Acc Care Center

Based on observation, interview, and record review, the facility failed to ensure one of 34 sampled residents (Resident 17) received appropriate treatment and services for diagnosis of vascular dementia (impairment of brain function caused by damage to the blood vessels in the brain), by failing to offer non-pharmacological interventions and document the rationale prior to initiation of Seroquel (a psychotropic medication that affect brain activities associated with mental processes and behaviors and indicated for treating psychiatric conditions). In addition, there was no evaluation and rationale provided when Resident 17 was diagnosed with psychosis (a severe mental condition in which thoughts and emotions so affected that contact with reality is lost). These failures had the potential to expose Resident 17 to adverse side-effects (unwanted, uncomfortable, or fatal effects, including but not limited to sedation, increased risk for falls and negatively impact Resident 17's overall health and safety.Findings:A review of the facility's policy titled, Behavioral Assessment,…

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 account for and reconcile administered controlled medication for one of five residents, Resident 111. This failure had the potential for accidental medication exposure to Resident 111 and had the potential for drug diversion.Findings:During an observation of medication storage on 9/3/25, at approximately 10:23 a.m. ,in the hallway outside of Resident 111's room, observed Licensed Nurse 4 (LN 4) perform narcotics count (the mandatory procedure of physically counting all controlled substances) for Resident 111's oxycodone ( prescription opioid used to treat moderate to severe pain) 5 milligrams (mg, a unit of measurement). Eight oxycodone pills were left from a dispensed count of 15 pills with six administration entries logged in the medication cart narcotics log (for documentation of a narcotic administered) leaving one oxycodone 5mg pill unaccounted for.During an interview on 10:28 a.m. with LN 4, LN4 stated s/he administered the oxycodone earlier in the morning and that it is charted in the patient chart,…

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, Resident 19's allergy to onion was not accommodated when resident was served with mixed vegetables containing onion.This failure had the risk potential for an allergic reaction. Findings:During a review of the lunch meal tickets on 9/3/25 at 11:00 a.m., Resident 19's meal ticket indicated an allergy to onion. This meal ticket also indicated that the resident ate in his room and received food in bowls. Review of Resident 19's diagnosis indicated a history of being legally blind.During an observation of the lunch meal plating on 9/3/25 at 11:35 a.m., the menu included Orange Beef, [NAME] Rice, Oriental Vegetables (including peppers, onions, and broccoli), a roll and cookie. The [NAME] stated that barbequed chicken was available as an alternative to the main entree, but there was not another vegetable available.During a meal observation on 9/3/25 at 12:30 p.m. in Resident 19's room., a Certified Nursing Assistant (CNA) removed his meal tray from the cart. Upon request the CNA allowed the survey team to lift the lids of his meal bowls.…

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 meet professional standards of quality for one of three sampled residents (Resident 1) when Resident 1's prophylactic (intended to prevent disease) aspirin was discontinued incorrectly. This failure resulted in Resident 1 not receiving aspirin as ordered and had increased potential for developing blood clots. Findings: Resident 1 was initially admitted in November 2024 with an admission diagnosis of a left broken thigh bone and was re-admitted in December 2024 with admission diagnoses of blood clot in the lungs and sudden development of a blood clot in the legs. Resident 1 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 14 out of 15 which indicated Resident 1 was cognitively intact. During an interview on 1/6/25 at 10:36 a.m. with Resident 1, Resident 1 stated, I had a blood clot. I have no idea whatsoever what happened. I was here and next thing I knew I was back at the hospital. My…

