Casa Coloma Health Care Center

Based on observation, interview, and record review, the facility failed to provide catheter (a thin flexible tube to drain urine) care in a manner to prevent catheter related infections for 1 of 32 sampled residents (Resident 161) when Resident 161's urinary (catheter placed into bladder) drainage bag and nephrostomy (catheter inserted into the kidney) drainage bag were laying on the floor in the same privacy bag.This failure had the potential to result in urinary tract infections for Resident 161. A review of Resident 161's admission Record indicated she was admitted to the facility in April 2026 with multiple diagnoses including encephalopathy (damage or disease that affects brain function), tubulo-interstitial nephritis (inflammation that damages structures of the kidneys), urinary tract infection (an infection in any part of the urinary tract system), and hydronephrosis (swelling of the kidney when urine cannot drain out from the kidney due to blockage or obstruction). A review of Resident 161's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 respiratory care was provided in accordance with professional standard of practice when:The oxygen order was not followed for Resident 135;The oxygen tubing was not labeled, and oxygen in use signage was not in place for Resident 52 and,The oxygen titration order was not followed for Resident 121.These failures had the potential for Resident 135, Resident 121, and Resident 52 to experience respiratory distress, and an increased risk for fire hazards for Resident 52. 1. A review of the admission Record indicated Resident 135 was admitted [DATE] with diagnoses including asthma (chronic lung disease causing airways to become inflamed, narrow, making it hard to breathe) and obstructive sleep apnea (brief episodes of stopped breathing or restricted airflow reduce blood oxygen). Resident 135's Brief Interview for Mental Status (BIMS- an assessment tool to screen and identify memory, orientation, and judgement status of the resident)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pain management in accordance with professional standards and resident centered care plan for one of 32 sampled residents (Resident 74), when facility did not assess Resident 74's pain, did not offer non-pharmacological (strategies that do not involve use of pain medications) interventions, and did not offer pain medications. This failure had the potential for Resident 74 to be in pain and have ineffective pain management.A review of the admission record indicated the facility admitted Resident 74 in 2017 with multiple diagnoses which included osteoarthritis (pain, stiffness, and swelling of multiple joints) and inflammatory radiculopathy of lower back (pinched nerve, causing pain that goes down the leg (s).A review of Order Summary Report for Resident 74 contained a physician order to administer Tylenol 500 milligram (mg, unit of measurement) to administer for pain every 6 hours as needed.A review of Resident 74's Minimum Data…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 services in accordance with physician order, plan of care, and assessment for one of 32 sampled residents (Resident 74), when the right sided bed rail utilized for Resident 74's bed was not correctly sized.This failure had the potential to affect Resident 74's safety.A review of the admission record indicated the facility admitted Resident 74 in 2017 with multiple diagnoses which included cognitive impairment, weakness, and history of falling.A review of Order Summary report for Resident 74 contained a physician order dated 1/4/26 which indicated, Side rails 1/4 [quarter size] x 2 for bed mobility (turning and repositioning).A review of Resident 74's Minimum Data Set (MDS, a federally mandated resident assessment) dated 3/27/26, the MDS indicated the resident scored 7 out of 15 in a Brief Interview for Mental Status (cognitive assessment), which indicated moderate cognitive impairment.A review of Resident 74's care plan initiated 3/8/24 indicated that the resident required assistance from staff for…

