Country Oaks Care Center

Based on interview and record review, the facility failed to ensure six of six licensed nurses (Treatment Nurses [TN], 1, 2, 3, 4, 5 and 6) had assessments to demonstrate competency for the handling and management of Pleurx catheters (a small, soft tube that doctors put into the chest to help drain extra fluid that builds up around the lungs).This failure had the potential to result in compromised safety for the residents with Pleurx catheters and the potential to result in TNs 1, 2, 3, 4, 5, and 6 not to deliver high quality of care when handling Pleurx catheters due to lack of competency validation. Cross Reference: F656 and F684Findings:During an interview on 7/17/2025 at 10:55 AM, Treatment Nurse (TN) 3 stated TN 3 received in-service training on Pleural effusion (a condition where excess fluid builds up in the space between the lungs and the chest wall) and Pleurx catheters a few months ago (no date recall). TN 3 stated TN 3 did not remember completing an assessment to demonstrate TN 3's competency to properly care for resident with or manage Pleurx catheters.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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a care plan (CP) upon admission for one of three sampled residents (Resident 1) who had a Pleurx catheter (a small, soft tube that doctors put into the chest to help drain extra fluid that builds up around the lungs). that addressed the presence of the device.This failure had the potential to result in unmet individualized needs for Resident 1 and the potential to affect Resident 1's physical well-being. Cross Reference: F684 and F726Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 7/3/2025, and re-admitted the resident on 7/11/2025, with diagnoses including malignant neoplasm of the prostate (a cancerous lump or growth on the small gland in men that helps make fluid for semen), pleural effusion (when extra fluid builds up between the lungs and the chest wall, making it harder to breathe), and neutropenia (when you have too few neutrophils [a type of white blood cell that helps…

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

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received treatment and services in accordance with professional standards of practice. The facility failed to obtain a physician's order prior to draining Resident 1's Pleurx catheter (a small, soft tube that doctors put into the chest to help drain extra fluid that builds up around the lungs) on 7/5/2025. This failure placed Resident 1 at risk for complications like hypotension (low blood pressure, complication from Pleurx drainage due to rapid fluid shifts), infection, respiratory complications, and fluid imbalance. Additionally, the failure had the potential to result in a physical decline to Resident 1.Cross Reference: F656 and F726Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 7/3/2025, and re-admitted the resident on 7/11/2025, with diagnoses including malignant neoplasm of the prostate (a cancerous lump or growth on the small gland in men that helps make fluid for semen), pleural effusion (when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain accurate medical records for one of four sampled residents (Resident 3), according to the facility's policy and procedure (P&P) titled, Documentation in Medical Record, by failing to: Ensure licensed nurses (LNs) documented the redness on and leaking from Resident 3's gastrostomy tube (G-tube- tube inserted through the belly that brings nutrition directly to the stomach) stoma (surgically created opening in the abdomen) in Resident 3's Progress Notes (PN) under Advanced Skilled Evaluation (PN ASE) between 2/17/2025 and 2/20/2025. This failure had the potential for Resident 3 to not receive the care and services needed to appropriately treat the redness and leaking from Resident 3's G-tube stoma, and for Resident 3 to develop further infection. Findings: During a review of Resident 3's admission Record (AR), the AR indicated the facility initially admitted Resident 3 on 12/20/2022, and readmitted Resident 3 on 3/10/2025, with diagnoses 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.

