Woodcrest Post Acute & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with the facility's policy and procedures and physician's order, for four of four residents (Residents 1, 2, 3, and 4).This failure has the potential to result in reduced effectiveness of Residents 1, 2,3, and 4's medications.On July 16, 2025, at 5:06 a.m., an unannounced visit was conducted at the facility to investigate quality of care issues.On July 16, 2025 at 5:23 a.m., during an interview with Licensed Vocational Nurse (LVN) 1, she stated she started the 6 a.m. and 6:30 a.m. medication pass (med pass - the process through which medication is administered to residents) at 4:20 a.m. LVN 1 stated she should start med pass at 5 a.m. but she started 40 minutes early because there were a lot of blood sugar checks, medications to be administered through G-tubes (gastrostomy tube - a tube inserted to the stomach used to give food and medications) and documentation to complete. LVN 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.

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 A) received a post-discharge plan of care, which contained the necessary information for the continuation of care after discharge. This failure resulted in Resident A ' s family calling the facility for advice and sending Resident A to the emergency room, within 24 hours of his discharge from the facility. Findings: On March 28, 2025, at 9:50 a.m., an unannounced visit to the facility was conducted to investigate quality of care concern and discharge rights. On March 28, 2025, at 1 p.m., an interview was conducted with the Social Service Assistant (SSA). The SSA stated the case managers and social service director are the ones who help the residents plan for discharge and follow up care. The SSA stated Resident A was discharged on March 18, 2025, and she called Resident A twice following his discharge, but she did not speak with Resident A. On March 28, 2025, at 1:10 p.m., an 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to treat with respect and dignity, for two of five residents (Residents A and B), when the facility left a deceased resident (Resident C) in the same room with Residents A and B for approximately 12 hours, before removing the body. This failure resulted in Residents A and B ' s experiencing negative psychosocial (a person ' s well-being- mental, emotional, social, and spiritual health) outcomes. Findings: On [DATE], at 9:05 a.m., an unannounced visit to the facility was conducted to investigate a complaint of resident rights. On [DATE], at 9:50 a.m., Resident C's bed was observed to be not made up and the sheets were dirty. Two wheelchair footrests were observed on top of the bed. On [DATE], at 10:00 a.m., an interview was conducted with Resident B. Resident B stated Resident C passed away early in the morning of [DATE], and the Resident C's body was left in the room until 7:30 p.m., that night. Resident B stated, it was a very traumatic…

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 answer the call light within a reasonable time for three of three residents reviewed (Residents 5, 6, and 7). This failure had the potential to result in needs not to be met efficiently for Residents 5, 6, and 7. Findings: 1.On October 13, 2024, Resident 5 ' s electronic record was reviewed. Resident 5 was admitted on [DATE], with diagnoses which included osteoarthritis- right hip (type of arthritis when the cartilage that lines the joint is worn down), muscle wasting and atrophy (loss of muscle tissue and strength) and history of falling. On November 13, 2024, at 3:36 p.m., a telephone interview was conducted with Resident 5's family representative (FR 3). The FR stated Resident 5 called the family some weeks ago and stated she (Resident 5) pushed her call light button for assistance to the restroom and no one responded. 2. On November 13, 2024, Resident 6 ' s electronic record was reviewed. Resident 6 was admitted on [DATE], 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 record review, interview, and facility policy review, the facility failed to ensure the accuracy of Level I preadmission screening and resident review (PASARR) for 2 (Resident #3 and Resident #59) of 2 sampled residents reviewed for PASARR requirements. Findings included: A facility policy titled, admission Criteria, revised in 09/2023, revealed, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. The policy revealed, a. The facility will ensure PASARR screen has been completed by hospitals or facility of origin for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD. 1. An admission Record revealed the facility admitted Resident #3 on 06/16/2024. According to the admission Record, the resident had a medical history that included diagnoses of dementia (onset 06/16/2024), schizophrenia (onset 06/16/2024), and major depressive disorder (onset…