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

Based on observation, interview, and record review, the facility failed to ensure residents are free of any significant medication errors for one of 32 sampled residents (Resident 162) when Resident 162's Insulin Glargine (a long-acting type of insulin - a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) was not administered as scheduled per physician's order.This failure had the potential to result in uncontrolled blood sugar for Resident 162 and placed Resident 162 at risk for developing signs and symptoms of high blood sugar.During a review of Resident 162's admission records, the records indicated Resident 162 was admitted to the facility in April 2026 with diagnosis that included Type 2 Diabetes Mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). Resident 162's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 4/4/21, indicated Resident 162 had intact cognition.During a review of Resident 162's physician order, dated 4/20/26, the order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prescribed therapeutic diets (Physician prescribed meal plans that modify nutrient, calorie, or texture intake to treat medical conditions, and manage chronic diseases) for three residents (Resident 95, Resident 99, and Resident 134), for a census of 131.These failures had the potential for negative health outcomes for Resident 95, Resident 99, and Resident 134. During an observation in the facility kitchen on 4/22/26, at 12:05 p.m., Resident 99's food tray ticket was observed to read Diet: 2gm [gram, unit of measure] Sodium. Kitchen staff prepared Resident 99's lunch meal. Kitchen staff prepared the regular entree item country fried steak for Resident 99, and placed the tray on the food cart.During an interview on 4/22/26, at 12:05 p.m., with Certified Dietary Manager (CDM) CDM stated, Resident 99 got the wrong entree item and should have received the beef patty.During a review of the Facility's Diet Spreadsheet dated 4/22/26, spreadsheet indicated, for the 2gm Sodium diet the lunch item was a beef…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 there was uninterrupted power supply for life sustaining equipment during a power outage, for a census of 131. This failure had the potential for vulnerable residents to experience life threatening situation during power interruptions. During an observation on 4/23/26 starting at 1:14 p.m., the facility had a power interruption. The facility staff were observed taking out extension cords and they were checking residents with oxygen concentrators and those with air mattress. The staff brought out flashlights and power cords to plug into the red emergency outlets to power the oxygen concentrators in Station 2. The staff stated the outlets were not working and they needed oxygen tanks.During an interview on 4/23/26 at 1:35 p.m., with the Social Services Director (SSD), the SSD stated the emergency outlets were not working. During an observation on 4/23/26 at 1:38 p.m., 24 minutes later, the emergency power kicked in.During an interview on 4/23/26 at 1:43 p.m., the Assistant Director of Nursing (ADON)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurate accountability of controlled medications (those with high potential for abuse or addiction) when: 1. Licensed Nurse 7 (LN 7) disposed tramadol (a controlled substance medication to treat pain without another LN to cosign the destruction; 2. Two out of five medication cart-controlled drug sign-in/sign-out sheets (sheets used to reconcile inventory of controlled medications in the medication cart by the outgoing and the incoming LN during a shift change) did not have signatures of the outgoing and the incoming nursing shift; and 3. The DON and pharmacist did not document destruction of controlled medications in accordance with facility policy and procedure (P&P). These failures resulted in the facility not having accurate accountability of controlled medications with the potential for abuse or misuse of these medications. Findings: 1. During a medication pass observation on 1/28/25 at 9:36 a.m. with LN 7, LN 7 was observed administering medications to Resident 138, including tramadol 50…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 had an 8.82% error rate when three medication errors out of 34 opportunities were observed during a medication pass for two of four Residents (Residents 101 and 138). This failure resulted in medications not given in accordance with the prescriber's orders and potential to affect the residents' clinical conditions. Findings: During a medication pass observation on 1/28/25 at 9:30 a.m. with Licensed Nurse 6 (LN 6), LN 6 was observed preparing ten medications, including acarbose (a medication to lower blood sugar) 50 milligrams (mg, a unit of measurement) and ferrous sulfate (a medication to prevent low blood cells in the body) 325 mg for Resident 138. LN 6 administered the medications. A review of Resident 138's medical record indicated the following physician's orders: - Acarbose 50 mg: Give one tab by mouth three times a day, take with first bite of meal, ordered 12/28/24; - Ferrous gluconate 324 (37.5 Fe) mg: Give one tablet by mouth two times a day for supplement, ordered 12/28/24. During a concurrent interview and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure multi-dose medications were dated with an open and discard date to ensure they were not used beyond the discard date. The deficient practices had the potential for residents to receive medications with unsafe and reduced potency from being used past their discard date. Findings: During a concurrent observation and interview on [DATE] at 12:30 p.m. with Licensed Nurse 6 (LN 6), an inspection of Medication Cart 5 (Med Cart 5) identified one Stiolto Respimat (a medication used to treat chronic obstructive pulmonary disease (a lung disease that makes it hard to breathe) 2.5 microgram/2.5 microgram (mcg, a unit of measurement) inhaler and one fluticasone/salmeterol (a medication to treat asthma (a lung disease that makes it hard to breathe) 500 mcg/50 mcg inhalers, both opened and unlabeled with open dates. LN 6 confirmed the manufacturer's labeling on Stiolto indicated, Discard 3 months after insertion of cartridge into inhaler. LN 6…

