Roseville Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure accurate assessments were completed for two of 52 sampled residents (Resident 170 and Resident 176) when: 1. Resident 170's Minimum Data Set (MDS- a federally mandated resident assessment tool) did not indicate the correct number of pressure ulcer or pressure injury (PU or PI) present on admission; and, 2. Resident 176's MDS did not reflect the resident's status at the time of discharge from the facility. These failures increased the potential for Resident 170 not to receive consistent care and for Resident 176 not to receive referral for necessary services in the community. Findings: 1. A review of the admission Record indicated Resident 170 was admitted early part of June 2025 with diagnoses including rhabdomyolysis (breakdown of muscle tissue) and unstageable pressure ulcer (or pressure injury [PI], base of wound covered by a layer of dead tissue that may be yellow, brown or black and stage is unclear) of other site. A review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to protect one of 52 sampled residents (Resident 160) from further injury when they did not implement specified interventions from the care plan to prevent skin tears. This failure resulted in Resident 160 sustaining additional skin tears to her left leg. Findings: A review of Resident 160's admission record indicated she was admitted on [DATE] after a syncopal episode with a ground level fall resulting in a left femur (thigh bone) and left humerus (upper arm bone) fractures. A review of Resident 160's change of condition (COC) note, dated 6/7/25, indicated Resident 160 had sustained a new skin tear to left lower leg during a wheelchair transfer with a Certified Nursing Assistant (CNA). A review of Resident 160's Potential for Skin Tears care plan, initiated on 6/7/25, indicated interventions to prevent skin tears were to keep her nails trimmed and short, pad the wheelchair arms and legs, wear protective sleeves, use a pressure relief…

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

Based on observation, interview, and record review, the facility failed to provide services that met professional standards of quality for one of 52 sampled residents (Resident 731), when the facility did not follow a physician order for straight catheterization (a thin, flexible tube is inserted into the urethra to drain urine and removed immediately) when the resident complained of inability to urinate and inserted a Foley catheter (a flexible plastic tube inserted into the bladder) to provide continuous urinary drainage. This failure had the potential to result in urinary tract infection. Findings: A review of the admission Record indicated Resident 731 was admitted to the facility in June 2025 with multiple diagnoses which included aftercare following joint replacement surgery and retention of urine (inability to urinate). A review of the physician order for Resident 731, dated 6/21/25, indicated,If patient is unable to urinate after 6 hours, bladder scan [a portable medical device to measure how much urine the bladder has]. If bladder scan and RV [residual volume] greater than…

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 Findings: A review of Resident 732's admission Record indicated the facility admitted the resident recently after hospitalization for lung infection. Resident 732's multiple diagnoses included muscle weakness and unsteadiness on feet. A review of the 'Order Summary Report' contained a physician's order dated 6/8/25 indicating that Resident 732 had capacity to make healthcare decisions. A review of Resident 732's care plan titled Malnutrition: Resident is at risk for malnutritioninitiated on 6/8/25, indicated resident's goal was to maintain adequate nutritional status as evidenced by stable weight. The care plan interventions indicated, Assist with meals/fluids as needed, encourage adequate nutrition and hydration, encourage position [sic] of choice of meals. The care plan did not contain resident's food preferences, weight monitoring, and was not updated with new interventions addressing Resident 732's weight loss. A review of Resident 732's clinical records contained a Nutritional Risk Assessment dated 6/13/25.…

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 safety for one of 52 sampled residents (Resident 100) with gastrostomy tube (G-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) when the facility did not follow the physician's order to keep Resident 100's head of bed (HOB) elevated at 30 degrees during tube feeding. This failure increased the risk for Resident 100 to experience aspiration (inhaling liquid, vomit or saliva) and develop pneumonia or lung infection. Findings: A review of the admission Record indicated Resident 100 was readmitted [DATE] with diagnoses including dysphagia (difficulty swallowing) and paralytic syndrome (loss of muscle function). A review of Resident 100's care plan revised 1/13/25 indicated resident requires tube feeding related to swallowing problem. The goal of care was for resident to be free of aspiration. The interventions included, The resident…