Based on observation, interview, and record review, the facility failed to follow the facility ' s policy and procedure (P&P) titled, Safe Resident Handling/Transfers, by failing to ensure one of three sampled residents (Resident 1) had two staff members with Resident 1 when staff used a mechanical lift (a device used to assist in lifting and transferring individuals who have difficulty moving independently). This deficient practice had the potential to place Resident 1 ' s safety at risk. Findings: During an observation on 4/15/2025 at 10:43 am, Resident 1 was observed being lifted above the bed on a sling (a soft fabric or mesh material used with a mechanical lift to support and cradle a patient during transfer or movement) attached to a mechanical lift. Restorative Nursing Assistant (RNA) 1 was observed using the mechanical lift to put Resident 1 on the bed and was observed to be the only staff member in the room with Resident 1. During a review of Resident 1 ' s admission Record (AR), the AR indicated the facility admitted Resident 1 on 3/28/2025 with diagnoses that included…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 its policies and procedures (P&P) titled, Hand Hygiene (procedures that included the use of alcohol-based hand rubs (containing 60%-95% alcohol) and hand washing with soap and water), and Enhanced Barrier Precautions (EBP- set of infection control measures that use personal protective equipment [PPE- equipment worn to minimize exposure to hazards] to reduce the spread of multidrug-resistant organisms [MDRO- organism that is resistant to most antibiotics] by wearing a gown and gloves), for one of four sampled residents (Resident 3) by failing to: 1. Ensure Sitter 1 and Sitter 2 wore gloves while providing care to Resident 3. 2. Ensure Sitter 1 and Sitter 2 performed hand hygiene before donning gloves and providing care to Resident 3. These failures had the potential to transmit and spread infection from staff to residents that could result in widespread infection in the facility. Findings: During a review of Resident 3's admission Record (AR), the AR indicated the facility initially admitted Resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a clean, safe, sanitary, and homelike environment for the following: a. 1 of 1 kitchen affecting 31 of 64 residents, who received food from the kitchen. b. 2 resident rooms affecting 4 residents (Resident 54, Resident 14, Resident 43, and Resident 45) c. Bathroom [ROOM NUMBER] affecting 4 residents (Resident 16, Resident 34, Resident 166, and Resident 167). This practice had the potential for residents to be exposed to dirt, mold, rust and drywall dust, which can lead to a decline in the residents' health and result in irritation of the eyes, skin, nose, throat, and lungs. This deficient practice could result in prolonged exposure that could cause serious problems such as acute (sudden) respiratory illness, persistent coughing, and asthma (narrowed airways in the lungs that make it difficult to breath). Findings: a. During an observation on 3/3/25 at 8:41 a.m., two areas of the kitchen ceiling near the food preparation were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adequate gastrostomy tube (GT, a tube inserted into the stomach through a surgical incision used for feeding and administration of medications for a resident unable to swallow) treatment and services were provided for two of two sampled residents (Resident 40 and Resident 20), who were receiving enteral feedings (liquid nutrition, delivery of nutrients through a feeding tube directly into the stomach) when: A.On 3/5/2025, Resident 40's GT was observed disconnected from the GT feeding pump with enteral feeding spilling on the floor. B.On 3/3/2025, the facility failed to follow infection control precautions to minimize the risk of GT contamination, Resident 20's GT tip touched the floor. Additionally, the facility failed to utilize feeding tubes in accordance with current clinical standards of practice by failing to ensure Certified Nursing Assistant 1 (CNA 1) did not disconnect or turn Resident 20's GT feeding pump off/on as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 52 and Resident 116) received care and services for the provision of peripheral IV (intravenous, the administration of substances, such as fluids, medications, or blood products, directly into the vein) site (a thin, flexible tube is inserted through the skin into a small vein in the periphery such as the hand, elbow, or foot and can remain in place for several days) in accordance to facility's policy and procedure (P&P), titled, Intravenous Therapy, when, A and B.On 3/3/2025, Resident 52 and Resident 116's IV sites were not labeled with a date and time, to indicate when the IV dressings were changed. These failures had the potential to result in IV complications and infections to Residents 52 and Resident 116 and the potential to affect the resident's well-being. Findings: A. During a review of Resident 52's MDS dated [DATE], the MDS indicated, Resident 52 had severe impaired cognition…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 acquiring and dispensing of medications by failing to: A. Ensure accountability of the narcotic (medications that have compounds with paralyzing [causing a person or part of the body to become partly or wholly incapable of movement] or numbing properties) medications stored in one of two medication carts (Med Cart #2) between the off-going nurse and the on-coming nurse on 3/1/2025 for the morning (AM) and the evening (PM) shifts. B. Ensure, the correct dose of Polyvinyl Alcohol Ophthalmic Solution (eyedrops, medication used to relieve eye dryness an soreness, particularly where the dryness is caused by a reduced flow of tears) was administered as ordered by the physician for one of one sampled resident (Resident 50). This deficient practice had the potential to lead to diversion (illegal distribution of abuse of prescription drugs or their use for unintended purposes) of narcotic medications and resulted in an inadequate eyedrop dose…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to implement infection control practices to reduce and/or prevent the spread of infection when: A. One of two staff (Respiratory Therapist, RT) failed to properly wear an isolation (staying away/kept away from others) gown during tracheostomy care (procedure performed routinely to keep tracheostomy [surgical opening created through the neck into the windpipe to allow air to fill the lungs] and the surrounding area clean and reduce the induction of bacteria [living organism that can cause an infection] into the windpipe and lungs) for one of six sampled residents (Resident 6) who was under enhanced barrier precaution (EBP-infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO, bacteria that are resistant to three or more classes of antimicrobial drugs] that employs targeted gown and gloves use during high contact resident care activities). B. One of two staff (Certified Occupational Therapy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a safe and sanitary bathroom (Bathroom [ROOM NUMBER]) for 4 of 4 sampled residents (Resident 16, Resident 34, Resident 166 and Resident 167). This deficient practice had the potential for residents to be exposed to dirt, mold, rust and drywall dust, which can cause respiratory/breathing problems. Cross Reference F584 Findings: During an observation on 3/3/25 at 12:45 p.m., in Bathroom [ROOM NUMBER] (shared bathroom between Residents 16, 34, 166, and 167) the following were observed: 1. On the left corner and right corner of the toilet and along the baseboard was a dark black substance. 2. On the left and right side of the toilet the baseboard along the wall was warped. 3. Around the water shut off valve on the left side of the toilet there was a brown substance, and the wall area was cracked and peeling. 4. On the right side of the toilet, the tile floor had a 3-inch crack with a ¼ inch groove in the tile. 5. The safety grab bar…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a call light was kept within reach for one of one sampled resident (Residents 55) in accordance with the facility's policy and procedure (P&P), titled, Call Lights: Accessibility and Timely Response. This failure had the potential for Resident 55 to receive delayed care and services necessary to meet the residents' needs. Findings: During a review of Resident 55's admission Record (AR), the AR indicated Resident 55 was admitted to the facility on [DATE] with diagnoses that included difficulty with walking and chronic respiratory failure (condition that occurs when the lungs cannot get enough oxygen) with hypoxia (low levels of oxygen in the body tissues). During a review of Resident 55's Fall Risk assessment (FR- method of assessing a patient's likelihood of falling), dated 1/10/2025, the FR indicated Resident 55 was at risk for falls due to being chair bound, taking three or more medications, and due to the presence of three 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 ensure information regarding an Advance Directive (AD, a written preferences regarding treatment options, a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions) was provided to one of one sampled resident's (Resident 20) Responsible Party (RP) 1 in accordance with the facility's policy and procedure (P&P), titled, Residents' Rights Regarding Treatment and Advance Directives. This deficient practice had the potential to result in lack of knowledge regarding care and treatment decision making and in result in provision of medical treatment that was against RP 1's wishes. Findings: During a review of the Letter of Conservatorship, dated 1/22/2020, the letter indicated RP 1 was Resident 20's Conservator (a court-appointed person responsible for managing the financial and personal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assessment entries on the Minimum Data Set (MDS - a resident assessment tool) related to active diagnoses was accurately documented to reflect the resident's health status for one of two sampled residents (Resident 168). This deficient practice resulted in an inaccurate MDS assessment for Resident 168. Resident 168 received Aripiprazole (medication to treat psychosis [mental health condition characterized by a loss of touch with reality]) for 5 days for schizophrenia (a mental illness that is characterized by disturbances in thought, perception, emotions, and social interactions) with no documented diagnosis of schizophrenia. Findings: During a review of Resident 168's admission Record (AR), the AR indicated, Resident 168 was admitted to the facility on [DATE], with diagnoses that included metabolic encephalopathy (a change in how your brain functions), acute and chronic respiratory failure (a condition where you don't have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop a care plan (CP), for one of one sampled resident (Resident 52), that included management of intravenous (IV, the administration of substances, such as fluids, medications, or blood products, directly into the vein) therapy for Resident 52. This failure had the potential to result in unmet individualized needs for Resident 52 and the potential to affect the resident's physical well-being. Findings: During a review of Resident 52's MDS dated [DATE], the MDS indicated, Resident 52 had severe impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 52 was dependent (helper does all of the effort) on staff for toileting hygiene, showering, lower body dressing, and putting on/taking off footwear. The MDS indicated, Resident 52 needed maximum assistance (helper does more than half the effort) for oral hygiene, upper body dressing, and personal hygiene. During a…