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

Based on observation, interview, and record review, the facility failed to ensure food safety when: 1. One container of prepared apple juice and one container of iced tea concentrate were found expired in the walk-in refrigerator. 2. A box soaked with cooking oil was found in the dry food storage area of the kitchen. 3. Cracked light cover found overhead in between the steam table and food prep area. Missing light covers found in the dry storage area. 4. No air gaps were found on the food production sink, the three compartment sink, and the large sink next to the dishwasher. These failures had the potential to result in food contamination which could cause illness in medically vulnerable residents who received and consumed food from the facility kitchen for a census 130. Findings: 1. A concurrent observation and interview on 1/28/25 at 11:25 a.m. with Dietary Aide 3 (DA 3) in the walk-in refrigerator., DA 3 confirmed that the container of prepared apple juice and the container of iced tea concentrate were expired and should have been thrown out yesterday on 1/27/25. An interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an effective infection control program when: 1. The facility did not implement proper infection control for two of 33 sampled residents (Resident 85 and Resident 301) when staff entered rooms of residents on droplet precautions without donning proper PPE (personal protective equipment- equipment worn to minimize exposure to infection); 2. The facility did not offer six out of 33 sampled residents (Resident 108, Resident 35, Resident 3, Resident 48, Resident 16, and Resident 110) to wash or sanitize their hands before meals; 3. Enteral feeding (providing nutrition) through a gastrostomy (G-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) equipments were not labeled and changed as scheduled. 4. A glucometer (a medical device used to test blood sugar levels) was not cleaned and disinfected by a wipe that was approved to be safe and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 5 out of 33 sampled residents (Resident 3, Resident 108, Resident 137, Resident 20, and Resident 110) were provided with hot water in the bathroom sinks. In addition, the entire Hall 30's which housed 24 residents had no hot water in bathroom sinks when the heater pump was turned off for over 20 days period. This failure resulted in multiple residents not having comfortable water to wash their hands and faces and negatively impacted their physical wellbeing, and had the potential to result in delayed provision of care. Findings: During an observation and interview on 1/29/25, at 8:55 a.m., Resident 3 was observed awake and sitting in bed. Resident 3 stated it took 15 - 20 minutes to get luke warm water from the bathroom sink. Resident 3 added, I can never wash my face and hands there. I have rheumatoid arthritis [RA, an autoimmune disease that affects joints, causing pain and stiffness] and ice cold water in the sink is very…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 records review, the facility failed to ensure staff answered call lights (devices used by residents to signal his or her need for assistance from staff) in a timely manner for two of 33 sampled residents (Resident 108 and Resident 3). In addition, the dedicated call system at nursing station 1, which was designed to facilitate communication between residents and staff, was muted. These failures had the potential to result in the resident's requests and care needs not being met jeopardizing the health and safety of residents. Findings: A review of the facility's 'Answering the Call Light' policy and procedure revised 9/2022, indicated, The purpose of this procedure is to ensure timely response to the residents' requests and needs. A review of the admission record indicated the facility admitted Resident 108 in 2023 with multiple diagnoses which included heart and kidney disease. A review of Resident 108's Minimum Data Set (MDS - a federally mandated resident assessment tool),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician orders were appropriate and followed as ordered for two of 33 sampled residents (Resident 94 and Resident 37) and failed to ensure Resident 109 took all the medications, when: 1. Resident 94 had conflicting orders for a knee brace, and 2. Resident 94 had order for oxygen that was not followed, and 3. Resident 37 had orders for monitoring for a medication that was no longer ordered. 4. Loose pills in a medication cup were observed at the bedside of Resident 109. These failures had the potential for Resident 94, Resident 37 and Resident 109 to receive care and treatment that was contradictory to the physician's orders leading to adverse outcomes. Findings: A review of Resident 94's admission Record indicated Resident 94 was admitted to the facility in October 2022 with multiple diagnoses including asthma (condition in which airways become narrow making it difficult to breathe), morbid obesity (severe obesity), 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 ensure services were provided to one of 33 sampled residents (Resident 87) when Resident 87 was not assisted in the repair or daily use of their hearing aids. This failure had the potential to cause Resident 87 psychosocial harm by making him frustrated and angry due to his inability to hear clearly and communicate properly with staff, other residents, and visitors. Findings: A review of Resident 87's facesheet indicated Resident 87 was admitted to the facility in February of 2024 with a diagnoses including presence of left artificial shoulder joint with severe weakness, sensorineural hearing loss ( a type of hearing loss that occurs when there is damage to the inner ear (cochlea) or the auditory nerve that carries sound signals to the brain), and need for assistance with personal care. A review of Resident 87's Order Summary Report dated 2/5/24 indicated Resident 87 is capable of understanding rights, responsibilities, and Informed Consent. A concurrent observation and interview on 1/29/25 at 08:58 a.m. 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 ensure the safety of one of 33 sampled residents (Resident 78), who had tube feeding (TF, a medical device surgically implanted into the stomach, so the person who can not eat normally due to swallowing problems can receive liquid nutrition), when the facility did not follow the physician's order to keep Resident 78's head of bed (HOB) elevated at 30 degrees during administration of nutrition through the TF on multiple occasions. This failure had the potential for Resident 78 to experience aspiration (inhalation of TF formula) and develop aspiration pneumonia (a lung infection that develops after the person inhales food or liquids into their lungs where the bacteria will grow and cause an infection) which could lead to death. Findings: A review of the admission record indicated the facility admitted Resident 78 in the fall of 2024 with multiple diagnoses which included pneumonitis (lung infection that causes inflammation and swelling of…

