Riverwalk Post Acute

Based on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with professional standards of practice for one out of five residents (Resident 159) observed during medication administration. The failure to clarify incomplete physician orders, including a Vitamin D3 (supplement) order without a specified dose and a Toprol XL (metoprolol succinate extended release - medication for high blood pressure) order with an inappropriate holding parameter of hold if HR (heart rate) <110, resulted in unsafe medication orders for Resident 159. Findings: During a medication administration observation on December 8, 2025 at 9:21 a.m., Licensed Vocational Nurse (LVN) 2 was observed preparing and administering medications to Resident 159. 1. During a review of Resident 159's clinical record on December 8, 2025, the record indicated a physician order of Vitamin D3 (Cholecalciferol - supplement), give 1 (one) capsule by mouth one time a day every Thu (Thursday) for supplement, dated November 25, 2025. The order did not specify 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 maintain a safe environment and provide adequate supervision to prevent accidents for one resident reviewed (Resident 2) when smoking materials were observed at Resident 2's bedside.This failure had the potential for environmental risk, hazards and accidents including fire and/or burn injuries.Findings:On December 9, 2025, at 5:53 a.m., Resident 2 was observed sitting in his motorized wheelchair, well groomed, alert and interviewable with a red carton of cigarettes between his legs. Resident 2 stated he kept his cigarettes with him at bedside.On December 9, 2025, at 7:50 a.m., Resident 2 was observed in his room and a clear yellow lighter was observed on Resident 2's bedside table. Resident 2 stated he kept his cigarettes and lighter with him at bedside.On December 9, 2025, at 7:55 a.m., a concurrent interview and record review was conducted with the Activity Director (AD). The AD stated the facility process is for the activity department…

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 received appropriate care to prevent complications of enteral feeding (feeding received directly through a tube in the stomach) when one of five residents (Resident 7) reviewed for tube feeding (TF - nutrition provided through a tube inserted into the stomach) was positioned with the head of the bed (HOB) not elevated 30-45 degrees while receiving tube feeding.This failure had the potential for Resident 7 to experience complications from tube feeding, such as aspiration (food or liquid accidentally enter the lungs), nausea, vomiting, or abdominal pain.Findings:On December 8, 2025, at 12:35 p.m., Resident 7 was observed lying in bed, receiving tube feeding nutrition. Resident 7 was observed awake, and unable to communicate. The tube feeding was infusing, and the HOB was observed flat (not elevated between 30 to 45 degrees). On December 8, 2025, at 12:44 p.m., a concurrent observation and interview was conducted 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.

Based on observation, interview, and record review, the facility failed to ensure safe and effective pharmaceutical services were provided to meet the needs of the residents when: 1. For Resident 66, medications were left unattended during medication administration.This failure had the potential for medication misuse, contamination, or access by unauthorized individuals, including residents, staff, or visitors. 2. For Resident 142, as-needed controlled substance (CS - medication with high potential for abuse and addiction) pain medication was not administered according to the physician's order.This failure had the potential to result in inadequate pain management, prolonged pain, and unnecessary discomfort for the residents. 3. For two out of nine randomly selected residents (Resident 4 and 142), documentation on Controlled Drug Record (CDR - medication count sheet, an inventory record used to document the receipt, use, and count of CS) did not reconcile with Medication Administration Record (MAR).These failures resulted in inaccurate accountability of controlled substances, which…

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

Based on observation, interview, and record review, the facility had a medication error rate of 11.11% when three medication errors occurred out of 27 opportunities during the medication administration, for two out of five residents observed (Resident 142 and 159). These failures included administration of an incorrect dosage form (aspirin chewable tablet administered for a delayed-release order) and administration of as-needed pain medication without required pain assessment prior to administering medication, resulting in medications not being administered in accordance with physician orders and the facility's policies and procedures, which had the potential to compromise residents' medication therapy and safety.Findings: 1. During a medication administration observation on December 8, 2025 at 8:38 a.m., Licensed Vocational Nurse (LVN) 1 was observed preparing and administering seven medications to Resident 142, including aspirin (used to prevent blood clots) 81 mg (milligram - unit of measurement) chewable tablet. During a review of Resident 142's medical record on December 8,…

