Park View Nursing And Subacute

Based on observation, interview, and record review the facility failed to ensure safe and sanitary food storage and distribution practices when:A case of thickened dairy drink was served beyond the printed best by date.A bag of dry pasta was stored without a seal or closure. A utensil scoop store inside container of white flour. These deficient practices had the potential to result in harmful bacterial growth that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or toxins) in 55 of 89 residents who received food from the facility kitchen.During an observation in the walk-in refrigerator in the facility's kitchen on 06/01/26 at 8:48 AM, a half-full carton of thickened dairy drink (a specialized milk-based drink that flows more slowly used to prevent choking and aspiration in patients with swallowing difficulty or disorders) had a printed best by date of 05/27/26. The carton had a 5/22 written in a black marker on the top near the best by date and had Open 6/1/26 on the long side of the carton. During continued observation in…

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

Based on observation, interview and record review, the facility failed to provide care in a manner that maintained a resident`s dignity and respect by failing to ensure Certified Nursing Assistant 1 (CNA 1) knocked prior to entering a resident`s room for one of one resident (Resident 92) reviewed under the dignity care area. This deficient practice violated the resident's right to be treated with respect and dignity and had the potential to affect Resident 92`s sense of self-worth and self-esteem. Findings: During a review of Resident 92's admission Record (AR), the admission record indicated the facility admitted the resident on 1/24/2025 with diagnoses including, paraplegia (a medical condition characterized by the partial or complete loss of motor and sensory function in the lower half of the body) and gastro-esophageal reflux disease (stomach acid flows back up into the esophagus and causes heartburn). During a review of Resident 92's Minimum Data Set (MDS-a resident assessment tool) dated 5/08/2026, the MDS indicated the resident had the ability to make self-understood and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide one of three sampled residents (Resident 32), a safe, clean, comfortable, and homelike environment when the facility failed to ensure Resident 32's living area was kept clean and clutter-free.This failure had the potential to make the resident feel uncomfortable and place the resident at increased risk for accidents and infections. Findings: During a review of Resident 32's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility originally admitted Resident 32 to the facility on 1/29/2026 and readmitted on [DATE] with diagnoses including but not limited to metabolic encephalopathy (brain dysfunction caused by chemical imbalances), pneumonia (an infection/inflammation in the lungs), and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of the Minimum Data Set (MDS - a…

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

Based on interview and record review, the facility failed to ensure a resident or their representative participated in the Interdisciplinary Team (IDT- an interdisciplinary team is a group of health care professionals working collaboratively toward a common goal. This team includes professionals with different roles involved in treating a patient's condition or diagnosis) care planning process conducted on 11/9/2025 for one of 19 residents (Resident 92) reviewed under Care Planning. This deficient practice had the potential to result in Resident 92 not receiving person centered care (person-centered care allows patients to make informed decisions about their treatment and well-being) to meet the resident`s needs. Findings: During a review of Resident 92's admission Record, the admission Record indicated the facility admitted the resident on 1/24/2025 with diagnoses including, paraplegia (a medical condition characterized by the partial or complete loss of motor and sensory function in the lower half of the body) and gastro-esophageal reflux disease (stomach acid flows back up into…

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

Based on observation, interview and record review, the facility failed to provide care in accordance with professional standards and facility policy and procedures (P&P) for one (1) of five (5) residents (Resident 74) observed for medication administration, by failing to not crush (pressing very hard so that the shape is destroyed and forms a soft powder) metoprolol succinate ER 24-hour (a slow-release medication used for high blood pressure throughout a 24-hour period) tablet. This deficient practice had the potential to result in Resident 74 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have,) and health complications such as stomach irritation, and ineffective blood pressure control resulting in Resident 74's health and well-being to be negatively impacted. Findings: During an observation on 6/3/2026 at 9:20 a.m., in Medication Cart 1, Licensed Vocational Nurse (LVN) 3 was observed crushing (pressing very hard so that the shape is destroyed and forms a soft powder) metoprolol succinate ER 24-hour tablet and mixing…

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 residents received care consistent with professional standards of practice to prevent pressure injuries (PI/PU, injuries to the skin and underlying tissue resulting from prolonged pressure) for two of four residents (Resident 66 and 82) by failing to ensure: 1. Resident 66's both heels were floated (a technique of offloading [any method used to reduce or remove] that involves completely suspending or elevating a body part off a bed or support surface) on pillows. 2. Resident 82's low air loss mattress (LALM - designed to distribute a patient's body weight over a broad surface area and help prevent skin breakdown) was set to the resident's weight per physician`s order. These failures placed the residents at risk of discomfort, development of new pressure ulcers and delayed wound healing. Findings: 1. During a review of Resident 66's admission Record, the admission Record indicated the facility admitted Resident 66 on 5/13/2026 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 environment was free from accidents and hazards by failing to ensure the floor mat did not have the over-bed table on top of the floor mat for one of four sampled residents (Resident 29) investigated under accidents care area. This failure placed Resident 29 at risk for injury should a fall occur. Findings: During a review of Resident 29's admission Record, the admission Record indicated the facility initially admitted Resident 18 on 5/11/2025 and readmitted on [DATE] with diagnoses that included type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) difficulty in walking and muscle weakness, During a review of Resident 29's History and Physical (H&P) dated 5/27/2026, the H&P indicated Resident 29 did not have the capacity to understand and make decisions. During a review of Resident 29's Minimum Data Set (MDS, a resident assessment tool), dated 6/29/2025, 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 ensure that a resident who was receiving dialysis (clinical purification of blood as a substitute for the normal function of the kidney) treatment received services consistent with professional standards of practice by failing to ensure the post dialysis assessment was completed for one of two sampled residents (Resident 29) investigated under the dialysis care area. This deficient practice placed the resident at risk for missed monitoring and delayed identification of complications associated with renal disease and dialysis, including hypertension, fluid overload, shortness of breath, and the potential need for hospitalization.Findings: During a review of Resident 29's admission Record, the admission Record indicated the facility initially admitted Resident 18 on 5/11/2025 and readmitted on [DATE] with diagnoses that included type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) 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 interview and record review, the facility failed to maintain complete and accurate clinical records for one of five sampled residents (Resident 48) reviewed for unnecessary medications by failing to document Resident 48's blood glucose (BG-the main sugar found in the bloodstream) levels and the insulin (medication that lowers the blood sugar) administered to Resident 48, in the Medication Administration Record (MAR) on 5/28/2026 and 5/30/2026. This failure placed the resident at risk for not receiving appropriate care and treatment due to incomplete information in the medical record. Findings: During a review of Resident 48's admission Record, the admission Record indicated the facility originally admitted Resident 48 on 4/29/2025 and re-admitted the resident on 5/16/2024, with diagnoses including acute respiratory failure (condition where the lungs cannot adequately exchange oxygen and carbon dioxide, leading to low oxygen), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing),and sepsis (a life-threatening…

