Community Care On Palm

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a care plan was initiated and/or developed to address the diagnoses of epistaxis (bleeding from the nose) for one of one residents reviewed for quality of care (Resident 1).This failure had the potential for Resident 1 to not be monitored for epistaxis complications and delayed treatment, increasing the risk of further harm. Findings:On November 25, 2025, at 8:00 a.m. an unannounced visit was conducted at the facility to investigate a facility reported incident.On November 25, 2025, at 8:00 a.m., an observation with a concurrent interview was conducted with Resident 1. Resident 1 was observed in bed, alert and interviewable. Red stains resembling blood were observed on Resident 1's gown, specifically in the chest area. Similar stains were also noted on a washcloth located beside Resident 1. Resident 1 stated she experienced nose bleeds often. On November 25,2025, at 8: 15a.m, an interview was conducted with Licensed Vocational…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of two residents reviewed for breathing treatment therapy (Residents 4 and 2), were monitored during and after nebulizer treatments (breathing treatments that turn liquid medicine into a mist).This failure placed the residents at risk for delayed treatment related to possible complications of the nebulizing treatment such as rapid heart rate, restlessness, chest pain and/or difficulty breathing.Findings:1.On November 25, 2025, at 8:30 a.m., and observation was conducted with Resident 4. Resident was in bed, alert, and non-verbal. A nebulizer mask (mask used to breathe in medicated mist) was observed connected over her nose and mouth. The medication chamber (small cup that holds the liquid medicine) was observed empty. There was no licensed nurse observed beside Resident 4.On November 25, 2025, at 8:45 a.m., an interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated she should have stayed in the room 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 interview and record review, the facility failed to ensure pharmacy services were provided to meet the needs of the resident when one prescribed medication was not administered as ordered on twelve separate occasions for one of one resident (Resident 23). This failure had the potential to result in ineffective treatment of Resident 23's symptoms and interrupted care. Findings: Resident 23's record was reviewed. Resident 23 was re-admitted to the facility on [DATE], with diagnoses which included dementia with psychotic disturbances (a cognitive decline accompanied by psychosis - hallucinations and/or delusions) and impulse disorder (inability to resist urges or impulses that can lead to harmful or disruptive behaviors). A review of Resident 23's Physician Order, dated March 14, 2025, indicated, .increase Rexulti (antipsychotic medicine used to treat dementia that helps balance chemicals in the brain known to affect mood and thoughts.) 0.5 mg (milligram - a unit of measurement) to Rexulti 2 mg by mouth…

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

Based on observations, interviews, and record review, the facility failed to ensure that dietary staff safely and effectively carried out the functions of food and nutrition services when: 1. Dietary staff, including the dietitian, were not aware of the manufacturer's recommended time guidelines for testing the red bucket Quaternary (Quat) sanitizer (sanitizing solution used for sanitizing food contact surfaces); 2. [NAME] 2 did not demonstrate competency in performing assigned duties; (Cross reference 803) 3. [NAME] 1 did not demonstrate competency in performing assigned duties; and (Cross reference 803) 4. [NAME] 3 did not follow the prescribed recipe when preparing pureed macaroni and cheese during dinner on April 9, 2025. These failures had the potential to cause foodborne illness for 49 out of 50 sampled residents and compromised the nutritional status of residents receiving food from the facility's kitchen. Findings: 1. A review of the Quat sanitizer manufacturer's guidelines posted above 2 compartment sink at the kitchen indicated, Dip test paper for 10 seconds in test…

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

Based on observations, interviews and record reviews, the facility failed to ensure: 1. [NAME] 2 followed the recipe when preparing pureed meat and peas during lunch on April 9, 2025; 2. [NAME] 2 used the correct scoop to portion mechanical soft meat during lunch on April 9, 2025; 3. Resident 34, who had a physician-ordered Consistent Carbohydrate (CCHO) diet, was served the correct portion of taco during lunch on April 8, 2025; 4. Resident 3, who had a physician-ordered renal diet, was served appropriate food items during lunch on April 9, 2025, and April 10, 2025; and 5. Resident 33, who had physician-ordered heart healthy diet, was served appropriate food items during lunch on April 9, 2025. These failures had the potential to result in residents receiving food that did not meet their prescribed dietary needs, which could lead to nutrition-related health complications. Findings: (Cross Reference 802) 1. During a general food production observation and interview conducted on April 9, 2025, at 10:41 a.m., in the kitchen with [NAME] 2 (CK 2), CK 2 was observed preparing pureed peas.…