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

Based on interview and record review, the facility failed to ensure residents were free from misappropriation of property for a census of 84 when multiple doses of controlled pain medications and count sheets were missing and unaccounted for. These failures resulted in the facility's lack of accountability of residents controlled medications with potential for uncontrolled pain and suffering. Findings: During a review of the facility provided statement signed by Licensed Nurse 2 (LN 2), dated 10/15/24, the statement indicated, I was assigned to the first cart on [name of the hall]. I received the report from [LN 3], the NOC [night shift] nurse, at around 0615 [6:15 a.m.]. When we counted the narcotics [controlled medications], we noticed that the medication for [Resident 1] was missing. The count sheet issued by the pharmacy for that medication was in the binder. We also discovered that the count sheet for the medication for [Resident 3] was missing, though the medication itself was present in the narcotic box .We thoroughly searched the narcotic and non-narcotic medications, but…

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 professional standards of practice were followed when Licensed Nurse (LN 1) entered orders, wrote prescriptions, and discontinued controlled medications without physician authorization for five of nine sampled residents (Residents 1, 3, 4, 5, and 6). This failure resulted in the facility not having accurate accountability of controlled medications, the potential for abuse or misuse of these medications, and the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions. Findings: During a review of the facility provided statement signed by LN 2, dated 10/15/24, the statement indicated, I was assigned to the first cart on [name of the hall]. I received the report from [LN 3], the NOC [night shift] nurse, at around 0615 [6:15 a.m.]. When we counted the narcotics [controlled medications], we noticed that the medication for [Resident 1] was missing. The count sheet issued by the pharmacy for that medication was in the binder. We also discovered that the count sheet for 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 accurate accountability of controlled medications (that have high potential for abuse, misuse and are addictive) for a census of 84 when: 1. Multiple doses of and Controlled Drug Records (CDR) for Oxycodone (medication used to treat moderate to severe pain) were missing and unaccounted for; 2. Random controlled medication audits of the Medication Administration Record (MAR) and CDRs for seven of nine sampled residents (Residents 1, 2, 3, 6, 7, 8, and 9) did not reconcile to indicate they were given to the residents; and 3. Licensed Nurse (LN 1) entered orders, wrote prescriptions, and discontinued controlled medications without physician authorization for five of nine sampled residents (Residents 1, 3, 4, 5, and 6). These failures resulted in the facility not having accurate accountability of controlled medications, the potential for abuse or misuse of these medications, and the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions. Findings: 1. During a review 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 observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: 1. There were metal pans and cooking pans found stored away in the clean and ready-to-use storage areas: a. Several various sizes metal sheet pans were found stacked wet with white substances and food debris on the inside and outside surfaces of the pans. b. Three various sizes of cooking pans were found stored wet, had food debris, significant scrapes on the cooking surfaces and black greasy substances on the cooking surfaces. 2. Ice machine in the kitchen was not clean. 3. There were outdated food items found in the resident's food refrigerator located in the family room. These failures had the potential to lead to foodborne illness for a total of 89 out of 91 residents who received facility prepared foods. Findings: During an observation of the kitchen on 8/5/24 at 9:12 a.m., there were several metal pans and cooking pans found stored in the clean and ready-to-use areas: - Ten of 1/3 metal sheet pans…

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 equipment was maintained in safe operating condition when the dishwashing machine's required minimum temperatures and sanitizer concentration levels were not reached. This failure placed 89 out of 91 residents who received food from the facility kitchen at risk for food borne illness. Findings: During an interview with the Dietary Aide (DA) 2 on 8/5/24, at 9:40 a.m., she stated the wash and rinse water temperatures for the dishwashing machine should be at 120 degrees Fahrenheit (F) and the concentration for the sanitizer should be 100 PPM (part per million, a unit to measure the sanitizer concentration). The Food Service Supervisor (FSS) joined the interview and stated the dishwashing machine was new and installed a few weeks ago, and the machine company technician gave an in-service to some staff. FSS stated DA 2 did not get the in-service because she was on vacation. A follow up observation, interview and record review of the dishwashing machine operation with the DA 3 and the FSS were conducted 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 interview and record review, the facility failed to complete annual performance evaluations and staff competency in skills and techniques for five of five sampled Certified Nursing Assistants (CNAs; CNA 7, CNA 8, CNA 9, CNA 10, and CNA 11). This failure increased the risk of residents receiving poor-quality care from the CNAs. Findings: During a concurrent interview and record review on 8/6/24 at 3:45 p.m. with the Director of Nursing (DON), the CNAs personnel records indicated the following dates of hire (DOH): CNA 7 - 11/16/04; CNA 8 - 11/22/22; CNA 9 - 11/9/15; CNA 10 - 7/20/15; and, CNA 11 - 8/1/1991. During a concurrent interview and record review on 8/6/24 at 5 p.m. with the DON, the DON confirmed, by looking at the performance evaluations and staff competency in skills and techniques documents, no performance evaluations nor staff competency in skills and techniques were completed in 2024. During a concurrent interview and record review on 8/6/24 at 5:20 p.m. with the Clinical Compliance Nurse (CCN), the CCN stated, We are having a hard time locating them…