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

Based on observation, interview, and record review, the facility failed to ensure one of 52 sampled residents (Resident 82) was provided with respiratory care when Resident 82 was not provided with a functioning continuous positive airway pressure (CPAP, a breathing machine designed to increase air pressure, keeping the airway open when the person breaths in) machine. This failure had the potential to result in Resident 82 experiencing respiratory distress. Findings: During a review of Resident 82's clinical record, the record indicated Resident 82 was admitted in late 2022 with multiple diagnoses including sleep apnea (a sleep disorder where the individual stops breathing for short periods when sleeping) and obstructive sleep apnea (a sleep disorder where the throat muscles relax and block the airway). A review of Resident 82's Minimum Data Set (MDS- a federally mandated assessment tool), Cognitive Patterns, dated 3/21/2025, indicated Resident 82 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 10 out of 15 that indicated Resident 82 had moderately…

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 pain management was provided consistent with professional standards of practice for one of 52 residents (Resident 15) when doses of Resident 15's PRN (as needed) pain medications were given without indication. This failure had the potential to increase Resident 15's risk of exposure to side effects and dependence to pain medication. Findings: During a review of Resident 15's admission records, the records indicated Resident 15 was admitted in May 2025 with diagnoses that included Lumbar Spondylosis (the degeneration of bones in the lower back), rheumatoid arthritis (a chronic inflammatory disorder affecting small joints in the hands and feet), lumbosacral radiculopathy (a condition where a nerve root in the lower back is compressed or irritated), and fibromyalgia (causes pain in muscles and soft tissues all over the body). Resident 15's Minimum Data Set (MDS, a federally mandated resident assessment tool indicated Resident 15 had moderate cognitive impairment. During a review of Resident 15's physician…

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

2. During a review of Resident 579's admission records, the records indicated Resident 579 was admitted in June 2025 with diagnoses that included end stage renal disease and dependence on renal dialysis. Resident 579's MDS indicated Resident 579 had intact cognition. During a review of Resident 579's care plan, initiated 6/7/25, the care plan indicated, Dialysis: Resident Requires Hemodialysis .and has an AV Fistula (shunt) (left arm) .Avoid taking blood pressure .on the AV site extremity . During a review of Resident 579's physician order, dated 6/12/25, the order indicated, Avoid taking BP [blood pressure] on Left Arm . During a review Resident 579's Weights and Vitals Summary, the summary indicated blood pressures were taken on Resident 579's left arm twice on 6/9/25 and once on 6/19/25. During a concurrent interview and review on 6/27/25 at 8:56 a.m. with the Director of Nursing (DON), the DON stated, .They are not supposed to check bp on the arm with fistula .not on that arm . The DON confirmed Resident 579 had an order to avoid taking BP on left arm and confirmed BP was taken…