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 Certified Nursing Assistant 3 (CNA 3) and the Physician Assistant (PA) wore appropriate personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) while performing high contact activities (tasks involving prolonged or close physical interaction) to one of three sampled residents (Resident 47) placed on enhanced barrier precautions (EBP- infection control interventions to prevent the spread disease). This failure had the potential to result in staff spreading multidrug-resistant organisms (MDRO - bacteria or germs that have developed resistance to multiple antibiotics, making infections hard to treat) to other residents. Findings: During a review Resident 47's admission Record, the admission Record indicated the facility admitted Resident 47 on 10/14/2025 with diagnoses including but not limited to pressure ulcer of sacral region (a wound on the tissue over the sacrum - the triangular bone at the base of the…

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

Based on interview and record review, the facility failed to ensure two of three sampled staff, (Certified Nursing Assistant [CNA] 3 and Licensed Vocational Nurse [LVN] 3), received enhanced barrier precautions (EBP - infection control interventions to prevent the spread disease) competency training. This failure had the potential to result in the spread of infectious organisms (germs that may cause disease or harm) to residents when staff are not trained, assessed, and monitored to ensure infection control and prevention standards of practice are followed. Findings: During a concurrent interview and record review on 6/4/2026 at 11:10 a.m. with the Infection Preventionist Nurse (IPN), the IPN was unable to provide documentation that CNA 3 and LVN 3 received EBP training. During a concurrent interview and record review on 6/4/2026 at 11:51 a.m. with the Director of Staff Development (DSD), the Annual CNA Competency form for CNA 3 dated 9/25/2025, and Initial/Annual License Nurse Competency form for LVN 3 were reviewed. The competency forms did not indicate CNA 3 and LVN 3 received…

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 Registered Nurse 1 (RN 1) documented on a resident's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications given to a resident) right after administering insulin (hormone that regulates the amount of glucose [sugar] in the blood) lispro (rapid-acting insulin) for one of two sampled residents (Resident 1). This deficient practice had the potential to result in medication errors and negatively affect the delivery of care and services to Resident 1.Findings: During a review of Resident 1's admission Record, the admission Record indicated that the facility admitted Resident 1 on 2/17/2026 with diagnoses that included but not limited to cerebral infarction (stroke, loss of blood flow to a part of the brain resulting in damage to brain tissue), diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too…

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 grievance submitted on behalf of a resident's family member was addressed and investigated per the facility's policy and procedure (P&P) for one of two sampled residents (Resident 1). This deficient practice violated the resident's right to have their grievance addressed and had the potential for further concerns to not be addressed. Findings: During a review of Resident 1's admission Record, the admission Record indicated that the facility admitted Resident 1 on 2/17/2026 with diagnoses that included but not limited to cerebral infarction (stroke, loss of blood flow to a part of the brain resulting in damage to brain tissue), diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]). During a review of Resident 1's Minimum Data Set (MDS -a resident assessment tool) dated 2/23/2026, the MDS indicated that Resident 1's cognition (ability to think, reason,…

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 a summary of a resident's baseline care plan (a document that summarizes a resident's needs, goals, and care/treatment) to a resident and/or their representative for one of two sampled residents (Resident 1). This deficient practice had the potential to negatively affect the residents' care.Findings: During a review of Resident 1's admission Record, the admission Record indicated that the facility admitted Resident 1 on 2/17/2026 with diagnoses that included but not limited to cerebral infarction (stroke, loss of blood flow to a part of the brain resulting in damage to brain tissue), diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]). During a review of Resident 1's Minimum Data Set (MDS -a resident assessment tool) dated 2/23/2026, the MDS indicated that Resident 1's cognition (ability to think, reason, and function) was intact. The MDS indicated…

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

Based on observation, interview, and record review, the facility failed to ensure proper use of a low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure ulcer/injuries [PU/PI- injuries that breakdown the skin and underlying tissue when an area of skin is placed under pressure]) by placing multiple layers of linens on top of the LALM for one of thirteen sampled residents (Resident 2). This deficient practice had the potential to increase the resident's risk of skin breakdown and/or delayed healing of existing PU/PI.Findings: During a review of Resident 2's admission Record, the admission Record indicated that the facility admitted Resident 2 on 3/17/2026 with diagnoses that included osteoarthritis (a degenerative joint disease where the cartilage that cushions the ends of bones gradually wears away, leading to pain, stiffness, and reduced movement) left knee, presence of left artificial knee joint, and pressure ulcer of sacral (refers to the lower back area right above the buttocks) region, stage III (deep wound where the skin is…

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

Based on observation, interview, and record review, the facility failed to develop and implement policies and procedures (P&P) for the use of a low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure ulcer/injuries [PU/PI - injuries that breakdown the skin and underlying tissue when an area of skin is placed under pressure]) for 12 of 12 sampled residents (Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12 and Resident 13) reviewed for PU/PI prevention. This deficient practice resulted in inconsistent use of the LALM and had the potential to compromise its effectiveness placing residents at risk for skin breakdown and/or delayed healing of PU/PI.Findings: During a review of the facility's Order Listing Report dated 3/25/2026, the Order Listing Report indicated the following:- Resident 2 had an order for LALM dated 3/18/2026.- Resident 3 had an order for LALM dated 1/3/2026.- Resident 4 had an order for LALM dated 4/11/2025.- Resident 5 had an order 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 that the call light (an alerting device for nurses to assist a patient when in need) was within a resident`s reach while in bed for one of three sampled residents (Resident 2). This deficient practice had the potential to result in a delay in meeting the residents' needs for assistance which could have left the resident feeling isolated, a sense of decreased self-worth, self-esteem and dignity along with an increased risk for falls or accidents.Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 3/16/2022 and most recently readmitted the resident on 12/9/2025 with diagnoses that included metabolic encephalopathy (a brain disorder that can cause confusion personality changes and drowsiness), functional quadriplegia (a permeant state of immobility and inability to care for oneself), type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN-high blood pressure),…