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 keep one of five residents reviewed (Resident 1) belongings safe from theft or loss after the resident passed away in the facility.This failure resulted in Resident 1's belongings being lost and not available to the family.Findings:On [DATE], at 10:20 a.m., an unannounced visit was conducted to investigate an allegation of missing personal items.On [DATE], Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included cerebrovascular disease (loss of blood flow to part of the brain), cerebral infarction (where part of the brain tissue dies due to a lack of blood supply), anemia (not have enough healthy red blood cells), and palliative care (similar to hospice, medical care focused on improving the patient's and their family's quality of life by managing symptoms and stress related to the serious illness). On [DATE], at 1:20 p.m., a concurrent interview and record review was conducted with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an antihypertensive medication was held in accordance with the physician order for one of two sampled residents (Resident 1). In addition, the facility facility failed to ensure the physician was notified that Resident 1's antihypertensive medication was not administered in accordance with the physician order. These failures had the potential to negatively affect the resident's medical condition. Findings: On July 19, 2025, at 10:36 a.m., during an interview, Resident 1 stated a nurse did not give her blood pressure (BP) medication last week. A review of Resident 1's admission Record, indicated she was admitted to the facility on [DATE], with diagnoses which included hypertension (HTN-high blood pressure). A review or Resident 1's History and Physical, dated May 5, 2025, indicated the resident had decision-making capacity. A review of Resident 1's Order Summary Report, dated June 19, 2025, indicated, Losartan Potassium-HCTZ (losartan-hctz – a BP…

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 food in accordance with the physician's order for one of two sampled residents (Resident 1). This failure has the potential to result in poor intake, leading to weight loss. Findings: On July 19, 2025, at 10:36 a.m., during interview, Resident 1 stated she was allergic to gluten (a protein found in the wheat plant and some other grains), but the facility kept serving her food with gluten. Resident 1 stated when she eats gluten, it upsets her stomach. A review of Resident 1's admission Record, indicated she was admitted to the facility on [DATE], with diagnoses which included hypertension (HTN-high blood pressure), and she was allergic to gluten. A review or Resident 1's History and Physical, dated May 5, 2025, indicated the resident had the capacity to make decisions. A review of Resident 1's Order Summary Report, dated June 19, 2025, indicated .Fortified, NAS diet Regular texture, thin liquids consistency, gluten free diet . was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their weight management policy for one of five residents (Resident 2), when Resident 2 was not weighed weekly after severe weight loss was noted on January 8, 2025. This failure had the potential to lead to continued unmonitored weight loss which could negatively impact Resident 2's health condition. Findings: On April 29, 2025, at 8:45 a.m., an unannounced visit was conducted at the facility to investigate a quality care concern. A review of Resident 2's, admission Record, indicated the resident was admitted to the facility on [DATE], and re-admitted to the facility on [DATE], with diagnoses which included muscle wasting and atrophy (a breakdown of muscle tissue). A review of Resident 2 ' s, Weights and Vitals Summary, indicated the following: 12/10/2024 139 lbs., (pounds) 01/08/2025 122 lbs., (17 lbs. weight loss in a month); and 02/04/2025 109 lbs. (13 lbs. weight loss in a month). A review of eInteract SBAR summary for Providers, 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 and interview and record review, the facility failed to ensure residents' rooms were maintained clean and comfortable when: 1. room [ROOM NUMBER] had adhesive residue, chipped paint and black horizontal lines across the wall in front of the residents' bed, chipped baseboards and the floor had yellow and black stains; and 2. room [ROOM NUMBER] had adhesive residue, chipped paint and black horizontal lines across the wall in front of the residents' bed. This failure had the potential to negatively impact the psychosocial well-being of Residents 1, 2, 3, 4, 5 and 6. Findings: On March 27, 2025, at 10:54 a.m., during an observation in room [ROOM NUMBER], there were three residents, Residents 1, 2 and 3. The wall in front of them had adhesive residue, chipped paint, black horizontal lines and chipped baseboard. The floor had yellow and black stains. On March 27, 2025, at 10:58 a.m., during an observation in room [ROOM NUMBER], there were three residents, Residents 4, 5 and 6. The wall in front 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 two residents, Resident 1, the power of attorney (POA-someone who is legally authorized to act on the resident's behalf) was notified when Resident 1 ' s physician ordered lorazepam (an anti-anxiety medication). This failure resulted in Resident 1 ' s POA to be unaware of his overall condition. Findings: On February 21, 2024, at 3:09 p.m., during an interview with Resident 1 ' s POA, the POA stated Resident 1 was administered lorazepam, and she was not notified about it. On March 3, 4, and 5, 2025, unannounced visits were conducted at the facility. A review of Resident 1 ' s medical record indicated he was admitted to the facility on [DATE], with diagnoses which included obstructive uropathy (blockage of urine flow) and he had a POA. A review of Resident 1 ' s Nurse ' s Note dated November 22, 2024, written by Licensed Vocational Nurse (LVN) 1, indicated, Received new order from MD (medical doctor) for resident to start Ativan…