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 with a prescribed nectar-thick liquid consistency, as ordered by the physician, was served regular thin liquid coffee, for one of nine residents (Resident 8). This failure had the potential to cause resident to choke or aspirate (inhalation of food or liquid into the lungs), placing them at risk for serious health complications. Findings: On April 8, 2025, at 12:17 p.m., during a concurrent observation and interview with the Certified Nursing Assistant (CNA). Resident 8 was observed eating her lunch in the dining room. Resident 8 was served a cup of regular thin liquid coffee. The CNA who was assisting Resident 8 with feeding, stated, the coffee was provided ready to drink and stated she had not checked the consistency. The CNA stated, Resident 8 should not have received a thin liquid. On April 10, 2025, Resident 8's record was reviewed. Resident 8 was admitted to the facility on [DATE], with diagnoses which included…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. Dust was observed on kitchen equipment and in various locations within the kitchen; 2. An expired sanitizer test strip was found in use. 3. A box of nutritional shake was stored next to defrosting raw meat in the refrigerator; 4. Wilted cilantro was found stored in Reach in Refrigerator # (number) 1; 5. An open bottle of lemonade syrup was stored next to a sanitizer solution bucket; 6. Dust accumulation was oberved on the floor under a table counter; 7. Black grime buildup was observed on the outside of the oven; 8. Three white plastic spatula, two serving tongs handle, and one small spatula had chipped; 9. A trash bag was used as a liner to store a bulk quantity of sugar; and 10. One unlabeled soda was found in a resident's refrigerator. These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food) in a medically vulnerable population of 49 out of 49 residents who…

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 comprehensive nutritional assessment was completed within 14 calendar days after admission for one of three residents reviewed (Resident 42). This failure had the potential to delay the provision of resident-centered care (care focusing on the needs of individuals) and nutritional interventions necessary to address the resident's health needs. Findings: On April 8, 2025, at 12:26 p.m., during a concurrent observation and interview in Resident 42's room, Resident 42 was observed eating her lunch meal. Resident 42 stated she had a new denture and was ready to eat regular food. Resident 42 further stated, she was tired of eating baby food and she did not like to lose weight. On April 10, 2025, Resident 42's record was reviewed. Resident 42 was admitted to the facility on [DATE], with diagnoses which included protein-calorie malnutrition (inadequate intake of nutritional food). A review of Resident 42's History and Physical, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications and biologicals were properly stored and disposed of when expired sterile (entirely free of microorganisms) dressings (medical bandage designed to protect a wound from infection), were found inside a treatment cart and were readily available for use. This failure had the potential to result in residents receiving wound treatments with expired dressings, leading to ineffective treatment and an increased risk of infection. Findings: On [DATE], at 11:55 a.m., during a treatment cart inspection with the Registered Nurse (RN), expired dressings were found stored in the cart and available for use. One pack of sterile, non-adhesive (designed to not stick to the wound) foam dressing with an expiration date of [DATE], and five packs of sterile gauze (made from woven fabric) dressings with an expiration date of [DATE], were observed in the treatment cart. In a concurrent interview, the RN stated the expired dressings should not…