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

Based on interview and record review the facility failed provide supervision, consistent with the needs of one of one sampled resident (Resident 18), and implement interventions indicated in the facility's policy and procedure (P&P) titled, Fall Prevention Program. This deficient practice resulted in Resident 18 experiencing an unwitnessed fall on 2/27/2025 and had the potential to result in injury to Resident 18. Findings: During a review of Resident 18's admission Record (AR), the AR indicated Resident 18 was initially admitted to the facility 2/6/2025 with multiple diagnoses including Alzheimer's disease (a condition that occurs late in life and worsens with time in which brain cells degenerate; it is accompanied by memory loss, physical decline, and confusion) and rheumatoid arthritis (persistent joint inflammation). During a review of Resident 18's Minimum Data Set (MDS - a resident assessment tool) dated 2/12/2025, the MDS indicated Resident 18's cognition (ability to understand and process information) was moderately impaired and Resident 18 required maximal assistance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 appropriate infection control guidelines related to a urinary catheter bag lying on the floor for a resident with an indwelling urinary catheter for 1 of 2 sampled residents (Resident 167). This deficient practice had the potential to result in urinary tract infections for Resident 167. Findings: During a review of Resident 167's admission Record (AR), the AR indicated, Resident 167 was initially admitted to the facility on [DATE], and then readmitted on [DATE] with diagnoses that included anoxic brain damage (where the brain is deprived of oxygen for a prolonged period, leading to damage or death of brain cells), chronic respiratory failure with hypoxia (the lungs cannot deliver enough oxygen to the body over time, leading to chronic oxygen deficiency), Moyamoya disease (certain arteries in the brain are constricted), dependence on ventilator status (a serious medical condition that occurs when a patient is unable to breathe…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled resident's (Resident 50) nasal cannula tubing (a medical device, a soft tubing, used to deliver supplemental oxygen, the tube's ends splits into two prongs) was place properly by placing both nasal prongs in the Resident 50's nostrils in accordance with the facility's policy and procedure (P&P), titled, Oxygen administration. This deficient practice placed Resident 50 at risk for shortness of breath and/or hypoxia (low levels of oxygen in the body tissues) and had the potential to result in a physical decline to Resident 50. Findings: During a review of Resident 50's admission Record (AR), the AR indicated Resident 50 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure (a condition where the lungs cannot get enough oxygen into the blood) with hypoxia (the body's tissues do not receive enough oxygen), dependence on supplemental oxygen, and encounter for attention 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 of one sampled staff (Certified Nurse Assistant 1 [CNA 1]) was competent with providing gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition directly to the stomach) care for one of two sampled residents (Resident 20) in accordance with the facility's policy and procedure (P&P), titled Care and Treatment of Feeding Tube. This failure had the potential to place the residents with GTs, under the care of CNA 1, at risk for not having their needs met safely and in a manner that promoted each resident's physical well-being. Cross Reference F693 Findings: During a review of Resident 20's admission Record, the AR indicated Resident 20 was admitted to the facility on [DATE] with diagnoses that included encounter for attention to gastrostomy (creation of an artificial external opening into the stomach for nutritional support) and dysphagia (swallowing difficulty). During a review of Resident 20's Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure specific indication for the use of Ativan (medication used to treat anxiety [group of mental disorders characterized by feelings of anxiety [an unpleasant state of inner turmoil] and fear]) for one of five sampled residents (Resident 55) as indicated in the facility's policy and procedure (P&P), titled Use of Psychotropic [medications that affect the brain and nervous system, used to treat mental health conditions], Medications. This deficient practice had the potential to result in the use of unnecessary psychotropic drugs and result in an adverse drug event (injuries resulting from medication use including physical and mental harm, or loss of function) to Resident 55. Findings: During a review of Resident 55's admission Record (AR), the AR indicated Resident 55 was admitted to the facility on [DATE] with diagnoses that included difficulty with walking and chronic respiratory failure (a condition where the lungs cannot get enough oxygen into…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 proper food handling practices by one of three dietary staff observed during lunch tray line. This deficient practice had the potential for cross-contamination of food that could result in food borne illness (any illness resulting from eating contaminated/spoiled foods) for 31 of 64 residents who received food from the kitchen. Findings: During an observation of the kitchen tray line on 3/5/25 at 12:03 p.m., the cook, who was assisting the dietary assistant (DA) with plating lunch food, was observed wearing blue nitrile gloves and using silver oven mittens to hold plates, and then passing the plates to the DA who was placing food on the plates. The cook was observed using silver oven mittens to remove hot plates from the oven. The cook was observed touching the top of table with blue gloves, then touching the top of the oven mittens that were lying off to the side on the table. Next, the cook was observed slicing bread (to be served with lasagna); the cook holding the knife in her right hand (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.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of three sampled residents (Resident 1) by failing to develop and implement interventions to address Resident 1's behavior of refusing to be changed after becoming soiled with urine. This failure had the potential for Resident 1 to contract a urinary tract infection (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra). Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 6/15/2022, and readmitted Resident 1 on 11/29/2023, with diagnoses including metabolic encephalopathy (brain disease that alters brain function or structure), functional quadriplegia (the condition in which both the arms and legs are paralyzed), and hypertension (high blood pressure). The AR indicated Resident 1's Responsible Party (RP) was RP 1. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 12/20/2024, the MDS indicated Resident 1…