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, weight loss for two of three residents reviewed was evaluated (Residents 1 and 2). This failure had the potential for Residents 2 and 3 to experience further weight loss and not have their nutritional needs met. Findings: On March 3, 4, and 5, 2025, unannounced visits were conducted at the facility. A review of Resident 1 ' s medical record indicated he was admitted to the facility on [DATE], with diagnoses which included obstructive uropathy (a condition in which the flow of urine is blocked). A review of Resident 1 ' s care plan titled Malnutrition: Resident is at risk for malnutrition . initiated on November 19, 2024, included interventions which included .Notify the physician of weight loss .Refer to RD (Registered Dietician) as needed . A review of Resident 1 ' s Weights tab in PointClickCare (an electronic health care software) indicated Resident 1 weighed: a. 168 lbs. (pounds – unit of measurement) on November 20, 2024.…

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 behavior of anxiety (feelings of worry, unease, and tension) was evaluated and monitored prior to obtaining a PRN (as necessary) lorazepam (an anti-anxiety medication), for one of two sampled residents, Resident 1. This failure had the potential for unnecessary medication use. Findings: On March 3, 4, and 5, 2025, unannounced visits were conducted at the facility. A review of Resident 1 ' s medical record indicated he was admitted to the facility on [DATE], with diagnoses which included obstructive uropathy (occurs when urine cannot drain through the urinary tract). A review of Resident 1 ' s Nurse ' s Note dated November 22, 2024, indicated .Received new order from MD for resident to start Ativan (lorazepam) for anxiety and restlessness. Also gave order for psych eval. Orders noted and carried out, communicated with staff . A review of Resident 1 ' s Physician ' s Orders indicated .LORazepam Tablet 1 MG Give 1 tablet by mouth every 4 hours as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow its policy and procedure for prevention of pressure injuries, for one of two residents, Resident 1, when a dressing (a covering put on a wound to protect it while it heals) was placed on Resident 1's right hip and no further assessment or follow up was conducted. After removal of the dressing, Resident 1 was found to have an unstageable pressure injury (a sore that is covered by slough [tan, yellow or green debris] or eschar [thick black or brown scab or crust]) to his right hip. This failure resulted in Resident 1's wound to not be properly assessed and treated. Findings: A review of Resident 1's medical records indicated the following: a. Resident 1 was admitted to the facility on [DATE], with diagnoses including cerebral palsy (a chronic condition that affects a person's ability to move and maintain balance and posture) and unspecified local infection of the skin and subcutaneous (beneath or under, all the layers of the skin)…

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 medical record was complete, for one of one resident, Resident 1, when a care conference meeting was not documented in the medical record. This failure had the potential to impact Resident 1 ' s plan of care by not having a clear understanding of the resident ' s needs, preferences, and any changes in the care plan. In addition, this failure had the potential to create miscommunication among the care team, Resident 1, and Resident 1 ' s caregiver. Findings: On November 1, 2024, at 9:55 a.m., an unannounced visit was conducted at the facility to investigate a complaint. On November 1, 2024, a review of Resident 1's medical record indicated she was admitted to the facility on [DATE], with diagnoses which included fracture of the right tibia (shinbone), mild intellectual disability and cerebral palsy (a group of neurological disorder that permanently affect body movement and muscle coordination). A review of Resident 1's History and Physical…