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 record review and interview, the facility failed to notify the appropriate state-designated authority after a resident was diagnosed with a new mental illness for 1 (Resident #59) of 2 sampled residents reviewed for preadmission screening and resident review (PASARR) requirements. Findings included: An admission Record revealed the facility admitted Resident #59 on 12/15/2023. According to the admission Record, the resident had a medical history that included diagnoses of psychosis (onset 12/15/2023) and major depressive disorder (onset 12/15/2023). The admission Record revealed the resident received a diagnosis of schizophrenia on 12/29/2023. An quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/22/2024, revealed Resident #59 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident had active diagnoses to include psychotic disorder and schizophrenia. Resident #59's care plan included a focus area initiated 12/25/2023, that indicated the resident had a mood…

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

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the medication error rate was 5% or less. This was evidenced by two medication errors out of 33 opportunities, which resulted in a medication error rate of 6.06%, that affected 2 (Resident #10 and Resident #39) of 5 residents observed for medication administration. Findings included: A facility policy titled, Administering Oral Medications, revised in 09/2023, revealed, The purpose of this procedure is to provide guidelines for the safe administration of oral medications. The policy further revealed, Steps in the Procedure included 5. Select the drug from the unit dose drawer or stock supply. 6. Check the label on the medication and confirm the medication name and dose with the MAR [medication administration record]. 1. An admission Record revealed the facility admitted Resident #10 on 01/10/2024. According to the admission Record, the resident had a medical history that included a diagnosis of unspecified anemia. An annual Minimum Data Set (MDS), with an Assessment Reference…

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 administered on time as prescribed by the physician and according to the facility ' s policy for three of three residents reviewed (Residents 1, 2, and 3). This failure had the potential to result in an increased risk of changes of condition to Residents 1, 2 and 3. Findings: On August 12, 2024, at 9:20 a.m., an unannounced visit was conducted at the facility to investigate a complaint. On August 12, 2024, at 9:49 a.m., during a concurrent observation and interview with Resident 1, Resident 1 was in his room, sitting on his wheelchair by the door, alert and conversant. Resident 1 stated he received his medications on time, but he looked for the nurse when it ' s time for his pain medication. On August 12, 2024, at 10:04 a.m., during a concurrent observation and interview with Resident 2, Resident 2 was lying on his bed, watching television, alert and conversant. Resident 2 stated he received his medications 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 provide sufficient nursing staffing to provide care and services for the residents of the facility. This failure had the potential to cause residents in the facility to experience delays and inadequate care. Findings: On July 23, 2024, at 5:06 a.m., an unannounced visit was conducted at the facility. On July 23, 2024, at 5:26 a.m., during an interview with Certified Nurse Assistant (CNA) 1, CNA 1 stated the facility needed more staffing so they can be able to do their work effectively for the residents. On July 23, 2024, at 5:58 a.m. during an interview with Licensed Vocational Nurse (LVN) 1, LVN 1 stated there had been staffing issues at the facility. LVN 1 stated there was one night shift (11-7) when there was only four CNAs on the floor. LVN 1 stated they tried to get coverage, but nobody wanted to work. LVN 1 further stated that they are always short-staffed, weekday or weekend. On July 23, 2024, at 5:50 a.m. during an interview 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 updated staffing information of the total number and actual hours worked by the licensed and unlicensed nursing staff was posted in a prominent place readily available to residents and visitors. This failure had the potential for the facility not to be able to provide and determine the actual nursing hours required for the provision of care and services for the residents in the facility. Findings: During an observation on July 15, 2024, at 9:34 a.m., the facility document titled, Census and Direct Care Service Hours Per Patient Day (DHPPD - used to measure the duration of care residents receive in a day) was posted on the wall of the facility lobby next to the receptionist's desk. The DHPPD information was not updated. The DHPPD forms did not indicate the actual total direct care service hours, actual total CNA (certified Nursing Assistant) direct care service hours, the average patient census, the actual DHPPD and the actual CNA DHPPD on multiple dates. During a concurrent interview and record review…

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 three residents, Resident 2, had the call light within her reach. This failure had the potential to result for Resident 2 to not be able to call for help. Findings: On June 24 and 25, 2024, unannounced visits were conducted at the facility. On June 24, 2024, at 2:25 p.m., during a concurrent observation and interview with Resident 2, Resident 2 was lying in bed and alert. Resident 2 was mouthing words and her responses were unclear. Resident 2 was observed moving her left hand towards her right side. Resident 1 nodded her head up and down when asked if she needed help. Resident 2 ' s call light was found hanging on the TV mount of her roommate by Resident 2 ' s right hand-side. On June 24, 2024, at 2:27 p.m., during an interview with Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 2 ' s call light was not within her reach. CNA 1 stated, Resident 2 will not be able to ask for help if the call light was not within…

