Arlington Gardens Care Center

Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food safety when one unopened carton of 237 ml (milliliter - a unit of measurement) Boost (nutritional supplement) with an expiration date of September 24, 2025, was found stored in residents' refrigerator # (number) 1 located in nurse's station 1.This failure had the potential to cause foodborne illnesses when consumed by a medically vulnerable resident.Findings:On January 7, 2026, at 10:38 a.m., an inspection of Residents' refrigerator #1 located in Nurse's Station 1 was conducted with Licensed Vocational Nurse (LVN) 9. One unopened carton of 237ml Boost with an expiration date of September 24, 2025, was found stored in Residents' refrigerator #1 and readily available for consumption. LVN 9 stated the expired Boost should have been discarded since it had an expiration date of September 24, 2025. LVN 9 stated she was not sure why the expired Boost was still in the refrigerator when the residents' refrigerator was inspected…

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 on one of three residents (Resident 1) reviewed for medication administration, the facility failed to ensure medication administration was conducted in accordance with professional standards of practice when LVN 2 prepared and administered some of Resident 1's medications but did not sign the medication administration record. This failure resulted in inaccurate medication administration record and had the potential for Resident 1 and/or other residents for medication error. Findings:On December 17, 2025, at 9:08 a.m., an unannounced visit was conducted at the facility to investigate a quality care issue. On December 17, 2025, at 11:12 a.m., during an interview, LVN 1 stated:- She (LVN 1) was the licensed nurse assigned to Resident 1 on December 2, 2025;- LVN 2 assisted her with the 9 a.m. med pass for Resident 1 on December 2, 2025;- LVN 2 prepared the prescription medication (RX- medications that cannot be purchased and dispensed without a prescription from a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain complete and accurate clinical records for one of four residents reviewed (Resident 1) when:1. Resident 1's Notice of Proposed discharged (Notice of Proposed Discharge - a written document from a healthcare facility that informs a resident and/or their representative of the facility's intent to end the resident's stay) issued on September 30, 2025 (the day of discharge), had signatures of the resident and her family. Resident 1 was cognitively impaired. In addition, Resident 1's family was not present when the NOPD was issued;This failure resulted in Resident 1 and her family not being able to exercise their right to appeal the proposed discharge to the state long-term care agency.2. The LVN (Licensed Vocational Nurse) did not accurately document the time of family notification when Resident 1 had a fall on August 10, 2025.This failure had the potential to prevent the family from making informed decisions, providing critical information to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure grooming was provided when one resident (Resident 1) who was observed with long fingernails did not receive on-going grooming services.This failure had the potential for Resident 1 to be at risk for avoidable skin injuries.Findings:On August 25, 2025, an announced visit was conducted at the facility to investigate a complaint.On August 25, 2025, at 2:33 p.m., Resident 1 was interviewed. Resident 1 was alert, oriented, and well-dressed. Resident 1 was observed with long fingernails on her right hand and stated she would like to have her fingernails cut.On August 25, 2025, at 2:38 p.m., a concurrent observation, interview and record review was conducted with the treatment nurse. The Treatment Nurse (TN) was observed measuring Resident 1's fingernails on her right hand. The following measurements were observed, right index fingernail 1.6 cm (cm- centimeters a unit of measurement), right middle fingernail 1.8 cm, right ring fingernail…

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 foot care was provided when one resident (Resident 1) who was observed with long toenails and did not receive on-going podiatry (foot care provided by a specialty doctor) care.This failure had the potential for Resident 1 to be at risk for avoidable skin injuries.Findings:On August 25, 2025, an announced visit was conducted at the facility to investigate a complaint.On August 25, 2025, at 2:33 p.m., Resident 1 was interviewed. Resident 1 was alert, oriented, and well-dressed. Resident 1 stated she had painful toenails.On August 25, 2025, at 2:38 p.m., a concurrent observation, interview and record review was conducted with the Treatment Nurse (TN). Resident 1 was observed with long curved toenails on both feet. The TN was observed measuring Resident 1's toenails on her left foot. The following measurements were observed, left great toenail 2.0 cm (centimeters-a unit of measurement), left second toenail 0.7 cm, left third toenail…

