Roseville Point Health & Wellness Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure equipment was maintained in working order when the arm rests of two wheelchairs (Resident 11 and Resident 35) out of 54 wheelchairs in use in the facility were in disrepair. This failure increased the potential for discomfort and skin tears to resident forearms. Resident 11 was admitted to the facility with diagnoses which included muscle weakness and difficulty in walking.During a review of Resident 11's Minimum Data Set (MDS, an assessment tool), dated 3/18/26, the MDS indicated Resident 11 was alert and oriented, able to make her needs known.During a review of Resident 11's care plan (CP) titled [Resident 11] has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to].DIFFICULTY IN WALKING. revised 2/14/26, the CP indicated independent with.wheelchair mobility.During a concurrent observation of Resident 11's wheelchair armrests and interview with the Director of Staff Development (DSD) on 5/18/26 at…

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

Based on observation, interview and record review, the facility failed to maintain a functional, accessible communication system that allowed one of 27 sampled residents (Resident 28) to easily request staff assistance from his bedside when there was no call light or bell within reach.This failure increased the risk Resident 28 would not have to ability to call for help in an emergency or when needing assistance. Findings: Resident 28 was admitted to the facility in the summer of 2024 with diagnoses which included hemiplegia (paralysis) of the left side and hemiparesis (weakness) of the right side, respiratory failure, seizures, chronic pain, dysphagia (difficulty in swallowing).During a review of Resident 28's Minimum Data Set (MDS, an assessment tool), dated 3/26/26, the MDS indicated Resident 28 had moderate memory impairment and was dependent with most activities of daily living (ADLs).During a review of Resident 28's care plan (CP) titled, [Resident 28] is at risk for fall and self injury related to medical conditions affecting strength, balance & endurance.hemiplegia.h/o…

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 six sampled residents (Resident 1) was free from abuse when Activity Assistant (AA) 1 aggressively yelled at and grabbed Resident 1's shoulder.This failure had the potential to cause psychosocial harm to Resident 1.Findings:A review of Resident 1's clinical record indicated that the resident was admitted to the facility in March 2026 with diagnoses including dementia with agitation (a condition in which a person has memory and thinking problems and also becomes easily upset, restless, angry, or difficult to calm down) and metabolic encephalopathy (a change in how the brain works that can cause confusion, memory problems, or difficulty thinking clearly).A review of Resident 1's Minimum Data Set (MDS-assessment tool) dated 3/11/26 showed a Brief Interview for Mental Status (BIMS, a cognitive screening tool) score of 0/15, which indicated severe problems with thinking and memory.During an interview on 4/27/26 at 10:39 a.m. with Interim Director of Nursing (IDON) 1, IDON 1 stated that Resident 1 had…

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

Based on observation, interview, and record review, the facility failed to follow proper infection control procedures for one of six sampled residents (Resident 1), when Certified Nurse Assistant (CNA) 1 and CNA 2 provided care to Resident 1 without wearing the appropriate personal protective equipment (PPE- worn to protect against hazards like infections).This failure decreased the facility's potential to prevent the spread of infection among vulnerable residents.Findings:A review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility in March 2024 with diagnoses including a gastrostomy (a surgical procedure into the stomach to insert a feeding tube for long-term nutrition.) and stenosis of the larynx (buildup of scar tissue in the throat).During an observation on 3/4/26 at 10:34 a.m. in Resident 1's room, a sign outside the door indicated Resident 1 was on enhanced barrier precautions (EBP- infection control measures in nursing homes requiring staff to wear gowns and gloves during high-contact care for residents at high risk of spreading multi-drug…

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 six sampled residents (Resident 2) was free from abuse, when Resident 3 touched Resident 2's groin area. This failure decreased the facility's potential to maintain Resident 2's highest practicable physical, mental, and psychosocial well-being.Findings:A review of an admission record indicated Resident 2 was admitted to the facility in July 2024 with diagnoses including cognitive communication deficit (difficulty communicating) and dementia (a progressive decline in memory, thinking, reasoning, executive function). A review of Resident 2's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/21/25, indicated a Brief Interview of Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of five out of 15 with memory problems and severe cognitive impairment. A review of an admission record indicated Resident 3 was admitted to…

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

Based on interview and record review, the facility failed to report immediately to the Department an alleged incident of sexual abuse for one of six sampled residents (Resident 2), when the Department received the facility's report of alleged sexual abuse after two hours of occurrence. This failure had the potential to cause a delayed response by enforcement agencies to ensure Resident 2's safety.Findings:A review of an admission record indicated Resident 2 was admitted to the facility in July 2024 with diagnoses including cognitive communication deficit (difficulty communicating) and dementia (a progressive decline in memory, thinking, reasoning, executive function). A review of an admission record indicated Resident 3 was admitted to the facility in October 2024 with diagnoses including aphasia (a disorder that makes it difficult to speak) and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). During an interview on 9/2/25 at 2:20 p.m. with Activity Assistant (AA), AA stated while she was conducting facility activities in the activity room on…

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

Based on observation, interview, and record review, the facility failed to follow infection control practices for one of six sampled residents (Resident 6), when the Housekeeper did not apply the required Personal Protective Equipment (PPE, gloves, gown, and/or goggles/face shield if risk of splash and spray) while cleaning Resident 6's room. This failure had the potential to spread infection among vulnerable residents.Findings: A review of an admission record indicated Resident 6 was admitted to the facility in June 2022 with a diagnosis of stage 4 pressure ulcer (a severe deep open wound that extends through the skin and into the muscle, bone or tendons) to the sacrum (triangular shaped bone located at the base of the spine). During an observation on 9/2/25 at 10:31 a.m. inside Resident 6's room, the Housekeeper was observed not wearing the proper PPE while cleaning the room. Housekeeper stated he was aware that Resident 6 was on Enhanced Barrier Precaution (EBP, infection control intervention to reduce transmission of resistant organisms). During a concurrent observation 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.

Based on observation, interview, and record review the facility failed to maintain resident's right to privacy and confidentiality of personal and medical records for a census of 79 when documents with resident's personal information were found outside the facility unsecured.This failure had the potential for unauthorized access to residents' personal and medical information.Findings:During an observation on 8/25/25 at 9:22 a.m. by the facility's back patio, boxes of documents with resident's personal information were found on top of two carts unattended and unsecured.During a concurrent observation and interview on 8/25/25 at 11:25 a.m. with the Director of Nursing (DON), DON confirmed the documents laying outside by the back patio belonged to residents. DON stated the documents should have been secured, shredded, and properly disposed of to protect the residents' right to privacy.A review of the facility's policy titled, Resident's Rights-Quality of Life, revised in March 2017, indicated, The facility shall maintain an environment in which confidential clinical information is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Resident 1 received care which met professional standards when there was no documentation:1. Resident 1 received wound treatments as ordered;2. Resident 1's coccyx wound was assessed; 3. Resident 1's pain was assessed every shift;4. Resident 1's pain medication was given as ordered; and 5. Resident 1's weight loss was assessed.These failures had the potential to result in unmet needs for Resident 1.Resident 1 was admitted to the facility on [DATE] with diagnoses that included severe protein-calorie malnutrition and palliative care (care that provides symptom relief, comfort and support for someone with a serious illness).1. Resident 1's clinical record contained a physician's order, dated 5/24/24 for coccyx (buttock) wound treatment every day shift.During a review of Resident 1's Treatment Administration Record (TAR) for May 2024, the TAR indicated no documentation, as evidenced by the Licensed Nurse (LN) initials, that Resident 1's coccyx wound…