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 professional standards of practice, to prevent pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) for one of five sampled residents (Resident 1) when: 1) Daily skin checks were not documented, 2) Bowel and bladder care were not provided at regular intervals. These failures resulted in Resident 1 developing Stage 2 pressure ulcers (partial-thickness loss of skin, presenting as a shallow open sore or wound) on Resident 1's left and right buttocks. Findings: During a review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated, Resident 1 was admitted to the facility December 2024 with multiple diagnoses which included Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's admission Comprehensive 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 one out of three sampled residents (Resident 3) in a census of 179 was seen by their physician as required. This failure had the potential for a delay in services and treatment of the resident. Findings: A review of an admission record indicated Resident 3 was admitted to the facility in the winter of 2013 with diagnoses including dementia (a degenerative disorder that affects the mind, memory and behavior), epilepsy (a disorder that causes seizures), depression, cerebellar ataxia (a disorder that causes inability to control muscle movement, which can cause problems with balance and walking) anxiety, hydrocephalus (a buildup of fluids in the brain), and history of falls. During a review of Resident 3 ' s BRIEF INTERVIEW FOR MENTAL STATUS [BIMS] ., dated 8/1/24, the BIMS indicated she had moderate memory loss. During a concurrent interview and record review on 8/16/24 at 8:48 a.m. with the Licensed Vocational Nurse (LVN), the LVN was unable 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 interview and record review, the facility failed to ensure residents were free from significant medication errors for one of four sampled residents (Resident 1) when Resident 1 received Isavuconazonium Sulfate Capsule (an antifungal medication- used to treat lung infections) every eight hours when the physician's order from the hopsital was to receive the medication one time per day. This failure resulted in Resident 1 receiving 32 extra doses of medication, which increased the potential for adverse systemic effects and jeopardized Resident 1's health. Resident 1 was admitted to the facility in mid-2024 with diagnoses which included allergic bronchopulmonary aspergillosis (a fungal infection of the lung), chronic obstructive pulmonary disease (lung disease that damages the airway and other parts of the lung making it difficult to breath) and chronic kidney disease (damage to the kidneys that occurs over time). During a review Resident 1's MEDICATION SUMMARY FOR PATIENT TRANSFER, dated 7/22/24, the medication summary indicated, ISAVUCONAZONIUM SULFATE CAP [capsule], ORAL 372…

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

Based on observation, interview, and record review, the facility failed to provide care according to professional standards for one of three sampled residents (Resident 1) with an indwelling urinary catheter (a thin tube that is inserted into the bladder, held in place by a soft balloon, and used to drain urine) when: 1. There was no active physician order for an indwelling urinary catheter nor was the presence of the catheter included in the plan of care or weekly summary notes. 2. There was no documented evidence of care and management of the urinary catheter and drainage bag according to professional standards. 3. Resident 1's urine collection bag was observed lying on the floor with no privacy cover. These failures, individually and collectively, had the potential for Resident 1 to develop a urinary tract infection (an infection in the system of organs that make urine) which can result in pain, fever, and confusion. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted in September 2023 with diagnoses including dementia (impaired ability 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 interview and record review the facility failed to report allegations of abuse to the Department on a timely manner for one of four sampled residents (Resident 1) when the Department received the report of alleged abuse the day after the incident occurred. This failure resulted in a delay in the abuse investigation and decreased the facility's potential to protect the resident from harm. Findings: A review of an admission Record for Resident 1 indicated she was admitted in March 2024 with diagnoses including post-traumatic stress disorder (PTSD) and unspecified psychosis. A review of Resident 1's Minimum Data Set (MDS, an assessment tool used for care), dated 6/11/24, indicated a Brief Interview of Mental Status (BIMS, an assessment tool) score of 12 out of 15 with memory problems. During a concurrent interview and record review on 6/24/24 at 12 p.m. with the Social Services Director (SSD) Resident 1's Progress Notes were reviewed, SSD confirmed a nurses' note that indicated an alleged abuse incident involving Resident 1 occurred on 6/18/24 but was reported to the…

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

Based on observation, interview, and record review, the facility failed to ensure the protection of residents' personal information for census of 179, when tray tickets were thrown into the trash and outside dumpsters. This failure had the potential to place resident personal information at risk for misuse. Findings: During a concurrent observation and interview on 5/6/24 at 8:47 a.m. with Dietary Aide 1 (DA 1) and Assistant Dietary Services Supervisor (ADSS) in the kitchen, the DA 1 was observed stripping the breakfast trays. The DA 1 was throwing the meal tickets into the regular trash along with food scraps. The meal tickets contained the resident's name, resident's ID (medical record number), room number, diet order, food allergies, food preferences, and special instructions. The ADSS stated this was their process for disposing of the meal tickets . During an interview on 5/6/24 at 8:55 a.m. with the Dietary Services Supervisor (DSS) in the kitchen, the DSS stated there was no other method of disposing of meal tickets. During an interview on 5/8/24 at 3:04 p.m., with the…