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 accommodate the needs for one of 27 sampled residents (Resident 126), when the call light button was observed not within reach. This failure had the potential for Resident 126 not to be able to call staff for assistance which could result in needs of the resident not being met as well as the delay in the provision of care. Findings: On October 21, 2024, at 10:24 a.m., during an observation and concurrent interview with Resident 126, the resident's call light button was observed on the floor behind the resident's bed. Resident 126 stated he was not sure where the call light was and he could not reach his call light for assistance. Resident 126's record was reviewed. Resident 126 was admitted to the facility on [DATE], with diagnoses that included urinary tract infection, obstructive uropathy (condition in which the flow of urine is blocked) and diverticulosis (a condition in which you have small pouches in your colon). A review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed for three of eight residents reviewed (Resident 183, 101, and 32) to ensure: 1. For Resident 183, the central dialysis catheter was identified, assessed and monitored; This failure had the potential to delay the necessary care and services Resident 183 may need if complications developed with the central dialysis catheter; 2. For Resident 101, the physician order for fluid restriction was followed; This failure had the potential to result in fluid overload and a decline in Resident 101's health condition; and 3. For Resident 32, a skin condition was identified, assessed, monitored, and necessary treatment was implemented. This failure had the potential to result in Resident 32's development of skin breakdown and other skin complications. Findings: 1. On October 21, 2024, at 11:38 a.m. Resident 183 was observed lying in bed with his eyes closed not responsive to verbal call. Resident 183 was on oxygen at two liters per minute through nasal…

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 infection prevention and control program practices were implemented for two of seven residents reviewed (Residents 48 and 39) when: 1. For Resident 48, the oxygen nasal cannula (a plastic tube with two prongs that deliver oxygen through the nose) was left exposed on top of the resident's bed; and 2. For Resident 39, the wound vacuum, also known as vacuum-assisted closure (VAC - a machine that uses suction to help the wound heal more quickly) was left at the bedside table. These failures had the potential to increase the spread and the development of infection and would have placed Resident 39 and 48 at risk for illnesses and other complications. Findings: 1. On October 21, 2024, at 1:19 p.m., Resident 48 was not in her room. Resident 48's oxygen nasal cannula tubing was observed lying on top of her bed. The oxygen was on at three liters (a unit of measurement) per minute. On October 21, 2024, at 2 p.m., Resident 48's oxygen nasal…

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 that the discharge from the facility was necessary for one of three sampled residents (Resident 4), even after Resident 4 was cleared and the psychiatric hold was discontinued during hospitalization. This failure has the potential to negatively affect the resident's psychosocial well-being, who considered the facility as her home. Findings: On [DATE], at 11:45 a.m., an unannounced visit was conducted to investigate issues of Admission, Transfer and Discharge Rights. A review of Resident 4's medical record on [DATE], indicated Resident 4 was admitted to the facility on [DATE], with diagnoses which included spinal tumor resection, hemiplegia (paralysis) and hemiparesis (weakness on one side of the body), major depressive disorder (persistent low mood), and generalized anxiety disorder (excessive, uncontrollable worry). A review of records indicated a Notice of proposed 30- day discharge, dated [DATE], was effective the same day it was provided…

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 a notice of discharge for one of three sampled residents (Resident 4), when the facility made the determination not to accept the resident back to the facility while the resident was still at the general acute care hospital (GACH). In addition, the facility failed to provide a copy of Resident 4's updated notice of discharge to the representative of the Office of the State Long Term Care (LTC) Ombudsman. These failures had the potential for the resident and the resident's representative not to fully understand the reason for not being able to return to the facility which was her home since 2015; and could delay the Ombudsman in advocating for the resident. Findings: A review of Resident 4's medical record on June 26, 2024, indicated Resident 4 was admitted to the facility on [DATE], with diagnoses which included spinal tumor resection, hemiplegia (paralysis) and hemiparesis (weakness on one side of the body), major depressive disorder…