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

Based on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5% for one of five sampled residents (Resident 29), when: 1. A Licensed Nurse (LN) crushed and administered the following uncrushable medications: oxybutynin ER (an Extended Release medication for overactive bladder) 100mg (milligram, unit of measure) and pantoprazole DR (a Delayed Release medication to reduce stomach acid) 20 mg; and, 2. An LN did not administer Resident 29's calcium-vitamin D (a combination of a vitamin and a mineral) 600-200 mg-u (milligram-unit, unit of measure) as ordered by the physician. These failures resulted in three errors identified out of 33 opportunities during the observation of medication administration; the facility medication error rate was 9.09%. Findings: 1. During a medication pass observation on 8/5/24 at 8:22 a.m., with LN 3, LN 3 crushed and administered all of Resident 29's medications together which included oxybutynin ER and pantoprazole DR tablets. LN 3 confirmed the medications were crushed prior to administering…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement their medication storage policy when: 1. An expired vial of insulin was not removed from a medication cart; 2. A multi-dose inhaler did not have an open date label to determine its expiration date; and, 3. 16 pills were stored in a plastic cup without a proper pharmaceutical product label and expiration date. These failures had the potential for residents to receive medications with unsafe and reduced potency from being used past their discard date and incorrect medications from inadequate labeling. Findings: 1. During a concurrent observation and interview on [DATE] at 9:49 a.m., with Licensed Nurse (LN 1), at a medication cart, an expired 10 ml (milliliter, unit of measure) vial of Humulin R (a medication used to lower blood sugar level), with an expiration date of [DATE] was found in medication cart 2. LN 1 confirmed the insulin vial was expired and indicated this practice could lead to negative resident outcomes. 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 failed to ensure the menu was followed for the therapeutic diet (a modification of a regular diet, tailored to fit the nutritional needs of a particular person normally prescribed by a physician) during the lunch meals on 8/5/24 and 8/6/2024 when: 1. Six residents (Resident 14, 20, 29, 34, 64, and 545) were on fortified (enriched with extra nutrients) diets who did not receive extra melted butter on the vegetables; 2. Four residents (Resident 25, 31, 47 and 49) who were on small portion diets received the incorrect portion of salmon for their meals; 3. Three residents were on Dysphagia Mechanical Soft (a modified texture diet is soft and moist for people who has chewing or swallowing issues) texture diet when: a. Resident 46 and 85 received the incorrect consistency for their meal; and, b. Resident 292 received an incorrect portion of broth for her meal; 4. Resident 8 was on bite-size texture diet received ground (finely chopped) chicken instead of cut-up cubed chicken; and, 5. The cook did not follow the recipe when…