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

Based on observation, interview, and record review the facility failed to adequately maintain pharmacy services for 3 out of a census of 185 when: 1. An injectable Emergency medication box with a fill date of 2/29/24 was found to be opened and unsealed without proper documentation and not replaced within 72 hours; 2. An Emergency medication E-kit (a box with a supply of medications that may be used for residents when pharmacy services are not available) in the refrigerator was accessed and used without proper documentation when one used lorazepam (a medication used to treat mood disorders) injectable medication was not documented; 3. Prescription medication for 3 residents (Resident 97, Resident 114, and Resident 7) were not available at the time of administration; and, 4. A dose of lacosamide (a medication given for seizures) was given and not signed on out by the LN (Licensed Nurse). This failure had the potential to cause inaccurate accountability of controlled medications, unauthorized individuals' access to controlled medications and worsening of the resident's clinical…

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 and labeled, when: 1. A partially used Multi dose inhaler was found without an open date label in a medication cart; 2. Two partially used glucose test strips containers without an open date label were found in two medication carts; 3. An intravenous IV antibiotic bag was found on one of the medication carts in the narcotic binder, accessible to residents and unauthorized individuals; 4. A medication cart was left unlocked with one of the drawers open, with four medication blister packs on top accessible to residents and unauthorized individuals; 5. The medication refrigerator was left unlocked with an unlocked medications box inside for controlled medications; and, 6. Five loose pills were found in three medication carts. This failure had the potential for residents to receive medications with unsafe or reduced potency from being used past their discard date or improper storage, and misuse 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, the facility failed to conserve the nutritive value and flavor of pureed foods for 17 out of 179 residents (Resident 1, Resident 2, Resident 17, Resident 26, Resident 30, Resident 37, Resident 52, Resident 56, Resident 69, Resident 74, Resident 86, Resident 133, Resident 470, Resident 570, Resident 571, Resident 572, and Resident 573) when the recipes were not followed. This failure had the potential for malnutrition, weight loss, slow wound recovery, and vulnerability to diseases. Findings: During a concurrent observation and interview on 5/7/24 at 9:45 a.m. with the [NAME] in the kitchen, the [NAME] was observed preparing the pureed foods for the lunch, including pasta and meat balls. No recipe or measuring tools were seen on the counter as the [NAME] set food items into the blender. During the preparation of pureeing the pasta, the cook added an unmeasured amount of pasta and pasta water to the blender before mixing. During the preparation of pureeing the meatballs, the cook added an unmeasured amount of meat and the cooking…

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 store, prepare, and distribute food in accordance with professional standards for food service safety for a total of 179 residents who received facility prepared foods when: 1. Milk and eggs were stored only 1.5 above floor level; 2. Opened food items were not sealed in the dry storage area; 3. Food products were not labeled to ensure food safety; 4. Kitchen floors contained build-up of black grime, broken tile, and walls with chipped paint; 5. Unsafe kitchenware stored and available for use; 6. Emergency food was not monitored to ensure safety; and, 7. Resident refrigerator log in C3 showed two days of recordings above safe food storage range without corrective actions. These failures had the potential to lead to contamination and/or food borne illness. Findings: 1. During a concurrent observation and interview on 5/6/24 during the initial kitchen tour at 8:15 a.m., the walk-in refrigerator contained a ledge consisting of two stacked wooden slats sitting approximately 1.5 above the floor, running along the…