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

Based on observation, interview and record review, the facility failed to ensure a resident's ankle foot orthosis (AFO-a medical device worn on the lower leg and foot to support, stabilized and improve function of the affected joint) was properly applied in accordance with the physician's order for one of three (Resident 1) sampled residents. This deficient practice had the potential to promote the development of further contractures (a condition of shortening and hardening of muscles, tensons or other tissue, often leading to deformity and rigidity of joints), decreased movement, strength and overall health status. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 1/20/2017 and readmitted the resident on 3/9/2025 with diagnoses that included traumatic brain injury (an acquired injury to the brain caused by an external force that disrupts normal brain function), seizures (a sudden, uncontrolled electoral disturbance in the brain which and cause uncontrolled jerking, blanking stares, and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. During a review of Resident 76's admission Record, the admission Record indicated the facility admitted Resident 76 on 5/1/2025 with diagnoses that included, but not limited acute and chronic respiratory failure with hypoxia (low levels of oxygen in your body tissues), malignant neoplasm (cancerous tumor) of the larynx (area of the throat known as the voice box), dysphagia (swallowing difficulties), and difficulty walking During a review of Resident 76's H&P, dated 4/8/2025, the H&P indicated Resident 76 did not have the capacity to understand and make decisions. During a review of Resident 76's MDS, dated [DATE], the MDS indicated Resident 76 had the capacity to make himself understood and to understand others. The MDS indicated Resident 76 needed moderate assistance with activities such as oral hygiene and dressing and movements such as rolling left to right and sit to stand. During a review of Resident 76's Resident is at Risk for Falls/Injury Due to Impaired Mobility Care Plan (CP), the CP indicated an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a licensed nursing staff possessed the competency (a measurable pattern of knowledge, skills, abilities, behaviors that an individual needs to perform work roles successfully) necessary to follow a physician's order by failing to take a Resident 62's apical pulse (a pulse point on the chest that gives the most accurate reading of the heart rate taken with a stethoscope [a device to listen to the heartbeat]) before giving a heart medication for one (LVN 2) of four licensed nurses observed during the medication pass observation. This deficient practice had the potential to cause complications such as bradycardia (slow heart rate with less than 60 beats per minute [bpm.]) dizziness, and syncope (fainting). Cross referenc to F760 Findings: During a review of Resident 62's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (an irregular, often…

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 have the pharmacy exchange the emergency kit (e-Kit, a collection of medications that need to be given immediately such as pain or antibiotic medication) within 72 hours according to the facility's policy and procedure for two (Subacute Nursing Station, Skilled Nursing Facility Nursing Station) of two Medication Rooms. This had the potential for medications to not be available in emergency situations. Findings: During a review of Resident 145's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted the resident on 4/22/2025 with diagnoses that included sepsis (a life-threatening blood infection). During a review of Resident 145' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 5/8/2025, the MDS indicated Resident 145 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free from any significant medication errors for one (Resident 62) of four residents observed during the medication pass observation. Licensed Vocational Nurse 2 (LVN 2) failed to check Resident 62's apical pulse (a pulse point on the chest that gives the most accurate reading of the heart rate taken with a stethoscope [a device to listen to the heartbeat]) before giving a heart medication. This deficient practice had the potential to cause complications such as bradycardia (slow heart rate with less than 60 beats per minute [bpm.]) dizziness, and syncope (fainting). Findings: During a review of Resident 62's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (an irregular, often rapid heart rate that causes poor blood flow). During a review of Resident 62's Minimum Data Set (MDS, a federally mandated resident assessment…

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

Based on observation, interview and record review, the facility failed to prepare foods in a form designed to meet individual needs when seven of eight residents on puree diet (food that is prepared in a way that is smooth with no lumps and has a texture like pudding) were served puree lemon crisp that was too thick. This deficient practice had the potential to result in a resident having difficulty swallowing and choking. Findings: During a concurrent test tray (a process of tasting, temping, and evaluating the quality of food) observation and interview on 5/21/2025 at 1:58 p.m. with the Dietary Supervisor (DS) and the Regional Dietary Supervisor (RDS), observed the puree dessert lemon crisp. The DS stated the lemon crisp was too thick to serve to residents. The DS stated it had the potential for someone to have difficulty to swallow the food. The DS stated the dessert should be similar to mashed potatoes, smooth, and should drop off the spoon when conducting the spoon tilt test (a method used to assess the cohesiveness and stickiness of foods, particularly in the context of the…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen by failing to: 1. Ensure peppers stored in refrigerator were labeled with a date when placed in the refrigerator. 2. Ensure the temperature of food items on the tray line (a system of food serving in which a tray is moved along an assembly line to ensure a resident gets their prescribed diet) were taken. 3. Ensure Dietary Aide1 (DA 1) did not touch his glasses with a gloved hand multiple times and did not wash hands or change gloves until asked by the Dietary Supervisor to do so. These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, and other toxins) in 57 medically compromised residents who received food from the kitchen. Findings: 1. During an initial observation of the kitchen with the Dietary Supervisor…

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. Develop and implement a comprehensive person-centered care plan (CP, a plan for individual's specific health needs and desired health outcomes) with individualized oral care interventions for one of one sampled resident (Resident 67) with a tracheostomy (a surgical procedure to create an opening through the neck into the trachea [windpipe]) and dependent on ventilator (a medical device that helps a person breathe when they are unable to do so on their own) during a random observation. This deficient practice had the potential to cause health complications for Resident 67 due to inadequate oral hygiene. 2. Implement a care plan (CP- a plan for individual's specific health needs and desired health outcomes) intervention of providing a floor mat (padded mat placed on the floor to cushion falls and prevent injury) for one of one sampled resident (Resident 76) reviewed under the accidents care area. This deficient practice placed the…

