McKinley Park Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure respiratory care was provided according to professional standards for three of 22 sampled residents (Resident 104, Resident 42, and Resident 27) when:Resident 104 and Resident 42's nebulizer masks were not stored in a bag after use;Resident 42's BiPAP (bilevel positive airway pressure- breathing device providing higher pressure when breathing in to help open the lungs and a lower pressure when breathing out making it easier to exhale) order was incomplete; andResident 27 did not have an order for CPAP (continuous positive airway pressure - treatment for obstructive sleep apnea) in the clinical record and CPAP was not used until over one month after admission to the facility. These failures increased the risk for Resident 104 and 42 to develop respiratory infections due to improper storage of masks, and for Resident 42 and Resident 27 to experience respiratory distress and discomfort.1a. A review of the admission Record 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 provide pain management in accordance with professional standards and resident centered care plans for two of 22 sampled residents (Resident 73 and Resident 18) when:The facility failed to reassess Resident 73 for pain within the required one-hour timeframe after receiving a PRN (as needed) pain medication.The facility failed to consistently assess Resident 18's pain and offer non-pharmacological (strategies that do not involve use of pain medications) interventions. These failures had the potential for Resident 73 and Resident 18 to be in pain and have ineffective pain management.1.During an observation on 1/20/26, at 10:49 a.m., in Resident 73's room. Resident 73 was observed to be moaning that her stomach was hurting. During an interview on 1/20/26, at 10:50 a.m., with Resident 73, Resident 73 stated her stomach was hurting and she was constipated. Resident 73 stated she got pain medicine earlier, but she is still in pain. During an interview on 1/20/26, at 11:03 a.m., with the Director of Nursing (DON),…

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 identify trauma triggers for one of 22 sampled residents (Resident 83) with post-traumatic stress disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event).This failure had the potential for Resident 83 to experience re-traumatization (re- experience a traumatic event causing similar stress reactions) and possible increased symptoms such as restlessness, irritability and social withdrawal. A review of the admission Record indicated Resident 83 was admitted to the facility May of 2022 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought) and PTSD. Resident 83's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 12/4/25 indicated Resident 83 was cognitively intact. A review of Resident 83's care plan dated 12/31/25 indicated, [Resident 83] has impaired visual function [related to] [Resident 83] stated she lost her eye due to her retina detaching due to res. having diabetes. [Resident…

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

Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was less than five (5) percent (%). The facility had a cumulative medication error rate of 7.4% consisting of two errors for one Resident (Resident 42) in a sample size of 27 opportunities for error.This failure had the potential to jeopardize Resident 42's health and well-being.During a medication pass observation on 1/21/26 at 7 a.m., with Licensed Nurse (LN 3), LN 3 was observed preparing Resident 42's morning medications. LN 3 placed Resident 42's medications, including Ferrous Sulfate (iron supplement for anemia) and Carvedilol (heart failure and blood pressure medication) in a small plastic cup, added less than one teaspoon of apple sauce and administered to the resident. LN 3 explained that the resident prefers to take her medications with small amount of apple sauce. LN 3 did not offer Resident 42 any snacks or food before leaving the resident's room. There was no food observed on Resident 42's bedside table. There were no breakfast trays available in the hallway…

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 safe storage, labeling and effective accountability of the medications in accordance with accepted professional standards, when a bottle of Lyrica (a prescription medication to treat pain; controlled medication with potential for abuse) tablets was stored unsecured on the open shelf in medication room and Fluticasone Propionate and Salmeterol Inhalation Powder (inhalation medication to treat lung disease and relieve allergic symptoms) for Resident 73 was stored inside Medication Cart 1 not dated when opened.These failures had the potential for controlled substance medication diversion due to lack of secure storage and for Resident 73 to receive expired medication with reduced potency. During an observation and interview with Licensed Nurse (LN 4) in the Medication Room on [DATE] at 7:54 a.m., four paper bags with medications were observed on an open shelf in medication room. LN 4 explained that medications in the bag were brought…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a comfortable environment for 14 of 14 sampled residents, when the temperature in the residents' rooms were above 81 degrees Fahrenheit (F). This failure had the potential for the residents to have an uncomfortable room temperature and possible heat exhaustion.During a tour of the facility on 8/15/25 at 4:50 p.m. accompanied by the Administrator (ADM), the following resident's room temperatures were obtained with the facility's infrared (IR) temperature gun (an instrument that measures the temperature by detecting the IR radiation emitted by an object) which indicated the temperatures of the following rooms:room [ROOM NUMBER] - 84 degrees F;room [ROOM NUMBER] - 83 degrees F;room [ROOM NUMBER] - 83 degrees F; androom [ROOM NUMBER] - 82 degrees F. During an interview with the ADM on 8/15/25 at 5 p.m., the ADM indicated the ideal temperature ranges in the facility should be between 71 degrees to 81 degrees Fahrenheit. The ADM stated…