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 supervision and monitoring was provided for one resident (Resident 3) when Resident 3 fell on four separate occasions within seven days.This failure had the potential for Resident 3 to experience avoidable accidental injuries. Findings:On August 25, 2025, an announced visit was conducted at the facility to investigate a complaint.On August 25, 2025, at 2:26 p.m., Resident 3 was interviewed. Resident 3 was alert and oriented. Resident 3 was observed in bed dressed and well groomed. Resident 3 stated he was unsure how many times he fell at the facility, but he remembers going to the hospital for a fall.On August 25, 2025, Resident 3's medical records were reviewed.The admission record indicated Resident 3 was admitted to the facility on [DATE], with the diagnoses which included hemiplegia (paralysis affecting one side of the body), hemipheresis (brain injury affecting one side of the brain), diabetes mellitus (high blood sugar), 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 failed to provide the proposed transfer and discharge notice to the Office of the State Long-Term Care (LTC) Ombudsman at the same time the notice was provided to the resident and/or resident's representative in accordance with the policy and procedure for two of 23 sampled residents (Residents 3 and 8). This failure resulted in missed opportunity for the LTC Ombudsman to advocate for the residents to ensure a safe and appropriate discharge. Findings: On May 22, 2025, at 10:15 a.m., an unannounced visit was conducted to the facility to investigate one complaint related to transfer and discharge Process. A review of Resident 3's record indicated the resident was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses which included fracture of the pelvis (hip bones fracture). A review of Resident 3's physician's order dated May 14, 2025, indicated, DC (discharge) to board and care on hospice Wednesday 5/14/2025 . A review of the Social…

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

Based on observation, interview, and record review, the facility failed to ensure the infection control policy and procedure for masking was followed when: 1. Two Certified Nursing Assistants (CNA) used an N95 mask (a protective device used to achieve a very close facial fit and very efficient filtration of airborne particles) over a surgical mask (face mask); and 2. One CNA used an N95 mask while caring for a Covid 19 (a highly infections respiratory virus) positive resident without a fit test(specialized test to determine the proper fit of a specific N95 for an individual). These failures had the potential to increase staff and resident exposure and transmission of the Covid 19 virus resulting in illness. Findings: 1. During a concurrent observation and interview on August 22, 2024, at 3:05 p.m., CNA 1, was observed wearing an N95 mask over a surgical mask. CNA 1 stated she would lower the N95 mask when was not inside the isolation room and use the surgical mask and vice versa. CNA 1 stated she would lower the surgical mask when she was inside the isolation room. CNA 1 stated she…

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.

2. An admission Record revealed the facility admitted Resident #18 on 01/01/2024. According to the admission Record, the resident had a medical history that included diagnoses of unspecified psychosis not due to a substance and major depressive disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/09/2024, revealed Resident #18 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had diagnoses of depression (other than bipolar) and psychotic disorder (other than schizophrenia). Resident #18's Preadmission Screening and Resident Review (PASRR) Level I Screening dated 01/01/2024, revealed the resident did not have a serious diagnosed mental disorder such as depression or symptoms of psychosis. The screening revealed the results of the Level I screening were negative. A letter from the Department of Health Care Services dated 01/01//2024 revealed Resident #18' Level I screening was negative, the resident did not have a mental illness, and a Level II…

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, record review, facility policy review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure a quarterly Minimum Data Set (MDS) assessment was completed timely for 1 (Resident #37) of 19 resident MDS assessments reviewed. Findings included: A facility policy titled, Resident Assessments, revised 10/2023, specified, 4. Non-Comprehensive MDS assessments include a select number of items from the MDS used to track the resident's status between comprehensive assessments and to ensure monitoring of critical indicators of the gradual onset of significant changes in resident status. The policy revealed, Non-comprehensive assessments include Quarterly assessments and SCQAs [significant correction to prior quarterly assessment]. The policy revealed, 5. The RAI [Resident Assessment Instrument] User's Manual (Chapter 2) provides detailed information on timing and submission of assessments. The Centers for Medicare and Medicaid Services (CMS) Long-Term Care…

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, record review, facility document review, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) was accurate for 1 (Residents #103) of 19 residents reviewed for accurate assessments. Findings included: A facility policy titled, Resident Assessment, revised 10/2023, revealed, 11. All persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. 12. Information in the MDS assessments will consistently reflect information in the progress notes, plans of care and resident observations/interviews. An admission Record revealed the facility originally admitted Resident #103 on 01/12/2024 and readmitted the resident on 03/29/2024. The admission Record revealed Resident #103 was discharged from the facility on 04/09/2024. A discharge MDS, with an Assessment Reference Date (ARD) of 04/09/2024, revealed Resident #103 had discharged to a short-term general hospital. The MDS revealed the resident had discharged on 04/09/2024. Resident #103's Discharge Summary -…