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

Based on observation, interview, and record review, the facility failed to ensure proper technique for administering medications through an enteral tube (a tube inserted into the gastrointestinal tract to deliver nutrition and medications) for one of two residents (Resident 74) observed during the medication administration task observation when: 1. Excess crushed tablets were left in the medication cup after the medication was administered. 2. The enteral tube was not flushed with the amount of water indicated in the physician's order between medications. These deficient practices had the potential to cause complications for Resident 74 including clogging the enteral tube and not receiving the full amount of medication as ordered. Findings: During a review of Resident 74's admission Record, the admission Record indicated the facility originally admitted the resident on 12/28/2024 and readmitted the resident on 5/6/2025 with diagnoses including but not limited to encephalopathy (any disease that alters brain function or structure) and respiratory failure. During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain oral hygiene for one of one sampled resident (Resident 67), who is unable to carry out activities of daily living, when Resident 67's lips were dry, cracked and had a thick layer of dried saliva and skin on them. This deficient practice resulted in Resident 67 having poor oral hygiene and had the potential to negatively affect the residents' psychosocial wellbeing. Findings: During a review of Resident 67's admission Record, the admission Record indicated the facility admitted Resident 76 on 6/4/2024 and readmitted on [DATE] with diagnoses including hemiplegia (one-sided muscle paralysis or weakness), respiratory failure (a serious condition that makes it difficult to breathe on your own) with hypoxia (low levels of oxygen in your body tissues), dysphagia(swallowing difficulties) and dependence of respirator [ventilator] status (a machine that helps someone breathe when they are unable to breathe…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent (lacks voluntary control over urination) of bladder (organ in the pelvis that stores urine) received appropriate treatment and services to prevent urinary tract infections (UTIs, common infections that happen when bacteria infect the urinary tract) by failing to ensure the urinary catheter did not coil (unwanted twist or bend) or loop to one of one sampled residents (Resident 60) reviewed under the urinary catheter (a tube that is inserted into the bladder, allowing urine to drain) care area. This deficient practice had the increased potential for Resident 60 to obtain a UTI. Findings: During a review of Resident 60's admission Record, the admission Record indicated the facility admitted Resident 15 on 4/7/2025 with diagnoses including hemiplegia (a condition causing paralysis on one side of the body, often resulting from brain damage) and hemiparesis (weakness or the inability to move on one side of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) center completed a post-dialysis assessment (evaluation done after hemodialysis by the hemodialysis licensed nurses) by not ensuring the dialysis center recorded a resident's post dialysis weight (the weight after fluid is removed during the dialysis treatment) on 5/15/2025. This deficient practice had the potential for Resident 43 to have unidentified complications after dialysis treatment such as abnormal vital signs (pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions). Findings: During a review of Resident 43's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including end stage renal disease (ESRD, irreversible kidney failure). During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medication was properly stored when one of three inspected medication carts (Subacute Medication Cart 2) had an unlabeled, unpackaged tablet in the bottom of a cart drawer. This deficient practice placed residents at risk of receiving an incorrect or expired medication. Findings: During a concurrent observation and interview on [DATE] at 2:11 p.m. with Licensed Vocational Nurse 3 (LVN 3) at Subacute Medication Cart 2, one white, round unlabeled and unpackaged tablet was observed on the bottom of a cart drawer. LVN 3 stated the medication should be packaged and labeled when stored in the cart so they can verify the correct medication is being given by comparing it to the resident's orders in the resident's electronic health record (EHR-an electronic version of a resident's medical record, including physician orders). LVN 3 further stated the tablet should have been kept in its original packaging so the expiration date can be…

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 accuracy of a medical record when one of twelve residents investigated under the Advance Directive care area (Resident 34) had an Advance Directive Acknowledgement form that indicated the resident had an Advance Directive when he did not. This deficient practice resulted in inaccurate documentation of the existence of an Advance Directive in Resident 34's medical record. Findings: During a review of Resident 34's admission Record, the admission Record indicated the facility admitted the resident on 12/13/2024 with diagnoses including pneumonia (an infection/inflammation in the lungs), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and schizophrenia (a mental illness that is characterized by disturbances in thought). The admission Record further indicated Resident 34 is deaf and non-speaking. During a review of Resident 34's Minimum Data Set (MDS - a resident assessment tool), dated 9/17/2025, the MDS…

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

Based on interview and record review, the facility failed to develop a comprehensive care plan (a document that summarizes a resident's needs, goals, and care/treatment) with resident-centered interventions to address a resident's preference of wanting keep food at the resident's bedside for one of three sampled residents (Resident 2). This deficient practice had the potential outcome to have a negative affect Resident 2's quality of life, as well as the quality of care and services received. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility readmitted the resident on 5/14/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), patient's noncompliance with other medical treatment and regimen due to unspecified reason, and functional quadriplegia (paralysis [complete or partial loss of muscle function] of all four limbs). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 2/1/2025, the MDS indicated 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.

Based on interview and record review, the facility failed to ensure a resident's discharge summary was completed for one of three sampled residents (Resident 3). This deficient practice had the potential for inconsistent care coordination due to incomplete records for Resident 3. Findings: During a review of Resident 3's admission Record, the admission Record indicated the facility readmitted the resident on 12/19/2024 with diagnoses that included cervical disc degeneration (a condition affecting the neck's spinal discs, causing pain and discomfort), laceration (cut) without foreign body of unspecified part of head, and history of falling. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool) dated 12/23/2024, the MDS indicated the resident had intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). During a concurrent interview and record review on 2/6/2025 at 4:55 p.m., with the Medical Records Director (MRD), reviewed Resident 3's admission Record. The MRD stated Resident 3…