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

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for one of three sampled residents (Resident 1) when a trash can liner was tied to the end of a pull cord which operated Resident 1's overhead light. This failure had the potential for Resident 1 to feel uncomfortable in her room. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 6/15/2022, and readmitted Resident 1 on 11/29/2023, with diagnoses including metabolic encephalopathy (brain disease that alters brain function or structure), functional quadriplegia (the condition in which both the arms and legs are paralyzed), and hypertension (high blood pressure). The AR indicated Resident 1's Responsible Party (RP) was RP 1. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 12/20/2024, the MDS indicated Resident 1 had no impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 3 required 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 protect a resident's right to remain free from verbal (the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents) and physical abuse (willful infliction of injury, deliberate aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1), when Certified Nursing Assistant 1 (CNA 1) physically and verbally abused Resident 1 on 10/27/2024. This failure had the potential to result in bodily injury to Resident 1 and/or for Resident 1 to feel afraid and not safe while under the care of the facility. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 12/20/2022 and readmitted on [DATE] with diagnoses including chronic respiratory failure (when the lungs can't get enough oxygen into the blood), profound intellectual disability (limitations in cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure abdominal X-ray (pictures of the inside of the abdomen) results were received timely for 2 of 3 sampled residents (Resident 1 and Resident 2). These failures resulted in Resident 1 and Resident 2 not receiving their gastrostomy tube (G-tube, a feeding tube inserted through the abdomen that brings nutrition directly to the stomach) feeding (liquid nutrition given through the G-tube) and medications for 3 days. Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure and dysphagia (difficulty swallowing foods or liquids). The AR indicated Resident 1 had a tracheostomy tube (a tube inserted in a surgically created hole in the windpipe to provide an alternative airway for breathing) and a G-tube. During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of the…

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

Based on interview and record review, the facility failed to ensure four of six sampled staff (Licensed Vocational Nurses [LVN] 1, 2, 3, and 4) received In-service training (a type of professional training or staff development that is given to staff while they are employed) before signing the facility's document titled, In-Service Form (signing the In-service Form indicated the staff received training). This failure had the potential for facility staff to not receive the required training while employed at the facility and had the potential to negatively affect residents' safety and the provision of care to the residents of the facility. Findings: During a review of the facility's document titled, In-Service Form, initiated 9/13/2024, the In-Service Form indicated the training topic was, Dementia (a group of thinking and social symptoms that interferes with daily functioning). The In-Service Form indicated LVNs 1, 3, and 4 signed the form to indicate LVNs 1, 3, and 4 received the training about Dementia. During a review of the facility's document titled, In-Service Form, initiated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of four sampled residents (Residents 8 and 9), who were incontinent of bladder, received appropriate treatment and services to prevent urinary tract infections (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra) according to the facility's policy and procedure (P&P) titled, Incontinence, dated 12/19/2022. The facility staff failed to check for incontinence and/or provide incontinent (lacking voluntary control over urination or defecation) care to Resident 8 and Resident 9 every two hours. This failure had the potential to result in Residents 8 and 9 to experience skin breakdown and/or placed Residents 8 and 9 at risk of experiencing a UTI. (Cross Reference F725) Findings: 1. During a review of Resident 8's admission Record (AR), the AR indicated, Resident 8 was admitted to the facility on [DATE], with diagnoses including chronic respiratory failure (when the lungs can't get enough…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sufficient staffing to ensure incontinence (cannot holding in urine or stool) care was provided for two of four sampled residents (Residents 8 and 9) in a timely manner. This failure had the potential to result in Residents 8 and 9 to experience skin breakdown and/or placed Residents 8 and 9 at risk of experiencing a urinary tract infection (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra). (Cross Reference F690) Findings: 1. During a review of Resident 8's admission Record (AR), the AR indicated, Resident 8 was admitted to the facility on [DATE], with diagnoses including chronic respiratory failure (when the lungs can't get enough oxygen into the blood), chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), and encephalopathy (brain disease that alters brain function or structure). During a review of Resident…