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, that the responsible party (RP) was notified when Resident 1 had a change of condition (COC) and was transferred out to a general acute care hospital (GACH). This failure resulted in Resident 1 ' s RP to not be aware of Resident 1 ' s health condition. Findings: On June 24 and 25, 2024, unannounced visits were conducted at the facility. On June 25, 2024, at 10:48 a.m., during an interview with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the doctor, family members or responsible party were notified when a resident had a COC. On June 25, 2024, at 3:30 p.m., during an interview with the Director of Nursing (DON), the DON stated the staff should notify the doctor and RP when a resident had a COC. The DON stated the RP should be notified as well when a resident was sent out to the hospital. A review of Resident 1 ' s admission Record indicated Resident 1 was initially admitted to the facility on [DATE], and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure, for one of one resident, Resident 1, that a physician ' s order for physical therapy was communicated with the hospice (care that focuses on the comfort and quality of life rather than curing a disease) provider. This failure resulted for Resident 1 not receiving physical therapy as ordered by the physician. In addition, this failure resulted for the hospice provider to not be fully aware of Resident 1 ' s overall condition. Findings: On June 24 and 25, 2024, unannounced visits were conducted at the facility. On June 24, 2024, at 2:01 p.m., during a concurrent observation and interview with Resident 1, Resident 1 was observed in her room, lying in bed, alert and conversant. Resident 1 stated she required assistance with activities of daily living. A review of Resident 1 ' s medical record was conducted. Resident 1 was initially admitted to the facility on [DATE], with diagnoses which included supraventricular tachycardia (irregular heartbeat)…

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 cardiopulmonary resuscitation (CPR - a way to help a person who has stopped breathing, and whose heart may have stopped beating, to stay alive) for one of two sampled residents (Resident 1), when Resident 1 was found unresponsive. This failure resulted in Resident 1 not receiving the necessary life saving measures. Findings: On [DATE], and 10, 2024, unannounced visits were conducted at the facility to investigate an allegation of neglect. A record review of Resident 1's medical record indicated Resident 1 was initially admitted to the facility on [DATE], with diagnoses which included atrial fibrillation and hypertension. A review of Resident 1's History and Physical indicated that Resident 1 has the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - an assessment tool) dated [DATE], indicated Resident 1 was a full code (full support which includes cardiopulmonary resuscitation-CPR, if the patient has no…