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

Based on interview and record review, the facility failed implement their hydration and prevention of dehydration policy by failing to ensure one of three sampled residents (Resident 1) intake (consumption) was documented in the resident's medical record. This deficient practice had the potential to place Resident 1 at risk for dehydration and placed Resident 1 at risk for medical complications related to inadequate hydration. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 12/28/2024 with diagnoses that included osteomyelitis (infection of the bone that causes inflammation and pain) of vertebra (one of the bones that make up the spinal column) and sacrococcygeal (tailbone) region, low back pain, and chronic kidney disease (progressive damage and loss of function in the kidneys). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 12/31/2024, the MDS indicated that Resident 1 had severely impaired cognition (mental action or process of acquiring knowledge and…

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

Based on observation, interview and record review, the facility failed to implement their policy on preventing foodborne illness (refers to illness caused by the ingestion of contaminated food or beverages) for one of one sampled resident (Resident 2) by failing to ensure cooked eggs found on Resident 2's bedside table were discarded and not left on Resident 2's bedside table for over 24 hours. This deficient practice placed Resident 2 at risk for foodborne illnesses. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility readmitted the resident on 5/14/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and functional quadriplegia (complete inability to move due to severe disability or frailty caused by another medical condition). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 2/1/2025, the MDS indicated the resident cognition (the mental action or process of acquiring knowledge and understanding 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement its policy titled, Enhanced Barrier Precautions (EBP - an infection control method that uses targeted gown and gloves to reduce the spread of multidrug-resistant organisms [MDROs - microorganisms, mainly bacteria, that are resistant to one or more classes of antimicrobial [a substance that kills microorganisms such as bacteria or mold, or stops them from growing and causing disease agents]), and Hand washing/Hand hygiene (HH - cleaning hands by either washing with soap and water, or by using a hand sanitizing [removing germs] gel) by failing to ensure: 1. Certified Nurse Assistant 1 (CNA 1) donned (to put on) a gown while changing the bed linen for one of three sampled residents (Resident 1) on EBP. 2. CNA 1 perform HH after removing gloves for one of three sampled residents (Resident 1) on EBP. These deficient practices placed the residents at increased risk of developing an infection. Findings: During a review 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.

Based on observation, interview, and record review, the facility failed to maintain residents' room temperature level between 71-81 degrees Fahrenheit (F- unit of measure for temperature), as required by the federal regulation for one of three sampled residents (Resident 3) and two of seven rooms (Room A and Room B). This deficient practice resulted in the Resident 3's increased level of discomfort and had the potential to negatively impact the residents' quality of life. Findings: During a review of Resident 3's admission Record, the document indicated the facility admitted the resident on 9/12/2024 with diagnoses that included left pelvic (the area of the body below the abdomen that is located between the hip bones) fracture (a partial or complete break in the bone), left hip fracture, heart failure (when the heart muscle does not pump blood as well as it should), and insomnia (difficulty falling or staying a sleep). During a review of Resident 3's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, 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 follow their policy and procedure (P&P) titled, Physical Environment, Power Strip (a device that provides multiple electrical outlets connected to a single cable that plugs into an electrical outlet) Policy, by not placing power strips in a safe location while in use for two of three sampled residents (Resident 2 and Resident 4). This deficient practice had the potential for residents, visitors, and staff to have an increased risk of falls, trips, and occupational hazards (hazard experienced in the workplace) while in the facility. Findings: During a review of Resident 2's admission Record, the document indicated the facility admitted the resident on 11/24/2023 with diagnoses that included cervical disc disorder (a condition that occurs when the discs in the neck wear down and cause pain), contracture (a permanent tightening of the muscles, tendons, skin and nearby tissues that cause the joints to shortens and become very stiff) of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its policy and procedure on Fall Management and Neurological (deals with problems affecting the nervous system [includes the brain, spinal cord, and a complex network of nerves]) Evaluation by failing to ensure a neurological assessment was completed after an unwitnessed fall on 8/17/2024 for one of three sampled residents (Resident 1). This deficient practice had the potential to result in a delay of care and placed the resident at risk of not receiving appropriate care due to incomplete resident medical care information that may lead to additional falls or complications. Findings: During a review of Resident 1's admission Record indicated the facility admitted the resident on 8/10/2024 and readmitted on [DATE] with diagnoses that included sepsis (a serious condition in which the body responds improperly to an infection), autonomic neuropathy (occurs when there is damage to the nerves that control automatic body functions), muscle weakness, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility to implement their facility's pain management policy by failing to ensure Licensed Vocational Nurse 1 (LVN 1) notified the physician timely to obtain orders to treat residents' pain of for one of three sampled residents (Resident 1). This deficient practice had the potential to result in Resident 1 to experience continued unrelieved pain on 8/18/2024 and not reach the highest possible level of comfort. Findings: During a review of Resident 1's admission Record indicated the facility admitted the resident on 8/10/2024 and readmitted on [DATE] with diagnoses that included sepsis (a serious condition in which the body responds improperly to an infection), autonomic neuropathy (occurs when there is damage to the nerves that control automatic body functions), muscle weakness, and repeated falls. During a review of Resident 1's Minimum Data Set (MDS - standardized assessment and care planning tool) dated 8/16/2024, indicated Resident 1's cognition (the mental action…