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

Based on observation, interview, and record review, the facility failed to ensure the required in-service training and competency in skills and techniques for seven out of seven sampled facility employed Certified Nursing Assistants (CNAs; CNA 7, CNA 8, CNA 9, CNA 10, CNA 11, CNA 12, and CNA 13) and two out of two Contracted Certified Nursing Assistants (CCNA; CCNA 14 and CCNA 15), when: 1. Four of seven CNAs (CNA 8, CNA 9, CNA 10, and CNA 11) and one of two CCNAs (CCNA 14) had no abuse prevention training. Two out of seven CNAs (CNA 7 and CNA 13) and two out of two CCNAs (CCNA 14 and CCNA 15) had no dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities) management training. These failures had the potential to result in CNAs and CCNAs not identifying and reporting abuse nor being able to provide effective and competent care for residents. Findings: 1. During a concurrent interview and record review on 8/6/24 at 5:10 p.m. with the Director of Nursing (DON), the DON confirmed…

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 dignity was promoted for one of 19 sampled residents (Resident 22) when a Certified Nursing Assistant (CNA) stood up in front of the resident while assisting with her lunch meal. This failure had the potential to result in Resident 22 not attaining her highest practicable physical, mental and psychosocial well-being. Findings: o Resident 22 was admitted to the facility in late 2023 with diagnoses which included memory impairment and weakness. During a review of Resident 22's assessment titled, Functional Abilities and Goals, dated 6/25/24, the assessment indicated, Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth .supervision or touching assistance. During an observation on 8/5/24 at 12:50 p.m. in the facility dining room, CNA 1 assisted Resident 22 during lunch meal. CNA 1 stood up at the side of Resident 22 and put food in the resident's mouth with a spoon. Resident 22 turned her face away and tried to push away the hands of CNA 1. During an interview on 8/5/24 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 develop and implement comprehensive care plans for two out of 19 sampled residents (Resident 148 and Resident 4), when: 1. No activities care plan was developed or implemented for Resident 148; and, 2. No care plan was developed or implemented for a skin laceration with staples for Resident 4. These failures had the potential to result in residents not attaining their highest practicable physical, mental and psychosocial well-being. Findings: 1. Resident 148 was admitted in the middle of 2024 with diagnoses which included anxiety, depression, and difficulty walking. During a review of Resident 148's Baseline Care Plan (BCP), dated 7/23/24, the BCP had no documented evidence of an assessment for activities and hobby preferences. During a review of Resident 148's Nursing Care Plan (NCP) dated 7/23/24, the NCP indicated, [Resident 148] is Spanish speaking and has a language barrier with staff .prefers to communicate in Spanish. There was no documented evidence for an activities care plan developed or…

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

Based on observation, interview, and record review, the facility failed to revise the comprehensive care plan for one of 19 sampled residents (Resident 71), when the nutrition care plan was not updated after an added intervention ordered by the physician. This failure had the potential to result in Resident 71 not attaining her highest practicable well-being. Findings: Resident 71 was admitted to the facility in early 2024 with diagnoses which included unspecified endocrine disorder (e.g. diabetes, abnormal blood sugar levels), hyperlipidemia (elevated levels of fat in the blood) and difficulty swallowing. During a review of Resident 71's Minimum Data Set (MDS, an assessment tool), dated 7/14/24, the MDS indicated Resident 71 had no memory impairment and needed partial assistance with activities of daily living. During a review of Resident 71's Nursing Care Plan (NCP), dated 7/19/24, the NCP indicated, Alteration in nutrition and at risk for weight loss related to poor meal intake. There was no documented evidence the NCP was revised or updated. During a review of Resident 71'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 provide care and services in accordance with acceptable professional standards of quality for two out of 19 sampled residents (Resident 4 and Resident 65) when: 1. An assessment was not found for a new laceration to Resident 4's index finger; and, 2. Oxygen was not provided per physican's orders for Resident 65. These failures had the potential of worsening the residents' clinical conditions. Findings: 1. Resident 4 was admitted to the facility in mid-2024 with diagnoses which included Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors), osteoarthritis (joint break down), disorder of bone density and structure. During an interview and observation on 8/5/24 at 8:45 a.m. Resident 4 was seen with a splint on her left hand. And stated in Spanish, I fall and cut my finger. During a concurrent interview and record review on 8/7/24 at 9:10 a.m. with Licensed Nurse (LN 8), LN 8 reviewed Resident 4's computerized records and confirmed there were no documented…