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 therapeutic diet order (diet ordered by a physician) prescribed by the physician was followed for one of three residents (Resident 42) who had an order for a fortified diet (additional nutrients). This failure had the potential for Resident 42 to not receive adequate nutrition, which could further compromise her medical status. Findings: On April 8, 2025, at 12:26 p.m., during a concurrent observation and interview in Resident 42's room, Resident 42's meal tray card indicated a fortified diet. Resident 42 was served a full eight oz cup (ounce-unit of measurement) of tea. Resident 42 stated, she was always served tea at lunch but would prefer milk. Resident 42 further stated, I don't want to lose weight. On April 10, 2025, Resident 42's record was reviewed. Resident 42 was admitted to the facility on [DATE], with diagnoses which included mild protein-calorie malnutrition (deficiency of protein and/or calories). 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 interview and record review, the facility failed to ensure, for one of four residents, Resident 1, who was identified as at risk for elopement (a resident leaving the facility unsupervised and unnoticed) and was on line of sight (a resident being within the view of staff members) monitoring was supervised by staff. This failure resulted in Resident 1 eloping from the facility on October 13, 2024, which placed Resident 1 at risk for sustaining serious injury such as being struck by a vehicle or death. Findings: On November 5, 2024, at 9:28 a.m., an unannounced visit was conducted at the facility to investigate a facility reported incident. A review of Resident 1's medical record was conducted. The admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included cardiac arrhythmia (irregular heart rhythm) and schizophrenia (mental illness) and that he was under a conservatorship (a legal status which a court appoints another person to act or make decisions 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 one of three residents reviewed (Resident 1) was free from physical abuse when Certified Nursing Assistant (CNA) 1 slapped Resident 1 on the face. This failure had the potential for Resident 1 to suffer physical and emotional injury. Findings: On September 3 and 4, 2024, unannounced visits were made to the facility to investigate an allegation of physical abuse. On September 3, 2024, Resident 1 ' s record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss) and schizophrenia (a mental disorder that affects a person ' s ability to think, feel, and behave clearly). During a concurrent observation and interview on September 3, 2024, at 10:23 a.m., with Resident 1, Resident 1 was observed lying in bed, awake and alert. Resident 1 was verbally responsive and was Spanish speaking. The interview was conducted with the assistance of a Spanish speaking staff. Resident 1 stated…

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 infection control practice was followed when two of three direct patient care staff were observed to wear long and artificial nails. This failure had the potential for the vulnerable residents to be exposed to bacterial cross contamination and the development of infection. Findings: On April 24, 2024, an unannounced visit was conducted to investigate a facility reported incident and a complaint. During a concurrent observation and interview on April 24, 2024, at 5:10 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 was observed to wear long painted nails on both hands. The fingernails were pointed, and approximately more than quarter of an inch long passed the tip of the finger. CNA 1 stated she was from the registry (a staff personnel provided by a placement service on a temporary or on a day-to-day basis). CNA 1 stated she was allowed by the registry to have long fingernails at work. During a concurrent observation and interview on April 24, 2024, at 5:18 a.m., with the Licensed Vocational Nurse…

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 conditions were maintained in the kitchen for food storage methods and food sanitation equipment when the ice machine was observed to have a build-up of a slimy pink, yellow and bright green substances where ice is formed. This failure had the potential for contamination, which could result in food borne illnesses for all residents who consume ice from the facility's ice machine. The facility census was 44. Findings: On March 11, 2024, at 9:31 a.m., an observation and concurrent interview with the facility's Maintenance Supervisor (MS) was completed. The MS opened the interior of the ice machine, there was a slimy pink and yellow substances on the white shield that was over the ice grates. There was bright green build-up where the water flows out of the ice grates. The MS stated the ice machine was last cleaned on January 11, 2024, with a descaler (a solution used to remove a coating, layer, or crust from a surface). The MS stated he uses a descaler to clean the ice machine every six…

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 facility assessment was reviewed and updated annually and as needed. This failure resulted in an inaccurate evaluation of the facility's population and resources needed to provide the necessary care and services for the residents. During a concurrent interview and record review on March 14, 2024, at 11:02 a.m., with the Administrator (ADM), the ADM stated he was responsible for conducting the facility assessment. The ADM stated the facility assessment should have been reviewed and updated annually. The ADM stated the facility assessment was not reviewed or updated annually. The ADM stated he was not able to initiate the facility assessment. The ADM stated the last facility assessment was on April 18, 2021. During a review of the facility's policy and procedure (P&P), titled, Facility Assessment, revised October 2018, the P&P indicated, .A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations .Once 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 initiate and implement their water management program to ensure safe measures in the building's water system. This failure had the potential to increase the risk of the development of Legionella (a specific bacteria that can cause serious type of pneumonia - lung infection) called Legionnaires disease, and other water-borne pathogens in the building's water system which can affect the health and safety of the residents. Findings: On March 13, 2024, at 9:25 a.m., an interview and a review of facility's Legionella Water Management Program was conducted with the Director of Staff Development/Infection Preventionist (DSD/IP). The DSD/IP stated the facility had no current water management measures to prevent Legionella. The DSD/IP was not able to provide documented evidence of the facility's monitoring measures to prevent the growth of Legionella in the facility's building water system. The DSD/IP stated the facility's Legionella Water Management Program was not acted upon and initiated. On March 14, 2024, at 10:08 a.m., 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.