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

Based on interview and record review, the facility failed to post actual worked nursing hours at the start of each shift for one of three days, according to the facility's policy and procedure (P&P) titled, Nurse Staffing Posting Information, dated August 2022. This failure had the potential to result in residents (in general) and/or visitors not knowing the facility's nurse staffing information. Findings: During an observation on 8/26/2024 at 10:42 a.m. the nurse staffing posting was located on the wall across from Nurse Station 1. The nurse staffing posting was observed to be dated 8/20/2024. There was no nurse staffing information posted for 8/26/2024. During a concurrent interview and record review on 8/28/2024 at 8:38 a.m. with the Director of Staff Development (DSD), the facility's nurse staffing posting, untitled, dated 8/20/2024, was reviewed. The DSD stated nurse staffing information was posted on the wall across from Nurse Station 1. The DSD stated the nurse staffing information should be posted by the night shift for the upcoming day. The DSD stated she did not know why…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 four of eight sampled residents (Residents 2, 4, 5, and 6) were free of risk from accidents using an assistive device based on the facility's Policy and Procedure (P&P) titled, Safe Resident Handling/Transfers, and the user manual for Battery Powered Patient Lift, by failing to: 1. Ensure Certified Nurse Assistants (CNAs) 5 and 7 used a Hoyer lift (mobile patient lift that helps caregivers safely transfer people from one surface to another) appropriately to transfer Resident 6 from the bed to geri-chair (large, padded chair designed to help the residents with limited mobility [ability to move]) on 8/12/2024. 2. Ensure CNA 4 used a Hoyer lift with the assistance of another staff member during the transfer of Residents 2, 4, and 5. As a result of these failures, Residents 2, 4, 5, and 6 were at risk for falls and injury due to inappropriate use of the Hoyer lift. Findings: 1. During a review of Resident 6's admission Record (AR), 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 interview and record review the facility failed to conduct a reference check before hire, for one of three sampled staff (Certified Nursing Assistant [CNA] 1), in accordance with the facility's Policy and Procedure (P&P) titled, Abuse, Neglect and Exploitation, dated 5/31/2024 and CNA's, Pre-Employment Check List. This failure placed 70 residents residing at the facility at risk for abuse by CNA 1. Findings: During a concurrent interview and record review on 7/31/2024 at 1:35 PM with the Director of Staff Development (DSD), CNA 1's employee file was reviewed. CNA 1's Employment History, dated 7/11/2022 indicated CNA 1's previous places of employment before working at the facility. CNA 1's Employment History indicated who CNA 1's previous supervisors were and contact numbers for the supervisors. CNA 1's employee file contained a blank document titled, Pre-Employment Check List, undated. The Pre-Employment Check List indicated, INSTRUCTIONS: Obtain at least two references for each applicant . The DSD confirmed CNA 1's employee file did not indicate the facility conducted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility's policies and procedures (P&P) titled, Infection Prevention and Control Program, Hand Hygiene, and Handling Soiled Linen, by failing to: 1. Ensure Housekeeping 1 (HK 1) wore gloves as a personal protective equipment (PPE- equipment worn to minimize exposure to hazards that cause serious workplace injuries or illnesses) and performed hand hygiene before and after the tasks. 2. Ensure HK 1 covered the barrel labeled soiled linen with a lid during transport in the facility's hallway. These deficient practices had the potential to result in cross-contamination (the transfer of harmful bacteria from one person, object, or place to another) and the spread of infection throughout the facility. Findings: During an observation on 7/25/2024 at 11:31 am, in the hallway in front of Room A, HK 1 was observed pushing an uncovered yellow barrel lined with a plastic bag and labeled soiled linen on the outside of the barrel. HK 1 reached into HK 1's pocket for one glove and HK 1 put the glove on HK 1'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 observation, interview and record review, the facility failed to maintain a homelike environment by failing to ensure two of two shower rooms in the facility were kept clean. This failure had the potential to result in an unsanitary environment for the residents. Findings: During an observation on 7/13/24 at 4:58 p.m., the resident shower room located in Skilled Nursing Facility 1 (SNF 1) had chipped paint on the tile located inside the shower stall and had black colored substance in the far-right corner of the shower stall. During a concurrent observation of the resident shower room located in SNF 1 and an interview with Maintenance Supervisor (MS) on 7/13/24 at 6:00 p.m., MS observed the peeling paint on the shower tiles inside the shower room. MS observed black colored substance between the wall tiles and in the corner of the shower, and between the grout on the gray floor tiles inside the shower room. MS stated the colored substance was black and dirty and MS described the black colored substance as dirt build up. MS stated he missed the chipping paint on the shower…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident's dignity was maintained for one of four sampled residents (Resident 4). This failure violated Resident 4's right to be treated with dignity and respect which could affect Resident 4's physical, mental, and psychosocial well-being. Findings: During a review of Resident 4's admission Record (AR), the AR indicated, Resident 4 was readmitted to the facility on [DATE], with diagnoses that included dysphagia (difficulty swallowing) following other intracranial hemorrhage (bleeding within the skull), functional quadriplegia (the complete inability to move due to severe disability or frailty), and noninfective gastroenteritis and colitis (inflammation of your stomach, intestines). During a review of Resident 4's History & Physical (H&P), dated 2/6/24, the H&P indicated, Resident 4 did not have the capacity to understand and make decisions. During a review of Resident 4's Minimum Date Set (MDS), a resident assessment and care-screening…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 for one of four sampled residents (Resident 4) was within reach. This deficient practice had the potential to result