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, record review, facility document review, and facility policy review, the facility failed to ensure a medication allergy was documented for 1 (Resident #256) of 5 residents reviewed for unnecessary medications. Findings included: A facility policy titled, admission Assessment, revised 09/2012, specified, The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments, including the MDS [Minimum Data Set]. An admission Record revealed the facility admitted Resident #256 on 06/30/2024. According to the admission Record, the resident had a medical history that included diagnoses of fracture of the left femur, aftercare following joint replacement surgery, pain due to internal orthopedic prosthetic devices, implants and grafts, dementia, and major depressive disorder. Resident #256's Care Plan included a focus area initiated 07/01/2024, that indicated the resident was…

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

Based on interview, record review, facility document review, and facility policy review, the facility failed to ensure a resident was safe from eloping from the facility for 1 (Resident #91) of 3 residents reviewed for elopements. The failure resulted in Resident #91 leaving the facility during an excessive heat wave, leading to a visit to the emergency room. Findings included: A facility policy titled, Elopements, revised on 12/2007, indicated, Staff shall investigate and report all cases of missing residents. The policy revealed, 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. An admission Record revealed the facility admitted Resident #91 on 06/11/2024. According to the admission Record, the resident had a medical history that included diagnoses of cerebral infarction (stoke), muscle weakness, and difficulty in walking. An admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/18/2024, revealed Resident #91 had a Brief Interview for Mental Status (BIMS)…

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, record review, and facility policy review, the facility failed to maintain a medication error rate less than 5 percent (%) with a medication error rate of 7.69%. The facility had two medication errors out of 26 opportunities which affected 1 (Resident #29) of 4 residents observed for the medication administration task. Findings included: A facility policy titled, Administering Medications, revised 04/2019, indicated, Medications are administered in a safe and timely manner, and as prescribed. The policy revealed, 4. Medications are administered in accordance with prescriber orders, including any required time frame. An admission Record indicated the facility admitted Resident #29 on 03/18/2019. According to the admission Record, the resident had a medical history that included diagnoses of multiple sclerosis and immunodeficiency. Resident #29's Care Plan included a focus area initiated on 05/20/2024 that indicated the resident had a risk for constipation. Interventions directed staff to administer medications per physician order (initiated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a safe and orderly discharge was provided for one of three sampled residents (Resident 1), when the discharge location was not confirmed with family before transferring the resident. This failure had the potential for Resident 1 to be discharged to the wrong address which could cause anxiety to the family and to the resident. Findings: On June 6, 2024, an unannounced visit was conducted at the facility to investigate a complaint on admission, transfer, and discharge rights issue. A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses which included acute respiratory failure (when lungs cannot release enough oxygen into the blood), Type 2 diabetes (long-term condition in which body has trouble controlling blood sugar), chronic kidney disease (long standing disease of the kidneys leading to renal failure) and hypertension (force of the blood against the artery 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide an updated notice of transfer and discharge for one of three residents' (Resident 2) responsible party (RP) and the Long-term Care Ombudsman office to indicate the changes to the discharge location for Resident 2. This failure had the potential for Resident 2's RP and the Ombudsman not to be aware and be able to advocate for Resident 2's safe discharge. Findings: On March 27, 2024, at 10:43 a.m., an unannounced visit to the facility on a complaint investigation was initiated. A review of Resident 2's History and Physical dated December 22, 2023, indicated he had the capacity to understand and make decisions. On March 27, 2024, at 2:17 p.m., an interview was conducted with the Social Service Director (SSD). The SSD stated that Resident 2 was discharged to a board and care on March 25, 2024. The SSD stated that on March 25, 2024, she received a call from the transporter, informing her that the board and care (Board and Care 1) refused to accept…