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 a notice of bed-hold for one of three residents (Resident 4) reviewed, upon transfer to the acute care hospital. Resident 4 was transferred to the acute care hospital on June 18, 2024. This failure resulted in Resident 4 not being aware of the bed-hold policy of the facility. In addition, this failure resulted in the resident not to be aware of her rights to be allowed to go back to the facility. Findings: On June 26, 2024, at 11:45 a.m., an unannounced visit to the facility was conducted to investigate an admission, transfer, and discharge issue. A review of Resident 4's record indicated Resident 4 was admitted to the facility on [DATE], with diagnoses which included diagnoses including major depressive disorder (all-encompassing low mood) and generalized anxiety disorder (long lasting anxiety). A review of the progress notes dated June 18, 2024, indicated, . Patient is seen for a comprehensive psychiatric evaluation at request of facility…

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 4) clinical behavior or condition was re-evaluated for re-admission to the facility after a therapeutic hospitalization. Resident 4 was cleared and the psychiatric hold was discontinued on [DATE], but was refused re-admission at the facility. This failure had the potential for Resident 4 not to be provided the opportunity to return to the facility she considered home since 2015, which could negatively affect the psycho social well-being of Resident 4. Findings: On [DATE], at 11:45 a.m., an unannounced visit was conducted to investigate issues of Admission, Transfer and Discharge Rights. A review of Resident 4's medical record on [DATE], indicated Resident 4 was admitted to the facility on [DATE], with diagnoses which included spinal tumor resection, hemiplegia (paralysis) and hemiparesis (weakness on one side of the body), major depressive disorder (persistent low mood), and generalized anxiety disorder…

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 notice of transfer or discharge was sent to the Office of the Long-Term Care (LTC) Ombudsman prior to the transfer or discharge of three sampled residents (Residents 1, 2, and 3). In addition, the facility failed to maintain consistent documentation that the notice was sent to the Ombudsman. This failure has the potential for the Ombudsman not to be able to advocate for the residents in protecting their rights form inappropriate transfer and discharge. Findings: On February 15, 2024, at 9:45 a.m., an unannounced visit was made to the facility to investigate a transfer and discharge issue. On February 15, 2024, at 8:33 a.m., an interview was conducted with the Ombudsman. The Ombudsman stated the facility staff were sending via fax the resident's discharge notices, on the day of their discharge and not at the time the resident were notified of their discharge. The Ombudsman further stated, she did not have the opportunity to contact the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an environment free from abuse, for three of four residents reviewed (Residents 1, 2, and 3), when Certified Nursing Assistant (CNA) 1 used a cellular telephone to record a video of CNAs 2, 3, 4, and 7, providing resident care. In addition, CNA 1 distributed the video via group text (a text communication between several individuals) to persons not employed at the facility. This failure had the potential to negatively impact the residents psychosocial and mental well-being. Findings: On December 28, 2023, at 1:05 p.m., the department received a facility reported incident indicating CNA 1 had posted a video on social media (network interactions among people where ideas and information are exchanged, examples include: Facebook, Tik Tok, Instagram, etc .) of three residents (Residents 1, 2, and 3). On December 29, 2023, at 12:55 p.m., an unannounced visit was conducted at the facility to investigate the reported incident. On December…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow the physician's order for fluid restrictions for one resident (Resident 1). This failure had the potential to result in fluid overload and decline in the resident's health condition. Findings: On January 24, 2024, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included chronic congestive heart failure (CHF - fluid build-up in the body because the heart cannot pump well enough) and chronic kidney disease (kidneys are damaged and excess fluid and waste remain in the body). The physician's order dated December 12, 2023, indicated, .Fluid Restriction 1200 cc (or milliliters [a unit of measurement]/24 hrs . The care plan, initiated December 18, 2023, indicated, .At risk for impaired cardiac function and complications related to CHF .Fluid Restrictions as ordered 1200 CC/24 HRS . The I&O (intake and output) record (a record indicating the total amount of fluid per day) for the month of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the call lights (devices that emit a tone and light up indicating the location of the call, used by the residents to signal a need for assistance from facility staff), were answered timely, when four out of four residents (Residents 1, 2, 3, and 4), who required assistance from staff with activities of daily living (ADLs), verbalized their concerns of facility staff not answering their call lights and/or attending to their needs in a timely manner. This failure had the potential for delayed medical management and unmet care needs. Findings: On December 15, 2023, at 10:40 a.m., an unannounced visit was conducted at the facility for two linked complaints. On December 15, 2023, at 11:10 a.m., Resident 1 was observed dressed, sitting on the edge of his bed. During a concurrent interview, Resident 1 stated he had been at the facility for about one month. Resident 1 stated it could take up to one hour or longer for call light response. Resident 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a discharge order was transcribed into the resident's electronic medical record (EMR) for one of three residents (Resident 1). This failure had the potential to affect Resident 1's overall health and well well-being. Findings: On October 10, 2023, at 8:05 a.m., an unannounced visit to the facility was conducted to investigate a complaint regarding admission, transfer and discharge. A review of Resident 1's record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included hypertension (high blood pressure). During a review of Resident 1's Minimum data Set (MDS- an assessment tool), dated September 17, 2023, the MDS indicated a Brief Interview for Mental Status (an evaluation aimed at evaluating aspects of cognition in patients) score of 10 (moderately impaired cognition). A review of Resident 1's Nurse's Note, dated August 23, 2023, indicated, .Resident discharged home with transport and 3 personal . A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of seven residents, (Resident 3), had the call light within reach. This failure had the potential for Resident 3 to have unmet needs and assistance. Findings: On August 25, 2023, at 10:35 a.m., an unannounced visit to the facility was conducted for two complaint investigations regarding resident rights. A review of Resident 3 ' s medical record indicated she was admitted to the facility on [DATE], with diagnoses of hemiplegia, (paralysis of one side of the body), and hemiparesis, (weakness of one side of the body), following a stroke, type 2 diabetes mellitus, (a chronic condition that affects the way the body uses sugar. The body either resists the effects of insulin - a hormone that regulates the movement of sugar into the cells - or doesn't produce enough insulin to maintain normal sugar levels), epilepsy, , (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, 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.

