Cedarwood Post Acute

Based on observation, interview, and record review the facility failed to ensure residents received their prescribed therapeutic diet (a meal plan prescribed by a physician and tailored by a registered dietitian) for one of 17 sampled residents (Resident 39). When Resident 39 was served lunch with a salt packet, while on a no added salt diet during lunch mealtime. This failure had the potential for Resident 39's chronic medical conditions of high blood pressure and chronic kidney disease to worsen, causing negative health outcomes. During an observation on 6/14/26, at 12:30 p.m., in Resident 39's room, Resident 39 was eating her lunch while in bed, with her family member at bedside. A salt packet was noted on Resident 39's meal tray. Resident 39's meal tray ticket read NAS (No Added Salt).During an interview on 6/14/26, at 12:31 p.m., with Resident 39's family member, family stated, [Resident 39] is probably not supposed to have salt because she has high blood pressure.During an interview on 6/14/26, at 12:34 p.m., with Certified Dietary Manager (CDM), outside of Resident 39's room,…

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 maintain a system to monitor COVID-19 vaccination status of staff and education to staff related to benefits and potential side effects of the COVID-19 vaccine. This failure resulted in the facility not having accurate monitoring of the staff's COVID-19 vaccination status with the potential for infection to staff and residents. During an interview on 6/16/26 at 9:44 a.m. with Licensed Nurse (LN 5), LN 5 stated she has received information regarding the COVID-19 vaccine and that it was offered yearly. During an interview on 6/16/26 at 11:23 a.m. with the Infection Preventionist (IP), the IP stated he started as the IP at the facility in January 2026. The IP stated that COVID-19 vaccines are offered to the staff. Requested tracking or monitoring log for staff COVID-19 vaccination status and education. The IP stated the only tracking of staff vaccinations is currently in the personnel files. The IP stated the vaccination consents and declinations are in the personnel files. The IP stated if an employee reports to him that…

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

Based on observation, interview, and record review, the facility failed to maintain safe equipment for one of 17 sampled residents (Resident 40), when Resident 40's bed control power cord was frayed with exposed wires. This failure placed Resident 40 at risk for injury. A review of Resident 40's admission Record indicated Resident 40 was admitted to the facility in August 2025 with multiple diagnoses including metabolic encephalopathy (change in how the brain works due to an underlying condition causing confusion or memory loss), dementia (loss of memory, language, and thinking abilities that are severe enough to interfere with daily life), chronic obstructive pulmonary disease (lung condition that limits airflow into and out of the lungs), and dysphagia (difficulty swallowing). A review of Resident 40's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 4/14/26, indicated Resident 40 had a long-term and short-term memory problem and his cognitive skills for daily decision making were severely impaired. During an observation on 6/14/26 at 8:49…