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 pharmacy services were provided to meet the needs of the residents when four medications were not administered during the scheduled time with no documentation for one of five residents reviewed (Resident 1). This failure had the potential for Resident 1 to receive inadequate, ineffective medication treatment. Findings: On May 24, 2024, at 9:35 a.m., Resident 1 was interviewed. Resident 1 was alert and oriented. Resident 1 stated she had missed some medication doses of apixaban (Eliquis - an anticoagulant) and amiodarone (for arrhythmias - irregular heartbeats). On May 24, 2024, at 9:35 a.m., Resident 1's medical record was reviewed. Resident 1 was re-admitted at the facility on January 10, 2024, with diagnoses which included tachycardia (fast, irregular heart rate), cardiac arrest, severe obesity, and hyperlipidemia (high cholesterol). There was a physician order dated January 30, 2024, for the following medications to be given to Resident 1: amiodarone 200 mg by mouth every 12 hours for arrhythmia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an adequate preparation and orientation for a safe and orderly discharge was afforded to one of two sampled residents (Resident 2) and her family member. Resident 2 was living with a family member, who was not provided adequate preparation and orientation prior to the planned discharge. This failure had the potential for Resident 2 to have an increased risk of accidents and rehospitalization if she was discharged from the facility. Findings: On April 23, 2024, at 10:45 a.m., an unannounced visit was conducted at the facility to investigate an issue on discharge and transfer. On April 23, 2024, at 10:53 a.m., a concurrent interview and observation was conducted with Resident 1. Resident 1 was sitting on her wheelchair, watching television, alert, and conversant. Resident 1 stated she told the staff she wanted to go home by the end of February 2024. Resident 1 stated she was not able to go home last February 29, 2024, because her family member 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 ensure the family member (FM), who was designated as the Power of Attorney (POA- a legal document that allows someone else to act on your behalf), was notified about a change of condition, for one of two residents, Resident 2. This failure resulted for Resident 2's FM to not be aware of Resident 2's change in condition and the inability to fulfill POA duties effectively. Findings: On April 4, 2024, an unannounced visit was conducted at the facility for an investigation of a complaint. A review of Resident 2's records was conducted. Resident 2 was admitted to the facility on [DATE]. Resident 2 passed away at the facility on February 17, 2024. Resident 2's, History and Physical (H&P), dated August 21, 2023 indicated Resident 2 had diagnoses which included type 2 diabetes mellitus (high blood sugar level) with ulcer (break on the skin) of right foot , end stage renal disease (a permanent kidney failure) on dialysis (a procedure to remove waste products…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received care according to professional standards of practice for Resident 1 and 2, when the facility failed to: 1. Initiate a care plan, document a Change of Condition (COC), and complete a weekly skin assessment, for Resident 1 ' s stage 2 (shallow, open), coccyx (tailbone), Pressure Injury (PI – Damaged skin integrity due to prolonged pressure). 2. a) Complete a weekly skin assessment on Resident 2 ' s stage 2, coccyx PI; b) Carry over a doctor ' s (Dr ' s) order of Calmoseptine cream (Moisture barrier that helps heal skin) to Residents 2 ' s Treatment Administration Record (TAR); and c) Follow-up on Resident 2 ' s urine culture results from the General Acute Care Hospital (GACH) following treatment for sepsis related to a UTI (Urinary Tract Infection). These failures had the potential for changes in Resident 1 and 2 ' s PIs to go unidentified and the potential for a delay of treatment for Resident 1 and 2's PI's, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) was being repositioned in accordance with the care plan. In addition, the facility failed to ensure treatment for the left heel pressure injury was provided in accordance with the physician order. These failures had the potential for Resident 1 to develop pressure injury or can result in worsening of an existing pressure injury. Findings: On December 28, 2023, at 10:30 a.m., an unannounced visit to the facility was conducted to investigate quality of care issues. A review of Resident 1's medical records indicated he was admitted on [DATE], with diagnoses which included pneumonia, (infection in the lungs), atrial fibrillation, (irregular heartbeat), acute respiratory failure, (a serious condition that develops quickly without warning when the lungs can ' t get enough oxygen into the blood), type 2 diabetes mellitus, (a chronic condition that affects the way the body uses sugar. The body either resists…

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 basis for discharge of a resident endangering others were documented as necessary by one of three sampled residents' (Resident 1) physician. This failure has the potential to place the resident at risk for inappropriate discharge which could negatively affect the psychosocial needs of Resident 1. Findings: On December 6, 2023, at 9:15 a.m., an unannounced visit was conducted at the facility for the investigation of a complaint. A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), hyperlipidemia (elevated cholesterol and/or triglycerides) and unspecified dementia (a group of symptoms affecting memory, thinking and social abilities). A review of Resident 1's History and Physical, dated August 2, 2023, indicated the resident can make needs known…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was permitted to return following hospitalization unless the needs cannot be met, or the resident's behavior posed a danger to other residents at the facility. This failure had the potential to affect continuity of care for a resident who lived and received services from staff familiar to his needs. The resident has a diagnosis of dementia (a group of symptoms affecting memory, thinking and social abilities). The resident had to be placed to another skilled nursing facility. Findings: On December 6, 2023, at 9:15 a.m., an unannounced visit was conducted at the facility for the investigation of a transfer and discharge concern. A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), hyperlipidemia (elevated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of five residents reviewed (Resident 1) was free from abuse when Resident 2 grabbed her breast. This failure had the potential for other residents in the facility to experience inappropriate sexual behavior from Resident 2. Findings: On October 9, 10, and 26, 2023, unannounced visits were conducted to investigate a facility reported incident. 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 dementia (memory loss) and hypertension (high blood pressure). During a review of Resident 1's History and Physical (H&P), dated August 4, 2023, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 2's AR, the AR indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included dementia and hypertension. During a review of Resident 2's H&P, 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 implement their policy and procedure on abuse investigation when a Certified Nursing Assistant (CNA) 1 was not suspended after an allegation of verbal abuse was made by one of three residents reviewed (Resident 1). This failure resulted in CNA 1 to continue caring for other residents exposing residents at risk for potential harm. Findings: On October 12, 2023, at 10:06 a.m., an unannounced visit was conducted to the facility to investigate one Facility Reported Incident related to an allegation of abuse by Resident 1 on CNA 1. During a review of Resident 1's record on October 12, 2023, the record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included schizophrenia (a mental illness) and depressive disorder. Resident 1's history and physical dated July 28, 2023, indicated resident was able to make her needs known and able to care for herself. The Minimum Data Sheet (MDS - an assessment tool) dated August…