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

Based on observation, interview, and record review the facility failed to maintain an effective infection control program when: 1. Certified Nurse Assistant 3 (CNA 3) did not wear the proper Personal Protective Equipment (PPE) while giving care to Resident 12 who was on Enhanced Barrier Precautions (EBP) and did not perform hand hygiene in between tasks of providing care and collecting garbage; and, 2. Licensed Nurse 2 (LN 2) did not disinfect the glucometer (a device used to measure blood sugar) according to manufacturer's recommendation during a medication pass observation. These failures increased the risk of spreading infection at the facility. Findings: A review of Resident 12's admission Record indicated she was originally admitted to the facility in November 2021 with diagnoses including type 2 diabetes (adult-onset diabetes characterized by high blood sugar and insulin resistance) with chronic foot ulcer. A review of an Order Summary Report dated 1/22/24 indicated Resident 12 was on Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce…

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 own policy for medication self-administration for one of 36 sampled residents (Resident 422) when the facility did not obtain a physician's order for Resident 422 to self-administer medications. This failure had the potential to result in an unsafe medication self-administration. Findings: A review of Resident 422's admission Record indicated she was admitted [DATE] with diagnoses including the presence of intraocular lens to both eyes. During a concurrent observation and interview on 5/6/24 at 8:40 a.m. inside Resident 422's room, observed Resident 422 instill own eye drops after Licensed Nurse 16 (LN 16) handed her the vial of a single use eye drop. Resident 422 was not instructed to do hand hygiene before administration and stated she wanted to reuse the used vial. A review of Resident 422's Order Summary Report, dated 4/26/24, indicated an order for cyclosporine emulsion 0.05% (eye drop medication for dry eyes due 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 interview and record review the facility failed to ensure a Significant Change of Status Assessment (SCSA) was completed within 14 days after discharging from Hospice Care (end of life care) for one of 36 sampled residents (Resident 97). This failure decreased the facility's potential of providing appropriate care and services to Resident 97 based on his current status. Findings: A review of Resident 97's admission Record indicated he was admitted in 2/24 with diagnoses including bladder cancer. A review of Resident 97's Order Summary Report, dated 4/10/24, indicated Resident 97 was admitted to Hospice Care due to bladder cancer. A review of Resident 97's Minimum Data Set (MDS, an assessment tool) dated 4/14/24, indicated an SCSA was initiated and completed due to admission to Hospice Care and a change in cognition. A review of a document titled, Revocation of the Election of Hospice Care, dated 4/15/24, indicated Resident 97's family decided to discontinue his enrollment from Hospice Care. A review of Resident 97's MDS assessments indicated no SCSA had been initiated 14…

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 accurately assess three of 36 sampled residents (Resident 101, Resident 88, and Resident 143), when: 1. Resident 101's Minimum Data Set (MDS; an assessment tool) indicated restorative nursing program (RNA; a program to maintain a person's highest level of physical, mental, and psychosocial function) was not performed; 2. Resident 88's MDS assessment did not reflect continuous oxygen use; and, 3. Resident 143's MDS wound assessment was coded inaccurately. These failures decreased the facility's potential to identify residents' care needs accurately. Findings: 1. A review of Resident 101's admission Record, indicated Resident 101 was admitted to the facility in May 2022 with diagnoses including lumbar (lower back) region spondylosis (age-related wear and tear of the spinal disks), muscle weakness and abnormalities of gait and mobility. A review of Resident 101's MDS, dated [DATE], indicated RNA program was not performed in the last seven…

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 4. A record review of Resident 525's admission record indicated Resident 525 was admitted in early May 2024 for aftercare following right hip replacement surgery. A review of Resident 525's OSR for active orders as of 5/9/2024, indicated Resident 525 was prescribed, [Oxycodone] Oral Tablet 5 MG [milligram a unit of measure] .Give 3 tablet by mouth every 4 hours as needed for severe pain . start date 5/2/2024 . An interview on 5/8/24 at 4:07 p.m., LN 12 stated when giving a resident a controlled drug (drugs that can cause physical and mental dependence), nurses are expected to document the time and how many tablets/pills given to the resident on the controlled drug record form as well as document in the resident's electronic health record (EHR). LN 12 added the EHR will indicate the accurate time when the controlled drug was administered to the resident. During a concurrent interview and record review on 5/9/24 at 8:34 a.m. with LN 13 and the DON, Resident 525's EHR and progress notes, dated 5/5/24, were…