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 interviews and record review, the facility failed to ensure a Minimum Data Set (MDS, a standardized assessment tool used in skilled nursing facilities) Significant Change in Status Assessment (SCSA, an MDS assessment done within 14 days after a resident has a significant change in their health status) was completed for one of six sampled residents (Resident 3) when Resident 3 developed a stage 3 pressure ulcer (tissue damage that results in full-thickness loss of skin and the layer of fat under the skin may be visible) and was not assessed.This failure had the potential to delay wound treatment, placing Resident 3 at risk for increased pain, infection, and a decline in functional status for the resident. Findings:Resident 3 was admitted to the facility in March of 2026 with diagnoses that included a femur fracture.A review of Resident 3's document titled admission Assessment: Nursing - V2, dated 3/14/26, indicated that Resident 3 did not have a pressure ulcer at the time of the assessment.A review of Resident 3's document titled Wound Assessment Report, dated 5/14/26, 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 interviews and record review, the facility failed to ensure that Minimum Data Set (MDS, a standardized assessment tool used in skilled nursing facilities) assessments accurately reflected residents' current clinical status for two of six sampled residents (Resident 1 and Resident 2), when Resident 1's chest incisions were not coded on the MDS admission assessment and Resident 2's ongoing dialysis (a treatment that filters waste and excess fluid from your blood when the kidneys are no longer functioning) treatment was not coded on a quarterly MDS assessment.These failures could have resulted in Resident 1 not receiving necessary wound care and Resident 2 missing or receiving poorly coordinated dialysis treatments.Findings:Resident 1 was admitted to the facility in May of 2025 with diagnoses that included atherosclerotic (buildup of fatty plaques made of cholesterol, fat, and other material inside the arteries) heart disease.During a review of Resident 1's admission MDS assessment section M (MDS section that assesses residents for skin conditions), dated 6/5/26, 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 store, prepare, distribute and serve food properly in accordance with professional standards for food service safety for a census of 49 when: 1) Two metal bowls and 9 plate cover lids stored wet and stacked, 2) Two plastic cups had white film build up inside the cups, 3) Two thermometers missing inside freezers, 4) Open food items were not labeled with use by date, and, 5) Food items were not covered during resident food distribution of meal trays These failures increased the potential for food borne illness. Findings: 1.During a concurrent initial tour observation and interview on 6/10/25 at 8:20 a.m. with the Dietary Manager (DM), nine plate cover lids and two small bowls were stored upright with water collected at the bottom of the bowl. The DM stated that the plate cover lids and bowls should be on a drying rack to air dry completely before storing. During an interview on 6/12/25 at 1:10 p.m. with the Registered Dietician (RD), RD stated lids and bowls should always be air dried and confirmed that if not…

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 resident needs were accommodated for seven out of 19 sampled Residents (Resident 13, Resident 47, Resident 152, Resident 19, Resident 4, Resident 5, and Resident 10), when 1. The call light was not within reach for Resident 13, Resident 47, Resident 152 and Resident 19; 2. Resident 4 and Resident 5 did not have interventions regarding inability to use call lights in their care plans; and, 3. Resident 10 did not have a call light that accommodated his special needs These failures had the potential to result in the residents not attaining their highest practicable physical, psychosocial and emotional well-being. Findings: 1. Review of Resident 13's admission Record indicated Resident 13 was admitted [DATE] with diagnoses including rhabdomyolysis (a condition which damaged skeletal muscle breaks down rapidly), muscle weakness, other abnormalities of gait (a person's manner of walking) and mobility, and need for assistance with personal…

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 error rate was below 5% or greater when the error rate was 25.81% based on eight medication errors out of 31 opportunities observed during a medication administration observation for four out of six residents (Resident 20, Resident 36, Resident 101, and Resident 25). This failure resulted in medications not given in accordance with the prescriber's orders or manufacturer's specifications and had the potential to affect the residents' clinical conditions. Findings: 1.During a medication administration observation on 6/11/25 at 7:55 a.m. with Licensed Nurse (LN) 1, outside of Resident 20's room, LN 1 was observed preparing 6 medications for Resident 20, including chewable aspirin (ASA-medication for pain that can be used as prevention for heart disease) and omeprazole delayed-release tablet (medication used to treat excess stomach acid and help control heartburn). At 8:01 a.m., LN 1 went inside the room with a 5 oz (ounces-unit of measurement) cup of water to give the medications to 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 implement and maintain an effective infection prevention and control program for a census of 49 residents when a shared blood pressure (BP) cuff was not cleaned and sanitized properly in between resident use. This failure resulted in increased risk for cross-contamination (transfer of bacteria from one person, object, or place to another) and may cause infections among residents. Findings: During an observation on 6/11/25 at 7:48 a.m., Licensed Nurse (LN) 1 took the blood pressure (BP) of Resident 20 using a BP cuff from the medication cart without sanitizing it. LN 1 placed the BP cuff on Resident 20's right arm. After completing the task, LN 1 exited the room and placed the BP cuff in the medication cart without sanitizing it. At 8:04 a.m., LN 1 used the same BP cuff on Resident 36 without sanitizing it prior to use. LN 1 did not sanitize the BP cuff in between resident use before placing it back into the medication cart. During an observation on 6/11/25 at 8:51 a.m., LN 2 was observed taking the blood…