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 1) was free from physical abuse, when Resident 2 punched Resident 1 ' s leg in the activity room. This failure decreased the facility ' s potential to maintain Resident 1 ' s highest practicable physical, mental, and psychosocial well-being. Findings: A review of Resident 1 ' s admission Record, dated 6/17/25, indicated, Resident 1 was admitted to the facility in 2025 with a diagnosis of anxiety (a feeling of worry, nervousness, or unease). A review of Resident 1 ' s clinical record included the following documents: A Minimum Data Set (MDS, an assessment tool), dated 5/16/25, indicated, Resident 1 had a Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) scored 14 out of 15 with no memory impairment. A Progress Notes, dated 6/11/25 and written by Activities Director (AD), indicated, [Resident 1] was in the activity room when another resident [Resident 2]…

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 protected from verbal abuse and neglect when the resident was told, You will stay on the floor until the end of the f*cking shift and Certified Nursing Assistant (CNA) 1 placed a pillow under his head and placed a blanket on him and then left. This failure had the potential to negatively impact the resident's psychosocial well-being. Findings: Review of Resident 1's admission record indicated his original admission date was 3/6/25 with diagnoses that included aphasia (difficulty speaking) following cerebral infarction, cognitive communication deficit, and acute and chronic respiratory failure with hypoxia (low levels of oxygen). Review of Resident 1's admission Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 3/26/25, indicated Resident 1 had short and long-term memory problems, severely impaired cognitive skills for daily decision making, and no delirium or behavioral…

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 two of four sampled residents (Resident 1 and Resident 2) were free of accident hazards, when care provided was not consistent with care plan intervention and facility fall management policy. This failure resulted in delay of care for an unwitnessed fall of Resident 1, which potentially caused Resident 1's hip fracture, and had the potential for Resident 1 and Resident 2 to have repeat falls. 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 September 2019 with multiple diagnoses which included dementia (a progressive state of decline in mental abilities). During a review of Resident 1's care plan, initiated 11/29/22, the care plan indicated, . [Resident 1] is at risk for falls .goal .resident will be free of falls .resident will not sustain any injury if fall happens again .interventions…

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 one of four sampled residents (Resident 1) was free from abuse when Certified Nursing Assistant 1 (CNA 1) hit Resident 1 on the back. This failure had the potential for Resident 1 to obtain physical injuries and have a negative impact on his psychosocial well-being. Findings: A review of Resident 1's admission record indicated he was originally admitted in September 2019 with diagnoses including unspecified dementia (a progressive state of decline in mental abilities). A review of Resident 1's Minimum Data Set (MDS- a federally mandated assessment tool), dated 11/26/24, indicated Resident 1's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 0 out of 15 with an inability to express ideas and wants, and behaviors which included wandering. A review of Resident 1's care plan, dated 3/27/23 and revised on 5/21/24, indicated impaired cognitive function/dementia or impaired thought processes. A 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.

Based on interview and record review, the facility failed to ensure that allegations of abuse were reported within the required timeframe for one of four sampled residents (Resident 2) when the allegations of abuse were not reported within two hours to the Department. This failure had the potential to cause a delayed response by enforcement agencies to ensure resident safety. Findings: A review of Resident 2's admission record indicated she was admitted in December 2024, with diagnoses including bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). A review of Resident 2's Minimum Data Set (MDS- a federally mandated assessment tool), dated 12/23/24, indicated Resident 2's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 15 out of 15 with good memory. A review of a facility document presented from the Administrator (ADM) on 3/6/25 at 4:50 p.m., for Resident 2,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain privacy of communication for one of four sampled residents (Resident 1), when Resident 1 ' s mail was opened without consent by the Business Office Manager (BOM). This failure decreased the facility ' s potential to protect Resident 1 ' s communications privacy. Findings: A review of Resident 1 ' s Face Sheet, indicated she was admitted to the facility on [DATE]. During an interview on 2/25/25 at 11:32 a.m. with BOM, BOM stated in January 2025 she opened a letter with an envelope containing an electronic benefit transfer (EBT) card and the letter belonged to Resident 1. BOM further stated if mails, including EBT cards, addressed a resident, then staff, mainly the Activities Director, would deliver it directly to residents and would not be opened by BOM. During an interview on 2/25/25 at 1:25 p.m. with the Administrator (ADM), ADM stated the business office personnel should have not opened Resident 1 ' s mail without consent, because it would…

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 three of four sampled residents (Resident 1, Resident 4, and Resident 5) participated in their care planning, when care conferences for Resident 1, Resident 4, and Resident 5 were not conducted quarterly as scheduled. This failure decreased the facility ' s potential to enable residents to exercise their right to participate in care plan meetings. Findings: A review of an admission record, indicated Resident 1 was admitted to the facility in October 2022 with a diagnosis of quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury). A review of Resident 1 ' s Minimum Data Set (MDS, federally mandated resident assessment tool), indicated Resident 1 ' s Brief Interview of Mental Status (BIMS) score was 15 out of 15 with full understanding and capacity to make health care decisions. During an interview on 12/24/24 at 9:26 a.m. with Resident 1, Resident 1 stated his care conference that was scheduled for 12/18/24 did not take place as guaranteed by staff. During an…

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

Based on observation, interview, and record review, the facility had a 9.09 % error rate when three medication errors out of 33 opportunities were observed during a medication pass for one of seven residents (Resident 2). This failure decreased the facility's potential to administer residents' medications according to prescriber's orders and manufacturer's specifications. Findings A review of an admission record indicated, Resident 2 was admitted to the facility in June 2024 with diagnoses including depression and hypertension (HTN-high blood pressure). During an observation on 10/7/24 at 8:23 a.m., Licensed Nurse 4 (LN 4) was observed preparing medications for Resident 2. LN 4 crushed all medications, mixed it with apple sauce and spoon fed it to Resident 2. During an interview on 10/7/24 at 08:26 a.m. with LN 4, LN 4 stated there was no order to crush Resident 2's medications. A review of Resident 2's Order Summary Report, dated 10/9/24, indicated physician orders for: 1. Carvedilol (blood pressure medication) oral tablet 3.125 milligrams (mg- metric unit of measurement, used 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.

Based on observation, interview, and record review, the facility failed to ensure medications were stored correctly for a census of 80. This failure increased the residents' risk of infection and receiving expired medications. Findings: During a concurrent observation and interview on 10/8/24 at 8:12 a.m. with Licensed Nurse 2 (LN 2) in the medication storage room, 10 bottles of 16 ounces (oz; a unit of measure) sorbitol solution (a laxative) were found with an expiration date of 9/24. LN 2 stated the expired medication should be discarded and not stored in the medication room. During a concurrent observation and interview on 10/8/24 at 10:47 a.m. with LN 4 in the skilled nursing medication cart three, the following medications were stored: 1. A used insulin pen (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) was stored without a plastic bag, 2. A medication card of benzonatate (a cough suppressant) 100 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) pills was found with an…

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

Based on observation, interview, and record review, the facility failed to ensure dietary staff demonstrated sufficient skills during red bucket and low temperature dishwasher test strip testing for a census of 80. This failure decreased the facility's ability to carry out the functions of the food and nutrition services safely and effectively. Findings: During an observation on 10/9/24 at 2:06 p.m. in the kitchen, one dietary aide (DA) demonstrated how to use the chemical sanitization test strip on low temperature dishwasher and on the red bucket. The DA ran the dishwasher at wash and final rinse. Using the test strip, the DA dipped the test strip, then immediately compared the test strip color against the test strip kit. The DA did not blot the test strip on a tissue paper lightly prior to comparing it against the test strip kit. During an interview on 10/9/24 at 2:09 p.m. with the DA, the DA confirmed she did not follow the manufacturer's specifications in using the chlorine test strips for the low temperature dishwasher. During a concurrent observation and interview on 10/9/24…