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 proper care and services to one of 36 sampled residents (Resident 420) when Resident 420's order for enteral feeding (a method of providing nutrient directly to the stomach or small bowel using a tube) did not include the kind of feeding formula to be infused, its duration, and the mechanism of administration. This failure had the potential to cause an error during administration of the feeding. Findings: A review of an admission Record for Resident 420 indicated he was admitted [DATE] with diagnoses including cancer of the tonsils and the presence of a feeding tube. On 5/6/24 at 11 a.m. during an observation inside Resident 420's room, a half-filled bottle of enteral feeding formula was hanging by the side of the bed, which indicated the formula was hung on 5/5/24 at 3:32 p.m. A review of Resident 420's Order Summary Report (OSR) for 5/2/24 indicated an incomplete order for an enteral feeding; the order did not include the…

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

Based on observation, interview and record review, the facility did not ensure the medication error rate was less than 5% when a medication was not available for one resident, an extended release medication was crushed, and a chewable aspirin was given and not the delayed release medication. This failure resulted in 3 errors out of 28 opportunities during an observation of medication administration, which resulted in an error rate of 10.71 % for the faclility. Findings: During a medication pass observation on 5/6/24 at 8:26 a.m., with LN 1 (Licensed Nurse), LN 1 was observed preparing Resident's morning medicaions which did not include Phenazopyridine. In an interview with LN 1 on 5/6/24 at 8:30 am, LN 1 stated that the morning dose of phenazopyridine (medication used to treat pain experienced during urination) was not available to be administered with Resident 97's other medications. A review of Resident 97's physician orders, dated 4/10/24, indicated that phenazopyridine 100 mg tablets (mg = milligram, a unit of measure), 1 tablet was to be given every eight hours for dysuria…

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 protect the residents' protected health information (PHI, such as individuals' health, treatment and payment information) visible and accessible to the public when the Kiosk/computer located between resident's room and storage room was left unattended and the computer screen showed information for the census of 179 residents. This failure had the potential for the public to access unauthorized residents' PHI and cause a breach of confidentiality. Findings: During a concurrent observation and interview on 5/6/24 at 2:35 p.m., with Licensed Nurse 15 (LN 15), LN 15 confirmed the Kiosk/computer screen was turned on, left unattended and showing the resident's PHI. LN 15 stated, residents' information should be protected at all times to prevent unauthorized accessed to their personal information which can be used to other peoples' advantage. LN 15 further stated, We should adhere to the Health Insurance Portability and Accountability Act (HIPAA, federal regulatory standards defining the lawful use protected health…

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 one of three sampled residents (Resident 2's) safety when, the resident's bed locks were not completely secured in place. This failure had the potential to contribute to Resident 2's fall and placed the resident at a greater risk for avoidable accidents. Findings: Review of the clinical record for Resident 2, the admission Record indicated Resident 2 was a short-term resident in the facility for aftercare of surgery with diagnoses that included spine and thoracic (upper and middle part of the back) region fusion, thoracic vertebra (bones) fracture and morbid obesity. In a concurrent observation and interview on 4/16/24 at 10:38 a.m., Resident 2 was in a wheelchair in his room and stated he had two back surgeries and had come to the facility from the hospital for rehabilitation. Resident 2 reported he fell on his back the previous night because the bed was not secured. The resident recounted the fall incident; he stated he decided to get out of the bed to grab a blanket for himself that was placed at the…