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 complete the food preference assessment within 48 hours as per facility policy and protocol for four of five sampled residents (Resident 1,2,3 and 4). This deficient practice had the potential to result in decreased meal intake which can then lead to weight loss. Findings: 1. A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included Charcot ' s joint (a destructive joint disorder initiated by trauma), left ankle and foot (progressive musculoskeletal condition that affects the joints) and diabetes mellitus (elevated blood sugar). A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 5/6/2024, indicated that Resident 1 has intact cognition (mental process of thinking and understanding). A review of Resident 1 Food Preference Interview indicated that the interview was conducted on 7/11/2024. 2. A review of Resident 2 ' s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call light (a device used by a resident to signal his/her need for assistance from staff) was within reach for three of 24 sampled residents (Resident 2, 7, and 70). This deficient practice had the potential to cause a delay in resident care and for the residents' needs to remain unmet. Findings: a. A review of Resident 2's admission Record indicated the facility originally admitted the resident on 5/27/2024 with diagnoses including dementia (a general term for loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). A review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/31/2024, indicated the resident had the ability to make self-understood and the ability to understand others. The MDS also…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident's clinical records were updated with an advance directive (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to healthcare providers) for four of nine sampled residents (Resident 26, 58, 29 and 82) by failing to maintain current copies of the residents' advance directives in their medical records. This deficient practice had the potential to result in confusion in the care and services for Resident 26, 58, 29, and 82 and placed the residents at risk of receiving unwanted treatments and/or not receiving appropriate care based on their wishes. Findings: a. A review of Resident 26's admission Record indicated the facility admitted the resident on 5/29/2024 with diagnosis of sepsis (a life-threatening complication of an infection). A review of Resident 26's Minimum Data Set (MDS- standardized assessment and care planning 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 interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a written document that summarizes a patient's needs, goals, and care/treatment) for three of 24 sampled residents (Residents 82, 30, 32) as evidenced by: 1. Resident 82 did not have a care plan in place for antibiotic-use that the resident was receiving for a urinary tract infection (UTI- an infection in any part of the urinary system). 2. Resident 30 did not have a care plan in place for Restorative Nursing Assistant (RNA, a program designed to ensure each resident maintains their physical and functional abilities) exercises that accurately reflected the physician's orders. 3. Resident 32 did not have a care plan in place for obstructive and reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow). These deficient practices had the potential to result in failure to deliver the necessary care and services. Findings: a. A review of Resident 82's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the low air loss mattress (LAL - a specialty bed that alternates pressure to help heal and prevent pressure ulcers [an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure]) was set correctly for three of five sample residents (Resident 29, 48, and 62). This deficient practice had the potential to increase the resident's risk of skin breakdown. Findings: a. A review of Resident 29's admission Record indicated the facility readmitted the resident on 2/14/2024 with diagnoses that included rhabdomyolysis (a breakdown of muscle tissue in the body that can cause kidney injury), bipolar disorder (a mental illness that causes severe changes in mood, energy, and activity levels), and dementia (progressive impaired ability to think, remember or make decisions that interferes with doing everyday activities). A review of Resident 29's Minimum Data Set (MDS, a standardized resident assessment 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 interview and record review, the facility failed to ensure licensed nurses attempted non-pharmacological interventions (any type of healthcare intervention which is not primarily based on medication) prior to administering as needed (prn) opioid pain medication (medication used to treat moderate to severe pain) on multiple dates for one of 24 sampled residents (Resident 30). This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention) from opioid pain medication. Findings: A review of Resident 30's admission Record indicated the facility originally admitted the resident on 12/3/2023 and readmitted the resident on 12/18/2023 with diagnoses that included acute respiratory failure (a condition that occurs when the lungs can't properly oxygenate the blood), tracheostomy (a surgical procedure that creates a temporary or permanent opening in the neck and into the windpipe to help a patient breathe) status, and gastrostomy (a surgical procedure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure there was documented evidence that multiple doses of Zosyn (an antibiotic [medicine that fights bacterial infections]) intravenous solution (IV- a medical technique that administers fluids, medications, and nutrients directly into a person's vein) were administered per physician's order for one of two sampled residents (Resident 2). This deficient practice had the potential for the resident to develop antibiotic-resistant bacteria (when bacteria change to resist antibiotics that used to effectively treat them) due to misuse which could lead to infections taking longer to heal. 2. Ensure the Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Records (MAR, a report detailing the drugs administered to a patient by the licensed nurses) for four of six sampled residents (Resident 387, 15, 39, and 44). These deficient practices 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: 1. Ensure resident's insulin (a hormone that lowers the level of glucose [sugar] in the blood) was dated when opened for two of two sampled residents (Resident 12 and 387). 2. Ensure an eye drop medication was not used past the expiration date for one of one sampled resident (Resident 33). These deficient practices had the potential to diminish the effectiveness of the medications. 3. Ensure only authorized personnel had access to one of two medication rooms (Medication room [ROOM NUMBER]). This deficient practice resulted in unauthorized personnel having access to resident medications and had the potential for drug diversion (illegal distribution or abuse of prescription drug). Findings: 1.a. A review of Resident 12's admission Record indicated the facility admitted the resident on 3/25/2014 with diagnoses that included diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]). A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain infection control practices for three of 24 sampled residents (Residents 337, 187, 188) by failing to: 1. Ensure a resident's nasal cannula (a medical device that provides supplemental oxygen or increased airflow to people who need respiratory help) was not touching the floor for Resident 187. 2. Ensure the urinals (a container used to collect urine) of Residents 187 and 188 were labeled with a resident identifier. These deficient practices had the potential to place the residents at increased risk of contracting an infection. 3. Label the intravenous (IV - into or by means of a vein or veins) administration set (medical device used to deliver IV fluids or medications) used to administer an antibiotic (medication that inhibits the growth of or destroys bacteria in the body) for Resident 337. This deficient practice had the potential to result in contamination of Resident 337's IV tubing and risked transmitting bacteria that could…

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 an indwelling urinary catheter (a flexible tube inserted into the bladder and left in place to continuously drain urine) collection bag (attached to the catheter tube for the purpose of collecting urine) was covered with a privacy bag (dignity bag- a bag that conceals urine in the collection bag) for one of two sampled residents (Resident 58). This deficient practice had the potential to affect the residents' sense of self-worth and self-esteem. Findings: A review of Resident 58's admission Record indicated the facility admitted the resident on 5/20/2024, with diagnoses of multiple sclerosis (a condition that happens when the immune system attacks the brain and spinal cord) and benign prostatic hyperplasia (prostate gland [gland in the male reproductive system] enlargement that can cause urination difficulty). A review of Resident 58's History and Physical (H&P - a formal assessment of a patient and their problem), dated 5/23/2024, indicated the resident had the capacity to make decision. A review of…