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 five residents out of a census of 49 (Resident 201, Resident 29, Resident 31, Resident 12, and Resident 44) were treated with dignity and respect when: 1) Resident 201's urinary catheter bag was not covered by a dignity bag; and, 2) RNA 1 and RNA 2 were standing up when assisting to feed Resident 29 and Resident 31; and, 3) Resident 12 and Resident 44 were not asked if they had a preference on using clothing protectors during their meals. These failures placed Resident 201, Resident 29, Resident 31, Resident 12 and Resident 44 at potential risk of diminished self-esteem and feelings of self-worth. Findings: 1.During a review of Resident 201's admission Record, indicated Resident 201 was admitted [DATE] with a diagnosis of metabolic encephalopathy (a condition characterized by altered brain function) and bacteremia (bloodstream infection). During a review of Resident 201's Minimum Data Set (MDS - a federally mandated 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 review and revise the comprehensive care plan for two of 49 sampled residents (Resident 255 and Resident 10) reflecting the residents' current health status and needs when: 1. Resident 255 's care plan was not updated for self-administration of medications; and, 2. Resident 10's care plan was not updated for wound dressings on his hands. These failures had the potential to result in Resident 255 and Resident 10 receiving outdated and not person-centered care placing the residents at risk for not meeting their highest practicable well-being. Findings: 1.During a review of Resident 255's admission Record indicated, Resident 255 was admitted to the facility May 2025 with multiple diagnoses which included Sjögren's syndrome (a chronic autoimmune disease where the body's immune system mistakenly attacks moisture-producing glands, particularly those in the eyes and mouth). During a review of Resident 255's Minimum Data Set (MDS - a federally…

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 a comprehensive care plan on wound care interventions for 2 of 6 sample residents (Resident 2 and Resident 4). This failure to develop and implement a comprehensive person centered care plan on specific wound care needs had the potential for Resident 2 and Resident 4 to receive inaccurate and inadequate care. Findings: During record review of Minimum Data Set (MDS, an assessment tool) for Resident 2 dated 10/1/2024, indicated, Resident 2 had diabetic foot ulcer under (MDS) section M. During interview with Resident 2 on 11/20/2022 at 3:25 p.m., stated, had . wound to right foot, wound dressings changed every other day . A record review of Resident 2's clinical record indicated treatment order dated 11/19/2024 for Right Plantar Foot, Diabetic . During record review of Resident 2's electronic health record, there was no care plan for Resident 2 ' s diabetic foot ulcer and wound order treatment. During record review of Resident 4's clinical record, indicated a primary diagnosis of Infection following 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 ensure hemodialysis (HD- treatment that filters waste from the blood when kidneys are not working) services were provided per facility policy for one of three sampled residents (Resident 1), when Resident 1 missed four outpatient hemodialysis appointments due to lack of transportation services and the physician was not notified of missed HD appointments. This failure resulted in Resident 1 going to the hospital for potential fluid retention increasing the risk for respiratory decline. Findings: A review of Resident 1's admission Record indicated Resident 1 was initially admitted to the facility in September 2024 with multiple dagnoses including cerebral infarction (stroke- disrupted blood flow to the brain causing brain tissue death), chronic obstructive pulmnary disease (lung disease that blocks airflow causing breathing difficulties), and end stage renal disease (kidneys stop functioning and no longer filter waste from the blood). A review of Resident 1's Minimum Data Set (MDS-a federally mandated…

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 appropriate indwelling catheter (a tube placed in the body to drain and collect urine from the bladder) care and services for one of 4 sampled residents (Resident 1) when Resident 1 did not have physician order for indwelling catheter care nor a catheter change for several months after admission to the facility. This failure had the potential to contribute to Resident 1's development of a urinary tract infection (UTI, a clinically detectable condition associated with invasion by disease causing microorganisms of some part of the urinary tract). Findings: During a review of Resident 1's facesheet (a document that gives a resident's information at a quick glance) dated 10/2/24, the facesheet indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including benign prostatic hyperplasia (BPH, age-associated prostate gland enlargement that can cause urination difficulty) without lower urinary tract symptoms, stage 4 sacral…