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

Based on interview and record review, the facility failed to manage one of three sampled residents (Resident 1's) pain timely when staff had incongruent (inconsistent) communication regarding the resident's complaint of pain. This failure resulted in Resident 1 having uncontrolled pain and a hospital transfer. Findings: Review of Resident 1's clinical record, the admission Record indicated the resident was admitted to the facility for aftercare of hip replacement surgery in March 2024. Review of Resident 1's clinical record, Nurse's Notes, dated 3/26/24, documented by Licensed Nurse (LN 2) indicated the resident complained of uncontrolled pain that occurred during physical therapy (PT) that morning. The Nurse's Note documented, [Resident 2] stated he heard a crack and has been hurting since then [PT in the morning]. Called [Name of Doctor] but call failed twice around 1700 [5 p.m.] .Resident and wife wanted him to go to [Name of hospital] .Resident was transferred to [Name of hospital] at 1725 [5:25 p.m.]. Review of Resident 1's clinical record, Medication Administration Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an environment free of hazards when one of five sampled residents, (Resident 1)'s, bed malfunctioned and the head of bed dropped suddenly. This failure resulted in Resident 1 experiencing neck pain. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in February 2023 with multiple diagnoses including wedge compression fracture of T11-T12 vertebra (a fracture in the the front of the vertebra located on the thoracic spine) and abnormalities of gait and mobility (difficulty walking). A review of Resident 1's Minimum Data Set (MDS- an assessment tool), Cognitive Patterns, dated 3/3/23, indicated she had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 11 out of 14 that indicated she was moderately cognitively impaired. Further review of Resident 1's MDS, Functional Status, dated 3/3/23, indicated she required limited assistance by staff to guide limbs for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan for one of three sampled residents (Resident 1) when the resident specific health condition and the pertinent care needs and services were not identified and addressed. This failure placed the resident at risk for unmet care needs and resulted in lack of coordination of Resident 1's care with the agency responsible for the protection and advocacy for residents living with developmental disability (DD). Findings: Resident 1 was a long term resident in the facility with developmental disorder and diagnoses that included altered mental status. In a telephone interview on [DATE] at 9:32 a.m., the regional care agency for nursing home residents with DD complained the facility failed to notify them when Resident 1 had changes in condition and/or upon her death. The regional care agency indicated the facility was to coordinate special care and services needed for the residents living with DD but the 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.

Based on observation, interviews and record review, the facility failed to maintain evidence of the results of any grievances for all residents in a census of 139 when: No record of grievances nor resolutions were retained by facility. This failure had the potential to violate the residents rights to file grievance and have it resolved. Findings: During an interview on 6/23/2021 at 11:25 a.m., the Social Service Assistant (SSA) stated that the Social Service Director (SSD) was the one who kept the Grievance log. SSA stated that SSA only kept the log for missing items. The missing items log was arranged alphabetically and filed one binder per year. During a concurrent interview and record review on 6/23/2021 at 1:50 p.m., the SSD stated that they never kept a grievance log. SSD stated that they resolved all the issues from the residents immediately, so they never kept a log. The SSD then stated that they kept the grievance log and the missing items record together. The SSD showed a binder for 2019. Inside the binder were blank grievance forms. There was no documentation of grievances…

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 facility policy review, the facility failed to ensure food was stored and prepared under sanitary conditions when: 1. Kitchen staff unable to explain the manual three-part sink dish washing steps; 2. Dusty fan by window with sill that had build-up of gray/black particles, leaving black smudge on finger when wiped; 3. Screen for kitchen window found with gap, allowing pest entry; 4. Dented cans found in canned good section for use.Food not properly cooled; 5. Floor under shelves in dry food storage with grayish, black build-up and was rough to touch; 6. Kitchen floor found with broken tiles; 7. Dishwasher not found with air gap; 8. Food not properly cooled. These failures had the potential to increase the risk of food borne illness for 139 residents receiving food from the kitchen. Findings: 1. During an observation, interview and record review on 6/22/21 at 9:55 a.m., during initial tour, the Dietary Aide 1 (DA 1) was unable to explain the sanitation steps in the manual dish washing process. The Director of Dietary Services (DDS) acknowledged that…