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

Based on interview and record review, the facility failed to: 1. Ensure a STAT (immediately) specimen for Fecal Occult Blood Test (a lab test used to check stool samples for hidden blood) was collected timely when one of one sampled resident (Resident 25) had a bowel movement. 2. Ensure the result of the FOBT was followed up with the laboratory and the result relayed to the provider promptly for one of one sampled resident (Resident 25). This deficient practice had the potential to delay the necessary intervention for a positive occult blood test which could lead to complications such as anemia (low levels of health red blood cells [delivers oxygen to tissues in your body]). Findings: A review of Resident 25's admission Record indicated the facility originally admitted the resident on 5/22/2024 with diagnoses including Guillain-Barre syndrome (a condition in which the body's immune system attacks the nerves) and myasthenia gravis (a rare long-term condition that causes muscle weakness). A review of Resident 25's Minimum Data Set (MDS - a standardized assessment and care screening…

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

Based on interview and record review, the facility failed to promote and facilitate resident's self-determination through support of choice, by denying two out of two residents (Resident 44 and 57) their preferred meal at dinner time. This deficient practice violated the residents' rights in food preferences and had the potential to affect the residents' sense of self-worth and self-esteem. Findings: a. A review of Resident 44's admission Record indicated the facility admitted the resident on 2/15/2024 for orthopedic aftercare following left knee surgery. A review of Resident 44's History and Physical (H&P - a formal assessment of a patient and their problem) indicated Resident 44 had the capacity to make decisions. A review of Resident 44's physician's orders indicated an order for consistent carbohydrate diet regular texture, ordered on 2/15/2014. During an interview on 6/11/2024 at 11:09 a.m., during the Resident Council meeting (a meeting held at the facility with residents who reside in the facility to discuss concerns residents have), Resident 44 stated she wanted to have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one of five sampled residents (Resident 82) by failing to ensure the Physician's Order for Life-Sustaining Treatment (POLST - a written medical order that helps give residents with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) form was complete for Resident 82. This deficient practice had the potential to result in Resident 82 receiving treatments that were undesired during the event of a medical crisis in which Resident 82 could no longer communicate Resident 82's wishes. Findings: A review of Resident 82's admission Record indicated the facility admitted the resident on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD - lung disease causing restricted airflow and breathing problems). A review of Resident 82'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.

Based on observation, interview, and record review, the facility failed to prevent the presence of insects and flies and seal off possible entryway for pests for one of one sampled resident (Resident 3). This deficient practice had the potential to cause an infection to 89 residents residing in the facility. Findings: A review of Resident 3's admission Record indicated the facility admitted the resident on 12/12/2022 with diagnosis including cerebral infarction (disruption of blood flow to the brain due to problematic vessels that cause lack of blood supply and oxygen to the brain), hemiplegia, (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) affecting her right dominant side. A review of Resident 3's History and Physical (H&P- a term used to describe a physician's examination of a resident) indicated Resident 3 did not have the capacity to understand and make decisions. A review of Resident 3's Minimum Data Set (MDS- a standardized resident assessment and care screening tool) dated 5/31/2024, indicated Resident 3 was dependent (helper does all of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accommodate food preferences for milk and more fruits each meal for one of three sampled residents (Resident 1). This deficient practice had the potential to result in decreased meal intake and can lead to weight loss. Findings: A review of Resident 1 ' s admission Record indicated the facility originally admitted Resident 1 on 4/25/2022 and readmitted on [DATE] with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe on your own) with hypoxia (low levels of oxygen in your body tissues), tracheostomy (a surgically created hole in your windpipe that provides an alternative airway for breathing), dependence on respirator (also called ventilator, a machine used to help a resident breathe), diabetes mellitus (a condition that happens when your blood sugar is too high), and bipolar disorder (is a serious mental illness that causes unusual shifts in mood, ranging from extreme highs to lows). A review of Resident 1…

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

Based on interview and record review, the facility failed to ensure Nurse Practitioner 1 (NP 1) did not willfully falsify ( knowingly make a false entry into a resident ' s medical record) progress notes for one of three sampled residents (Resident 1) on 1/22/2023, 2/6/2023, and 2/21/2023. This willful material falsification (WMF – when a staff purposefully documents false information in a medical record) resulted in the clinical record of Resident 1 fraudulently reflecting the care provided. Findings: A record review of Resident 1 ' s admission Record indicated the facility originally admitted Resident 1 on 4/25/2022 and readmitted Resident 1 on 2/28/2023 with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe) with hypoxia (low levels of oxygen in your body tissues), tracheostomy(a surgically created hole in a resident ' s windpipe that provides an alternative airway for breathing), dependence on respirator (a machine that provides the breath when a resident is unable to breathe on their own), diabetes mellitus (a group of disease that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) to address and accommodate the resident's food preferences for milk and more fruits each meal for one of three sampled residents (Resident 1). These deficient practices had the potential to result in a delay in or lack of delivery of care and services. Findings: A review of Resident 1's admission Record indicated the facility originally admitted Resident 1 on 4/25/2022 and readmitted on [DATE] with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe on your own) with hypoxia (low levels of oxygen in your body tissues), tracheostomy (a surgically created hole in your windpipe that provides an alternative airway for breathing), dependence on respirator (also called ventilator, a machine used to help a resident breathe), diabetes mellitus (a condition that happens when your blood sugar…

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 a safe, and comfortable environment for residents, staff and the public when on 1/7/2023, a stranger was able to enter the facility and steal food from the employee breakroom. This deficient practice placed the residents, staff, and the public safety at risk from issues such as theft. Findings: A review of the facility ' s Police Department Investigative Report dated 1/7/2023, indicated the following: 1. Date & Time of Occurrence: 1/7/2023 at 1:40 a.m. 2. Date & Time Reported to Police Department: 1/7/2023 at 8:20 a.m. 3. Type Property Stolen/Lost/Damaged: Chicken 4. Narrative information indicated that a suspect walked to the break room and selected chicken from the refrigerator, ate the chicken, and then left the location. During an interview with Registered Nurse 1 (RN 1) on 4/25/2024 at 6:20 a.m., RN 1 stated that facility staff locks the entrance door between 11 p.m. and 11:30 p.m. daily when the receptionist leaves. RN 1 stated that approximately 3 a.m., facility staff will then unlock the entrance door so…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a skin assessment was accurately completed during a weekly summary assessment for one of three sampled residents (Resident 2). This deficient practice placed Resident 1 at risk for further skin break down due to not receiving care and treatment related to the newly identified skin redness and red bumps on Resident 2's back and left shoulder. Findings: A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility on [DATE] from the General Acute Care Hospital (GACH), with diagnoses of type 2 diabetes (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities), hypertension (high 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 interview and record review, the facility failed to implement its abuse prohibition policy by not conduct pre-employment screening prior to hiring Certified Nurse Assistant 1 (CNA 1) who was accused of rough handling for one of four sampled residents (Resident 1). CNA 1 was hired on 1/2/2024 but the pre-employment screening was done after three months of employment. This deficient practice had the potential to place the residents at risk for elder abuse. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 2/3/2024 with diagnoses including parkinsonism (symptoms of Parkinson disease [a degenerative brain condition affecting body movements and moods]) and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 2/7/2024, indicated Resident 1 sometimes was able to understand and be understood and was moderately impaired to make decisions.…