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 food was prepared and stored in a safe and sanitary manner and air vents were sanitarily maintained for a census of 80, when: 1. A big container pan of cooked brussels sprout was uncovered and left exposed to contaminants on top of the stove burner; 2. A square-shaped stainless steel container with corn and sliced bell pepper was left on a counter corner undated and unlabeled; 3. A rectangle-shaped stainless steel container with cooked carrots was left uncovered, unlabeled, and undated in the counter corner; 4. Personal cell phone and water jug were placed next to the uncovered and unlabeled food; 5.Three packs of corn tortilla wrap was found expired in the dry storage area; and 6.The air vents horizontal slats in the dry storage area had whitish substance. These failures decreased the facility's potential to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Findings: During a kitchen observation on 10/7/24 at 8:15 a.m., the following 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.

Based on observation, interview, and record review, the facility failed to obtain an informed consent for one of 24 sampled residents (Resident 34), when Resident 34's representative did not sign a consent for the use of bilateral mittens. This failure had the potential to deprive the representative from making decisions regarding Resident 34's care. Findings: A review of Resident 34's admission Record, indicated he was admitted in July 2024 with diagnoses including chronic respiratory failure and anxiety disorder. During a concurrent observation and interview on 10/8/24 at 9 a.m. with Licensed Nurse 9 (LN 9), Resident 34 was wearing soft mittens on both hands while in bed. LN 9 stated staff put the mittens daily to prevent Resident 34 from pulling out his tracheostomy (a tube inserted into the windpipe from outside the neck to help air and oxygen reach the lungs) tube. A review of Resident 34's Order Summary Report, dated 9/27/24, indicated an order for the daily application of bilateral soft mittens and removal when family was present. During a concurrent interview and 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.

Based on interview and record review, the facility failed to provide a written bed hold agreement for one of 24 sampled residents (Resident 40) or his representative before and upon transfer to hospital. This failure had the potential for Resident 40 or his representative to be unaware of their right to return to the facility after hospitalization. Findings: A review of Resident 40's admission Record, indicated he was admitted in August 2021 with diagnoses including traumatic brain injury (TBI-a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head). A review of Resident 40's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 8/7/24, indicated Resident 40 was admitted back to the hospital on the same date for further evaluation. During a concurrent interview and record review on 10/9/24 at 1 p.m. with Licensed Nurse 2 (LN 2), Resident 40's clinical records were reviewed. LN 2 confirmed Resident 40 was sent to the hospital on 8/7/24 due to low oxygen saturation. LN 2 stated he could not find a copy of the…

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

Based on interview and record review, the facility failed to ensure an accurate Minimum Data Set (MDS - a federally mandated resident assessment tool) for one of 24 sampled residents (Resident 27), when Resident 27's prior level of function (PLOF) on admission was inaccurately coded. This failure increased Resident 27's risk for inadequate care planning. Findings: A review of Resident 27's admission Record, indicated she was admitted in August 2024 with diagnoses including lung cancer which required dependence to a ventilator (a medical device to help support or replace breathing). A review of Resident 27's comprehensive MDS assessment, dated 8/26/24, indicated Resident 27's PLOF was independent with indoor/outdoor mobility and transfers but used a mechanical lift. During a concurrent interview and record review on 10/9/24 at 2:45 p.m. with the MDS Coordinator (MDSC), Resident 27's comprehensive MDS assessment was reviewed. MDSC confirmed Resident 27 was independent with mobility and transfers and did not use any device to aid her during transfers. MDSC verified the comprehensive…

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 revise and review a person-centered comprehensive care plan for two of 24 sampled residents (Resident 2 and Resident 44), when: 1. Resident 2 had recurrent falls; and, 2. Resident 44's tracheostomy (a surgical procedure that creates an opening in the neck to provide an airway and facilitate breathing) was removed. This failure decreased the facility's potential to maintain the residents' psychosocial, physical, and mental well-being. Findings: 1. A review of Resident 2's admission Record, indicated Resident 2 had diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and repeated falls. A review of Resident 2's History and Physical, dated 9/22/24, indicated Resident 2 was hospitalized from [DATE] to 6/9/24 for recurrent falls. A review of Resident 2's fall care plan, dated 6/9/24, indicated it was not revised or modified to indicate new…

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 which meet professional standards of quality for two of 24 sampled residents (Resident 9 and Resident 45) when: 1.The tube feeding (TF, a tube inserted to the stomach to provide nutrition, fluid and medicine to people who are unable to eat or drink safely by mouth) was left connected to Resident 9 after its completion and the residual volume was not properly documented in the Medication Administration Record (MAR) to show it had been monitored as ordered; and, 2. An empty container of a TF was left hanging for more than 24 hours for Resident 45. These failures decreased the facility's potential to safely follow the physician's order to meet residents' needs. Findings: 1. A review of Resident 9's admission Record, indicated she was admitted in May 2022 with diagnoses including dysphagia (difficulty swallowing). A review of Resident 9's Order Summary Report, dated 8/20/24, indicated an order for a continuous tube feeding 70 milliliters per hour (ml/hr.; a unit of measurement) for a total of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide restorative nursing assistance to two of 24 sampled residents (Resident 9 and Resident 40) when: 1. Resident 9's left hand carrot and right hand foam roll splints were not placed as ordered; and 2. Resident 40's bilateral resting hand splints were not applied consistently as per plan of care. These failures decreased the facility's potential to help maintain range of motion (ROM) and prevent further contracture (a stiffening/shortening at any joint, that reduces the joint's ROM) for residents. Findings: 1. A review of Resident 9's admission Record, indicated she was admitted in May 2022 with diagnoses including cerebral infarction (loss of blood flow to a part of the brain) and bilateral hand contractures. A review of Resident 9's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/13/24, indicated Resident 9 was dependent with activities of daily living. A review of Resident 9's Order Summary Report,…

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 a tracheostomy (a surgical procedure that creates an opening in the neck to provide an airway and facilitate breathing) care risk and benefit assessment, care plan and physician's order were placed for one of 24 sampled residents (Resident 15), when Resident 15 was allowed to perform his own tracheostomy gauze change, suction, and inner cannula insertion. This failure decreased the facility's ability to provide proper tracheostomy care to maintain a patent airway and to prevent infection for Resident 15. Findings: A review of Resident 15's admission Record, indicated he had diagnoses which included acute and chronic respiratory failure (a condition that makes it difficult to breathe on your own) with hypoxia (a condition that occurs when the body doesn't have enough oxygen at the tissue level) and tracheostomy dependent. During an observation on 10/7/24 at 9:20 a.m., Resident 15 had a tracheostomy covered with white colored cloth dressing on his neck. During a concurrent observation and interview on…