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

Based on observation, interview, and record review, the facility failed to ensure two of 33 sampled residents (Resident 78 and Resident 93) received oxygen therapy as prescribed by the residents' physicians, when Resident 78 and Resident 93 received oxygen at a higher rate than ordered. These failures had the potential to contribute to residents' discomfort and decreased ability to breathe. Findings: A review of the admission record indicated the facility admitted Resident 78 in the fall of 2024 with multiple diagnoses which included chronic obstructive pulmonary disease (COPD, a chronic lung condition causing restricted airflow and breathing problems) and pneumonitis (lung infection that causes inflammation and swelling of the air sacs in the lungs) due to inhalation of food. A review of Resident 78's physician order dated 12/23/24 indicated, Oxygen inhalation at 2 liters [L, unit of measurement] per minute via NC [nasal cannula, a tubing used to deliver supplemental oxygen] continuously every shift. A review of the care plan titled, A risk for ineffective breathing pattern, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Resident 47 was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when Resident 47 received psychotropic medication without implementation of non-pharmacological (non-drug) interventions and inadequate indication for use. This failure resulted in unnecessary medication for the resident, which had the potential for exposure to unwanted side effects associated with psychotropic medications such as sedation, falls, abnormal involuntary movements, and memory loss and increased risk of death. Findings: A review of Resident 47's medical record (MR) indicated Resident 47 was admitted to the facility on [DATE] with diagnosis including dementia (a brain disorder that leads to decline in memory) with unspecified psychosis not due to a substance or known physiological condition ( a collection of symptoms that affect the mind, where there has been some loss of…

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

Based on observation, interview, and record review, the facility failed to ensure restorative services were provided for one of 33 sampled residents (Resident 15) when Restorative Nursing Services (RNS - nursing interventions that help people maintain or improve a resident's physical, mental, and emotional well-being.) were not initiated. This failure resulted in Resident 15 failing to maintain the highest practicable level of physical, functional, and emotional well-being. Findings: A review of Resident 15's facesheet indicated she was admitted to the facility in September of 2024 with diagnoses' which included Primary Osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of both knees, Heart Failure, Chronic Obstructive Pulmonary Disease(COPD-a chronic lung disease causing difficulty in breathing), Type 2 Diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and unspecified difficulty in walking. A review of Resident 15's BIMS (Brief Interview for Mental Status-an assessment tool used 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.