Based on observation, interview, and record review, the facility failed to ensure the lunch menu was followed on February 27, 2024, when residents were served two and a half ounces of chicken instead of three ounces as indicated on the menu for lunch on Monday, March 11, 2024. This failure had the potential for residents' nutritional needs not to be met by being served less than the menu stated portion in accordance with a prescribed regular diet. Findings: During an observation on March 11, 2024, at 11:54 a.m., of the facilities lunch preparation, the cook served a piece of chicken on each of the residents' plate who was on a regular diet. She used tongs to pick up the piece of chicken and place it on the residents' plates. The chicken portion being served was weighed by the Dietary Services Supervisor (DSS) and it was two and a half ounces. A review of the lunch menu for Monday, March 11, 2024, indicated Herb and Honey Glazed Chicken .3 oz. (ounces - unit of measurement). During an interview with the facility's Registered Dietitian (RD) on March 12, 2024, at 2:36 p.m., RD stated…

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 pureed (food blended to a smooth, creamy consistency) food was the appropriate consistency to meet the individual needs of four out of 44 residents (Residents 4, 5, 10 and 25). This failure had the potential for residents on a pureed diet to aspirate (draw food into the lungs) and/or negatively impact the resident's dining experience resulting in poor food intake, compromising their nutritional status. Findings: During tray line observation on March 11, 2024, at 11:53 a.m., the pureed chicken was a chunky consistency and not smooth. During a test tray evaluation on March 12, 2024, at 12:19 p.m., the pureed ground beef had a texture of crumbles, (not smooth) and required chewing to swallow. An interview with the Dietary Services Supervisor (DSS) was conducted on March 12, 2024, at 12:25 p.m. The DSS stated the pureed beef was not smooth and It needs to be more moist and should have more broth. The DSS further stated the beef was too crumbly. During an interview with the facilities Registered Dietician…

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 respect and dignity for one of four sampled residents (Resident 4) during mealtime when Certified Nursing Assistant (CNA) 1 was standing over Resident 4 while feeding her. This failure had the potential to negatively affect Resident 4's emotional health. Findings: During an observation on March 11, 2024, at 12:21 p.m., CNA 1 was feeding Resident 4 while eating lunch. CNA 1 was standing over Resident 4, who was sitting in a chair at the dining table in an upright position. The resident asked CNA 1 to go and get a chair. During an interview on March 13, 2024, at 9:55 a.m., with CNA 1, CNA 1 stated she assisted Resident 4 while eating lunch. CNA 1 stated she was standing and should have been sitting at eye-level while assisting Resident 4. During a review of the facility's policy and procedure (P&P) titled, Assistance with Meals, dated July 2017, the P&P indicated, .Residents who cannot feed themselves will be fed with attention and safety, comfort and dignity .not standing over residents while assisting…

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 their policy on abuse prevention when Licensed Vocational Nurse (LVN) 1 did not identify, recognize, and believe a resident's allegation that a staff member came to her room and slapped her buttock while changing her diaper, for one resident reviewed (Resident 16). In addition, LVN 1 did not identify Resident 16's allegation as abuse due to the resident's history of reporting false allegations. This failure had the potential for Resident 16 and other residents to not be protected from potential abuse and the allegation not being investigated timely. Findings: On March 13, 2024, at 10:30 a.m., during a confidential Resident Council meeting held during the facility's re-certification survey, Resident 16 stated a little girl came to her room on noc shift (night) and slapped her buttock while changing her diaper. During an interview on March 13, 2024, at 11:46 a.m., with LVN 2 she stated she was not aware of Resident 16'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 a resident's allegation of abuse was immediately reported to the Administrator or State Agency at the mandated time frame (immediately but not later than two hours), when a resident told Licensed Vocational Nurse (LVN) 1, a Certified Nursing Assistant (CNA) slapped her buttock while changing her diaper, for one of one resident reviewed (Resident 16). This failure had the potential to place Resident 16 and other residents' at risk from harm and delayed the investigation of an allegation of abuse. Findings: On March 13, 2024, at 10:30 a.m., during a confidential Resident Council meeting held during the facility's re-certification survey, Resident 16 stated a little girl came to her room on noc shift (night) and slapped her buttock while changing her diaper. During an interview on March 13, 2024, at 11:46 a.m., with LVN 2 she stated she was not aware of Resident 16's allegation. She stated she did not receive any report from the staff…