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

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented for a census of 80, when: 1. Licensed Nurse 4 (LN 4) did not perform hand hygiene during medication pass; 2. Resident 44's breath activated call cord disposable mouthpiece was not changed and had a large, brown substance in the end of it; 3. One container of food sitting on shelf labeled yogurt dated 10/6/24 was found inside Resident 17's room; and, 4. Resident 17's and Resident 44's privacy curtains were dirty, stained, and in disrepair. These failures had the potential to expose residents to infectious diseases. Findings: 1. During a medication pass observation on 10/7/24 at 8:23 a.m., LN 4 entered Resident 2's room, put on disposable gloves and checked Resident 2's blood pressure. LN 4 returned to the medication cart, removed gloves, accessed the computer, and began to prepare medication for the resident without performing hand hygiene. During an interview on 10/7/24 at 8:25 a.m. with LN 4, LN 4 stated hand hygiene needed to be performed when leaving 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 ensure care conferences were conducted quarterly (every 3 months) for one of three sampled residents (Resident 1). This failure resulted in violating the rights of Resident 1 to participate in choosing treatment options and making decisions regarding their plan of care. Findings: Resident 1 was admitted to the facility in 2022 with diagnoses that included quadriplegia (the inability to move arms or legs). A review of Resident 1's Minimum Data Set (MDS - an assessment tool used to guide care), dated 7/27/24, indicated Resident 1 had a Brief Interview for Mental Status score of 15 out of 15 which indicated Resident 1 had full understanding and capacity to make decisions. During a concurrent interview and record review with the Administrator (ADM) on 9/16/24 at 10:03 a.m., the ADM confirmed Resident 1 has had no care conference since October 2023. The ADM stated, Resident 1 should have had a care conference in the months of January and March. The ADM further stated, It is my expectation that residents receive a care…

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

Based on interview and record review, the facility failed to provide the requested medical records for 1 of 4 sampled residents (Resident 1) within two working days as required per the facility's policy. This failure resulted in the delay of the release of Resident 1's medical records. Findings: A review of the Nursing admission Record indicated, Resident 1 was admitted to the facility in 2023 with diagnoses that included respiratory failure. During an interview with the Director of Nursing (DON) on 8/15/24 at 9:52 a.m., the DON stated, The initial request for medical records was missed due to no designated medical records person at that time and was an oversight on our part. The DON further confirmed the policy had not been followed and stated, Our policy is to send medical records within two working days upon request. During an interview with Medical Records (MR) on 8/15/24 at 10:47 a.m., MR stated, At the time the initial request for medical records was made there was no fulltime medical records person assigned, which is possibly the reason the request was missed. MR further…

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 implement a care plan for one resident (Resident 1) of two sampled residents when Resident 1's preference for personal care needs was not provided by a female staff member. This failure resulted in Resident 1 not getting person-centered care and feeling uncomfortable during perineal care. Findings: A review of an admission record indicated Resident 1 had diagnoses which included major depressive disorder and lymphedema (swelling caused by a buildup of lymph fluid in the body between the skin and muscle). During a record review of Resident 1 Physician's Order (PO), dated 10/29/23, the PO indicated, Resident 1 was capable of making healthcare decisions. During a record review of Resident 1's care plan (CP), initiated on 2/13/23, the CP indicated, Resident prefers Female CNAs [Certified Nursing Assistants] for all personal care needs [example] changing and showers. During an interview with Resident 1 on 7/18/24 at 1:08 p.m., Resident 1 stated she preferred a female CNA to change her. Resident 1 stated she felt uncomfortable…

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 four of seven sampled residents (Resident 1, Resident 2, Resident 3 and Resident 4) were treated with dignity and respect when staff were overheard speaking in a foreign language throughout the facility. This failure resulted in residents feeling insecure and wondering if they were being talked about by staff. Findings: A review of Resident 1's admission record indicated she was last admitted in 4/24 with diagnoses including hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side. A Minimum Data Set (MDS, an assessment tool), dated 5/13/24, indicated she had no memory impairment. A review of Resident 2's admission record indicated he was last admitted in 11/23 with diagnoses including congestive heart failure (inability of the heart to pump blood adequately throughout the body). A MDS, dated [DATE], indicated he had no memory impairment. A review of…

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

Based on interview and record review the facility failed to implement its own policy and procedure for one of 4 sampled residents (Resident 4) when Resident 4's Responsible Party (RP) was not informed of a new medication order due to a change in condition. This failure had the potential to result in disregarding Resident 4 and her RP's right to be informed of her treatment. Findings: A review of an admission Record for Resident 4 indicated she was admitted in August 2020 with diagnoses including neurocognitive disorder with Lewy bodies (abnormal deposits of a protein in the brain that can lead to problems with movement, thinking, behavior, and mood). A review of Resident 4's Order Summary Report (OSR) dated 8/25/20 indicated she did not have the capacity to make own healthcare decisions, family or RP shall be informed of condition. A review of the same OSR for Resident 4 dated 6/10/24 indicated an order for ivermectin tablet 3 milligrams (mg, unit measurement) give four tablets one time for scabies (a contagious, intensely itchy skin condition caused by a tiny, burrowing mite)…

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 provide services which meet professional standards of quality for one of 4 sampled residents (Resident 3) when Resident 3's Blood Pressure (BP, the force of blood pushing against the walls of the arteries as the heart pumps blood in the body) was not checked against physician orders before administering his BP medication. This failure had the potential to affect Resident 3's health by receiving BP medication that is not in accordance with the physician's order. Findings: A review of an admission Record for Resident 3 indicated he was admitted in November 2023 with diagnoses including hypertension (high blood pressure) and end stage renal disease on dialysis. In an interview on 6/17/24 at 12: 45 p.m. with Resident 3, Resident 3 stated he filed a grievance regarding his concern for the nurses not checking his BP before giving his BP medications and that the incident had happened five times already. Resident 3 expressed his concern for his BP to go critically low, especially after receiving dialysis. A review of Resident 3's…

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

Based on observation, interview, and policy review, the facility failed to ensure medications were kept locked or under the direct observation of authorized staff for a census of 91. This failure had the potential for unauthorized staff or residents to access drugs and biologicals. Findings: During a concurrent observation and interview on 6/12/24 at 10:25 a.m., Licensed Nurse 1 (LN 1) left medication cart 4 unlocked and unattended. LN 1 was at the nursing station on the telephone. There were multiple residents and other staff in the hallway at that time. LN 1 stated the medication cart should have been locked. During an interview on 6/12/24/at 1:40 p.m., the Director of Nursing (DON), stated her expectation is the medication cart should be locked. A review of facility's policy titled, MEDICATION STORAGE IN THE FACILITY dated April 2008, indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the Licensed Nurse 1 (LN 1) failed to immediately notify the Nurse Practitioner (NP) and Responsible Parties (RP) for two residents (Resident 1 and Resident 2) of two sampled residents when LN 1 witnessed Resident 1 slap Resident 2 in the face. These failures resulted in delayed assessments and diagnostic testing for injury, and distress to Resident 1's RP when he discovered Resident 1's injuries without having been notified by facility staff. Findings: A review of Resident 1's admission record indicated admission to the facility on 8/25/20 with diagnoses which included neurocognitive disorder with Lewy Bodies (a type of progressive dementia that leads to a decline in thinking, reasoning, and independent function) and dementia with psychotic disturbance (the mental state where someone is not sure what is real or not). A review of a Minimum Data Set (MDS, an assessment tool), dated 3/4/24, indicated Resident 1 had a severe memory problem. A review of Resident 2's admission…