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 a safe and orderly discharge for one of three residents (Resident 2), when Resident 2 was discharged to a Board and Care that had not accepted the resident for admission, then was transferred to another Board and Care that was unaware of the resident going to their facility. This failure caused Resident 2 to have unnecessary transfer to the general acute care hospital. Findings: On March 27, 2024, at 10:43 a.m., an unannounced visit to the facility on a complaint investigation was initiated. A review of Resident 2's medical records indicated the resident was admitted on [DATE], and discharged on March 25, 2024, with diagnoses of left shoulder osteoarthritis, (a progressive disorder of the joints caused by gradual loss of cartilage and resulting in the development of bony spurs and cysts at the margins of the joints), dehydration, (a harmful loss of the amount of water in the body), colitis, (a chronic inflammation of the inner lining 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 ensure Resident 1's representative was informed of the findings of the investigation related to the incident which occurred while the resident was at a doctor's appointment. Resident 1 had a change of condition while at the doctor's office and had to be transferred to the acute care hospital. This failure had the potential for the family member or representative not to be aware of the circumstances surrounding the concern they had and to have unresolved issues. Findings: On March 5, 2024, at 10:22 a.m., an unannounced visit to the facility was conducted to re-investigate a quality care concern. A review of Resident 1's medical record indicated he was admitted on [DATE], and discharged on October 9, 2023, with diagnoses of hemiplegia, (paralysis of one side of the body), and hemiparesis (weakness of one side of the body), following cerebral infarction (stroke), affecting right dominant side, atrial fibrillation (irregular heart beat), benign prostatic…

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 initiate and provide notices of proposed transfer/discharge (NOPD- a form that will indicate the notification of resident and reason for transfer/discharge) to three out of 4 residents, Resident 4, 5, and 7 and/or their responsible parties. In addition, the facility failed to notify the Long-Term Care Ombudsman (an advocate for residents and families in long-term care facilities) of Residents 4, 5, and 7's transfer/discharge from the facility. These failures had the potential for Residents 4, 5, and 7 to be unable to reach the Ombudsman. In addition, these failures caused the Ombudsman the inability to ensure Residents 4, 5 and 7 rights were protected. Findings: On April 15, 2024, at 9:55 a.m., an unannounced visit was conducted at the facility. A record review of Resident 4's record was conducted. Resident 4 was admitted to the facility on [DATE], with the diagnoses which included stroke (a loss of blood flow to part of the brain), diabetes mellitus…

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 for one of four residents, Resident 9, had the call light button within his reach. This failure had the potential to result in Resident 9 not being able to call for help. Findings: On April 17, 2024, at 9:15 a.m., an unannounced visit was conducted at the facility to investigate a complaint allegation. On April 17, 2024, at 9:56 a.m., an observation with a concurrent interview was conducted with Resident 9. Resident 9 was lying in bed, alert and conversant. Resident 9's call light button was observed on the floor on the right side of the bed. Resident 9's call light button was not within his reach. Resident 9 stated his call light was usually near him. On April 17, 2024, at 10:01 a.m., an observation with a concurrent interview was conducted with the Licensed Vocational Nurse (LVN). The LVN stated Resident 9's call light button was on the floor. The LVN stated, the call light button should be within Resident 9's reach. The LVN…

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, for one of two residents, Resident 8, follow-up appointments with a cardiologist (a physician who is an expert in the care of the heart) and pulmonologist (a physician who is an expert in the care of the lungs) were scheduled. This failure had the potential to result in Resident 8 to have delayed treatments and additional increased risk of health complications. Findings: On April 17, 2024, at 9:15 a.m., an unannounced visit was conducted at the facility for an investigation of a complaint allegation. On April 17, 2024, at 9:40 a.m., an observation with a concurrent interview was conducted with Resident 8. Resident 8 was lying in bed, alert and conversant. Resident 8 stated she was concerned about her cardiology (study of the heart) appointment. Resident 8 stated she, her brother and sister-in-law had reached out to the Social Service Designee (SSD) about the status of her cardiology appointment. Resident 8 stated, she nor her brother 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 interview and record review the facility failed to document the time, date, medication name and dosage of a medication on the Medication Administration Record (MAR) and monitor for pain relief for one of three sampled residents (Resident 2). This failure had the potential for Resident 2 to receive extra doses of pain medication or no medication, resulting in increased pain. Findings: On February 28, 2024, at 8:40 a.m., an unannounced visit was conducted at the facility to investigate a complaint for quality-of-care issue. A review of Resident 2's admission record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnosis included status post right total knee replacement (is asurgical procedure to replace the weight-bearing surface of knee joint), Type 2 diabetes (condition in which body has trouble controlling blood sugar), hyperlipidemia (imbalance of cholesterol) and hypertension (force of blood against the artery wall is too high). A review of Resident 2's medical record…