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

Based on observation, interview, and record review, the facility failed to ensure the communication needs were met for two of 19 sampled residents (Resident 148 and Resident 40), when there were no communication sheet or device accessible at the bedside for the staff to communicate with the residents. This failure had the potential to result in not meeting the resident's highest practicable well-being. Findings: 1. Resident 148 was admitted in the middle of 2024 with diagnoses which included anxiety, depression, right hip pain, and difficulty walking. During a review of Resident 148's Baseline Care Plan (BCP), dated 7/23/24, the BCP indicated, Health and Safety History and Potential Risks: Communication Barriers/Devices/Interpreter. During a review of Resident 148's Nursing Care Plan (NCP) dated 7/23/24, the NCP indicated, [Resident 148] is Spanish speaking and has a language barrier with staff .Resident prefers to communicate in Spanish .The resident is able to communicate by: using communication board (located at bedside). During a concurrent observation and interview on 8/5/24 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 ensure one of 19 sampled residents (Resident 63) received a specialty mattress used to treat a Stage 4 pressure injury (PI, injury to the skin and underlying tissue from prolonged pressure on the skin. Stage 4, full thickness skin loss, wound can extend to muscle and bone). This failure had the potential for the wound to worsen and increased pain. Findings: Resident 63 was re-admitted to the facility in mid-2024 with diagnoses which included malnutrition, pressure injury of sacral region (tailbone) Stage 4, osteomyelitis (infection in the bone), right above the knee amputation, and rectal abscess. During a review of Resident 63's Braden Score [scale used to predict PI risk], dated 7/16/24, the Braden Score indicated Resident 63 was bedfast (confined to bed), and had very limited ability to change and control his body position. During a review of Resident 63's SKILLED NURSING FACILITY ORDERS FOR HOSPICE CARE, dated 7/16/24, the orders indicated, .continue with specialty bed- [brand name of low air loss…

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 pharmaceutical policies and procedures for one out of five sampled residents (Resident 29), when calcium-vitamin D (a type of vitamin and mineral) was not available to be given to the resident during medication pass. This failure resulted in Resident 29 not receiving her morning medication as prescribed by the physician. Findings: During a medication pass observation on 8/5/24 at 8:22 a.m., with Licensed Nurse (LN 3), LN 3 prepared and administered Resident 29's medications which did not include calcium with vitamin D. During a review of Resident 29's Physician Orders (PO), dated 6/8/24, the PO indicated, Calcium-vitamin D 600-200 mg-u (milligram, unit of measure) give one tablet by mouth two times a day for supplement. During a review of Resident 29's Medication Administration Record (MAR), dated August 2024, the MAR indicated the morning dose of calcium-vitamin D was not administered on 8/5/24. During an interview on 8/5/24 at 1:15 p.m. with LN 3, LN 3 stated, The calcium with vitamin D for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4. A review of Resident 3's admission record indicated she was admitted in 1/24 with diagnoses including dementia, diabetes, and vitamin deficiency. During a current observation, interview and record review on 8/5/24 at 12:51 p.m., with Resident 3, Resident 3's tray ticket (a ticket including resident's diet, date, allergies, specific food and beverage items, dislikes, likes) indicated Resident 3 should have a Healthshake (high protein supplement) and Udon (Japanese noodles) soup with her meal. A Healthshake and Udon soup was not present with Resident 3's meal, there was a tomato soup present. Resident 3 stated the tomato has no taste and she likes Udon soup it's good Japanese soup . A concurrent interview with Restorative Nursing Aide 1 (RNA 1), RNA 1 confirmed that the Healthshake and soup weren't present. During an interview on 8/5/24 at 1:00 p.m., with the Food Services Supervisor (FSS), the FSD also confirmed that Resident 3 did not receive the Healthshake and Udon soup. During an interview at 8/6/24 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 ensure proper infection practices were followed for three out of 19 sampled residents (Resident 47, Resident 63, and Resident 35) when: 1. Resident 47's oxygen and nebulizer tubing were not dated; 2. Licensed Nurses (LN) touched multiple items after performing a bandage change on Resident 63 who had Methicillin-resistant Staphylococcus aureus (MRSA, a bacteria that is resistant to many antibiotics) in his wound; and, 3. Unlabeled and undated oxygen tubing and face mask were found by Resident 35's bedside. These failures had the potential to spread infection. Findings: 1. Resident 47 was admitted to the facility mid-2024 with diagnoses which included cirrhosis of the liver (damaged liver tissue), hypertension (high blood pressure), renal failure, and diabetes (uncontrolled blood sugar). During a concurrent observation and interview on 8/5/24 at 8:45 a.m. with Licensed Nurse (LN) 9, LN 9 confirmed Resident 47's oxygen and nebulizer tubing were not labeled or dated, and stated, I think all tubing should be…