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 incident of abuse within the regulatory timeframe for two residents (Resident 1 and Resident 2) when Resident 1 slapped Resident 2 on the face. This failure resulted in Licensed Nurse 1 (LN 1) not reporting a known issue. Findings: A review of Resident 1's admission record indicated admission to the facility on 8/25/20, with diagnoses which included neurocognitive disorder with Lewy Bodies (a type of progressive dementia that leads to a decline in thinking, reasoning, and independent function) and dementia with psychotic disturbance (the mental state where someone is not sure what is real or not). A review of a Minimum Data Set (MDS, an assessment tool) dated 3/4/24 indicated Resident 1 had a severe memory problem. A review of a facility training regarding Abuse Prevention; Resident to Resident Altercations and Abuse Reporting; Mandated Reporter, dated 1/19/24 and 2/26/24, indicated LN 1 was in attendance. A review of Resident 2's admission…

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 Licensed Nurse 1 (LN 1) failed to provide care per professional standards for two residents (Resident 1 and Resident 2) of two sampled residents when LN 1 witnessed Resident 1 slap Resident 2 in the face and: 1. Did not assess both of the residents after the witnessed altercation; and, 2. Did not initiate a care plan for each of the residents after the witnessed altercation. These failures decreased the facility's potential to provide nursing care which encompassed the nursing practice. Findings: A review of Resident 1's admission record indicated admission to the facility on 8/25/20, with diagnoses which included neurocognitive disorder with Lewy Bodies (a type of progressive dementia that leads to a decline in thinking, reasoning, and independent function) and dementia with psychotic disturbance (the mental state where someone is not sure what is real or not). A review of an Minimum Data Set (MDS, an assessment tool), dated 3/4/24, indicated Resident 1 had a severe…

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 Licensed Nurse 1 (LN 1) failed to accurately document on medical charts for two residents (Resident 1 and Resident 2) of two sampled residents when LN 1 witnessed Resident 1 slap Resident 2 in the face and: 1. Did not document the details of the altercation in either of the residents' medical records; and, 2. Did not document the time at which both of the residents' Responsible Parties (RP) were notified. These failures resulted in delayed assessments and diagnostic testing for injury, and distress to Resident 1's RP when he discovered Resident 1's injuries without having been notified by facility staff. Findings: A review of Resident 1's admission record indicated admission to the facility on 8/25/20, with diagnoses which included neurocognitive disorder with Lewy Bodies (a type of progressive dementia that leads to a decline in thinking, reasoning, and independent function) and dementia with psychotic disturbance (the mental state where someone is not sure what is real…

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 interviews, clinical record review, and facility document review, the facility failed to follow their policy and procedure to prevent abuse for one of three sampled residents (Resident 1) when Resident 1 was closed in her room by Licensed Nurse 1 (LN 1). This failure resulted in Resident 1 to be isolated and had the potential for further abuse or injury while closed up in her room. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills), hypertension (high blood pressure), and unspecified dementia. During a review of Resident 1's admission Minimum Data Set (MDS-an assessment tool), dated 4/22/24, described her as usually able to make herself understood and usually able to understand others. Resident 1's mental status (BIMS-a brief screening that aids in detecting cognitive impairment) score was 10 which indicated she was moderately impaired. The MDS described Resident 1 as having 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 interview and record review, the facility failed to provide services according to professional standards of practice for 3 of 6 sampled residents (Resident 1, Resident 2 and Resident 3) when permethrin cream (medication used to treat scabies, a condition caused by tiny insects called mites that infest and irritate the skin) was not accurately documented in their Medication Administration Record (MAR). These failures had the potential for the 3 Residents to not receive proper treatment and/or prophylactic treatment for scabies. Findings: A review of Resident 1's clinical record indicated he was readmitted to the facility fall of 2023 with multiple diagnoses that included Scabies. Resident 1's laboratory record indicated he tested positive for scabies on 4/29/24. His physician note dated 4/30/24 indicated, .Patient scabies test is positive, and he is currently treated for scabies .10. Scabies .treated with premethrin [sic] 5% . A review of Resident 2's clinical record indicated he was readmitted to the facility spring of 2024 with multiple diagnoses that included pneumonia,…

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

Based on interview, record review, and facility policy review, the facility failed to follow their own policy and procedure for prevention of further abuse, when the facility allowed Certified Nursing Assistant 1 (CNA1) to continue to provide resident care after the Respiratory Therapist (RT) allegedly witnessed CNA1 tie Resident 1's hand to the side of the bed. This failure could have potentially resulted in physical and/or psychological harm to other residents of the facility, for a census of 87. Findings: Resident 1 was admitted to the facility in 2024 with diagnoses that included, chronic respiratory failure and heart failure. Review of the facility's policy titled, Reporting Abuse revised January 8, 2014 indicated, Upon an allegation of abuse by a Facility Staff member, the Facility Staff member will be suspended and removed from the premises. In a written statement by the RT on 5/5/24 at 3 a.m., the RT indicated she saw CNA1 using a sheet to tie Resident 1's hand to the bed. Resident 1 had a laceration on her nose and a swollen lip. During an interview with the Director 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 interview and record review, the facility failed to ensure the medical records were accurate and complete for two sampled residents (Resident 1 and Resident 3) for a census of 83 residents when licensed nurses (LNs) failed to document administration of medications in the Medication Administration Record (MARs) as per the facility's policy and procedure guidelines. These failures had the potential to negatively impact the management of these resident's medical conditions. Findings: Resident 1 was admitted to the facility in early February 2024 with diagnoses that included post procedural seroma of skin (accumulation of fluid at the surgical site). A review of Resident 1's Order Summary Report dated 2/1/24 through 2/12/24, indicated the following orders: Daptomycin intravenous (IV) solution reconstituted 500 mg (milligram, unit of measure) to be given in the afternoon. The LNs were to measure the arm circumference and external lumen (channel) catheter(s) weekly every evening shift, flush the IV lumen with 5 cc (cubic centimeter, volume measurements) NS (normal saline, sterile…

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 treated with dignity and respect when Licensed Nurse (LN) 1 walked out of Resident 1's room, while in the middle of providing care. This failure resulted in Resident 1 to feel fearful of staff. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (stroke-damage to tissue in brain due to loss of oxygen to the area) affecting right dominant side, tracheostomy (hole in windpipe that provides alternative airway for breathing), and other speech and language deficits following cerebral infarction. During a review of Resident 1's admission Minimum Data Set (MDS-an assessment tool), dated 2/13/24, described Resident 1 as having unclear speech, usually able to make himself understood, and usually able to understand others. Resident 1's BIMS (a brief screening that aids in detecting cognitive impairment) score was 11 which indicated he was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for a resident with a deep tissue injury pressure ulcer (DTI-PU, a purple or maroon area of discolored intact skin due to pressure) for one of five sampled residents, Resident 4. This failure prevented Resident 4 from receiving the care she needed to prevent the development of a pressure ulcer. Findings: During a review of the clinical record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included Hemiplegia (complete paralysis) and Hemiparesis (partial weakness) following a nontraumatic intracerebral hemorrhage (stroke) affecting the left non dominant side, and compression of the brain (brain gets compressed due to increase pressure caused by bleeding or swelling). During a review of Resident 4's Minimum Data Set (MDS - an assessment tool used to guide care) Cognitive Patterns, dated 12/14/23, indicated Resident 4 had a Brief Interview for Mental Status (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy and procedures to prevent a pressure sore from developing for one of five sampled residents (Resident 4) when, the resident developed a deep tissue injury pressure sore (DTI-PU- a purple or maroon area of discolored intact skin with underlying tissue damage due to pressure or shearing). This deficient practice caused the development of a deep tissue injury pressure sore to Resident 4's left and right buttocks, coccyx area. Findings: A review of the clinical record indicated Resident 4 was admitted to the facility on [DATE], with diagnoses that included Hemiplegia (complete paralysis) and Hemiparesis (partial weakness) following nontraumatic intracerebral hemorrhage (stroke) affecting the left non dominant side, and compression of the brain (brain gets compressed due to increase pressure caused by bleeding or swelling). During a review of Resident 4's Minimum Data Set (MDS - an assessment tool used to guide care) Cognitive Patterns,…