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

Based on observation and interview, the facility failed to dispose of garbage and refuse properly in order to prevent the harborage of pests when the dumpster lid was left open. This failure increased the risk of an unsanitary environment due to the potential for flies and rodents on facility grounds. Findings: During an observation and interview on 6/22/21 at 4:04 PM, the dumpster lid was propped open with the stick, though no one was throwing away garbage. The DDS stated that the kitchen trash was left on a trolley outside of the kitchen for housekeeping, as housekeeping had responsibility over the dumpsters. During an interview on 6/24/21 at 9:38 AM, the Housekeeping Supervisor (HS) stated that the expectation was the dumpster lids were kept shut when trash was being stored. Review of the Food and Drug Administration 2017 Food Code, outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents . Storing Refuse, Recyclables, and Returnable further explains that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a safe environment for residents, staff, and the public, when carpet throughout the facility was damaged. This failure had the potential to cause fall related injuries to residents. Findings: During an observation on 6/22/2021 at 2:00 p.m., the carpet at the intersection between the 300 and the 400 room hallways was ripped and frayed which created an uneven surface. During an observation on 6/24/2021 at 9:20 a.m., the carpet at the intersection of Nursing Station 1 was ripped and frayed with gray duct tape on some of the surrounding carpet which created an uneven surface, and the carpet at the intersection of the main entrance and the dining room was ripped which created an uneven surface. During an observation on 6/24/2021 at 12:30 p.m., the carpet was bulging up at the entrance of room [ROOM NUMBER] and between rooms [ROOM NUMBERS]. During an interview with Licensed Nurse 3 (LN 3) on 6/24/2021 at 11:22 a.m., LN 3 stated, I have…

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

Based on observation, interview, and record review, the facility failed to store medications in accordance with their policy and federal laws when: 1. An unlocked and unmonitored refrigerator, which contained an expired biological product, was found in a conference room; and 2. A drawer used to store controlled medications for disposition did not have a lock that sufficiently secured the drawer to prevent diversion. These failures had the potential for residents to have received a biological product that was less potent and increased the risk of unauthorized people having access to controlled medications with a high probability for abuse. Findings: 1. During an observation on 6/22/21, at 9:12 a.m., in the facility conference room, there was an unlocked mini refrigerator. The refrigerator contents were as follows: a multi-dose vial of Tuberculin (a biological product used to test for tuberculosis; a bacterial infection) with an opened date of 1/26/21; two containers of Med Pass (a nutritional supplement); one container of lemon flavored thickened water, one bottle of Glucerna (a meal…

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

Based on observation, interview, and record review, the facility failed to develop and implement a care plan for Dementia (a general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function) for one resident (Resident 117), that was person-centered and supportive of Resident 117's needs. The facility failed to develop care plan interventions to reduce Resident 117's confusion, which had the potential to cause the resident anxiety and an inability to achieve her highest level of functioning. Findings: During a review of Resident 117's Electronic Medical Record (EMR) on 6/24/2021 at 8:50 a.m., she had the following diagnoses: History of strokes (when blood supply to part of your brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients); Dementia with behavioral disturbances; and Alzheimer's disease (an irreversible, progressive brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). She also had a BIMS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of two residents (Resident 34 and Resident 144) in a census of 139 when: 1. Resident 34's prescription for lorazepam (a medication used to treat an active seizure) was expired and available for use in the medication refrigerator; and, 2. Resident 144 did not receive his morning dose of finasteride (a medication used to treat urinary retention) due to the medication not being available. These failures had the potential to result in Resident 34 receiving a medication that was no longer effective at treating his seizures, and Resident 144 experiencing discomfort. Findings: 1. Review of Resident 34's admission Record indicated he was admitted to the facility in 2014 with diagnoses, which included epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or seizure, associated with abnormal electrical activity in the brain). 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.