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 observations, interviews and record reviews, the facility failed to assure professional standards of care were followed when: 1. Resident 15, 19, and 29's oxygen tubing (a device that delivers extra oxygen through a tube into your nose) and humidifiers (devices used to humidify supplemental oxygen) were not labeled, dated and changed. 2. Resident 11's physician order for 1:1 (one on one) feeding assistance with meals was not carried out as ordered. 3. Resident 28's physician order for a plate guard (an adaptive device that prevents food from accidentally being pushed off the plate while eating) with all meals was not carried out as ordered. 4. Resident 30's admission medications order for Budesonide inhaler medication to treat a respiratory condition of Chronic Obstructive Pulmonary Disease (COPD) was not entered in the facility's Medication Administration Record and medication was not offered or administered to Resident 30 per physician's order. 5. Licensed Nurse 1 (LN 1) did not observe Resident 27 ingest his afternoon medication. 6. Resident 27's Medication…

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 and kept confidential multiple residents medical records. This failure had the potential to exposed multiple residents health information by persons not involved in the residents care, for a facility census of 51. Findings: On 8/20/24 at 1:54 p.m. a large open cardboard box was found underneath one of the desk in the Physical Therapy Department (PTD). The open box was observed to contain multiple residents confidential health information records of residents receiving Physical Therapy and Occupational Therapy (OT). The open and unsecured cardboard box was located near the doorway where other residents and visitors come and go outside to access the patio area. There was a potential for unauthorized access into the cardboard box and unauthorized persons not involved with patient care. During an additional observation of the Physical Therapy Department (PTD) there were no confidential records bins located in the PTD. The nearest accessible confidential records bin were 2 large bins observed located outside…

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 of the Medication Administration Record (MAR) and Controlled Drug Record (CDR) for three residents (Residents 9, Resident 28, and Resident 296) did not reconcile to indicate they were given to the residents. 2. Implement a system to accurately document and secure emergency medications (E-Kit). 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. Finding: 1. Resident 9 had a physician's order of oxycodone (a medication to treat moderate to severe pain) 5 milligrams (mg, a unit of measurement) , one tablet by mouth every six hours if needed, ordered 8/16/24.…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility had a 12.82% error rate when five medication errors out of 39 opportunities were observed during a medication pass for three of six sampled Residents (Residents 9, 21, and 30). This failure resulted in medications not given in accordance with the prescriber's orders and potential to affect the residents' clinical conditions. Findings: 1.During a medication observation on 8/20/24 at 8:30 a.m., with Licensed Nurse 2 (LN 2), LN 2 was observed preparing 11 medications including losartan (a medication to treat high blood pressure) and B Complex with vitamin C for Resident 9. A review of Resident 9's medical record indicated the following physician's orders: - Losartan 25 milligrams (mg, a unit of measurement): Give 1 tablet by mouth one time a day for hypertension with a meal/ food. Hold for SBP (systolic blood pressure, the maximum pressure in the heart when it pushes blood out to the body) is less than 110 or pulse is less than 60; 1 tablet by mouth…

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 14 sampled residents (Resident 30) was free of a significant medication error when Resident 30 missed 25 doses of Brovana (generic name aformoterol tartrate, a medication to treat breathing problems) when nursing staff did not know to check for it in the medication storage room refrigerator. This deficient practice had the potential to result in breathing complications and worsening of Resident 30's clinical condition. Findings: During a medication pass observation on 8/20/24 at 9:10 a.m. with Licensed Nurse (LN) 2, LN 2 was observed preparing 12 medications for Resident 30. LN 2 looked in the medication cart and could not locate Resident 30's Brovana (a medication used to treat breathing issues) and stated she would not be able to administer it as scheduled for that morning. A review of Resident 30's medical record indicated that the following physician's order: - Brovana Inhalation Nebulization Solution 15 micrograms /2 milliliters (mcg/ml, a unit of measurement): Inhale one vial orally via…