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 prevent a decrease in range of motion (ROM) for one of five sampled residents (Resident 1) when Resident 1's plan of care for the use of a wheelchair leg rest was not consistently implemented and Resident 1's order for a reevaluation after 90 days was not timely done. This failure resulted in Resident 1experiencing a decline of negative 15 degrees (unit of measurement) in her left ankle range of motion (AROM) dorsiflexion (backward bending and contracting of the foot). Findings: A review of Resident 1's clinical record indicated Resident 1 was admitted October of 2023 and had diagnoses that included parkinsonism (a group of motor symptoms that manifests as rigidity, tremors, and slowness of movement and speed), acquired absence of right leg above knee, and dementia (impairment of the ability to remember, think, or make decisions that interferes with everyday activities). Resident 1 only spoke Spanish. A review of Resident 1's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns,…

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 Resident 1 was made aware of his right to return to the facility when Resident 1 was transferred emergently to an acute care hospital and the facility did not provide a written bed-hold notice (holding or reserving a resident's bed during the resident's absence from the facility). This failure placed Resident 1 and his representative at risk for not understanding his rights to return to the facility. Findings: Resident 1 was a long-term resident in the facility with persistent vegetative state with an opening in the neck into the windpipe to provide air to breathe. Review of Resident 1's clinical record indicated the resident was transferred to the emergency department on 11/2/23, due to increased breathing rate at 36/minutes (normal rate for an adult ranges 12-18/min). Review of Resident 1's clinical record indicated there was no documented evidence that the facility provided a written bed-hold notice to the resident or the resident representative informing them of the facility's bed-hold duration, bed payment…

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

Based on interview, record review and facility policy review, the facility failed to provide the requested medical records for one of three sampled residents (Resident 1) within the two working days required per the facility's policy. This failure violated Resident 1's rights to allow her family to have a copy of her medical records. Findings: A review of the Skilled Nursing admission Record indicated, Resident 1 was admitted to the facility in 2022 with diagnoses that included dementia and epilepsy (a brain disorder characterized by recurrent seizures). During an interview with the Director of Nursing (DON) on 1/31/24 at 10 a.m., the DON stated, Resident 1's daughter had requested medical records and the request was not processed by the medical records department. As a result, the medical records were not released until approximately 7 weeks later. The DON further stated it was their policy to have released the medical records within 48 hours of the initial request. During an interview with the Director of Medical Records (DMR) on 1/31/24 at 10:45 a.m., the DMR stated, Resident 1's…

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

Based on observation, interview, and record review, the facility failed to ensure two incidents of allegations of abuse were reported and investigated as required by the regulations for one of three sampled residents (Resident 1). This failure resulted in a delay in the abuse investigation process and decreased the facility's ability to protect residents from physical and psychosocial harm. Findings: A review of the admission record indicated Resident 1 was admitted in 2022 with multiple diagnoses which included anxiety disorder. Her Minimum Data Set (MDS, an assessment tool) dated 10/21/23, indicated Resident 1 had moderate memory impairment. During a concurrent observation and interview on 1/19/24 at 10:20 a.m., in another resident's room, Resident 1 was in her wheelchair. Resident 1 stated, approximately 3-4 weeks ago, Resident 2 hit her with his arm on her chest in the hallway. She stated the maintenance guy was there and he saw the incident. Resident 1 stated she filed a grievance regarding the incident, and she was later informed that it was already closed. During an interview…

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 was maintained for one of three sampled residents (Resident 1) when Resident 1 was involved in two alleged incidents of altercation with Resident 2. This failure had the potential to result in injury and negatively impact Resident 1's psychosocial well-being. Findings: A review of the admission record indicated Resident 1 was admitted in 2022 with multiple diagnoses which included anxiety disorder. Her Minimum Data Set (MDS, an assessment tool) dated 10/21/23, indicated Resident 1 had moderate memory impairment. A review of the admission record indicated Resident 2 was admitted in 2023 with multiple diagnoses which included generalized anxiety disorder. His MDS, dated [DATE], indicated Resident 2 had no memory impairment, his behavior assessment indicated he had verbal behavioral symptoms directed toward others (threatening others, cursing at others). A review of Resident 2's Care plan, dated, 7/7/23, indicated, 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.

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 for one resident (Resident 1) of four sampled residents when a Certified Nurse Assistant (CNA) did not wear an N-95 respirator (a protective device designed to efficiently filtrate infectious airborne particles) and faceshield while providing care to a resident diagnosed with COVID-19 (an infectious virus that can cause respiratory illness and is spread by small liquid particles emitted by the mouth). The CNA also did not perform hand hygiene after providing care to Resident 1 and prior to exiting the resident's room. This failure decreased the facility's potential to prevent the spread of infection among a census of 88 residents. Findings: A review of an admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included COVID-19. A review of Resident 1's care plan, dated 12/7/23, indicated .test positive for COVID . Implement the following transmission based…

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 interviews, clinical record review, and facility policy and procedure, the facility failed to keep Resident 1's medical records in accordance with accepted professional standards and practices. The facility must maintain medical records on each resident that are complete and accurately documented. This failure resulted in an inaccurate and incomplete medical record. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses that included right elbow arthritis due to bacteria and iron anemia deficiency. Resident 1's admission Minimum Data Set (MDS-an assessment tool), dated 11/2/23, described her as having clear speech, able to make herself understood and as able to understand others. Resident 1's BIMS (a brief screening that aids in detecting cognitive impairment) score was 14 which indicated she was cognitively intact and as having no delirium or behavioral symptoms. Review of Resident 1's medical record revealed the following incomplete and inaccurate medical records: 1. Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Resident 1 was treated with dignity and respect when Licensed Nurse (LN) 1 was heard yelling at Resident 1 saying, What do you think the diet shot is going to do for you? Do you really think the diet shot is going to help you lose weight? No diet shot is going to keep you from lifting your arm to your mouth eating big bags of food. This failure resulted in Resident 1 to have felt awful and defeated. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD) and diabetes. Resident 1's Quarterly Minimum Data Set (MDS-an assessment tool), dated 8/5/23, described her as having clear speech, able to make herself understood and as able to understand others. Resident 1's BIMS (a brief screening that aids in detecting cognitive impairment) score was 15 which indicated she was cognitively intact. The MDS described Resident 1 as having inattention and altered level of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to properly apply side rails [bed rails] for 3 of 5 sampled residents (Resident 1, Resident 4, and Resident 5), when risk for entrapment (a position or situation from which it is difficult to escape) assessments were not completed prior to use of side rails. This failure had the potential to result in injury and entrapment. Findings: Resident 1 was admitted to the facility late 2023 with diagnoses which included cerebrovascular disease (affects blood flow in the brain), dementia (memory problem), and both legs amputated below the knee. During a review of Resident 1's Order Summary Report (OSR), order date 10/2/23, the OSR indicated, Bilateral ¼ side rails up as enabler for bed mobility and repositioning. During a review of Resident 1's Bed Rail Assessment, dated 10/10/23, the assessment indicated a change in safety awareness due to cognitive decline, a history of falls, and a recommendation for bilateral side rails. During an interview on…