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 report an allegation of missing money to the State Survey Agency within 24 hours for one of four residents, (Resident 2). This failure increased the risk for further misappropriation due to delayed notification to respond and advocate on behalf of Resident 1. Findings: On August 2, 2023, at 11:48 a.m., an unannounced visit to the facility was conducted to investigate an allegation of misappropriation of property. Resident 2 ' s History and Physical dated October 24, 2022, indicated he could make needs known but could not make medical decisions. On August 2, 2023, at 2:13 p.m., an interview was conducted with Resident 2. Resident 2 stated his wallet went missing and $400.00 was stolen. Resident 2 was unable to recall the date or time this occurred. Resident 2 stated the police came to investigate, and again was unable to recall the date or time. On August 2, 2023, at 4:05 p.m., an interview was conducted with the Licensed Vocational Nurse, (LVN). The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately complete the Preadmission Screening and Resident Review (PASRR - a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) for one of four residents (Resident 1), when Resident 1's diagnosis of mental illness and the use of psychotropic (medication capable of affecting the mind, emotions, and behavior) medications were not reflected in the PASRR. This failure had the potential for Resident 1 to not receive services she required in an appropriate setting as determined by the State agency. Findings: On August 2, 2023, at 11:48 a.m., an unannounced visit to the facility was conducted to investigate an allegation of abuse. On August 2, 2023, at 4:55 p.m., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated she was not responsible for the PASRR screening until three weeks ago. The ADON…

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 necessary care and services to achieve and maintain the highest practicable physical, mental, and psychosocial well-being were provided, for five of 25 residents reviewed, when: 1. For Resident 68, Ozempic (an injectable medication to treat diabetes mellitus [DM - abnormal blood sugar]) was not administered as ordered by the physician. This failure had the potential for Resident 68 to have uncontrolled blood sugar levels; 2. For Resident 31, morphine sulfate (a narcotic pain medication) was not administered as ordered by the physician. This failure had the potential for Resident 31 to experience pain and discomfort; 3. For Resident 86, licensed staff did not complete the neurological assessment (neurocheck) after the resident had unwitnessed fall incidents on September 10 and 16, 2021. This failure had the potential for delayed medical interventions. 4. For Resident 38, the physician was not notified when the blood sugar level 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 ensure sufficient nursing staff was provided, when: 1. Necessary services to maintain personal hygiene was not provided, for one of one resident reviewed for Activities of Daily Living (ADL) (Resident 27); 2. During the confidential Resident Council (RC- independent group of long-term care facility residents who typically meet regularly to discuss concerns and suggestions in the facility and to plan activities that are important to them) interview, 12 out of 18 residents in attendance stated there was a delay in the staff's response to call lights, and that there was not enough Certified Nursing Assistants (CNA) during night shifts and weekends; and 3. The facility was staffed below the minimum state requirements for direct care service hours per patient day on multiple dates. These findings had the potential for the residents in the facility to not receive necessary care and related services in a timely manner. In addition, these failures had 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 in accordance with professional standards of practice were provided to meet the needs of the residents when: 1. Multiple opened emergency kits (e-kit - an emergency storage box containing small quantity of critical medications used in emergent situations) were not replaced within seventy-two hours according to the facility's policy and procedure. In addition, the opened e-kits did not match the medications taken out from it. These failures had the potential to result in a delay in the administration of medications and potential for medication diversion (transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use) to occur; 2. Cyclosporine eye drops (medication for dry eyes) was not acquired by the facility timely, for one of 25 residents reviewed (Resident 15). In addition, the physician was not notified the cyclosporine eye drops was not administered 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.

