Joyce Eisenberg Keefer Medical Center D/P SNF

Based on interview and record review, the facility failed to ensure a resident's Minimum Data Set (MDS) annual assessment was transmitted to Centers for Medicare and Medicaid Services (CMS, a federal government agency that manages the Medicare and Medicaid programs, which provide health coverage to people) within the required 14 day timeframe for one of one sampled residents (Resident 87) reviewed under the resident assessment facility task. This deficiency prevents the CMS from having the most accurate information of Resident 87 and had the potential to result in delayed services for the resident. Findings: During a review of Resident 87's Face Sheet, the Face Sheet indicated the facility admitted Resident 87 on 3/23/2025 with diagnoses including chronic obstructive pulmonary disease (COPD - a progressive, long-term lung disease that makes it hard to breathe by restricting airflow), major depressive disorder (a mental health condition with persistent feelings of sadness and hopelessness.) and ileostomy (a surgical opening that lets stool pass from your body without going through…

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

Based on interview and record review, the facility failed to ensure the interdisciplinary team (IDT- a collaborative approach where healthcare professionals from various disciplines work together to provide comprehensive patient care) reviewed and revised a resident's care plan to include appropriate interventions addressing the resident's refusal of prescribed insulin injections for one of two (Resident 94) sampled residents. This deficient practice had the potential to result in failure to deliver the necessary care and services to Resident 94. Findings: During a review of Resident 94's Face Sheet, the Face Sheet indicated the facility originally admitted Resident 94 on 10/01/2023 and re-admitted resident on 1/12/2025, with diagnoses including diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), with diabetic polyneuropathy (nerve damage caused by diabetes that makes feet or hands feel numb, tingly, or painful), mild cognitive impairment(mild thinking or memory problems) of uncertain or unknow etiology (illness), and peripheral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: 1.Clarify with the physician the basis for determining the appropriate setting for a resident's low air loss mattress (LALM - designed to distribute a patient's body weight over a broad surface area and help prevent skin breakdown) in accordance with the facility policy for one (Resident 4) out of two sampled resident investigated for pressure ulcer/injury (a skin and soft tissue injury that occurs when skin is under pressure). This deficient practice placed the resident at risk of discomfort and development of new pressure ulcers (areas of damaged skin and tissue caused by sustained pressure that reduces blood flow to vulnerable areas of the body). 2. Complete a skin assessment for one of two sampled residents (Resident 1) reviewed for pressure ulcer/injury when Resident 1's skin impairment was re-classified from Stage 2 pressure injury (PI - injury to the skin and underlying tissue resulting from prolonged pressure on the skin) 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: 1.Ensure one of five sampled residents (Resident 40) reviewed for accidents, was safely transferred from bed to wheelchair using the sit-to-stand lift (Sara lift, a mechanical device that helps lift a resident to rise from a seated position. This requires a resident to be able to support at least partial body weight while standing) with a two-person assist in accordance with the facility policy. This deficient practice had the potential to place Resident 40 at risk for fall. 2. Ensure prepared medication was not left unattended on one of five medication carts (Medication Cart 2). This deficient practice had the potential to result in accidental ingestion of medication and can lead to adverse reactions (any unexpected or dangerous reaction to a drug). Findings: 1. During a review of Resident 40's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to complete a resident's Hemodialysis (HD, the removing of waste and excess fluid to prevent build up in the body for residents who have loss of kidney [organs that remove waste products from the blood and produce urine] function) Record with information including assessment of the arteriovenous fistula (AVF- a surgically created connection, typically between an artery and a vein in the forearm or upper arm, with the non-dominant arm preferred) for bruit and thrill (you can feel for a thrill at the fistula incision site. A thrill feels like buzzing under your skin. The bruit and thrill tell you that your fistula is working) for one of one (Resident 16) resident investigated under the Dialysis care area. This deficient practice placed the resident at risk for complications such as thrombosis (blood clot), stenosis (narrowing), or reduced blood flow, resulting in loss of access, infection, and inadequate dialysis treatment. Findings: During a review of…

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