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

Based on observation, interview, and record review, the facility failed to implement contact precautions for 2 residents (Resident 1 and Resident 2) for a census of 76 when staff were observed preforming tracheostomy care ( a procedure to remove excess secretions from an opening in the throat) in the resident's room without maintaining contact precautions (procedures used to prevent the spread of infection including performing hand hygiene before entering and exiting a room, and wearing a gown and gloves while in a resident room). This failure increased the potential for the spread of infectious diseases. Findings: In an observation, on 9/21/23 at 9:35 a.m., resident room [number] was noted to have a contact precaution sign to the right of the room number outside the doorway. In a concurrent observation and interview, on 9/21/23 at 9:35 a.m., the RT (Respiratory Therapist, cares for patients who have trouble breathing) was observed in the room [with contact precaution sign] performing tracheostomy care for Resident 1 and Resident 2 without performing hand hygiene between procedures…

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 3 sampled residents was free from a significant medication error when physician's orders regarding the administration of apixaban (blood thinner medication used to prevent recurrence of blood clots) were not followed. This failure resulted in Resident 1's abrupt/sudden rehospitalization due to chest pain with shortness of breath. Findings: A review of Resident 1's admission records indicated he was admitted to the facility on [DATE], with diagnoses including saddle pulmonary embolism (large blood clot stuck in the main pulmonary artery which blocks the flow of blood to the lungs). The resident was verbally responsive and had the capacity to make his own health care decisions. A review of Resident 1's Skilled Nursing Facility Orders, dated 7/7/23, indicated Resident 1 was to take Apixaban 5 milligrams (mg, unit of measurement) 2 tablets two times per day for 6 days from 7/7/23 until 7/12/23 a.m. Beginning on 7/12/23 afternoon, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the conservative use of antipsychotic medications for three residents (Resident 29, Resident 9, and Resident 69) of 33 sampled residents when: 1. Resident 29 did not have an informed consent for the use of quetiapine fumarate; 2. Resident 9 did not have a signed informed consent nor was there a consent form for the current dosage of quetiapine fumarate being administered; and, 3. Resident 69 did not have an informed consent for the use of ziprasidone. This failure decreased the facility's potential to ensure residents or their responsible person(s) were fully informed of the risks, benefits, and alternative treatment options prior to the use of an antipsychotic medication. Findings: 1. On 3/15/23 and 3/16/23, copies of informed consents for antipsychotic medications for Resident 29, Resident 9, and Resident 69 were requested from the Medical Records Coordinator (MRC) and the Assistant Director of Nursing (ADON). A review of an admission record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a safe, clean, comfortable and homelike environment for a census of 85 residents when: 1. A vinyl floor plank near nurse's station was observed damaged and partially unglued from the floor; 2. Resident 343's left bed rail was reported malfunctioning and rotating off the locked position; 3. Resident 52's room air vent was observed covered with black dust specks; and, 4. Resident 343's and Resident 1's windows were observed to be dirty and covered in dust. This failure resulted in the residents living in an uncomfortable environment and had the potential to cause fall-related injuries to staff, residents, and visitors. Findings: 1. In a concurrent observation and interview on 3/16/23 at 7:26 a.m., with Certified Nursing Assistant 3 (CNA 3) near nurse's station #2, the hallway floor near the station desk was observed to have a broken vinyl plank, missing approximately 1 inch around one of the corners of the plank. The broken end 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 provide care and services to prevent the development of pressure ulcers (PU; a breakdown of the skin and potential layers of fat and muscle beneath) for 5 of 32 sampled residents, (Resident 13, Resident 23, Resident 47, Resident 63, and Resident 66) when pressure ulcers increased in size and/or developed after admission while in the care of the facility staff. This failure resulted in the development of avoidable pressure ulcers which jeopardized the health and safety of residents and had the potential to cause infection, physical and mental anguish, and possible death. Findings: Resident 13 was admitted to the facility in 2016 with diagnoses including, stroke (when blood is blocked from getting to the brain, resulting in damage, disability, or even death), difficulty with mobility, dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), speech and language problems,…

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 discontinued medications and biologicals were labeled as discontinued, dated, and securely stored for destruction for a census of 85. This failure had the potential to encourage diversion of medications and compromise the health and safety of staff and residents. Findings: During a tour of the Medication Storage on [DATE] at 8:05 a.m. while accompanied by the Assistant Director of Nursing (ADON), the ADON opened the Medication Storage room door. On the right side of the entrance there were large garbage bags observed on the right bottom shelf. The bags were overflowing with bubble packs with resident labels attached to them. There were three large garbage bags overflowing with bubble packets of discontinued prescription medications. In a concurrent observation and interview with the ADON, the ADON confirmed the bags were full of the bubble packets for residents who had expired, discharged , or the medications had been discontinued.…

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

Based on interview and record review, the facility failed to ensure the facility assessment accurately reflected current care and services staff could provide to residents. This failure decreased the potential for the facility to ensure safe and knowledgeable care based on resident diagnoses. Findings: A review of the facility's assessment tool provided to the Department on 3/14/23 at 9:01 a.m., indicated the last date of assessment or update was 3/13/23. It also indicated staff were knowledgeable and were able to provide care to a resident with a wound vacuum assisted closure (VAC) machine (a device used to assist wound(s) to heal) and an external defibrillator vest (a device used to control dangerous heart rhythms by applying an electrical shock to the heart). The facility assessment did not indicate the facility was able to care for residents with the following diagnoses: epilepsy/ seizures (a brain disorder which causes recurring, unprovoked seizures); gastrostomy (an artificial external opening into the stomach for nutritional support and administration of medication); pressure…

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' personal and nutritional information when the residents' dietary meal tickets were disposed together with the food scraps in the regular garbage. This failure had the potential for residents personal health information to be accessible to those who were not involved in the residents' care, for residents receiving food prepared by the kitchen for a facility census of 85. Findings: During a concurrent observation and interview during a follow up tour of the kitchen on 3/16/23, at 8:30 a.m., the Dish Washer Personnel (DWP) was observed cleaning the dirty dishes from the breakfast meal served. The DWP was observed scraping away food scraps and resident meal tickets, and throwing all of it together into the regular trash. The DWP confirmed he scraped away all the food items from the trays including the residents meal tickets and threw them together in the regular garbage. The DWP confirmed the printed meal tickets had the resident's name, room number, type of diet, food allergies and food…

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 conduct in-service training to staff in the safe operation and care of equipment used to provide care for the residents. This failure had the potential to cause inadequate and inaccurate care and possible injury to the residents for a facility census of 85. Findings: A review of Resident 62's record indicates they were admitted with diagnoses of local infection of the skin and subcutaneous(below the skin) tissue, Methycillin Resistant Staphylococcus Aureus infection (MRSA, a type of antibiotic resistant bacteria), Pressure Ulcer (a wound caused by an injury that breaks down the skin and underlying tissue, caused when an area of skin is placed under pressure) Stage 4 (Stage 4 bedsores are where muscle or bone may become exposed in this stage, putting the patient at risk for serious infection) of the sacral area (an area near the tailbone). Resident 62 was admitted from the hospital with a Negative Pressure Wound Treatment machine (NPWT, also called vacuum-assisted wound closure machines) to treat a Stage 4 sacral pressure…

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 discuss and provide information on advanced directives for one resident (Resident 55) of 33 sampled residents. This failure had the potential to cause Resident 55's values and desires related to end-of-life care not to be honored. Findings: A review of Resident 55's admission record indicated admission to the facility on 2/2/22 with diagnoses which included cognitive communication deficit, type 2 diabetes (the bodies inability to regulate blood sugars), and bipolar disorder (a mental health condition that causes extreme mood swings). A review of Resident 55's Minimum Data Set (MDS, an assessment tool), dated 2/7/23, indicated she had severe cognitive impairment and was rarely understood. During a concurrent observation and interview with Certified Nurse Assistant 5 (CNA 5) on 3/14/23 at 8:46 a.m. Resident 55 was in bed and was unable to provide meaningful answers to the surveyor during attempted conversation. CNA 5 stated Resident 55 sometimes communicates yes or no answers. 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.