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 safety and supervision for one of three sampled residents (Resident 1), when the resident walked out of the facility unnoticed. This failure resulted in resident's injury and with the potential for further falls and injuries not maintaining his highest practicable well-being. Findings: Resident 1 was admitted in late 2023 with diagnoses which included dementia (memory impairment), communication impairment, difficulty walking, muscle weakness, and need for assistance with personal care. During a review of Resident 1's History and Physical (H&P), dated 11/28/23, the H&P indicated, At recent baseline, [Resident 1] is alert, able to follow commands, able to walk without a walker and most ADLs (activities of daily living) independently. During a review of Resident 1's Baseline Care Plan (BCP), dated 12/4/23, the BCP indicated Resident 1 was alert with periods of forgetfulness and a fall risk. During a review of Resident 1's Elopement Risk Assessment (ERA), dated 12/4/23, the ERA indicated Resident 1 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the resident needs and preferences were accommodated for four of 25 sampled residents (Resident 14, Resident 23, Resident 13, and Resident 51), when: 1. Resident 14 did not receive bottled water and food requests; 2. Resident 23 did not receive food requests and an adaptive device; and 3. Resident 13 and Resident 51's call light buttons were found on the floor out of their reach. These failures had the potential to result in the residents not attaining their unmet needs, not maintaining their highest practicable physical, emotional and psychosocial well-being, as well the potential to result in compromised resident safety. Findings: 1. Resident 14 was admitted to the facility in the middle of 2016 with diagnoses which included stroke, acid reflux disease, and difficulty swallowing. During a review of Resident 14's Nursing Care Plan (NCP) dated 4/27/17, the NCP indicated, [Resident 14] exhibits excessive demands .Anticipate and meet…

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 comprehensive care plan for two out of 25 sampled residents (Resident 41 and Resident 53), when: 1. Resident 41's communication care plan intervention was not implemented; and 2. Resident 53's care plan did not include interventions to monitor for side effects of an anticoagulation (blood thinner) medication. These failure had the potential to result in residents not attaining their highest practicable physical, mental and psychosocial well-being. Findings: 1. Resident 41 was admitted in the middle of 2020 with diagnoses which included anxiety, depression, right hip pain, and difficulty walking. During a review of Resident 41's Nursing Care Plan (NCP), dated 6/2/20, the NCP indicated, [Resident 41] has a communication problem r/t [related to] Language barrier. She speaks Spanish .Spanish communication sheets placed at bedside. During a review of Resident 41's Minimum Data Set (MDS, an assessment tool), dated 5/4/23, the MDS…