Based on interview and record review, for one (Resident 1) of five residents, the facility failed to accommodate Resident 1's reasonable request for assistance to arrange to visit his significant other on May 28, 2023, at 7:00 p.m. The facility failure to extend assistance had resulted to Resident 1 to miss his opportunity to spend the remaining time left to be with his significant other and pay his last respect. Findings: On August 29, 2023, at 10:30 a.m., an unannounced visit was conducted to investigate a complaint for violation of resident rights. A review of Resident 1's Progress Notes , dated May 28, 2023, at 7:38 p.m., by Licensed Vocational Nurse 1 (LVN) indicated, resident received phone call at approx. (approximately) 2010 (8:10 p.m.) that his (name of significant other) had passed away, resident is emotional, crying, will provided support for resident as he navigates through grieving process, will encourage to express emotions and monitor for any changes, requesting to see her before they pick up her body from (name of Skilled Nursing Facility/SNF), spoke to (name of…

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

Based on observation, interview and record review, on June 25, 2023 and July 3 and 4, 2023, the facility failed to allocate sufficient nursing staff to cover 54 residents for Station 1 Hallways A and B. The facility failure had a potential for the 54 residents to receive poor quality of care from the nurse who had limited time to attend to the residents. Findings: On July 3, 2023, at 4:06 a.m., an unannounced visit was conducted to investigate an allegation of staffing shortage at 11:00 p.m. to 7:00 a.m. shift. On July 3, 2023, at 4:23 a.m., Licensed Vocational Nurse 1 (LVN) was interviewed. LVN 1 stated she usually had to handle 32 residents for Station 1 Hallway B. LVN stated she had enough time but not for over 50 residents which usually happen 3 x a week when she had to handle both hallways, A and B on Station 1. On July 3, 2023, at 4:29 a.m., LVN 2 was interviewed. LVN 2 stated he had 42 residents, just enough time to attend to the residents but had at one time been assigned in Station 1 when he had to take care of hallways A and B. LVN 2 stated over 50 residents was hard 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 ensure, for one of three residents reviewed (Resident 1), a consistent monitoring of anxiety behaviors and monitoring of the effectiveness of the medication lorazepam (anti-anxiety medication; generic name for Ativan) was conducted after lorazepam was administered to Resident 1 on May 18, 19, 21, 23, 25, 26, and 29, 2023. This failure had the potential for Resident 1 to receive unnecessary psychotropic medication. Findings: On June 19, 2023, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE]. The Social Service Director (SSD) progress note dated May 12, 2023, at 4:48 p.m., indicated Resident 1 was calm and was in no apparent distress. The SSD progress note further indicated Resident 1 denied any feeling of depression or history of anxiety but worried about her situation. The Psychiatry progress note dated May 15, 2023, indicated Resident 1 was seen by the Physician Assistant (PA). The PA ordered lorazepam 0.5 milligrams…