Based on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained and food was stored in accordance with professional standards for food service safety when: 1. During the initial kitchen tour on September 20, 2021, multiple food items were stored past the use-by date (the last day that the manufacturer vouches for the product's quality); and 2. During dining observation, on September 20, 2021, a ham and cheese sandwich was served to Resident 38 with the use-by date of September 19, 2021. These failures had the potential for the growth of harmful microorganisms which may result in food-borne illnesses in a medically vulnerable population. Findings: 1. On September 20, 2021, at 7:10 a.m., an initial kitchen tour was conducted with [NAME] 1. One container of baking powder was observed in the dry storage area with a received date of December 24, 2020, and a use-by date of June 24, 2021. During a concurrent interview with [NAME] 1, she stated the container's contents should have been discarded and not readily available for use. One…

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 proper infection control measures were implemented when: 1. For Resident 287, the urinary catheter (indwelling catheter - a hollow, flexible tube that collects urine from the bladder) drainage bag was observed on the floor. This failure had the potential for Resident 287 to develop urinary tract infection due to inappropriate placement of the urinary catheter drainage bag; 2. The blood pressure apparatus was not disinfected in between residents' use. This failure had the potential to result in the transmission of infection to the residents in the facility; 3. For Resident 28, who was a PUI (Person Under Investigation - patient with potential exposure to Covid-19 [(a highly contagious respiratory illness caused by the novel corona virus that can be spread from person to person)]newly admitted resident), did not wear facial mask covering while outside of his room. In addition, Resident 18, who no longer required isolation…

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, for two of seven residents reviewed for Advance Directives (AD - a written instruction regarding the provision of health care when the individual is incapacitated) (Residents 86 and 65), the facility failed to ensure: 1. For Resident 86, a follow up with the resident's representative (RR) was conducted regarding obtaining a copy of the resident's AD; and 2. For Resident 65, written information regarding formulating an AD was provided to the resident and/or the (RR). These failures had the potential to result in not determining and/or following the residents' wishes related to the provision of medical treatment and health care services when the residents become unable to make decisions for themselves. Findings: 1. On September 22, 2021, Resident 86's record was reviewed. Resident 86 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (lung disease). The History and Physical Examination, dated May 28, 2021, indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for one of three residents reviewed (Resident 89), the facility failed to ensure a post-discharge plan of care was completed and provided to the resident upon the resident's discharge from the facility. This failure had the potential for the resident and care giver to not receive the necessary medical information needed for the continuity of care of the resident upon discharge to home. Findings: On September 24, 2021, Resident 89's record was reviewed. Resident 89 was admitted to the facility on [DATE], with diagnoses which included endocarditis (life-threatening inflammation of the inner lining of your heart's chambers and valves) and protein-calorie malnutrition. There was no documented evidence a post-discharge plan of care was completed in the resident's clinical record. Furthermore, there were no notes indicating discharge instructions were given to Resident 89. On September 24, 2021, at 10:42 a.m., an interview was conducted with Licensed Vocational Nurse (LVN 1). 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure necessary services to maintain personal hygiene were provided for one of one resident reviewed for Activities of Daily Living (ADL) (Resident 27). This failure had the potential to result in poor personal hygiene which could negatively affect Resident 27's physical well-being. Findings: On September 20, 2021, at 2:50 p.m., Resident 27 was observed awake and lying in bed. In a concurrent interview with Resident 27, he stated he did not get a shower last Saturday (September 18, 2021), according to his shower schedule of Wednesdays and Saturdays. He stated there were only two Certified Nursing Assistants (CNAs) assigned to their unit instead of six who were scheduled for that morning shift. He stated the facility was always short staffed. On September 23, 2021, Resident 27's record was reviewed. Resident 27 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (lung disease). The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an environment free of accident hazards was provided, for one of five residents reviewed for falls (Resident 6), when the resident did not have a fall/tab alarm placed to prevent falls according to the physician's order and plan of care. This failure resulted to Resident 6 sustaining another fall incident on September 21, 2021. In addition, this failure had a potential to result for further falls and sustain injuries for Resident 6. Findings: On September 20, 2021, at 2:49 p.m., Resident 6 was observed sleeping and lying in bed. Resident 6's bed was observed to be in the lowest position with two floor mats on each side of the bed. There was no fall/tab alarm placed on the resident. On September 21, 2021, Resident 6's record was reviewed. Resident 6 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss). The plan of care, dated November 6, 2020, indicated, .At risk for fall .Will reduce the risk…