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 initiate a care plan for resident's left lower chin swelling and redness on March 8, 2024, for one of one resident reviewed (Resident 5). This failure had the potential to delay the necessary care and services for Resident 5's left lower chin redness and swelling. Findings: On March 11, 2024, at 11:48 a.m., Resident 5 was observed sitting in a Geri chair (geriatric chair - used for patient with difficulty sitting upright) in the dining room. Resident 5 was alert and able to verbalize his needs. Resident 5's teeth was observed with blackish discoloration with irregular shapes and some teeth were missing. He stated he could chew on his food. His left lower chin area was observed with some swelling and some redness. Resident 5 was asked if he was seen by the dentist. He stated he did not want to see a dentist, he just wanted to take an antibiotic. The Activity Coordinator (AC) was present in the dining area. The AC stated she noticed…

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 facility staff have a current and active Cardio-Pulmonary Resuscitation (CPR - a life-saving procedure used to restart a person's heartbeat and breathing after one or both have stopped) certification, when two of 11 Certified Nursing Assistants (CNA) had expired CPR certification. This failure had the potential for the facility residents not to receive emergency care leading to resident harm and/or death. Findings: During a review of CNA 2's employee file, CNA 2 was hired by the facility on [DATE]. The copy of CNA 2's CPR certification indicated an expiration date of [DATE]. There was no documented evidence CNA 2 had a current CPR certification. During a review of CNA 1's employee file, CNA 1 was hired by the facility on February 22, 2023. A copy of CNA 1's CPR certification was not found in the employee file. During a concurrent interview and record review on [DATE], at 3:10 p.m., with the Director for Staff Development/Infection…

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 for two of two residents reviewed (Residents 22 and 42), to ensure: 1. For Resident 22, the licensed staff assessed, notified the physician, and documented when Resident 22 experienced low blood sugar (BS). This failure had the potential for a delay in treatment that could lead to harm and/or death for Resident 22. 2. For Resident 42, followed the regular diet order when Resident 42 received pureed (food blended to a smooth, creamy consistency) bread during lunch on March 13, 2024. This failure resulted in Resident 42's feeling of dissatisfaction with her meals. Findings 1. During an observation on March 13, 2024, at 11:29 a.m., Resident 22 wheeled herself to the nurse's station. Resident 22 asked for her nurse to check her BS. During an interview on March 13, 2024, at 11:35 a.m., with Resident 22, Resident 22 stated the nurses checked her BS three times a day before meals. Resident 22 stated she felt her sugar was low usually around 4 a.m.…

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 one of two residents reviewed for oxygen administration (Resident 10), when the physician's order for oxygen administration was not followed. This failure had the potential to result in ineffective oxygen therapy, respiratory distress, and decline in the resident's health condition. Findings: On March 11, 2024, at 11:04 a.m., Resident 10 was observed in bed with oxygen (O2) via nasal cannula (NC - a tube used to deliver oxygen through the nose). Resident 10's oxygen administration was observed at 3 liters per minute (LPM). On March 11, 2024, at 11:23 a.m., a concurrent observation, interview and record review was conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 confirmed the O2 level for Resident 10 was at 3 LPM. LVN 2 verified the physician order and stated the O2 level should be at 2 LPM, as per physician's order. LVN 2 stated the physician's order was not followed. On March 13, 2024, at…