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: 1. Ensure accurate accountability and effective storage of controlled medications (those with high potential for abuse or addiction) when random controlled medication audits for three out of four residents (Residents Resident 22, Resident 314, and Resident 315) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but were not documented accurately on the Medication Administration Record (MAR) to indicate they were given to the residents. 2. Have an efficient system in place to accurately document and secure emergency medications (E-Kit) for a census of 84. These failures resulted in the facility not having accurate accountability of controlled medications and potential for abuse or misuse of these medications, the potential for emergency medications to be unavailable when needed, and the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions. Findings: 1.…

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

Based on observation, interview, and record review, the facility had a 11.11% error rate when three medication errors out of 27 opportunities were observed during a medication pass for two of five Residents (Residents 21 and 512). This failure resulted in medications not given in accordance with the prescriber's orders and potential to affect the residents' clinical conditions. Findings: During a medication pass observation on 7/31/23 at 8:23 a.m. with Licensed Nurse 1 (LN 1), LN 1 was observed preparing ten medications, including glipizide (a medication to treat diabetes) 5 milligram (mg, a unit of measure) and aspirin (a medication to prevent blood clots) 81 mg delayed release (DR, a slow-release formulation) for Resident 512. LN 1 looked inside the medication cart and medication storage room for the aspirin but was unable to locate it. A review of Resident 512's medical record indicated the following physician's orders: - Glipizide 5 mg: 1 tablet two times a day. Give 30 minutes prior to meals, dated 7/26/23 - Aspirin (medication to prevent blood clots) 81 mg DR: 1 tablet one…

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

Based on observation, interview, and record review, the facility failed to ensure: - Medication carts were kept securely locked when left unattended; - Opened biologicals, multi-dose inhalers, and inhalation solutions were dated with an open and discard date, to ensure they were not used beyond the discard date; - Medications and single resident over-the-counter (OTC) products were appropriately labeled with a pharmacy label or name to correctly identify which resident they were for; - Food was stored separately from resident medications in the Medication Storage Room refrigerator; - Expired medications were not available for resident use; and - Biologicals were stored in accordance with facility policy and procedure. The deficient practices had the potential for residents to receive medications with unsafe or reduced potency from being used past their discard date or improper storage, and diversion or misuse of medications from not being securely stored in medication carts. Findings: During an observation on 7/31/23 at 8:14 a.m., the Medication Cart (med cart) in Elm Hall was…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the 67 residents eating facility prepared meals, when: 1) Two concentrated juice boxes were not labeled and dated; 2) Five plastic tubs were found wet, stacked in the ready to use shelves; 3) Five pieces of equipment were found worn, dirty and/or rusted; 4) One diet aide did not cover his beard adequately while working around food; and 5) One cook failed to follow food safety/sanitation procedures while preparing pureed meals. These failures had the potential to lead to food-borne illnesses. Findings: 1) During the initial kitchen tour on 7/31/23 at 9:05 a.m., two 3.5-liter boxes of orange guava juice concentrate did not have a received, use-by, or expiration label. During a concurrent observation and interview on 7/31/23 at 9:40 a.m., with the Dietary Supervisor (DS), the DS confirmed that there was no label on the orange guava juice. The DS stated, The lack of labels mean we do not have any dates…

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 dignity was promoted for two of 25 sampled residents (Resident 7 and Resident 46), when the urinary catheter bags were exposed. This failure had the potential to negatively impact Resident 7 and Resident 46's mental and psychosocial well-being. Findings: Resident 7 was admitted to the facility in mid 2019 with diagnoses which included bladder dysfunction and kidney failure. Resident 46 was admitted to the facility in mid 2022 with diagnoses which included bladder dysfunction, chronic kidney disease, and urine retention. During an observation on 7/31/23 at 8:25 a.m., Resident 7's urinary catheter bag was not covered by a privacy bag. During an observation on 7/31/23 at 3:27 p.m., Resident 46's urinary catheter bag was not covered by a privacy bag. During a concurrent observation and interview on 7/31/23 at 3:28 p.m. with the Certified Nursing Assistant 4 (CNA 4), CNA 4 confirmed neither Resident 7 nor Resident 46 had a privacy cover for their urinary catheter bags. CNA 4 stated, Neither resident has a…