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 respiratory care and treatment in accordance with the physician's order was provided, for one of one resident reviewed for oxygen use (Resident 34). In addition, the facility failed to ensure infection control measures were implemented when the oxygen tubing and nasal cannula (NC - a device used to deliver supplemental oxygen) were observed to be on the floor. These failures had the potential to result in ineffective oxygen therapy, respiratory distress, infection, and/or decline in the health condition for Resident 34. Findings: On September 22, 2021, at 10:46 a.m., Resident 34 was observed sleeping in bed. The oxygen machine was observed running at 3.5 LPM (liters per minute - unit of measurement). Resident 34 was observed not wearing the nasal cannula. The nasal cannula and oxygen tubing were observed on the floor. On September 22, 2021, at 10:56 a.m., a Certified Nursing Assistant was observed entering the room and 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 observation, interview, and record review, the facility failed to ensure the episodes of behavior related to the use of lorazepam (medication for mood disorder) were properly monitored, for one of five residents reviewed for unnecessary medication (Resident 6). This failure had the potential for Resident 6 to receive unnecessary psychotropic medications (medications used to treat mood disorder). Findings: On September 20, 2021, at 8:46 a.m., Resident 6 was observed sitting up in bed, yelling, and crying. On September 23, 2021, Resident 6's record was reviewed. Resident 6 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss). The plan of care, dated March 4, 2021, indicated, .Resident has diagnosis of Anxiety m/b (manifested by) restlessness .Will have less episodes of restlessness . Assessed (sic) for s/s (signs and symptoms) of anxiety/restlessness . The Medication Administration Record (MAR), for the month of August 2021, included a physician's order, 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 the medication error rate was below five percent when there were six medication errors out of 38 opportunities observed, for two of five sampled residents (Residents 58 and 15). This failure resulted in a medication error rate of 15.79% and could result in the residents' not receiving the full therapeutic effect of the medications. Findings: 1. On September 23, 2021, at 9:13 a.m., medication administration observation was conducted for Resident 58 with Licensed Vocational Nurse (LVN) 4. LVN 4 was observed placing the following medications in the medication cup: - One tablet of iron supplement 325 milligram (mg - unit of measurement); - One capsule of Florastor (probiotic); - One tablet of multivitamins with minerals; - One tablet of calcium carbonate (calcium supplement) 750 mg; - One soft gel of docusate sodium (stool softener) 250 mg; - One tablet of vitamin C 500 mg; - One tablet of folic acid (medication to treat anemia [low…

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 medications were stored according to the facility's policy and procedure and per state and federal requirements when controlled medications (regulated and classified medications that can cause physical and mental dependence, and have restrictions on how they can be filled and refilled) were not stored in separately locked compartments and were mixed with non-controlled medications. This failure had the potential for the controlled medications to be accessed by unauthorized personnel, which could potentially lead to diversion or misappropriation of restricted medications. Findings: On September 22, 2021, at 11:59 a.m., Station 2 Medication Room was inspected with Registered Nurse Supervisor (RNS) 2. The following controlled medications were observed stored together with non-controlled medications inside the medication refrigerator: - A box containing an opened bottle of lorazepam solution (medication to treat anxiety [mood disorder]) labeled for Resident 31; and - A box containing an opened bottle 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 basic metabolic panel (BMP - a laboratory test to measure electrolyte levels) was completed, as ordered by the physician, for one of 25 residents reviewed (Resident 38). This failure had the potential for an abnormal electrolyte level to not be identified timely and could potentially result in the delay in care and treatment for Resident 38. Findings: On September 20, 2021, at 1:35 p.m., Resident 38 was observed sitting at the side of the bed eating her lunch. She stated she had lost weight since she came to the facility five months ago. On September 21, 2021, Resident 38's record was reviewed. Resident 38 was admitted to the facility on [DATE], with diagnoses which included end stage renal disease (kidney disease). The History and Physical Examination, dated April 27, 2021, indicated Resident 38 had the capacity to understand and make decisions. The Lab (Laboratory) Results Report, dated July 16, 2021, indicated Resident 38 had a low…

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.