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 sanitary conditions were maintained in the food and nutrition services and food were stored in accordance with professional standards for food service safety, when: 1. Unlabeled/undated food item was observed stored in the refrigerator, readily available for use; and 2. Frozen meat was not properly labeled and thawed. These failures had the potential to result in foodborne illness to an already vulnerable facility population. Findings: On January 3, 2022, at 9:15 a.m., an initial tour of the kitchen was conducted with the Cook. The following were observed stored inside Refrigerator #1: - One piece of thawed, precooked turkey, approximately three pounds (lbs.), wrapped in plastic foil, was observed in Refrigerator #1, readily available for use. The turkey meat had no label with the preparation date or use by date. - A 10 lbs pack of uncooked ground beef was observed being thawed and wrapped in its original plastic. The plastic wrapping was observed to have multiple holes punctured in several places of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an assessment was conducted, for one of thirty-five residents reviewed (Resident 55), to safely self-administer medication. This failure had the potential for unsafe medication administration practices which could result in resident injury or death. Findings: On January 3, 2022, at 12:00 p.m., a concurrent observation and interview was conducted with Resident 55. Resident 55 was observed awake, alert, and oriented. Observed on his bedside table was a medicine cup that contained a white cream-like substance. Resident 55 stated it was a medicated lotion ordered by his doctor for his dry eyelids and he applied it three times a day. Resident 55 further stated he asked the licensed nurse to give him the medicated lotion and leave it at his bedside. On January 3, 2022, at 12:35 p.m., Resident 55's record was reviewed. Resident 55 was admitted to the facility on [DATE], with diagnoses which included seborrheic dermatitis (a type of skin…

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 vision consult, for one of two residents reviewed for vision (Resident 61). This failure had the potential for Resident 61 to not receive the necessary treatment timely to maintain effective vision. Findings: On January 3, 2022, at 12:06 p.m., Resident 61 was observed awake and lying in bed. In a concurrent interview, Resident 61 stated his vision was getting worse, and he was unable to see well with his right eye. Resident 61 stated he did not have eyeglasses and told staff about it, but there was no follow-up. On January 5, 2022, at 11:40 a.m., Resident 61's record was reviewed. Resident 61 was admitted to the facility on [DATE], with diagnoses which included glaucoma (group of eye conditions which could cause blindness) and cataract (medical condition resulting in blurred vision). The physician's order dated April 30, 2021, indicated, .ENT (Eyes, Nose and Throat) Consult and Tx (treatment) as indicated . A review of the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a safe environment was provided according to the facility's policy and procedure, for one of one resident reviewed for smoking (Resident 117), when a pack of cigarettes and lighter were observed in Resident 117's possession. This failure had the potential to increase Resident 117's risk for smoking related injuries and accidental fires. Findings: On January 3, 2022, at 11:05 a.m., Resident 117 was observed awake and sitting in a wheelchair at the designated smoking area. Resident 117 was observed taking out a lighter and a pack of cigarettes from her jacket's pocket. On January 3, 2022, at 11:15 a.m., an interview was conducted with the Activities Assistant (AA). The AA stated she supervised residents during smoke breaks. The AA stated she distributed and lighted cigarettes for the residents. The AA stated residents were not supposed to keep their own cigarettes and lighters, according to the facility's policy and procedure. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the use of straight catheter (a soft, thin tube inserted into the bladder to pass urine) during self-catheterization (procedure of inserting the catheter into the bladder) was monitored, for one of two residents reviewed for urinary tract infection (Resident 77). This failure placed the resident at risk for complications of catheter use. Findings: On January 4, 2022, at 12:24 p.m., Resident 77 was observed awake and lying in bed. In a concurrent interview with Resident 77, she stated she would perform self-catheterization when needed. Resident 77 stated she was not being monitored by the licensed nurse when she would perform self-catheterization. She stated she did not know if the licensed nurses would document in her record each time she self-catheterized. On January 6, 2022, Resident 77's record was reviewed. Resident 77 was admitted to the facility on [DATE] with diagnoses including paraplegia (paralysis of the legs and lower…