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 physician was notified of the presence a wound on the left shin for one of three sampled residents (Resident 2). This failure had the potential to result in delayed provision of treatment resulting in worsening of Resident 2's left shin wound. Findings: On December 21, 2023, at 9:15 a.m., an unannounced visit was conducted at the facility to investigate a quality care issue. On December 21, 2023, at 10:10 a.m., an observation was conducted with Resident 2. Resident was in his room, lying in bed, alert and oriented. On December 21, 2023, at 10:28 a.m., a concurrent observation, interview, and record review was conducted with Treatment Nurse (TXN) 1. TXN 1 was observed providing wound care to Resident 2. Resident 2 was observed with a wound on his left shin. TXN 1 stated the wound on Resident 2 ' s left shin is a scab, and she has not seen it before. TXN 1 stated Resident 2 ' s scab on the left shin was not documented in Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents' (Resident 2) left shin wound was assessed and monitored. This failure had the potential to result in worsening of Resident 2 ' s wound on the left shin. Findings: On December 21, 2023, at 9:15 a.m., an unannounced visit was conducted to the facility for an investigation of complaints. On December 21, 2023, at 10:10 a.m., an observation was conducted with Resident 2. Resident was in his room, lying in bed, alert and oriented. On December 21, 2023, at 10:28 a.m., a concurrent observation, interview, and record review was conducted with Treatment Nurse (TXN) 1. TXN 1 was observed providing wound care to Resident 2. Resident 2 was observed with a wound on his left shin. TXN 1 stated the wound on Resident 2 ' s left shin is a scab, and she has not seen it before. A review of Resident 2's record indicated the resident was admitted to the facility on [DATE], with diagnoses that included End Stage Renal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), was able to go to her scheduled eye surgery. This failure caused Resident 1 experiencing delayed eye surgery and feel anxious and upset. Findings: On January 22, 2024, at 1:00 p.m., an unannounced visit to the facility was conducted for an investigation of complaints. On January 22, 2024, at 3:15 p.m., a concurrent observation and interview was conducted with Resident 1 in her room. Resident 1 was lying in bed, alert and oriented. Resident 1 stated she had to cancel her cataract (cloudy area in the lens of the eye) surgery because transportation was not scheduled. In addition, Resident 1 stated it made her feel anxious and upset. On January 23, 2024, Resident 1 ' s record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses that included Multiple Sclerosis (a condition that affects the brain and spinal cord), Type 2 Diabetes Mellitus (high blood sugar level) 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 document the reason for the change of treatment, modify the care plan and perform weekly evaluations of a pressure injury (breakdown of skin integrity due to pressure) for one of three sample residents (Resident 2). These failures had the potential to result in worsening of Resident 2 ' s pressure injury. Findings: On December 21, 2023, at 9:15 a.m., an unannounced visit was conducted to the facility for an investigation of complaints. On December 21, 2023, at 10:10 a.m., an observation was conducted with Resident 2. Resident was in his room, lying in bed, alert and oriented. On December 21, 2023, at 10:28 a.m., a concurrent observation, and interview was conducted with Treatment Nurse (TXN) 1. TXN 1 was observed providing wound care to Resident ' s 2 left heel. TXN 1 stated that Resident 2 has a deep tissue pressure injury (DTPI) to his left heel. A review of Resident 2's medical record indicated Resident 2 was admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an adequate supply of pain medication was available for one of three sampled residents (Resident 1) reviewed. This failure had the potential to result in Resident 1 to have unrelieved pain. Findings: On January 22, 2024, an announced visit was conducted to the facility for an investigation of complaints. On January 22, 2024, a record review of Resident 1 ' s record was conducted. Resident 1 was admitted to the facility on [DATE], with diagnoses that included Multiple Sclerosis (an auto immune disorders that affects the nerves) and Polyneuropathy. On January 22, 2023, at 3:15 p.m., a concurrent observation and interview was conducted with Resident 1. Resident 1 was in her room, lying in bed, alert and oriented. Resident 1 stated she received Norco (pain medication) as needed (PRN) every 4 hours for pain. Resident 1 stated Norco was not available for her to use from January 18, 2024, to January 20, 2024. On January 23, 2024, at 11:49 a.m., a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of five residents (Resident 1) was free from abuse when Resident 2 attempted to kiss Resident 1. This failure had the potential for Resident 1 to experience emotional distress due to inappropriate sexual behavior of Resident 2. Findings: On November 22, 2023, an unannounced visit was conducted to investigate a facility reported incident. During a concurrent observation and interview, on November 22, 2023, at 9:17 a.m., with Resident 1, in her room, Resident 1 stated, on November 21, 2023, at around 3 a.m., Resident 2 entered her room. Resident 1 stated Resident 2 was naked. Resident 1 stated Resident 2 sat on the left side of her bed, held her face and tried to kiss her. Resident 1 stated Resident 2 attempted to kiss her three times. Resident 1 stated she tried stay calm to not agitate (to get excited and upset) Resident 2. Resident 1 stated staff came and took Resident 2 out of her room. During a telephone interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a written notice of bed-hold policy (reserving a resident's bed while resident is out of the facility for therapeutic leave or hospitalization) was provided to the resident/and or resident representative, for one of three residents reviewed (Resident A) when Resident A was transferred to the acute hospital. This failure had the potential for the resident or resident representative not to be informed of their right to hold the bed while out of the facility and the right to be readmitted back to the facility. Findings: On October 10, 2023, at 9:35 a.m., an unannounced visit to the facility was conducted to investigate a complaint regarding resident's rights. On October 10, 2023, Resident A's record was reviewed. Resident A was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (blockage of blood supply in the brain), metabolic encephalopathy (mental impairment), and gastrostomy status (presence of a tube placed…