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

Based on observation, interview, and record review, the facility failed to provide care and services in accordance with acceptable professional standards of quality for one of 25 sampled residents (Resident 512), when nursing staff failed to verify the contents of a probiotic (a supplement to support and promote gut health) administered to Resident 512. This failure resulted in Resident 512 receiving the incorrect probiotic and the potential for worsening of their clinical condition or complications related to gut health such as diarrhea, nausea and vomiting. Findings: During a medication pass observation on 7/31/23 at 8:23 a.m. with Licensed Nurse 1 (LN 1), LN 1 was observed preparing ten medications for Resident 512, including Florastor (a probiotic used to maintain or promote gut health) 250 milligrams (mg, a unit of measurement) 1 capsule. During a review of Resident 512's medical record indicated a physician's order, dated 7/30/23, for lactobacillus (a probiotic) 500 million units, 1 capsule once daily for seven days for GI (gastrointestinal) prophylaxis (protection). 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 failed to ensure the communication needs were met for one of 25 sampled residents (Resident 41), when there was no communication sheet or device accessible for the staff to communicate with the resident. This failure had the potential to result in not meeting the resident's highest practicable well-being. Findings: Resident 41 was admitted in the middle of 2020 with diagnoses which included anxiety, depression, right hip pain, and difficulty walking. During a review of Resident 41's Nursing Care Plan (NCP), dated 6/2/20, the NCP indicated, [Resident 41] has a communication problem r/t Language barrier. She speaks Spanish .Spanish communication sheets placed at bedside. During a review of Resident 41's Minimum Data Set (MDS, an assessment tool), dated 5/4/23, the MDS indicated Resident 41 had mild memory impairment, spoke Spanish language and needed interpreter to communicate, and required extensive assistance with activities of daily living. During a concurrent observation and interview on 7/31/23 at 9:58 a.m., Resident…

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

Based on observation, interview and record review, the facility failed to provide safety and supervision for one of 25 sampled residents (Resident 8), when the resident was left in a wheelchair unattended and unsupervised during care with hot water left running in the resident's room sink. This failure had the potential to result in accidents and falls and not maintaining the resident's physical and psychosocial well-being. Findings: Resident 8 was admitted in the middle of 2020 with diagnoses which included traumatic brain injury (TBI, an injury that affects how the brain works), memory impairment, and anxiety. During a review of Resident 8's Nursing Care Plan (NCP), dated 11/2/18, the NCP indicated, [Resident 8] is at risk for falls secondary to poor safety awareness .impaired mobility .unsteady gait/balance .has history of falls .Assist with ADL's [activities of daily living]. During a review of Resident 8's Order Summary Report (OSR), dated 11/9/18, the OSR indicated, [Resident 8] has no mental capacity to make decisions. Due to TBI. During a review of Resident 8's Minimum Data…

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

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program for one of 25 sampled residents (Resident 13), when an outdated nebulizer mask (breathing treatment device) was still in use and should have been discarded. This failure increased the potential risk for respiratory infection. Findings: Resident 13 was admitted to the facility in the summer of 2019 with diagnoses which included malignant cancer and comfort care. During a record review of Resident 13's Order Summary Report (OSR), dated 7/18/23, the OSR indicated, Albuterol sulfate (a medication used to treat shortness of breath), one vial inhale orally via nebulizer every six hours as needed. During a concurrent observation and interview on 7/31/23 at 10:34 a.m. with Director of Nursing (DON), DON confirmed Resident 13's nebulizer mask was dated 7/30/23. The DON indicated 7/30/23 was the expiration date and the mask should have been replaced with a new one on that date. The DON stated, The mask should be replaced every seven days to prevent infection. During…

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.