Based on observation, interview and record review the facility failed to ensure that staffing information, including the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, was posted daily for two of two days (3/9/2026 and 3/10/2026), in accordance with the facility's policy and procedure (P&P) on Administrative Manual. This deficient practice resulted in the total number of staff and the actual hours worked by the staff in the facility were not readily accessible to residents, staff and visitors. Findings: During an observation on 3/10/2026 at 2:30 p.m., a nurse staffing information posted near the lobby nursing station was dated 3/9/2026, and did not indicate the resident census, the total number and the actual hours worked by Registered Nurses, Licensed Vocational Nurses, and Certified Nursing Assistant s from 7 a.m. to 3 p.m., 3 p.m. to 11 p.m., and 11 p.m. to 7 a.m. During a concurrent observation and an interview with Registered Nurse 2 (RN 2) on 3/10/2026 at 2:33 p.m., observed nurse staffing information posted near…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents received the correct form of medication in accordance with the physician's order when one of four sampled residents (Resident 216), who had an order for lactobacillus acidophilus (probiotic/supplement medication) in capsule form was administered the tablet form during the medication pass observation. This deficient practice had the potential to alter the medication absorption and effectiveness, resulting in suboptimal treatment or increased risk of adverse effects (unwanted or harmful reaction to a medication or treatment).Findings: During a review of Resident 216's Face Sheet (FS), the Face Sheet indicated the facility Resident 216 was originally admitted on [DATE] and was re-admitted on [DATE] with diagnoses including acute respiratory disease (condition in which your blood does not get enough oxygen or has too much carbon dioxide), chronic kidney disease (CKD-a longstanding disease of the kidneys leading 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: 1. Remove Resident 72's discontinued medication from the medication cart after the physician discontinued the order in one (1) of five (5) inspected medication carts (Medication Cart 2). 2. Label an over the counter (OTC-medications available to consumers without a prescription) medication in one of three sampled medication storage rooms (Medication Storage Room C) These deficient practices had the potential to result in a medication error by allowing discontinued medication to remain in the cart and creating the risk of administering medication to the wrong resident, lost medication, or delayed treatment. Findings: 1. During a review of Resident 72's Face Sheet, the Face Sheet indicated the facility originally admitted Resident 72 on [DATE] and was re-admitted on [DATE] with diagnoses including sepsis a serious infection that is already affecting their organs, chronic kidney disease (CKD-a longstanding disease of the kidneys leading 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 prepare food by methods that conserved appearance and flavor for lunch when chicken was served with some of the quills (the hollow central part of a feather) still in the skin for one of three residents (Resident 172) during dining observation. This failure had the potential to result in the resident not consuming meals or having poor food intake, which could lead to unintended weight loss. Findings: During a review of Resident 172's Face Sheet, the Face Sheet indicated the facility admitted Resident 87 on 1/7/2026 with diagnoses including type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and gastro-esophageal reflux disease (a chronic condition where stomach acid frequently flows back up into the esophagus [food pipe]). During a review of Resident 172's History and Physical (H&P) dated 3/2/2026, the H&P indicated Resident 172 speaks in full sentences, was able to make her own needs…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prepare food in a form designed to meet individual needs for one out of ten residents (Resident 3) observed while dining when Resident 3 was served a sandwich made with softened bread with the crusts left on while on a soft and bite-sized diet (foods that are soft, tender, moist, and easy to chew and swallow). This deficient practice had the potential to result in Resident 3 having difficulty with chewing and swallowing leading to a potential decrease in food intake and choking (when food gets stuck in your airway, blocking the flow of air to your lungs). Findings: During a review of Resident 3's Face Sheet, the Face Sheet indicated the admitted the resident on 2/8/2024 with diagnoses including, but not limited to, chronic (long-term) atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow) and dementia (a progressive state of decline in mental abilities). During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 1/1/2026, the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately document the blood glucose (BG-the main sugar found in the bloodstream) level, amount of the insulin (medication that lowers the blood sugar) units, and injection site in Medication Administration Record (MAR) for one of two sampled residents (Resident 94). This deficient practice had the potential to negatively impact on the delivery of treatment and services to Resident 94.Findings: During a review of Resident 94's Face Sheet, the Face Sheet indicated the facility originally admitted Resident 94 on 10/01/2023 and re-admitted resident on 1/12/2025, with diagnoses including diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), with diabetic polyneuropathy (nerve damage caused by diabetes that makes feet or hands feel numb, tingly, or painful), mild cognitive impairment(mild thinking or memory problems) of uncertain or unknow etiology (illness), and peripheral vascular disease(a condition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the binding arbitration