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 interventions were put in place to prevent dislodgement of a gastrostomy tube (GT - a tube inserted through the stomach to provide food and medications), for one of three residents reviewed (Resident A) when the resident had behavior of grabbing onto her gastrostomy tube. This failure resulted in Resident A having her GT pulled out and sent to the hospital for reinsertion. Findings: On October 10, 2023, at 9:35 a.m., an unannounced visit to the facility was conducted to investigate a complaint regarding resident's rights. On October 10, 2023, at 10:55 a.m., Resident A was observed lying in bed, awake and alert. She stated she remembers the incident when her GT was pulled out but could not recall the exact date and time it happened. She further stated she could not remember why her GT was pulled out. She stated she was sent to the hospital to have her GT reinserted. On October 10, 2023, Resident A's record was reviewed. Resident A was admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to honor resident's request to go Out on Pass (leaving a nursing home or skilled nursing facility (SNF) for non-medical reasons is usually referred to as therapeutic leave [defined as a home or family visit to enhance psychosocial interaction]), for one of three residents (Resident A) reviewed. This failure resulted in Resident A's rights not being honored and the resident left the facility AMA (Against Medical Advice). Findings: On October 10, 2023, at 9:35 a.m., an unannounced visit to the facility was conducted to investigate complaints regarding resident's rights and discharge rights. On October 10, 2023, at 2:10 p.m., Resident A was interviewed. She stated she was told by the facility staff she needed a physician's order to go out on pass and could not leave the facility. She stated she just wanted to see her dying cat. On October 10, 2023, at 5 p.m., a follow up interview with Resident A was conducted. Resident A stated that she had gone out 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 observation, interview, and record review, the facility failed to ensure an assessment and evaluation for self-administration of medications was conducted, for one of three residents reviewed (Resident A). This failure had the potential to result in an unsafe administration of medications for Resident A. Findings: On October 10, 2023, at 9:35 a.m., an unannounced visit to the facility was conducted to investigate complaints regarding resident's rights. On October 10, 2023, at 2:10 p.m., a concurrent observation and interview was conducted with Resident A. Resident A was noted with a clean and dry bandage dressing on her feet. Resident A stated she had been taking her own medication, including administration of her insulin injections, and doing treatment for her foot wound. She further stated the facility staff allows her to self-administer her own medications and treatment since she was admitted in the facility. On October 10, 2023, at 2:50 a.m., an interview was conducted with the Treatment Nurse (TN)…

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 appropriate documentations to support discharge plan to include preparation for safe discharge, continuity of care, and post discharge follow-up were documented in the resident's clinical record, for one of three residents reviewed (Resident A). This failure has the potential for Resident A's post-discharge care needs not to be met. Findings: On October 10, 2023, at 9:35 a.m., an unannounced visit to the facility was conducted to investigate complaints regarding discharge rights. On October 10, 2023, Resident A's record was reviewed. Resident A was admitted to the facility on [DATE], with diagnoses which included Charcot's joint (nerve damage to the limbs, commonly cause by diabetes [abnormal blood sugar]) of the right and left ankle and foot, and diabetes mellitus (abnormal blood sugar). A review of Resident A's History and Physical, indicated Resident A had the capacity to understand and make decision. A review of Resident A's Progress Notes,…