Based on observation, interview, and record review, the facility failed to provide one of 33 sampled residents (Resident 117) with an accessible call light, when Resident 117's call light was bundled up and attached to the call light plate out of Resident 117's reach. This failure resulted in Resident 117 not able to call for assistance for care needs causing an increased risk for falls. Findings: A review of Resident 117's admission Record indicated Resident 117 was admitted to the facility in April 2024 with multiple diagnoses including protein calorie malnutrition (inadequate intake of protein and calories causing adverse effects on the body), weakness, and abnormality with gait and mobility. A review of Resident 117's Minimum Data Set (MDS- a federally mandated assessment tool), Cognitive Patterns, dated 12/27/24, indicated Resident 117 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 11 out of 15 that indicated Resident 117 was moderately cognitively impaired. A review of Resident 117's MDS, Functional Abilities, dated 12/27/25, indicated…

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

Based on observations and interviews, the facility failed to ensure services for one of four sampled residents (Resident 1) when medication was administered by a Certified Nursing Assistant (CNA 1) to Resident 1 (RES 1). This failure had the potential for harm when staff who are not trained to administer medications, administered medication outside of their scope of practice and job duties, which could cause medication errors. Findings: RES 1 was admitted to the facility in 2021 with diagnoses that included chronic pain (pain that lasts longer than 3 months) and morbid obesity (severe excess weight). Resident 1's Minimum Data Set (MDS, an assessment tool), dated 8/12/24 indicated the Brief Interview for Mental Status (BIMS) scored 13, meaning Resident 1 was cognitively intact. During a review of RES 1's Order Summary Report dated 9/23/24, the orders indicated lidocaine patch for the treatment of pain 4% (%, a percentage of medication) apply to both knees, shoulders, and back for 12 hours on and 12 hours off. During a concurrent observation and interview on 10/30/24 at 10:12 a.m., 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 observation and interview, the facility failed to ensure a safe and functional living environment for when two of four sampled residents (Resident 1 & Resident 3) had sliding glass doors in their rooms that were not able to be locked. This failure had the potential for people to enter the room from outside of the building and resulted in Resident 1 feeling unsafe. Findings: Resident 1 (RES 1) was admitted to the facility in 2021 with diagnoses that included depression. Resident 1's Minimum Data Set (MDS, an assessment tool), dated 8/12/24 indicated the Brief Interview for Mental Status (BIMS, a test of cognition) scored 13, meaning Resident 1 was cognitively intact. During an interview on 10/30/24 at 10:26 a.m., RES 1 stated that her sliding glass door does not lock and she has been asking for it to be fixed. During an observation on 10/30/24 at 10: 27 a.m., the Department was unable to lock the sliding glass door in RES 1's room. During a concurrent observation and interview on 10/30/24 at 10:35 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 was observed attempting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infection control practices for one out of a census of 112 when the Certified Nursing Assistant 1 (CNA 1) did not use gloves when handling soiled linen, and did not use proper hand hygiene practices when handling clean linen after touching soiled linen. These failures had the potential to spread infection in the facility. Findings: During a concurrent observation on 6/18/24 at 10:39 a.m. in the hallway by rooms [ROOM NUMBERS], CNA 1 was holding a soiled gown and linens with his bared hands, walked from room [ROOM NUMBER] to the hallway and placed it into the soiled linen bin near room [ROOM NUMBER]. Immediately afterward, CNA 1 walked to the clean linen closet, grabbed two clean gowns, and walked to room [ROOM NUMBER] to put on the resident in room [ROOM NUMBER]B. There was no hand hygiene observed when handling clean linen after touching soiled linen with ungloved hands. CNA 1 agreed he should have used a bag when transporting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 treatments according to physician orders for one of three sampled residents (Resident 1) when Resident 1 was not given multiple treatment medications as ordered by the physician in November 2023, December 2023, and January 2024. This failure increased the resident's potential to have unmet health needs. Findings: Review of an admission Record, indicated Resident 1 was admitted to the facility in 2022 with diagnoses including kidney disease and diabetes. Review of Resident 1's Minimum Data Set [MDS, an assessment tool], dated 1/14/24, indicated Resident 1 had no memory issues or behaviors. A review of Resident 1's clinical record included the following documents: --A Treatment Administration Record (TAR), dated 11/23, indicated clobetasol propionate cream (a dermatitis medication) was not administered on the evening shift on 11/16/23. --The treatment to apply house barrier cream (a medication to prevent skin break down) 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.