agreement (arbitration agreement, a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) was explained to residents' representatives in a form and manner that he or she understands for 1 (Resident 34) of 4 sampled residents. This had the potential for residents' rights to not be honored. Findings: During a review of Resident 34's Face Sheet (the front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included age-related physical debility (frailty, a syndrome characterized by progressive loss of muscle mass and reduced strength). During a review of Resident 34's Minimum Data Set…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 patient care equipment was maintained in safe, comfortable operating condition for one of five sampled residents (Resident 78) by failing to ensure Resident 78's wheelchair was repaired in a timely manner when Resident 78's wheelchair push rim (also called hand rim-metal or plastic ring attached to the outside of a manual wheelchair's large wheels that allow users to self-propel [push/move]) was damaged. This deficient practice resulted in Resident 78's inability to comfortably propel her wheelchair and had the potential to negatively affect the provision of care and service provided to Resident 78. Findings: During a review of Resident 78's Face Sheet (FS), the FS indicated the facility originally admitted Resident 78 on 2/1/2025 and re-admitted on [DATE] with diagnoses including cellulitis (bacterial skin infection) of right upper limb (arms/legs), right elbow bursitis (painful inflammation or swelling of a bursa [small,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 for one of two sampled patients (Resident 1), Resident 1's physician was notified of Resident 1's low blood pressure (BP, amount of force blood uses to move through the body), when Resident 1's blood pressure values were above and below their baseline (average). This deficient practice had the potential for Resident 1 to suffer from complications such as dizziness, stroke, hospitalization, and even death. Findings: During a review of Resident 1's History and Physical (H&P), dated 10/22/2024, the H&P indicated Resident 1 was admitted to the facility with a medical history of chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), depression (mental health condition affecting how you feel, think, and act), lymphoma (blood cancer [body cells grow and affect how other cells work] affecting how the body fights infections), lung and bladder cancer. During a concurrent interview and record review on 6/2/2025 at 3:15 p.m., with the Director of Nursing (DON), of Resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure there was documented evidence that non-pharmacological interventions (healthcare treatments that do not primarily involve medication) were attempted prior to administering as needed (PRN) opioid (medications prescribed by doctors to treat persistent or severe pain) pain medications on multiple dates for two (Residents 126 and 65) out of three sampled residents investigated under the care area of pain management. This deficient practice had the potential to place the residents at increased risk of experiencing adverse side effects such as drowsiness, constipation, and decrease in respiration (breathing). Findings: a. During a review of Resident 126's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility admitted the resident on 7/12/2021 and readmitted the resident on 10/26/2022 with diagnoses including hereditary and idiopathic (an illness that isn't connected…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure safe provision of pharmaceutical services to six (6) out of eight (8) sampled residents investigated under the storage of drugs and biologicals (Resident 219, Resident 36, Resident 4, Resident 51, Resident 214 and Resident 111) by failing to: 1. Label Resident 219's opened Lantus-100 (type of insulin [a hormone that works by lowering levels of sugar in the blood]) pen), with an open date to readily identify its beyond use date. This deficient practice had the potential for the for unintentional administration of possibly expired medications for Resident 219. 2. Ensure the opened (in-use) Olopatadine HCl solution (type of eye drops used to treat eye itching) 0.1% (measurement of concentration) vial was discarded after its beyond use date of 11/26/24 from medication cart team B on the second floor. This deficient practice had the potential for the Olopatadine HCl solution 0.1% to lose efficacy and be ineffective in the treatment 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 meet the nutritional needs for four of 49 sampled residents (Resident 35, Resident 68, Resident 163, and Resident 8) by failing to provide a mechanical soft diet as ordered by the physician by failing to: 1. Ensure kitchen staff placed chopped squash on the tray table for residents on mechanical soft (diet that is ground or chopped for those that have difficulty swallowing or have missing teeth) and dysphagia diets (diet that is chopped or pureed [prepared in a way similar to a pudding] for those with difficulty swallowing) for Resident 35, Resident 68, and Resident 163. 