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

Based on interview and record review, the facility failed to ensure Certified Nurse Assistant 1 (CNA 1) provided two-person physical assistance (help from two person) when using a mechanical lift (a device used to move those who are unable to stand on their own or whose weight makes it unsafe to move or lift them manually) machine to transfer the resident from the wheelchair to the bed for one of eight sampled residents (Resident 1). This deficient practice had a potential for resident to experience discomfort during transfer and may lead to accident such as fall, and injury. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 2/12/2024 with diagnoses including congestive heart failure (CHF- a condition in which the heart doesn't pump blood as efficiently as it should), atrial fibrillation (irregular and rapid heart rhythm, can lead to blood clots in the heart), morbid obesity (a complex chronic disease in which a person has a body mass index [BMI- measure of body fat based on height and weight] of 40 or higher or a BMI of 35 or higher…

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

Based on observation, interview and record review, the facility failed to: 1. Ensure one tube of Diclofenac Sodium External Gel 3% (used externally [outside of body] to relieve pain from arthritis [painful inflammation and stiffness of the joints] in certain joints such as those of the knees, ankle, feet, elbows, wrists and hands) for Resident 2 was placed with a cap in a separate compartment (separate division or section) from oral medications in one of two inspected medication carts (Medication Cart 2 [MC 2]). 2. Ensure one box of Diclofenac Sodium External Gel 1% for Resident 3 was placed in a separate compartment from oral medications in one of two inspected medication carts (MC 2). These deficient practices had the potential to result in poisoning accidents, compromise the therapeutic effectiveness of medication and placed Resident 2 and Resident 3 at risk for receiving medications that had become ineffective due to improper storage. Findings: 1. A review of Resident 2's admission Record indicated the facility admitted the resident on 11/18/2022 and readmitted 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.

Based on observation, interview, and record review, the facility failed to implement infection control practices by failing to ensure a used, unclean (with brown spots inside) bedside commode (a portable toilet) bucket was not left on top of the trash bin inside a resident's bathroom for one of eight sampled residents (Resident 1). This deficient practice had the potential to spread infection and cross contamination (the physical movement or transfer of harmful bacteria [germs] from one person, object, or place to another) among staff and other residents. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 2/12/2024 with diagnoses including congestive heart failure (CHF- a condition in which the heart doesn't pump blood as efficiently as it should), atrial fibrillation (irregular and rapid heart rhythm, can lead to blood clots in the heart), morbid obesity (a complex chronic disease in which a person has a body mass index [BMI- measure of body fat based on height and weight] of 40 or higher or a BMI of 35 or higher and is experiencing…

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 that one of four sampled residents (Resident 3) had a physician's order to administer supplemental oxygen (O2 - a treatment that provides you with extra oxygen to breathe in) prior to providing the resident with supplemental O2. This deficient practice had the potential to result in complications from excess or lack of sufficient oxygen level in the body and may lead to a negative impact in the resident's overall health. Findings: A review of Resident 3's admission Record indicated the facility admitted the resident on 1/11/2023 with diagnoses that included chronic obstructive pulmonary disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems). A review of Resident 3's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 1/11/2024, indicated the resident's cognitive (the mental action or 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.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program and prevent cross contamination (the transfer of bacteria or other microorganisms from one substance to another) for one of two sampled residents (Resident 1) by: 1. Not changing the nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) tubing and the mask weekly as ordered by the physician. 2. Not storing the nebulizer tubing and mask in a bag when not in use. These deficient practices placed residents at risk of respiratory infection. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 11/16/2023 with diagnoses including chronic respiratory failure (a serious condition that makes it difficult to breathe on your own) and pneumonia (lung infection caused by bacteria or viruses). A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-planning tool) dated 11/23/2023, indicated Resident 1 was able to understand and make decisions and required…

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 reviews, the facility failed to: a. Develop a Care Plan (CP-a formal process that correctly identifies existing needs and recognizes a resident ' s potential needs or risks) for one of five sampled residents (Resident 2) for excoriation (scraped skin between) around the anus (between the buttocks). b. Developed a Care Plan within 24 hours of identifying a wound for one of five sampled residents (Resident 2) for an unstageable (a bedsore whose severity cannot be determined with a visual exam) sacrococcyx (tailbone) pressure ulcer (a type of bed sore that occurs due to prolonged pressure on a specific area of the skin). These deficient practices had the potential to result in worsening of the wounds which could lead to serious infections such as septicemia ( a life-threatening complication of an infection). Findings: a. A review of Resident 2`s admission Record indicated that the facility originally admitted the resident on 02/06/2023 and readmitted on [DATE] with diagnoses that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain wound treatment order (physician prescribed orders for how to treat and address an identified wound of a resident) upon readmission to the facility of one of five sampled residents (Resident 2) for the management of an unstageable (unable to determine depth of a wound) sacrococcyx (tailbone) pressure ulcer (wound). This deficient practice resulted in a delay of necessary care and services to manage the wound of Resident 2. Findings: A review of Resident 2`s admission Record indicated that the facility originally admitted the resident on 02/06/2023 and readmitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and Type 2 Diabetes Mellitus (a chronic condition that affects the way the body processes sugar in the blood). A review of Resident 2's Minimum Data Set (MDS- a standardized assessment and screening tool), dated 05/13/2023, indicated the resident's cognitive skills (cognition refers to conscious mental activities,…

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.