in the delay of care for Resident 4 when Resident 4 was unable to reach Resident 4's call light to call staff for assistance. Findings: During a review of Resident 4's admission Record (AR), the AR indicated, Resident 4 was readmitted to the facility on [DATE], with diagnoses that included dysphagia (difficulty swallowing) following other intracranial hemorrhage (bleeding within the skull), functional quadriplegia (the complete inability to move due to severe disability or frailty), and noninfective gastroenteritis (inflammation from an infection in your stomach and intestines) and colitis (inflammation of the large intestine). During a review of Resident 4's History & Physical (H&P), dated 2/6/24, the H&P indicated, Resident 4 did not have the capacity to understand and make decisions. During a review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent physical abuse (willful infliction of injury, deliberate aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1). On 6/5/2024, Resident 2 hit Resident 1 on the right upper arm. This failure had the potential to cause a decline in Resident 1's physical and/or psychosocial well-being. Findings: a. During a review of Resident 2's admission Record (AR), the AR indicated the facility initially admitted Resident 2 on 3/15/2024. During a review of Resident 2's Minimum Data Set (MDS, a standardized resident assessment and care-planning tool), dated 3/22/2024, the MDS indicated Resident 2 had no impairment in cognition (ability to acquire knowledge and understand information). The MDS indicated Resident 2 required partial to moderate assistance with most self-care activities and mobility (ability to move). During a review of Resident 2's Initial Psychiatric Evaluation (IPE), dated 6/5/2024, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of resident-to-resident physical abuse (intentional bodily injury that includes slapping, pinching, choking, kicking, shoving, grabbing, and punching) to officials including, the State Survey Agency (SSA), law enforcement, and adult protective services, immediately but not later than two hours for one of four sampled residents (Resident 2) from the time the incident occurred, by failing to: Ensure the Administrator (ADM), who is the abuse coordinator, reported an allegation of abuse on 4/22/2024 when Resident 4 approached Resident 2 and grabbed Resident 2's right upper arm. The ADM reported the allegation of resident-to-resident abuse to the Department of Public Health on 5/7/2024 (15 days after Resident 2's allegation of abuse was made to the ADM). This failure had the potential to result in compromised safety and the reoccurrence of abuse to Resident 2 and the potential for incidents of abuse to occur throughout the facility.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 treatment and services to restore continence (ability to control movements of the bowels [intestines] and bladder [organ that stores urine]) to the extent possible for one of two sampled residents (Resident 1) by failing to: Ensure Resident 1, who was occasionally incontinent (less than seven episodes of incontinence [inability to control the bladder] in a seven-day period) of urine and had mobility issues, was provided alternative methods to go to the bathroom and assisted with the resident's toileting (urination) needs as indicated in Resident 1's care plan. These failures had the potential for Resident 1 to become more incontinent of urine and lead to a decline of Resident 1's health. Findings: During a review of Resident 1's admission Record (AR), the AR indicated, the facility admitted Resident 1 to the facility on 6/15/2022, with diagnoses of functional quadriplegia (the complete inability to move due to sever disability frailty caused by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide one of two sampled residents (Resident 1) with dignity and respect in accordance with the facility's policy and procedure (P&P) titled, Resident Rights, by failing to: Ensure Certified Nursing Assistant (CNA) 1 and CNA 2 provided Resident 1 with alternative methods to go to the bathroom and assisted Resident 1 with the resident's toileting needs. CNA 1 and CNA 2 told Resident 1 to void (urinate) in Resident 1's incontinence brief (brief used to capture urine) for CNA 1 and/or CNA 2 to change after voiding. This failure caused Resident 1 to have feelings of depression and burden and made Resident 1 feel like an animal. This failure had the potential to cause further psychosocial (mental, emotional, social, and spiritual effects) harm to Resident 1. Cross Reference F690 Findings: During a review of Resident 1's admission Record (AR), the AR indicated, the facility admitted Resident 1 to the facility on 6/15/2022, with diagnoses of functional…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete the fall risk assessment (a screening tool used to predict a person ' s risk of falling) for two of three sampled residents (Resident 2 and 3). This deficient practice had the potential to result in an inaccurate assessment of Resident 2's and Resident 3's risk for falls. Findings: During a review of Resident 2's admission Record (AR), the admission Record indicated the facility admitted Resident 2 on 1/26/23, with diagnoses of chronic respiratory failure (occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) with hypoxia (lack of oxygen), epilepsy (a brain condition that causes recurring seizures), and a history of falling. During a review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/26/24, the MDS indicated Resident 2's cognitive (ability to think and process information) skills for daily decision making was severely impaired. 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 implement the care plan intervention to prevent potential falls (an unplanned descent [moving downward] to the floor with or without injury) for one of three sampled residents (Resident 2) by failing to ensure Resident 2's floor mat (a device used to reduce the severity of injury in falls) was placed on the left side of the floor next to Resident 2's bed. This deficient practice had the potential to affect Resident 2's safety and increase the risk for injury. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 to the facility on 1/26/23, with diagnoses of chronic respiratory failure (occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), with hypoxia (lack of oxygen), epilepsy (a brain condition that causes recurring seizures), and a history of falling. During a review of Resident 2's annual Minimum Data Set ([MDS] a standardized assessment and care planning tool), dated 1/26/24, the MDS…