Based on observation, interview, and record review, the facility failed to ensure medications were stored locked for a census of 118 when the medication cart and treatment cart were left unlocked and unattended. These failures had the potential for medication misuse and drug diversion. Findings: During a concurrent observation and interview on 2/20/24 at 11:45 a.m. with Licensed Nurse 1 (LN 1), medication cart 1 in a hallway was unlocked and left unattended. The nurse was not in the hallway. There were residents and other staff in the hallway. LN 1 confirmed the medication cart was not locked and should have been locked. During a concurrent observation and interview on 2/20/24 at 1:50 p.m., the treatment cart was unlocked and unattended in the hallway. There were other staff walking in the hallway. The nurse was inside a resident room performing a dressing change. LN 2 confirmed the treatment cart was unlocked and unattended and should have been locked. During an interview on 2/20/24 at 1:53 p.m., the Director of Nursing (DON) confirmed the medication cart and treatment cart should…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, record review, and facility policy review, the facility failed to ensure the accuracy of the preadmission screening and resident review (PASARR) Level 1 screening for 1 (Resident #56) of 4 sampled residents reviewed for PASARR. Findings included: Review of the facility policy titled, admission Criteria revised in March of 2019, revealed, 9. All new admissions and readmission are screened for mental disorders (MD), intellectual disabilities (ID), or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level 1 PASARR screen for all potential admissions, regardless of payer source, to determine if the individual may meet criteria for a MD, ID, or RD. A review of Resident #56's admission Record revealed the facility admitted the resident on 10/31/2023 with a diagnosis to include post-traumatic stress disorder (PTSD). A review of Resident #56's Preadmission Screening and Resident Review Level I Screening dated 10/31/2023, revealed the resident did not have a serious diagnosed mental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, record review, and review of a facility policy, the facility failed to ensure a resident's care plan was revised to include contact precautions for clostridium difficile (C-diff) for 1 (Resident #78) of 8 sampled residents reviewed for infection control. Findings included: Review of a facility policy titled Care Plans, Comprehensive Person Centered, revised in December 2016, revealed 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; and o. Reflect currently recognized standards or practice for problem areas and conditions. A review of Resident #78's admission Record revealed the facility admitted the resident on 10/18/2023. Per the admission Record, Resident #78 received a diagnosis of C-diff on 12/12/2023. Review of Resident #78's Order Summary Report, with active orders as of 02/07/2024, revealed an order dated 12/12/2023, for isolation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interviews, record reviews, facility policy reviews, and document review, the facility failed to ensure staff wore personal protective equipment (PPE) when they provided care for 2 (Resident #40 and Resident #78) of 8 sampled residents reviewed for infection control. The facility also failed to ensure fit testing for 3 (Licensed Vocational Nuse #3, Registered Nurse #4, and Certified Nursing Assistant #5) of 4 staff reviewed for fit testing. Findings included: Review of a facility policy tilted Handwashing/Hand Hygiene revised in August 2019, revealed, 6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a. When hands are visibly soiled; and b. After contact with a resident with infectious diarrhea including, but not limited to infections caused norovirus, salmonella, shigella and C. difficile. 1. A review of Resident #40's admission Record revealed the facility admitted the resident on 05/24/2019. The admission Record revealed the resident received a diagnosis of resistance to multiple antimicrobial drugs 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 interview and record review, the facility failed to follow their abuse policy and procedure when abuse, dementia and resident's rights trainings including reference checks were not completed for one of 6 employees (Certified Nursing Assistant, CNA 1) prior to being assigned to provide care to residents. This failure placed the residents at risk for abuse, neglect and mistreatment. Additionally, the failure to provide CNA 1 with abuse prevention and reporting training denied her the ability to recognize incidents of abuse and the process for reporting such incidences. Findings: A review of the facility's policy titled, Background Screening Investigations, dated 3/2019 indicated, Our facility may conduct employment background screening checks, reference checks .on all applicants for positions with direct access to residents. An interview related to the facility reported incident for allegation of staff to resident abuse was conducted with the facility's Administrator (ADM) on 2/1/24 at 10:35 