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 according to the physician's order, for two of two residents reviewed for oxygen (Residents 49 and 321). This failure had the potential to result in ineffective oxygen therapy, respiratory distress, and decline in the resident's health condition for Residents 49 and 321. Findings: 1. On January 3, 2022, at 1:12 p.m., Resident 49 was observed in bed with a nasal cannula (N/C - a tube used to deliver oxygen through the nose) connected to an oxygen concentrator (a machine which delivers oxygen). The oxygen concentrator was observed to have a rate at five (5) liters per minute (LPM) - unit of measurement). In a concurrent interview with Resident 49, she stated she was supposed to be on two (2) LPM of oxygen at all times except at night. On January 3, 2022, Resident 49's record was reviewed. Resident 49 was admitted to the facility on [DATE], and re-admitted to the facility on [DATE], with diagnoses which…

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 pain assessment was conducted before pain medication was administered, for two of two residents reviewed for pain (Residents 34 and Resident 221). This failure had the potential for the residents to have ineffective pain management. Findings: 1. On January 6, 2022, at 9:40 a.m., a medication administration observation was conducted with Licensed Vocational Nurse (LVN) 5. LVN 5 was observed administering scheduled morning medications to Resident 221, which included Percocet (a narcotic pain medication) 10-325 milligram (mg - a unit of measurement) tablet. LVN 5 was not observed to conduct pain assessment before administering Percocet to Resident 221. A concurrent interview was conducted with LVN 5. LVN 5 stated the licensed nurse should conduct a pain level assessment before administering the pain medication. LVN 5 stated she did not conduct a pain assessment before administering Percocet to Resident 221. LVN 5 stated she should…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications were properly stored, disposed and/or discarded when: 1) Multiple medications for two discharged residents were not disposed timely and were still stored in the medication cart readily available for use. This failure had the potential for the medications to be administered to other residents; and 2) One opened insulin quick pen (medication to treat diabetes mellitus [DM - abnormal blood sugar]) without a proper label was stored in the medication cart readily available for use. This failure increased the possibility for residents to receive medications unsafely. Findings: On [DATE], at 10:46 a.m., an inspection of the medication cart was conducted with Licensed Vocational Nurse (LVN) 6. 1. The following medications of two discharged residents were observed stored in the medication cart and readily available for use: - One used bubble pack of Hydralazine (a medication used to treat high blood pressure) 25 milligram (mg -…

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 physician's order for HgbA1C (a laboratory test to check blood sugar level) was completed as ordered by the physician, for one of 35 residents reviewed (Resident 67). This failure had the potential to result in a delay in the care and treatment of abnormal blood sugar levels for Resident 67. Findings: On January 7, 2022, Resident 67's record was reviewed. Resident 67 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (DM- abnormal blood sugar). The physician's order included the following medications to treat DM: - .Humalog Solution 100 unit/ml (Insulin Lispro) (an injectable medication to treat DM) Inject 10 unit subcutaneously (administering medication under skin) three times a day .Give 10 units before meals ., order date February 4, 2021; - .Humalog Solution 100 unit/ml (Insulin Lispro) Inject as per sliding scale (dose of insulin medication based on blood sugar level) .subcutaneously before meals 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 infection control and prevention practices were observed when: 1. For Resident 77, a used straight catheter (a soft, thin tube used to pass urine from the body, used one time and then thrown away) was observed on top of the resident's over bed table, together with grooming materials and eating utensils. In addition, the straight catheter was being reused multiple times by Resident 77 to self-catheterize (inserting a catheter into the bladder). This failure had the potential to cause urinary tract infection (UTI - a bladder infection) for Resident 77; and 2. A yellow stained urinal (a bottle used for urination) was observed uncovered and unlabeled at Resident 76's bedside. This failure had the potential to increase the risk for bacterial growth, cross-contamination and spread of infection. Findings: 1. On January 4, 2022, at 12:24 p.m., Resident 77 was observed awake and lying in bed. In a concurrent interview with Resident 77, 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.