or lungs) pneumonia which could result in harm, serious illness, or death. Findings: During a review of Resident 68's admission Record (Face Sheet), indicated Resident 68 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing), dementia (loss of memory, language, problem-solving and other thinking…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 address the use of Trazadone (used to treat major depressive disorder [a mood disorder that causes a persistent feeling of sadness and loss of interest], anxiety disorders [persistent and excessive worry that interferes with daily activities], and insomnia [hard to fall asleep, hard to stay asleep]) order, on the medication regimen review (MRR, or Drug Regimen Review, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) for one of five sampled Residents (Resident 61) in accordance with the facility policy. This deficient practice had the potential for unnecessary medication administered to Residents 61, which could result to serious harm. Findings: A review of Resident 61's admission Record indicated an initial admission to the facility on 8/5/2021, and readmission on [DATE] with diagnoses of major depressive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 five (5) sampled residents (Residents 119 and 61) were free from unnecessary use of psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility policy and procedure by failing to ensure : 1. Resident 119 had a specific, measurable target behaviors related to the use of Quetiapine (antipsychotic [medication used to treat mental illness]) to ensure resident's drug regimen was free from unnecessary medications (any medication in excessive dose, excessive duration, without adequate monitoring). 2. Resident 61 was monitored for hours of sleep for the use of Trazadone (used to treat major depressive disorder [a mood disorder that causes a persistent feeling of sadness and loss of interest], anxiety disorders [persistent and excessive worry that interferes with daily activities], and insomnia [hard to fall asleep, hard to stay asleep]). This deficient practice 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.

Based on observation, interview and record review, the facility failed to ensure five (5) of seven (7) cereal prepared in a bowl were accurately measured using a measuring cup. These deficient practice had the potential to result in meal dissatisfaction, decreased nutritional intake and weight loss or gain of the five residents. Findings: During an observation in the facility's kitchen on 5/14/2024 at 6:20 AM, observed Kitchen Staff (KS 1) scooping cereal on her right hand with gloves transferring it to 5 brown bowls. During interview on 5/16/2024 at 9:10 AM with KS1, KS 1 stated when we measure the cereal, it should be measured using a measuring cup and it is important to follow serving size so the resident can have proper caloric intake. KS 1 also stated the facility has some residents who must gain weight and some who must lose weight and if the facility do not follow the portion size, the residents would not gain or lose the necessary weight. During the same interview on 5/16/2024 at 9:10 AM with KS 1, KS 1 stated it was 5 residents who requested corn flakes on Tuesday,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 20) had the mental capacity (ability to understand the nature and consequences of a decision and to communicate a decision) to understand the terms of the facility's arbitration agreement (a private agreement that allows individual parties to resolve disputes rather than in a lawsuit) and failed to explain the arbitration to Resident 20's legal representative. This failure resulted in Resident 20 and his legal representative, the conservator (a judge-appointed person to act or decide for a conservatee [a person who needs help]), not understanding their rights to make informed decisions and choices about important aspects of Resident 20's health, safety, and welfare. Findings: During a review of Resident 20's admission Record (Face Sheet), indicated the facility originally admitted Resident 20 on 9/17/2018 and re-admitted on [DATE] with diagnoses that included traumatic subdural hemorrhage (bleeding inside…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 keep one (1) of three (3) washing machines in good repair. This failure had the potential to result in the washing machine not being in a safe operable condition. Findings: During a concurrent observation and interview on 5/16/2024 at 9:05 AM with Infection Preventionist (IP) in the dirty laundry room, a washing machine on the furthest left side of the room was observed to have a large gash like hole on the top of the left panel of the washing machine. IP stated that hopefully they'll be able to fix it soon. During a concurrent observation and interview on 5/16/2024 at 1:30 PM with Maintenance Supervisor (MS) in the dirty laundry room, a washing machine on the furthest left side of the room was observed to have a large gash like hole near the top of the left side panel of the washing machine. MS stated that a tube that runs through the top side of the washing machine that contains the sanitizing chemicals had leaked at one point and caused the left side panel to erode (to slowly reduce or destroy) causing a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within the resident's reach (arm's length) for one (1) of 23 sampled residents (Resident 324). This deficient practice had the potential for Resident 324 not being able to call the facility's staff for help or assistance especially during an emergency. Findings: During a review of Resident 324's admission Record (Face Sheet), indicated Resident 324 was admitted to the facility on [DATE] with diagnoses that included Type 2 diabetes mellitus (DM- a chronic condition that occurs when blood sugar levels are too high), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and history of falling. During a review of Resident 324's Minimum Data Set (MDS-a standardized assessment and care planning tool), dated 5/2/2024, the MDS indicated Resident 324…

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