a.m. The ADM stated Resident 2 reported that her roommate (Resident 1) was verbally…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide adequate supervision to ensure safety for one of three sampled residents (Resident 1), when he left the facility unaccompanied and without staff knowledge and wandered 3 buildings away from the facility that is located next to a busy cross street. This failure placed Resident 1 at high risk for being hit by a moving vehicle, falls, and potentially endangered his life. Findings: A review of the admission Record indicated the facility admitted Resident 1 recently with multiple diagnoses which included dementia (a decline in memory or other thinking and reasoning skills), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and muscle weakness. A review of the physician orders dated 1/14/24 indicated, Resident [1] is NOT Capable of Understanding Rights, Responsibilities, And Informed Consent. A review of the admission assessment dated [DATE] at 4:23 p.m., indicated Resident 1 was oriented to person and had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the nutritional status was maintained and monitored accurately for one of three sampled residents (Resident 1) when: Restorative Nursing Assistants (RNA) weighed Resident 1 with NPWT (negative pressure wound therapy, also known as a wound vac, a device to aid in wound healing) device connected to Resident 1, and Certified Nursing Assistants (CNAs) did not document Resident 1's meal intakes 3 times daily in a consistent manner, and Resident 1's preference to have a pureed diet (diet that consists of soft smooth foods) was not honored in a consistent manner. These failures resulted in incorrect weights and inaccurate intake information, which had the potential to generate dietary interventions for Resident 1 based on inaccurate and incomplete information and cause resident dissatisfaction with meals with potential for weight loss. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted 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 interview and record review the facility failed to provide treatment and care in accordance with professional standards of practice for one of 6 sampled residents (Resident 1) when: 1. Resident 1 did not receive a TSLO brace (thoracolumbosacralorthosis - a brace for the mid to lower back used to provide support after back injury) as ordered by the physician on admission, and 2. Results for Resident 1's CBC (complete blood count, measures white and red blood cells and platelet count) lab ordered stat (needs to be performed immediately) were not obtained and reported timely. These failures had the potential to negatively affect the health, safety, and medical condition of Resident 1. Findings: 1. A review of the admission record indicated that Resident 1 was admitted to the facility in the summer of 2023 with diagnoses including fracture (a complete or partial break in a bone) of thoracic and lumbar vertebrae (middle and lower backbones), fracture of the right humerus (bone of the upper arm), fracture 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 protect one of three sampled residents (Resident 1) from loss of personal property when facility policies were not in place to protect personal property from loss. This failure resulted in Resident 1's dentures, glasses, and hearing aids to be missing which had the potential for Resident 1 to have decreased communication and functioning. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in February 2021 with multiple diagnoses including Alzheimers disease (disease that causes memory loss and confusion), chronic pain, and cervical disc degeneration (wear and tear on the intervertebral discs, neck bones, causing neck pain). A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility in July 2021 with multiple diagnoses including gastrostomy (opening into the stomach), dysphagia (difficulty swallowing), and myocardial infarction (heart attack-blockage of…

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

Based on interview and record review, the facility failed to provide preventative care, consistent with their own policies and procedures; Support Surface Guidelines, Prevention of Pressure Injuries, Repositioning, and Pressure Injury Risk Assessment, for one (Resident 1) of the three sample residents when Resident 1 developed an unstageable (when the stage is not clear) pressure ulcer (injury that breaks down the skin and underlying tissue) on his sacrum (area of the lower back and tail bone) which was identified on admission to the Acute Care Hospital (ACH). This failure had the potential to have caused Resident 1 to develop an unstageable pressure ulcer. Findings: Review of ACH clinical record for Resident 1, indicated that, Resident 1 arrived at the hospital from the facility on 4/8/23 at 6:56 p.m. Review of ACH ' s clinical record showed a picture of a sacral wound, scanned on 4/9/23 at 2:21 a.m. Release of Information Department (RID) at ACH validated that the picture was uploaded shortly after it was taken. A review of ACH ' s clinical record, titled, Flow sheet, 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.