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

Based on interview and record review, the facility failed to implement their Fall Prevention Program Policy and Procedure (P&P) for one of three sampled residents (Resident 2) by failing to ensure Resident 2's care plan interventions were reviewed for effectiveness and revised after every fall. Resident 2 had five (5) falls in 38 days This failure had the potential for Resident 2 to sustain preventable falls and injuries from falls. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 1/5/24 with diagnoses which included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and a history of falling. During a review of Resident 2's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 1/8/24, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY b. During a review of Resident 22's AR, the AR indicated Resident 22 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including hypertensive heart disease with heart failure (condition in which the heart cannot pump enough blood to all parts of the body), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and pressure ulcer (bed sore, injury to skin and underlying tissue resulting from prolonged pressure on the skin) of sacral region (the portion of your spine between your lower back and tailbone). During a review of Resident 22's MDS, dated 12/27/23, the MDS indicated Resident 22 was severely impaired (never/rarely made decisions) in cognitive skills (ability to make daily decisions). The MDS indicated Resident 22 was dependent (helper does all the effort) on staff for toileting, dressing, and bathing. During a concurrent interview and record review on 2/21/24 at 3:26 p.m. with Treatment Nurse (TN) 1, Resident 22's Treatment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure three of three sampled residents (Residents 22, 29, and 37) were provided proper interventions and/or monitoring of edema (swelling caused by too much fluid trapped in the body's tissues): a. For Resident 22, the facility failed to monitor and document the amount of pitting (a swollen part of your body has a dimple [or pit] after you press it for a few seconds) edema on Resident 22's arms and legs. b-c. For Residents 29 and 37, the facility failed to elevate the resident's upper extremities to decrease edema. These failures had the potential to result in worsening of edema to Residents 22, 29, and 37 and result in pain to the swollen areas and the potential to result in physical declines for the residents. (Cross Reference F656) Findings: a. During a review of Resident 22's admission Record (AR), the AR indicated Resident 22 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 b. During a review of Resident 22's admission Record (AR), the AR indicated Resident 22 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including hypertensive heart disease with heart failure (condition in which the heart cannot pump enough blood to all parts of the body), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and pressure ulcer/pressure injury (PI, bed sore, injury to skin and underlying tissue resulting from prolonged pressure on the skin) of sacral region (the portion of your spine between your lower back and tailbone). During a review of Resident 22's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/27/23, the MDS indicated Resident 22 was severely impaired (never/rarely made decisions) in cognitive skills (ability to make daily decisions). The MDS indicated Resident 22 was dependent (helper does all the effort) on staff for toileting, dressing, and bathing. During a…