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, kitchen staff failed to demonstrate appropriate competencies to carry out kitchen sanitation when: 1. Staff were unable to show the correct procedure for testing of sanitation solution buckets, and 2. Staff did not test dishwashing sanitation at the plate level, which was necessary to ensure adequate sanitation had occurred. These failures had the potential of leading to food borne illness for the 49 residents eating facility prepared food. Findings: 1. During the initial kitchen tour on 8/20/24 at 9:24 a.m., dietary aide 1 (DA1) was asked to show how the red sanitation buckets were tested to ensure the proper concentration of sanitizer. DA1 threw out the solution in the bucket and refilled from the dispenser on the wall. Another red bucket was in the sink, DA1 was asked to test the existing bucket. DA 1 took a test strip and held in in the solution for 10 seconds (directions on bottle stated to hold in solution for 5 seconds). Upon taking the strip out of the solution, he compared that the test strip to the color coding on the…

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

Based on observation, interview, and record review, the facility failed to ensure food storage, preparation and cleaning areas were in accordance with professional standards for food service safety when: 1) Foods that had been opened previously were not tightly closed, 2) A dirty fan was turned on and blowing onto clean plate guards, 3) Dishwash sanitizer solution test strips were not correct for solution type (to ensure sanitation occurred), 4) Resident refrigerator/freezer containing food for residents had food products marked with a room number but missing resident name. This failure had the potential to cause food borne illness in 49 of the 51 facility residents that received facility prepared foods. Findings: 1. During a concurrent observation and interview during the initial kitchen tour on 8/20/24 at 8:40 a.m., with Certified Dietary Manager (CDM), a bag of previously opened shredded cheddar cheese was found unsealed. The CDM verified that the bag of previously opened shredded cheese was not properly sealed. The CDM stated he would want to make sure that this gets sealed so…

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 informed consent was obtained (the process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) on the use of psychotropic medication (drugs that affect a person's mental state) for one of 14 sampled residents (Resident 447). This failure decreased the facility's potential to ensure Resident 447 and responsible party (RP) were aware of the risks, benefits, and alternatives of treatment offered to them. Findings: A review of Resident 447's admission records indicated admission to the facility on 8/12/24, with diagnoses which included dementia (the impaired ability to remember, think, or make decisions), bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and schizophrenia (a serious mental health condition that affects how people think, feel, and behave). Resident 447's admission records also indicated a relative was the RP. A review of Resident 447's medical…

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 observations, interviews and record reviews the facility failed to ensure resident assessments were accurate for one resident (Resident 15) out of nineteen sampled residents. This failure had the potential to establish incorrect baseline data and treatment for Resident 15. Findings: A review Resident 15's admission Record indicated Resident 15 was admitted to the facility in April 2024 with diagnoses which included metabolic encephalopathy (when problems with metabolism cause brain dysfunction) and generalized weakness. During a concurrent observation and interview on 8/20/24 at 9:10 a.m. in Resident 15's room, Resident 15 was lying in bed. There was no urinary catheter tube (a flexible tube used to empty the bladder) or catheter bag (a bag that collects urine) observed. Resident 15 stated, I can get out of bed myself, I don't use a [urinary] catheter. During a concurrent interview and record review on 8/22/24 at 3:52 p.m., with the Director of Nursing (DON) Resident 15's Order Summary Report (OSR, physician orders), Minimum Data Set (MDS, an assessment tool) dated 5/3/24…

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 develop a comprehensive care plan on the use of a BiPAP ( a noninvasive ventilator that helps people breathe by delivering pressurized air into their airways through a face mask) machine for 1 of 19 sampled residents (Resident 10). This failure to develop a care plan on the use of a BiPAP machine had the potential for Resident 10 to received inaccurate and inadequate care. Findings: During a record review of Resident 10's facesheet, the clinical record indicated Resident 10 was admitted with diagnoses of Type 2 Diabetes (a condition of too much sugar in the blood), and Neurocognitive Disorder (a category of mental health disorders that primarily affect cognitive abilities including learning, memory, perception, and problem-solving) with Lewy Bodies (clumps of abnormal protein particles that accumulate in the brain and caused a form of dementia). During the initial pool tour on 8/20/24 at 11 a.m., Resident 10 was observed lying in bed. Resident 10 was was interviewable but confused as to time and place.…