2. Ensure staff did not accidentally serve Resident 8 the incorrect diet when being served lunch. These deficient practices had the potential to place the residents at risk for choking which could then lead to hospitalization and death. Findings: 1.a. During a review of Resident 35's admission Record, the admission Record indicated the facility admitted the resident 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 adhere to professional standards of practice when Licensed Vocational Nurse 4 (LVN 4) did not record a resident's blood sugar after taking it for one (Resident 185) out of six residents observed during the dining observation task. This failure placed the resident at risk for complications such as hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) Findings: During a review of Resident 185's Face Sheet (admission record), the Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (high blood sugar). During a review of Resident 185' s Minimum Data Set (MDS, a resident assessment tool), dated 10/10/2024, the MDS indicated Resident 185 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact with skills required for daily decision making. The MDS indicated Resident 185 required set-up help (helper…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a resident was provided a communication device (a device that can help patients communicate with care providers and family using symbols, photos, or illustrations) with the language that the resident was able to understand for one of one sampled resident (Resident 10). This deficient practice had the potential to prevent the resident from communicating with the staff and had the potential to delay receiving appropriate care/treatment the resident needed. Findings: During a review of Resident 10's admission Record, the admission Record indicated the facility originally admitted the resident on 6/7/2021 and readmitted the resident on 9/27/2022 with diagnoses including benign prostatic hyperplasia (prostate gland [gland in the male reproductive system] enlargement that can cause urination difficulty), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood…

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

Based on observation, interview, and record review, the facility failed to ensure a resident's low air loss mattress (LALM - designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) was set to the correct setting for one (Resident 480) out of five sample residents investigated under the care area of pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence). This deficient practice had the potential to increase the resident's risk of skin breakdown. Findings: During a review of Resident 480's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility admitted the resident on 12/2/2024 with diagnoses including pressure-induced deep tissue damage of sacral region (a serious injury where the tissues deep beneath the skin over the sacrum [the bony area at the base of the spine] have been damaged due to prolonged pressure). During a review of Resident 480's Minimum Data Set (MDS - a 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.

Based on observation, interview, and record review, the facility failed to ensure a licensed nurse did not leave a cup of medications unattended at a resident's bedside for one (Resident 223) out of five sampled residents investigated under the care area of accidents. This deficient practice had the potential for Resident 223 to miss a dose of medications and residents obtaining medication without staff knowledge resulting in accidental ingestion causing harm to residents. Findings: During a review of Resident 223's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility admitted the resident on 3/21/2024 with diagnoses including dysphagia (difficulty swallowing) and dementia (a progressive state of decline in mental abilities). During a review of Resident 223's Minimum Data Set (MDS - a resident assessment tool), dated 10/1/2024, the MDS indicated the resident had moderately impaired cognition (the mental process of acquiring knowledge and understanding through thought, experience, and the senses)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. During a review of Resident 114's admission Record, the admission Record indicated that the facility initially admitted Resident 114 on 4/6/2022 and readmitted the resident on 8/16/2023 with diagnoses including hypertensive chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood well), Alzheimer's disease (a brain disorders that slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks), and 2019-nCov acute respiratory disease (Covid-respiratory illness that causes fever, coughing, and shortness of breath). During a review of Resident 114's Care plan initiated on 8/25/2023 and revised on 07/30/2024, the care plan indicated that Resident 114 had a respiratory system problem related to pneumonia (is an infection that inflames the air sacs [thin-walled structures composed of simple squamous epithelium] in one or both lungs) and being Covid positive. The care plan indicated an intervention to change oxygen tubing and label it every…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 report an incident of alleged abuse involving one of one sampled resident (Resident 1) to the Department in accordance with State law within five working days of the incident. Resident 1 made sexual allegations against one CNA 1 who worked at the facility. This deficient practice had the potential for the underreporting of abuse incidents and a delay in an investigation of abuse allegations, placing the affected Resident 1 and/or other residents at risk for potential further abuse. Findings: During a concurrent interview and record review on 3/27/2024 at 10:08 a.m. with Director of Nursing Services (DON), Resident 1's initial psychiatric evaluation, dated 2/23/2024, was reviewed. The initial psychiatric evaluation indicated that Resident 1 was admitted on [DATE], to the Skilled Nursing Facility section. with a diagnosis including mild cognitive impairment (a mental condition related to a disconnection with reality) amongst other past medical history.