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

Based on interview and record review, the facility failed to perform weekly weights for one of six sampled residents (Resident 32) who had a history of weight loss. This deficient practice had the potential to result in delayed interventions concerning Resident 32's nutrition and the potential to result in a physical decline to Resident 32. Findings: During a review of Resident 32's admission Record (AR), the AR indicated the facility admitted Resident 32 on 7/3/23 with diagnoses including gastro-esophageal reflux disease (when stomach acid repeatedly flows back into the tube connecting your mouth and stomach), gastrostomy (a surgical procedure used to insert a tube through the abdomen and into the stomach) and dysphagia (swallowing difficulties). During a review of Resident 32's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 1/9/24, the MDS indicated Resident 32's cognition (ability to understand and process information) was severely impaired and Resident 32 had weight loss of five percent or more in the last month or loss of 10% or more in the last…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 have a complete Facility Assessment that included the nursing direct care hours for Licensed Nurses (LN, a Registered Nurse or Licensed Vocational Nurse who cared for people who were sick, injured, convalescent, or disabled) and certified nursing assistants (CNA, an entry-level role that provided vital support to both patients and nurses) throughout each shift (working day) in their plan. This deficient practice had the potential for the facility to not provide the sufficient number of qualified staff to meet the residents needs and could decrease the quality of care provided to the residents. Findings: During a review of the facility's Facility Assessment Tool (FAT), dated 1/23/24, under Staffing Plan, the FAT indicated, nursing staffing was reviewed by leadership daily. The FAT indicated, calendars were prepared monthly and changes in acuity were addressed as they occurred to meet resident's needs at any given time. The FAT indicated, other categories were reviewed and revised by the Administrator (ADM) as needed based…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infection control practices were followed to prevent the transmission of disease and infection for five of eleven sampled residents (Residents 13, 15, 125, 22, and 124) when: a. For Residents 13, 15, and 125, who had foley catheters (urinary catheter, a medical device that drains urine from your bladder), the facility failed to provide enhanced barrier precautions (EBP, the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organisms [MDRO] to staff hands and clothing). Residents 13, 15, and 125 had increased risks of acquiring MDROs per the facility's policy and procedure (P&P), titled, Enhanced Barrier Precautions. b. For Resident 22, who had a pressure ulcer (PU/PI,bed sore, injury to skin and underlying tissue resulting from prolonged pressure on the skin) in the sacral region (the portion of your spine between your lower back and tailbone), the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Residents 38), was treated with dignity by failing to keep Resident 38's urinary catheter (a flexible tube used to empty the bladder [an organ like a bag inside the body of a person or animal that holds the urine] and collect urine in a drainage bag) bag unexposed in accordance with the facility's policies and procedures (P&P). This deficient practice had the potential for Resident 38 to feel humiliated, embarrassed, ashamed, and for Resident 38 to feel his value as a human being was not respected and could have resulted in Resident 38 not living comfortably during this period of care. Findings: During a review of Resident 38's admission Record (AR), the AR indicated Resident 28 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including unspecified injury at C6 (one of seven stacked bones called vertebrae in the cervical spine [neck region]) level 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 provide appropriate treatment to restore continence, to the extent possible, by failing to implement a prompted toileting program (caregiver prompts the resident to use the toilet) for one of one sampled resident (Resident 67). This failure resulted in Resident 67 urinating in the adult incontinence brief (diaper) and had the potential for Resident 67 to be at greater risk of developing a urinary tract infection (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra). Findings: During a review of Resident 67's admission Record (AR), the AR indicated Resident 67 was admitted to the facility on [DATE] with multiple diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (also called ischemic stroke, occurs as a result of disrupted blood flow to the brain), hypertension (high blood pressure),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 of three sampled residents (Resident 17), received proper respiratory (relating to breathing) care such as oxygen (O2, a colorless, odorless, tasteless gas essential for living) therapy in accordance with the physician ' s order and resident care plan. This failure resulted in Resident 17 not receiving the right amount of O2 as ordered by the physician. This failure had the potential to compromise Resident 17's respiratory status that could lead to respiratory distress and/or death. Findings: During a review of Resident 17's admission Record (AR), the AR indicated, the facility originally admitted Resident 17 to the facility on 4/28/21 and readmitted Resident 17 on 2/15/24, with multiple diagnoses including chronic respiratory failure (a serious condition that made it difficult to breathe on your own) with hypoxia (low levels of O2 in body tissues), hydrocephalus (a buildup of fluid within the brain), and anxiety disorder (a mental health disorder characterized by feelings of worry, panic, or fear…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 communicate the pharmacy consultant's recommendation in the Medication Regimen Review (a thorough evaluation of a resident's medication regimen with the goal of promoting position outcomes and minimizing adverse consequences associated with medication) to the physician for one of two sampled residents (Resident 15). This deficient practice had the potential to exacerbate (worsen) Resident 15's existing conditions. Findings: During a review of Resident 15's admission Record (AR), the AR indicated the facility admitted the resident on 3/16/22 and readmitted to the facility on [DATE] with diagnosis including senile degeneration of the brain (older individuals who suffer from m ental decline, particularly memory loss). During a review of Resident 15's History and Physical (H&P) dated 12/1/23, the H&P indicated Resident 15 did not have the capacity to understand and make decisions. During a review of Resident 15's Order Summary Report (OSR), with active…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 monitor and record occurrences of target behavior symptoms for one of five sampled residents (Resident 173) who was receiving psychotropic medications (medications that affects brain activities associated with mental processes and behavior) in according to the facility's policy and procedure (P&P) titled, Use of Psychotropic Medication, dated 12/19/2022. This failure had the potential for Resident 173 to take psychotropic medications unnecessarily. Findings: During a review of Resident 173's admission Record (AR), the AR indicated Resident 173 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), chronic respiratory failure (when the lungs can't get enough oxygen into the blood) with hypoxia (low levels of oxygen in your body tissues), and schizophrenia (a disorder that affects a person's ability to think, feel,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (a device used by a resident to signal the need for assistance) system was within reach for one of one sampled resident (Resident 14) as indicated in the facility's policy and procedure (P&P) titled, Call Lights: Accessibility and Timely Response. This failure had the potential to result in Resident 14's needs were not met in a timely manner and/or Resident 14 to experience harm if Resident 14 was unable to alert staff during an emergency situation. Findings: During a review of Resident 14's admission Record (AR), the AR indicated Resident 14 was admitted to the facility on [DATE] with multiple diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), hypertension (high blood pressure), and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 of two sampled residents (Resident 17) was provided a safe, sanitary, and comfortable environment. Resident 17's ceiling above the right side of Resident 17's bed was leaking rain water during a rainy day. This failure had the potential to result in Resident 17 getting wet and feeling uncomfortable and could be a fire hazard which had the potential to jeopardize the safety of the residents and staff. Findings: During a review of Resident 17's admission Record (AR), the AR indicated, the facility admitted Resident 17 to the facility on 4/28/21 and readmitted Resident 17 on 2/15/24 with multiple diagnoses including chronic respiratory failure (a serious condition that made it difficult to breathe on your own) with hypoxia (low levels of oxygen in body tissues), pressure ulcer (PU, injury to skin and underlying tissue resulting from prolonged pressure on the skin) of left buttock, stage 3 (PU that extend through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone), pressure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 3) received foods according to the therapeutic diet (diet ordered by a physician as part of treatment for a disease) prescribed by Resident 3 ' s physician. This failure had the potential for Resident 3 ' s health to be negatively impacted. Findings: During a review of Resident 3 ' s admission Record, the admission Record indicated the facility admitted Resident 3 on 11/15/2023 with diagnoses which included congestive heart failure (CHF, a condition in which the heart does not pump blood as efficiently as it should), chronic kidney disease (CKD, a condition in which the kidneys are damaged and cannot remove waste products from the blood as well as they should), and diabetes mellitus (DM, disease that results in too much sugar in the blood due to the body ' s inability to process carbohydrates [one of the basic food groups]). During a review of Resident 3 ' s History and Physical (H&P,…

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

Based on observation, interview, and record review, the facility failed to monitor how long the following food items were out of the refrigerator: resident snacks, nourishments, and supplements under refrigeration when a tray with sandwiches, bananas, fruit cups, crackers, a cup of sliced almonds, pureed fruits, puddings, and nutritional drinks. This failure had the potential to result in foodborne illness (caused by consuming contaminated foods or drinks) for 26 of 37 residents who received food from the kitchen. Findings: During a concurrent observation and interview on 12/26/2023 at 12:11 pm, with the Dietary Services Supervisor (DSS), in the kitchen, on the kitchen countertop, a tray with sandwiches, bananas, fruit cups, crackers, a cup of sliced almonds, pureed fruits, puddings, and nutritional drinks were found. The tray had a label on the side which indicated, [Extra] snacks 12-25-23 UB (use by) 12-26-23. The DSS called Dietary Aide 1 (DA 1) from the dry food storage area in the kitchen and the DSS stated DA 1 was working on getting the snacks ready. During a concurrent…

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