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 51 residents, when a medication cart (a lockable cabinet on wheels that stores drugs and supplies) and a treatment cart (a lockable cabinet on wheels that stores drugs and supplies) were unlocked and unattended. These failures had the potential for drug diversion and drug misuse. Findings: During a concurrent observation and interview on 8/20/24 at 8:22 a.m. with the Activities Director (AD) in the walkway in front of the nursing station, the AD confirmed a treatment cart was observed to be unlocked with keys hanging from the lock cylinder while no staff were present at the cart. The AD confirmed the cart stored drugs and should have been locked. During a concurrent observation and interview on 8/20/24 at 8:27 a.m. with Licensed Nurse 1 (LN 1), in the walkway in front of the nursing station, medication cart A was observed to be unlocked while no staff was present at the cart. The LN 1 confirmed the cart was unlocked while he was at the nursing station,…

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 a resident (296) the appropriate nutritive profile matching the physician prescribed renal diet when potatoes were served. This failure had to potential to lead to confusion regarding diet restrictions for the resident, as well as lead to heart issues due to the high potassium content from the meal provided. Findings: During an observation of the lunch meal on 8/20/24 at 12:50 p.m., Resident 296 was in his bed eating his lunch. The meal plate contained turkey, 2 scoops of mashed potatoes, and broccoli. Resident 296 points to the potatoes and stated that those aren't allowed on the renal diet. Resident 296's tray ticket showed that a renal diet had been ordered, and potatoes were listed as a dislike. During an interview on 8/20/24 at 3:45 p.m. with the Certified Dietary Manager (CDM), the CDM confirmed that renal diet restrictions were listed in the dislike column of the meal tray tickets to provide another cue to food servers of what they should not serve. In reviewing resident 296's tray ticket, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the infection prevention and control program guidelines and practices were maintained for a census of 51, when Certified Nursing Assistant 5 (CNA 5) was observed taking trash from one resident room to another and allowed trash bags to rest against her clothing. This failure had the potential to result in transmission and spread of infection for a vulnerable population. Findings: During a concurrent observation and interview on 8/22/24 at 8:15 a.m. with CNA 5 in the hallway outside of room [ROOM NUMBER], CNA 5 was observed removing and carrying two bags from room [ROOM NUMBER] and then entered room [ROOM NUMBER] with the two bags, and then CNA 5 exited room [ROOM NUMBER] with the two bags. CNA 5 stopped to speak with the Department and was observed resting the two bags against her leg, making direct contact with her pants. CNA 5 stated the two bags contained trash from room [ROOM NUMBER] and she had taken the two bags of trash…

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 administer a pneumococcal vaccine (immunization [process of becoming protected against a disease through vaccination] against pneumonia [an inflammatory condition of the lung]) for one of 19 sampled residents (Resident 15). This failure placed Resident 15 at an increased risk for illness that the vaccine could have prevented or decreased the severity of symptoms. Findings: A review of Resident 15's admission record, indicated Resident 15 was admitted to the facility in April of 2024 with diagnoses that included a history of having a tumor in the lungs and respiratory failure (not enough oxygen passes from the lungs to the blood). A review of Resident 15's Pneumococcal Vaccine Informed Consent, dated 4/27/24, indicated Resident 15 marked the option I hereby GIVE the facility permission to administer a pneumococcal vaccination . to the best of my knowledge, I have not received a pneumococcal vaccination in the past five years . A review of Resident 15's Minimum Data Set (MDS: an assessment tool), dated 8/3/24, indicated…