Based on observation, interview, and record review the facility failed to conduct a comprehensive assessment and complete a Significant Change in Status Assessment (SCSA, an assessment that indicates a major decline or improvement in the resident's status) when one resident (Resident 63) of 33 sampled residents developed a stage 4 (deep wound reaching the muscles, ligaments, and bones) pressure ulcer (PU) to the left ear. This failure decreased the facility's potential to develop a personalized plan of care to prevent a further decline in Resident 63's health status. Findings: A review of an admission record indicated Resident 63 was admitted to the facility in January 2022 with diagnoses which included traumatic hemorrhage of cerebrum (a type of stroke caused by an artery in the brain bursting causing bleeding in the surrounding tissues) and chronic respiratory failure. A review of Resident 63's MDS (Minimum Data Set, an assessment and care screening tool), dated November '22 and January 2023, indicated, .Hearing, Speech, and Vision .No speech .Functional status .2-person…

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 Preadmission Screening and Resident Review (PASRR) was conducted for one resident (Resident 29) of 33 sampled residents. This failure decreased the facility's potential to ensure residents attained or maintained their highest practicable physical, mental, and psychosocial well-being. Findings: A review of an admission record indicated Resident 29 was admitted to the facility on [DATE] with diagnoses which included bipolar disorder (a mental health condition that causes extreme mood swings). The admission record also indicated Resident 29's daughter was his Responsible Party (RP, a person designated to make healthcare decisions for the resident). A review of Resident 29's PASRR Level I Screening Document, dated 3/14/19, indicated, .18a .Has the attending physician certified before/upon admission to the NF [Nursing Facility] that the resident is likely to require less than 30 days of NF services? [no answer checked] .18b .Enter Physicians Name…

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 person-centered baseline care plan was completed and signed by the resident or responsible party within 48 hours of admission for one resident (Resident 69) of 33 sampled residents. This failure decreased the facility's potential to ensure residents and their responsible persons were aware of the plan of care being provided. Findings: A review of a clinical record indicated Resident 69 was readmitted to the facility on [DATE] with diagnosis including schizophrenia (a mental disorder in which people interpret reality abnormally) and chronic respiratory failure. In an interview on 3/15/23 at 8:45 a.m. Licensed Nurse 4 stated the Resident 69 was alert and oriented to voice her needs to staff, was dependent on two person assistance with all activities of daily living (ADLs), and was always cooperative with care with no episodes of behaviors. In an interview on 3/15/23 at 10:15 a.m. Resident 69 stated she did not remember if 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 services provided met professional standards of quality for three residents (Resident 56, Resident 25, and Resident 64) of 33 sampled residents when: 1. Resident 56's tube feed (TF) was left to continuously operate when the feed bottle was empty; 2. Resident 64's gastrostomy tube was discontinued 29 days late and was not documented in the medical chart; and, 3. Resident 25's hospice order was discontinued 22 days late. This failure had the potential to compromise residents' care and cause health complications. Findings: 1. During a review of Resident 56's clinical record it indicated Resident 56 was admitted [DATE] with diagnoses including dysphasia (impairment in speech) and dysphagia (difficulty in swallowing), after a cerebral infarction (stroke, a lack of blood and oxygen supply to brain cells). During a concurrent observation and interview on 3/14/23, at 5:45 a.m., inside room [ROOM NUMBER], station 1 with Certified Nurse…

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

Based on observation, interview, and record review the facility failed to ensure employee performance evaluations were completed annually for 2 of 5 sampled employees, Certified Nurse Assistant (CNA, [CNA1 and CNA2]). This failure increased the potential for CNAs to provide inadequate care and for residents to receive poor quality of care. Findings: During an interview on 3/17/23, at 10:10 a.m. with CNA 2, CNA 2 stated she started working at the facility three months ago, was hired 12/8/22, and stated, The staff who hired me said she will review my performance after 90 days, so far they haven't done it, maybe she's still busy. During an interview on 3/17/23, at 10:40 a.m. with CNA1, CNA 1 indicated she had performance evaluation done 2 years ago. She did not remember having her performance reviewed again after the facility had a lot of changes in the administration. In an interview on 3/17/23, at 11 a.m., with the Director of Staff Development (DSD), the DSD confirmed she was unable to find any documentation of the latest performance evaluation for CNA 1 and CNA 2. During a 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 interview and record review, the facility failed to act upon the pharmacist drug recommendations in a timely manner for two residents (Resident 9 and Resident 2). This failure decreased the facility's potential to provide immediate action to protect residents and prevent an occurrence of adverse drug events. Findings: A review of an admission record indicated Resident 9 was admitted to the facility on [DATE], with diagnoses which included bipolar disorder (a mental health condition that causes extreme mood swings) and depression. The admission record also indicated Resident 9 was her own responsible party (RP). A review of a Medication Regimen Review (MRR) report printed on 2/20/23 indicated, [Resident 29] .Quetiapine (a medication used to treat certain mental/mood conditions) 200 mg po [by mouth] qhs [every bedtime] .Per federal guidelines, residents on psychoactive medications should be evaluated for dose reduction twice in two separate quarters .the first year, then annually .Is this resident a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a gradual dose reduction (GDR) was attempted for the use of psychotropic medication (a drug that affects behavior, mood, thoughts, or perception) for one of 33 sampled residents (Resident 69). This failure had the potential to result in unnecessary prolonged use of psychotropic medication which may cause adverse consequences and a decline in Resident 69's health status. Findings: A review of Resident 69's clinical record indicated Resident 69 was readmitted to the facility on [DATE], with diagnoses including schizophrenia (a mental disorder in which people interpret reality abnormally) and chronic respiratory failure. During an interview on 3/15/23, at 8:45 a.m. with Licensed Nurse 4 (LN 4), LN 4 indicated her resident [Resident 69] was alert and oriented, able to voice needs to staff, dependent with all activities of daily living (ADLs), required 2-person assistance, always cooperative with care, and had no episodes of behaviors.…

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 administer significant medications as ordered by the physician for two residents (Resident 40 and Resident 9) out of 33 sampled residents. This failure decreased the facility's potential to ensure residents are able attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings: A review of an admission record indicated Resident 40 was admitted to the facility on [DATE], with diagnoses which included severe sepsis with septic shock (the most severe form of infection which can result in organ damage), bacteremia (bacteria in the blood), and human immunodeficiency virus (HIV, a virus that attacks the body's immune system). A review of a care plan regarding Resident 40's peripherally inserted central catheter (PICC, a thin, flexible tube inserted into a vein in the upper arm and into a large vein above the heart used to administer intravenous (IV) solutions) related to the use of an IV antibiotic, initiated on 3/4/23,…

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.