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 copy of requested records was provided timely for one of four sampled residents (Resident 2). This failure had resulted in the delay to utilize the record in whatever purposes they meant to use the record for. Findings. On September 5, 2023, at 11:00 a.m., an unannounced facility visit was conducted to investigate a resident's rights issue. A review of medical record calendar received from the Medical Record personnel (MR) indicated that on June 20, 2023, an entry was made that indicated, (Name of Resident 2 and Room Number), MR (Medical Record) REQUEST FROM 4/23 – 6/23 .(family member)– ASAP (as soon as possible)/ HER REQUEST The MR further provided a document that indicated Resident 2 ' s Resident Representative (RR) paid for and received 300 pages of Resident 2 ' s records on July 10, 2023, 20 days after they requested for the copy. On October 10, 2023, at 11:37 a.m., the MR was interviewed. The MR stated that per facility policy, medical records should be released within 1-3 business days to the resident or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement standard of care for management of diabetes mellitus (DM- a condition that affects the way the body processes blood sugar) for one of four sampled residents (Resident 1); when blood sugar was not consistently monitored and there were multiple different orders for blood sugar monitoring and physician ordered insulin injections. These failures had the potential to result in confusion causing medication errors subsequently causing a negative effect on the resident's medical condition. Findings: On September 5, 2023, at 11:00 a.m., an unannounced visit was conducted to investigate a quality care issue. On September 5, 2023, Resident 1 ' s record was reviewed. Resident 1 was re-admitted on [DATE], with diagnoses which included urinary tract infection (UTI), neurogenic bladder (lack of bladder control due to a brain, spinal cord, or nerve problem) with suprapubic catheter in place (hollow flexible tube that is used to drain urine from the bladder),…

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 transport one of four residents, (Resident 1) in a timely manner for a surgical procedure to place a dialysis, (a type of treatment that helps the body remove extra fluid and waste products from the blood when the kidneys are not able to), fistula, (a surgical connection between an artery and a vein for dialysis). This failure caused the resident to have dialysis through a tunneled central venous catheter (CVC - a type of access used for hemodialysis. are placed under the skin and into a large central vein, preferably the internal jugular veins. CVCs are meant to be used for a short period of time until a more permanent type of dialysis access has been established), which had a potential for infection. Findings: On September 20, 2023, at 8 a.m., a telephone interview was conducted with the complainant. The complainant stated that Resident 1 was scheduled for surgery for a fistula on September 20, 2023, with a check in time of 10 a.m. The complainant…

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 pharmacy services to meet the needs of the residents by not ensuring: 1. The nursing staff administering medications to have complete accountability of the movement of controlled substances (CS; medications that are tightly controlled by the government due to abuse and addiction) from accessing from the locked medication carts to the administration to residents and/or disposition of CS. The nursing staff failed to document the administration of medications on the electronic medication administration record (eMAR) for five of five residents' records reviewed (Residents 199, 200, 15, 11, and 58); This failure had the potential for drug diversion. 2. The nursing staff notified the physician of the high blood sugar measurement as ordered by the physician. Resident 198's order for Regular Insulin (medication to control blood sugar) per sliding scale did not have the insulin dose to be given to the resident associated with the high blood sugar measurements. This had the potential for complications from poor…

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 environment that meets professional standards for food service safety when: 1. Multiple bottles of thickened dairy drink stored in the kitchen refrigerator were found expired; and 2. Multiple food items stored in the two refrigerators, dedicated for the facility residents at the nurse stations, were found expired. These failures had the potential to result in food-borne illness in a highly susceptible resident population. Findings: 1. On May 16, 2022, beginning at 9 a.m., during the initial kitchen tour with the Dietary Supervisor (DS), the following items were found expired in the refrigerator: - six bottles of eight ounces thickened dairy drink beyond the use by date, April 18, 2022; and - 17 bottles of eight ounces of thickened dairy drink beyond the use by date, February 10, 2022. A concurrent interview was conducted with the DS. The DS stated there should not have been expired food items in the refrigerator. The DS stated the expired dairy drinks should have been discarded. The DS confirmed…

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 develop a person centered care plan specific to the care and treatment of the intravenous (IV - a tubing placed in the vein to deliver fluids or medications) catheter site for one of five residents reviewed (Residents 36). This failure had the potential to place Resident 36 at risk for the development of infection and complications when measurable goals and desired outcomes were not achieved towards the proper care and services for the IV catheter site. Findings: On May 18, 2022, at 9:30 a.m., Resident 36 was observed lying in bed awake, alert, and able to verbalize her needs. Resident 36 was observed with an IV catheter on her left upper chest covered with a transparent dressing and a dressing on her right upper chest. Resident 36 stated she went for her dialysis (a procedure to remove waste products from the blood when the kidney stop working using a special machine) yesterday. When she was asked where her site for dialysis was located,…