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

Based on observation, interview and record review, the facility failed to maintain the reach-in freezer in a safe operating condition when ice build-up was found on the freezer ceiling. This had the potential of leading to food borne illness for the 49 residents receiving facility prepared meals. Findings: During the initial kitchen observation on 8/20/24 at 9:04 a.m., the reach-in freezer was opened to reveal circles of ice crystals (approximately ½ inch in diameter) on the freezer ceiling. The freezer door gasket appeared misshapen in the upper, outer corners. During a concurrent interview with the Certified Dietary Manager (CDM), the CDM confirmed the ice build-up on the freezer ceiling. During a return visit to the kitchen on 8/22/24 at 9:20 a.m., the reach-in freezer was shown to the Maintenance Supervisor (MS). The MS noted the buildup of ice on the freezer ceiling and stated that it may be the result of the freezer door not being closed tightly. During an interview on 8/22/24 at 4:24 p.m. with the CDM, the CDM stated that the problem with ice build-up in the freezer was that…

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

Based on observation, interview, and record review, the facility failed to ensure a call light (a device used by a resident to signal the need for help) was accessible for one of 19 sampled residents (Resident 297), when Resident 297 was not physically able to use the type of call light provided. This failure had the potential to result in unmet resident needs and delayed staff response. Findings: A review of Resident 297's admission record indicated, Resident 297 was admitted in early August of 2024 with diagnoses that included dementia (a loss of memory and problem-solving abilities which interfere with daily life) and anxiety (a feeling of fear, dread, and uneasiness). A review of Resident 297's Minimum Data Set (MDS: an assessment tool), dated 8/12/24, indicated Resident 297 was always incontinent (lacks control) with bowel movements and urination and was dependent on staff to provide toileting hygiene. A review of Resident 297's care plan, dated 8/6/24, indicated, .Resident is at risk for falls and/or injuries .interventions .Keep the call light within reach and encourage…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow guidelines for infection control practices for two of five sampled residents, Resident 4 and Resident 5 when: 1. Social Services Assistant (SSA) did not wear the required Personal Protective Equipment (PPE) before entering Resident 4's room; and 2. Certified Nursing Assistant 1 (CNA 1) did not wear the full required PPE before entering Resident 5's room. This deficient practice had the potential to spread infections among residents, staff and visitors. Findings: 1. During a review of the admission Record for Resident 4, the admission Record indicated, Resident 4 was admitted to the facility on [DATE], with diagnoses that included sepsis (serious infection condition), and Methicillin Resistant Staphylococcus Aureus infection (MRSA, contagious bacterial infection, superbug). During a review of Resident 4's Order Summary, dated 7/31/24, the Order Summary indicated, [Name of Antibiotic], use 1 gram intravenously two times a day for MRSA…

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 coordinate with the PASRR (Preadmission Screening And Resident Review, for residents with a mental disorder) evaluation program for one of three sampled residents (Resident 1) when Resident 1 had positive results on Level I screening which required Level II screening to identify the specialized services required by the resident. This failure placed Resident 1 at risk for not receiving rehabilitative services that the resident needed. Findings: Review of Resident 1's clinical record, admission Record indicated the resident had diagnoses that included mental illness, mood disorder, unspecified dementia with behavioral disturbance, noncompliance with treatment and regimen, and history of frequent hospitalizations. Review of the Resident 1's clinical record, Nurses Progress Note, dated 6/6/24, indicated the resident sustained a 3 x 2 cm (centimeter) bump, a 0.5 cm laceration on left forehead and a 2 x 2 cm bump on the right cheek after a resident-to-resident altercation that occurred on 6/6/24. However, the resident refused 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 maintain reasonable accommodation of resident needs and preferences for one resident (Resident 1) in a facility census of 48 when Resident 1's personal items were moved beyond her reach and complaints about her roommate were not addressed timely to ensure her dignity and well-being. This failure resulted in Resident 1 feeling distressed and upset. Findings: Resident 1 was admitted to the facility October 2021 with multiple diagnoses which included pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of sacral region (near base of the spine) and type 2 diabetes mellitus (a disease where blood sugar is too high). During a review of Resident 1's face sheet (a document containing patient information), the face sheet indicated Resident 1 was her own responsible party. During an interview and concurrent document review on 1/9/24, at 12:35 p.m., with the Social Services Director (SSD), the SSD confirmed she received an email on 1/5/24 at 4:41 p.m. with a complaint that 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 interview and record review, the facility failed to follow their policy to protect one of three sampled residents (Resident 1's) right to be free from abuse when a fellow resident took her personal belongings. This caused Resident 1 to be feel distressed, emotionally unsafe, and unable to sleep. Findings: Resident 1 was admitted to the facility October 2021 with multiple diagnoses which included a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of the sacral region (near base of the spine) and type 2 diabetes mellitus (a disease where blood sugar is too high). During a review of Resident 1's face sheet (a document containing patient information), the face sheet indicated Resident 1 was her own responsible party. During an interview and concurrent document review on 1/9/24, at 12:35 p.m., with the Social Services Director (SSD), the SSD confirmed she received an email on 1/5/24 at 4:41 p.m. with a complaint that Resident 1's roommate had eaten Resident 1's snacks while she slept. The email indicated Resident 1 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.