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 44 residents (Resident 37), the call light was working. This failure had the potential to result in the delay in answering the call light which could affect the delivery of care for Resident 37. Findings: During a concurrent observation and interview on March 11, 2024, at 11:55 a.m., with Resident 37, Resident 37 was seen lying across the bed in a supine (face up) position. Resident 37 was observed calling out for assistance. Resident 37 stated he was not able to get up on his own. Resident 37 stated he was not using the call light because it was not working. Resident stated the call light had been broken since he was placed in his room. A staff member was called to assist Resident 37. During a concurrent observation and interview on March 11, 2024, at 11:57 a.m., with Certified Nurse Assistant (CNA) 4, CNA 4 assisted Resident 37 to get up and sit on the side of the bed. CNA 4 verified the call light for Resident 37 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed, for one of three residents reviewed (Resident 1), to provide a written notification to the Office of the State Long Term Care (LTC) Ombudsman, of the plan to transfer a resident to a general acute care hospital (GACH), on December 11, 2023. This failure has the potential for Resident 1 to not have access to an advocate at the Office of the State LTC Ombudsman. Findings: On February 1, 2024, Resident 1's record was reviewed. Resident 1 was originally admitted to the facility on [DATE], with diagnoses including schizoaffective disorder, bipolar type (A mental illness that may include delusions, hallucinations, disorganized speech, disorganized behavior, and diminished emotional expressions). The document titled, Discharge Summary, dated December 14, 2023, indicated, .Resident found by social worker slumped over in wheelchair and not responding to verbal, or physical stimuli. Resident transferred to bed and assessed . Resident send out for further care. 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 for one of five residents reviewed (Resident 1), to develop and implement care plans with appropriate interventions to address Resident 1 ' s post-fall major injuries. This failure had the potential for a delay in treatment of possible complications related to injuries. Findings: On December 5, 2023, at 8:39 a.m., an observation was conducted with Resident 1. Resident 1 was in bed asleep and was observed wearing a splint (supportive device) to the right arm. On December 5, 2023, at 9:30 a.m., an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated she was the nurse assigned to render care to Resident 1 during the morning shift of December 5, 2023. CNA 2 stated there were no precautions or care necessary for Resident 1's right arm splint. CNA 2 stated special care needs that were required to provide care to residents assigned were not relayed from one shift to another. On December 5, 2023, at 10:45 a.m., and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the as needed (PRN) order for Ativan (anti-anxiety medication) for one of three sampled residents (Resident 3) was limited to 14 days. In addition,the facility failed to ensure Resident 3's behavior of anxiety was evaluated and monitored prior to obtaining a PRN Ativan order. This failure has the potential for unnecessary medication use. Findings: On December 5, 2023, an unannounced visit was conducted at the facility to investigate a complaint allegation. On December 5, 2023, at 10:04 a.m., an observation was conducted with Resident 3. Resident 3 was alert and ambulating independently. Resident 3 appeared calm, with no signs of agitation. On December 5, 2023, at 12:26 p.m., a concurrent interview and record review was conducted with Registered Nurse (RN) 1. Resident 3 was admitted to the facility on [DATE], with diagnoses that included schizophrenia (serious mental illness) and anxiety (serious mental illness). The physician ' s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to readmit one of three sampled residents (Resident 1) after hospitalization. This failure had the potential to cause emotional distress to Resident 1 and her responsible person (RP). Findings: On October 31, 2023, at 10:05 a.m., a telephone interview was conducted with the General Acute Care Hospital (GACH) Social Worker (HSW). The HSW stated Resident 1 was sent to the GACH for behavioral concerns, was diagnosed with a urinary tract infection (UTI- infection of the urine which can cause behavior issues), was treated and ready to be discharged back to the facility. The HSW stated the facility refused re-admission and the GACH was told Resident 1 was not appropriate to return to the facility. The HSW stated Resident 1 was not having any further behavior issues and was tearful stating she wanted to go home. The HSW stated Resident 1 had resided at the facility for a couple of years and considered the facility home. The HSW stated Resident 1 was still on 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 pharmaceutical services were provided to meet the needs for two of seven residents (Resident 1 and Resident 2) when: 1. The routine medication Invega Sustenna (a medication to treat schizophrenia [a mental disorder]) was not available for administration; and 2. The physician order for the administration of Furosemide (a medication to treat fluid retention and swelling) was not followed. These failures had the potential to negatively affect the health and safety of Residents 1 and 2. Findings: 1. On November 8 and 9, 2023, an unannounced visit was conducted for the investigation of two facility reported incidents. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included paranoid schizophrenia (a type of schizophrenia where a person feels suspicious of other people). During a review of the Order Listing Report (OLR), dated November 8, 2023,…

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.