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 daily monitoring of resident's bowel movement was implemented for one resident reviewed (Resident 296). This failure resulted in Resident 296 having discomfort and feeling bloated when she did not have a bowel movement for two days. Findings: On May 16, 2022, at 4:03 p.m., Resident 296 was observed awake, alert and able to verbalize her needs. Resident was observed with an external fixator (a device used to keep fractured bones stabilized) on her right lower leg. Resident 296 stated she had surgery on her right ankle and the external fixator was for the broken bones on her right lower leg. She stated she stayed in bed all the time because of the external fixator. She stated she did not have a bowel movement for a few days, felt uncomfortable and bloated. She stated she normally had a bowel movement daily. On May 16, 2022, at 4:15 p.m., record review and a concurrent interview was conducted with Licensed Vocational Nurse (LVN) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide respiratory care and treatment for three of three residents reviewed for oxygen use (Residents 25, 97, and 198) when: 1. For Resident 25, the nasal cannula (a tube used to deliver oxygen through the nose) was not replaced after seven days, and the humidifier (provides moisture for resident comfort during oxygen therapy) was empty; 2. For Resident 97, the humidifier mask was left exposed on top of the humidifier machine; and 3. For Resident 198, oxygen was administered without a physician's order, oxygen tubing was unlabeled, and there was no care plan for oxygen use. These failures had the potential to result in ineffective oxygen therapy, respiratory distress, and decline in the residents' health condition. Findings: 1. On May 16, 2022, at 11:30 a.m., Resident 25 was observed in bed, using a nasal cannula (NC) for oxygen. The NC did not have a label to indicate the date when it was last changed. The humidifier was observed empty.…

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 residents were free from unnecessary medications when an anticoagulant, warfarin (a blood thinner), was administered to Resident 50 without adequately monitoring for signs and symptoms of bleeding. This had the potential for the resident to experience fatal bleeding. Findings: A review of Resident 50's medical record on May 18, 2022, indicated the resident's warfarin therapy was managed by the (Name of the Hospital) Anticoagulation Service. The warfarin management record received from the facility dating back to February 14, 2022, indicated the warfarin order to take 4 mg daily except 3 mg daily on Mondays, Wednesdays, and Fridays was continued as of the present day. A review of the resident's electronic medication record (eMAR) indicated the facility staff were monitoring for signs and symptoms of bleeding due to warfarin every shift since the evening of May 17, 2022. However, there was no monitoring documented before this date and as far back as the beginning of April 2022. A review of Resident 50's care plan…

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 storage and labeling of medications conformed to national standards and the facility's policy and procedure when: 1. One open acetylcysteine (medication used to loosen thick mucus) 20% vial did not have an open date; 2. One intact, unopened vial of Humulin R (insulin; medication used to control blood sugar) was stored not in the medication refrigerator but at room temperature in the drawer of the medication cart; and 3. Six vials of injectable lorazepam (medication used for anxiety) 2 mg/ml (milligram per milliliter; unit of measurement) for Resident 19 was kept in the medication refrigerator for residents' use. The medication order was discontinued on March 30, 2022. These failures could potentially result in residents receiving ineffective medication therapy from sub-potent medications. Findings: 1. On May 17, 2022, at 2:15 p.m., during a medication pass observation, Licensed Vocational Nurse (LVN) 6 was observed to take out the box containing vials acetylcysteine 20% from the medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident's Intravenous (IV) catheter site dressing was changed according to the facility's professional standard of infection control practices for one of five residents reviewed (Resident 91). This failure resulted in Resident 91's right upper arm Peripherally Inserted Catheter (PICC) site dressing not being changed for 13 days. In addition this failed practice placed Resident 91 at risk for infection and other complications. Findings: On May 16, 2022, at 12:54 p.m., Resident 91 was observed sitting in bed awake, alert, and able to verbalize his needs. Resident 91 stated he had a bad infection in his left foot that affected the bone. He stated his left foot looks better after he was given an Intravenous (IV - administration of antibiotic or fluids through the vein) antibiotic (medication for infection). Resident 91 was observed with right upper arm PICC line. The dressing was labeled with the date of May 3, 2022. Resident 91…

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.