Based on interview and record review the facility failed to report an allegation of abuse and theft/misappropriation of property to local, state, and federal agencies within 24 hours for one resident (Resident 1) in a facility census of 48, when a friend of Resident 1 reported to the Social Services Director (SSD) an allegation of Resident 1 feeling frightened and unsafe. This failure resulted in Resident 1 to remain fearful when the facility delayed reporting and investigating. Findings: Resident 1 was admitted to the facility October 2021 with multiple diagnoses which included pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of sacral region (near base of the spine) and type 2 diabetes mellitus (a disease where blood sugar is too high). During a review of Resident 1's face sheet (a document containing patient information), the face sheet indicated Resident 1 was her own responsible party. During an interview and concurrent document review on 1/9/24, at 12:35 p.m., with the SSD, the SSD confirmed she received an email on 1/5/24 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 interview and record review, the facility failed to implement its Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating Policy for one resident (Resident 1) in a facility census of 48 when the facility failed to ensure Resident 1's allegation of abuse and mistreatment was timely and thoroughly investigated. This failure to protect one of their vulnerable residents and provide a safe environment caused Resident 1 to feel emotionally unsafe and fearful. Findings: Resident 1 was admitted to the facility October 2021 with multiple diagnoses which included pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of sacral region (near base of the spine) and type 2 diabetes mellitus (a disease where blood sugar is too high). During a review of Resident 1's face sheet (a document containing patient information), the face sheet indicated Resident 1 was her own responsible party. During an interview and concurrent document review on 1/9/24, at 12:35 p.m., with the Social Services Director (SSD), the SSD 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 one of three residents (Resident 2 ' s) right to privacy was protected when the privacy curtain did not fully surround the resident's bed and provide her with full privacy. This failure resulted in Resident 2 to have felt exposed and subjected to bright lights that blinded her from the bathroom. Findings: Resident 2 was admitted to the facility in September 2023 with diagnoses that included paralysis of the legs and lower body. Review of Resident 2's MDS (Minimum Data Sheet, an assessment tool), dated 9/19/23, indicated she was cognitively intact with a score of 15/15 in the Brief Interview for Mental Status assessment. In a concurrent observation and interview on 11/20/23 at 11:45 a.m., Resident 2 was lying in her bed in a shared two-bed room. Resident 2 complained that she did not have full privacy in her room because the privacy curtain did not wrap around her bed fully and stated, I don't have no privacy. Resident 2 pointed to the privacy curtain between her and her roommate and stated it did not…

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, record review and facility policy review, the facility failed to maintain medical records in accordance with professional standards for 1 of 3 sampled residents (Resident 1). The facility must maintain medical records on each resident that are complete and accurately documented. This failure failed to provide sufficient information for staff to respond to the changing status, needs and after care of the resident. Findings: Review of Resident 1's medical record indicated he was admitted to the facility on [DATE], with diagnoses that include congestive heart failure (heart cannot pump blood efficiently), diabetes, and end stage renal disease (kidneys no longer function). Resident 1's Annual MDS (Minimum Data Set-an assessment tool), dated 7/9/23, described Resident 1 as able to make himself understood and 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 impaired. The MDS described 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.