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 further potential abuse when CNA 1 was allowed to finish his (CNA 1) shift after an allegation of abuse was made by one of one sampled resident (Resident 1) in accordance with the facility's policy and procedure regarding abuse investigation. This deficient practice had the potential for exposing Resident 1 and other residents to potential abuse by the alleged perpetrator by not removing him (CNA 1) from the facility pending investigation of the abuse allegation and allowing him (CNA 1) to work for the remainder of his (CNA 1) shift. Findings: During a concurrent interview and record review on 3/27/2024 at 10:08 a.m. with the Director of Nursing Services (DON), Resident 1's initial psychiatric evaluation, dated 2/23/2024, was reviewed. The initial psychiatric evaluation indicated that Resident 1 was admitted on [DATE] to the Skilled Nursing Facility section with a diagnosis including mild cognitive impairment (a mental condition related to a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to: 1. Ensure Licensed Vocational Nurse 1 (LVN 1) administered medications via the physician ordered oral (PO, by mouth) route (location at which a drug is administered) for one of 14 sampled residents (Resident 61) investigated during the Medication Administration task. This deficient practice had the potential to reduce medication effectiveness, increase the risk of toxicity (the degree to which a substance is poisonous), and increased the likelihood of obstruction of the gastrostomy tube (G-tube- a tube placed directly into the stomach to give direct access for supplemental feeding, hydration, or medicine). 2. Ensure LVN 1 completed documentation indicating reconciliation (a system of recordkeeping that ensures an accurate inventory of medications that have been received, dispensed, and administered) of controlled medications (substances that have an accepted medical use, have a potential for abuse, and may also lead to physical or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the refrigerator temperature was maintained per the facility's policy and procedure for refrigerated stored medications for one of three medication rooms (Medication Room A) and two of two sampled residents (Resident 90 and 209) investigated during the Medication Storage and Labeling task. This deficient practice had the potential to result in residents receiving medications that have decreased in efficacy resulting in mismanagement of resident illness. Findings: a. A review of Resident 209's Face Sheet (admission record) indicated the facility admitted the resident on 7/3/2023 and readmitted the resident on 8/27/2023 with diagnoses including type two diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]) and unspecified dementia (general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life). A review of Resident 209'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 observation, interview, and record review, the facility failed to maintain infection control practices by failing to: 1. Ensure the licensed nursing staff disinfected the silver metal trays used to hold and transport resident medications before and after preparing resident medications for seven of 14 sampled residents (Resident 61, 115, 171, 184, 207, 224, and 4) investigated during the Medication Administration task. These deficient practices had the potential to spread communicable diseases and infections among staff and residents. 2. Ensure a gallon of distilled water is not placed on the floor beside an oxygen concentrator in the resident`s room for one of one resident (Resident 210) investigated under Infection Control. This deficient practice had the potential to result in waterborne illnesses caused by drinking a water or using the water as humidifier (add moisture to indoor air) which is contaminated by disease-causing microbes (tiny living things that are found all around us and are too small…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a resident was not wearing a hospital gown for multiple days despite the resident's request to wear her own personal clothes for one of one sampled resident (Resident 63) investigated under resident rights. This deficient practice resulted in the resident not being treated with dignity and respect which had the potential to affect the resident's sense of self-worth and self-esteem. Findings: A review of Resident 63's Face Sheet (admission record) indicated the facility admitted the resident on 4/6/2021, with diagnoses including chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems) and insomnia (persistent problems falling and staying asleep). A review Resident 63's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 1/12/2024, indicated that Resident 63 had the ability to make self-understood and had the ability to understand others. The MDS indicated Resident 63 is dependent on staff for personal hygiene 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 accommodate a resident's preference of keeping his urinal (a container used to collect urine) by his bedside for one of one sampled resident (Resident 21) investigated for accommodation of needs. This deficient practice violated the resident's right to make choices. Findings: A review of Resident 21's Face Sheet (admission record) indicated the facility admitted the resident on 12/4/2019 with diagnoses including chronic kidney disease (a disease characterized by progressive damage and loss of function in the kidneys) and dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 21's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/20/2023, indicated the resident had intact cognition (the mental process of acquiring knowledge and understanding through thought, experience, and the senses) and required supervision for most activities of daily living (ADLs - 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 a copy of the resident's advance directive (a written statement of a person's wishes regarding medical treatment) is kept in the resident's chart and easily retrievable for one of eight sampled residents (Resident 215) investigated for advance directive. This deficient practice had the potential to create confusion which could lead to conflict with the resident's wishes regarding their health care. Findings: A review of Resident 215's Face Sheet (admission record) indicated the facility originally admitted the resident on 6/27/2022 and readmitted the resident on 7/23/2023 with diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), dementia (a group of thinking and social symptoms that interferes with daily functioning), and chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems). A review of Resident 215's Minimum Data Set (MDS - a standardized assessment and care screening 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: 1. Ensure Certified Nursing Assistant 1 (CNA 1) provided bodily privacy to a resident while the resident was in the bathroom for one of two sampled residents (Resident 38) investigated for dignity. 2. Ensure a resident's rights to personal privacy and confidentiality of their personal and medical records by failing to ensure Licensed Vocational Nurse 2 (LVN 2) did not leave an unattended computer screen in a public area displaying a resident's Medication Administration Record (MAR, a record of all medications taken by a resident on a day-to-day basis) for one of two sampled residents (Resident 19). This deficient practice violated the residents' right to privacy. Findings: 1. A review of Resident 38's Face Sheet (admission record) indicated the facility originally admitted the resident on 11/8/2021 and readmitted the resident on 7/27/2022 with diagnoses including obstructive and reflux uropathy (a disorder of the urinary tract 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 interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan (a centralized document of a resident's condition, diagnosis, the nursing team's goals for the resident, and measure of the resident's progress) for a resident's use of an antibiotic (medicine that fights bacterial infections) for one of six sampled residents (Resident 224) investigated for antibiotic use. This deficient practice had the potential to result in failure to deliver necessary care and services. Findings: A review of Resident 224's Face Sheet (admission record) indicated the facility admitted the resident on 12/5/2023 and readmitted the resident on 1/3/2024 with diagnoses including enterocolitis (inflammation of the digestive tract) due to clostridium difficile (C-diff - a bacterium that causes diarrhea and colitis [inflammation of the colon]). A review of Resident 224's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/7/2024, indicated the resident had intact cognition (the mental process of acquiring knowledge…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 update and revise a resident's care plan (a document that summarizes a resident's health conditions, care needs, and treatments) to reflect an actual choking incident for one of four sampled residents (Resident 142) investigated for care plans. This deficient practice had the potential to result in the resident not receiving appropriate care and treatment specific to the resident's needs. Findings: A review of Resident 142's Face Sheet (admission record) indicated the facility originally admitted the resident on 2/6/2020 and readmitted the resident on 8/10/2023 with diagnoses including dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), hemiplegia (one-sided paralysis) and hemiparesis (one-sided muscle weakness), Parkinsonism (a term that refers to brain conditions that cause unintended or uncontrollable movements), and dysphagia (difficulty swallowing). A review of Resident 142's Minimum Data Set (MDS - a standardized…

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

Based on interview and record review, the facility failed to ensure a physician's order for hydrocodone-acetaminophen (medication used to relieve moderate to severe pain) 10-325 milligrams (mg- unit of measurement) every six hours as needed (PRN) for back pain was clarified to prevent overmedicating one of one sampled resident (Resident 101) investigated under pain management. Resident 101's physician order for hydrocodone-acetaminophen 10-325mg every six hours PRN did not include a pain scale (numeric rating scale: Zero is considered no pain; one to three is mild pain; four to six is moderate pain, and seven to 10 is severe pain). This deficient practice had the potential to result in adverse event (undesired harmful effect resulting from a medication or other intervention) such as respiratory depression (shallow breathing rate) which could lead to cardiac arrest (a condition in which the heart suddenly stops beating) and death. Findings: A review of Resident 101's Face Sheet (admission record) indicated the facility admitted the resident on 8/1/2023 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.