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

Based on interview, and record review, the facility failed to protect one of four sampled residents from abuse (Resident 2) when another resident (Resident 1) hit Resident 2 on the thigh repeatedly. This failure had the potential to cause injury, fear and distress to Resident 2. Findings: During a review of Resident 1's admission record, Resident 1 was admitted in April of 2025 with a diagnosis of Vascular Dementia (a type of dementia caused by brain damage resulting from impaired blood flow) with other behavioral disturbance. Resident 1 ' s Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 1 had severe cognitive impairment. During a review of Resident 2 ' s admission record, Resident 2 was admitted in January of 2024 with a diagnosis of Rhabdomyolysis (a muscle condition manifested by muscle pain, feeling weak and tired) and crushing injury of the left shoulder and upper arm. Resident 2 ' s MDS indicated he was cognitively intact. During a review of a facility submitted document titled REPORT OF SUSPECTED DEPENDENT ADULT/ELDER ABUSE [SOC 341]…

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 treat one of five sampled residents (Resident 4) with respect and dignity when Resident 4 stated, through an interpreter, that Certified Nursing Assistant (CNA 2) was rough, aggressive, and raised her voice when she performed care to Resident 4. This deficient practice had the potential to cause psychological harm and emotional distress to Resident 4. Findings: A review of Resident 4 ' s admission Record, indicated, Resident 4 was admitted to the facility in December 2024, and had diagnosis that included left side hemiplegia (partial or complete paralysis on one side of the body) and hemiparesis (one-sided muscle weakness), and dysarthria (speech disorder). A review of Resident 4 ' s Brief Interview for Mental Status, Section C, (BIMS, cognitive screening test), indicated, Resident 4 had moderate cognitive impairment. A review of Resident 5 ' s admission Record, indicated, Resident 5 was admitted to the facility in November 2024, and had diagnosis that included End Stage Renal Disease (kidney disease) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the comprehensive care plan was updated and revised for one of four sampled residents (Resident 1), when the fall care plan was not revised timely after Resident 1's fall. This failure decreased the facility's potential to prevent Resident 1 from sustaining another fall and had the potential to result in Resident 1 not attaining his highest practicable well-being. Findings: During a review of Resident 1's admission records, the record indicated Resident 1 was admitted in December 2024 with diagnoses that included and hemiparesis hemiplegia (paralysis and weakness of the arm, leg, and trunk on the same side of the body), and muscle weakness. Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 1 had moderate cognitive impairment. During a review of Resident 1's Fall Risk Observation/Assessment, dated 12/11/24, the assessment indicated Resident 1 scored 22, which indicated Resident 1 was high risk…

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

Based on observation, interview, and record review the facility failed to store, prepare, and serve food in accordance with professional standards when: 1. Food equipment was not working properly, 2. Employees were unable to state sanitation process, 3. Expired food, food without proper labeling/dating, and foods that were not covered were found in food storage, 4. A dirty lid, and 6 wet containers were found in the ready to use storage area, 5. Worn food preparation equipment that was no longer able to be sanitized was not discarded, 6. Vents and sprinklers over trayline and residents' microwave found dirty, 7. Buckets containing sanitizer found on food preparation counter, and 8. An air gap was not found under the fruit/vegetable preparation sink. These failures had the potential to lead to food borne illness for the 78 residents eating facility prepared meals. Findings: 1. During the initial kitchen tour on 10/1/24, beginning at 8:20 a.m., Dietary Aide 1 (DA 1) was cleaning the pots and pans from breakfast. As she demonstrated the process for putting them through the dish…

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 three (3) of 20 sampled residents (Resident 25, Resident 73, Resident 63) when: 1. Magnetic resonance imaging (MRI, a non-invasive medical imaging technique) prescriber's order for osteomyelitis (a type of bone infection) for Resident 25 was not processed promptly per facility policy. 2. Resident 73's medication order was not clarified with the prescribing physician. 3. Resident 63's feeding formula was not labeled. These failures had the potential for Resident 25, Resident 73, and Resident 63 to received inaccurate and inadequate care. Findings: 1. The following documents were reviewed in Resident 25's medical record: - admission Record, dated 10/1/24 (print date), indicated Resident 25 was admitted to the facility in August of 2024 with diagnoses including pneumonia (a lung infection) and type 2 diabetes (inability to properly process blood sugar). - A review of prescriber's handwritten orders, dated 9/30/24 and…

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

Based on interview and record review, the facility failed to ensure sufficient staffing was provided for a census of 80 residents when: 1. Multiple staff stated the facility was insufficiently staffed; and 2. Resident 55 had five unwitnessed falls in one month. These failures decreased the facility's potential to provide residents with timely, necessary care and services to maintain their highest practicable physical, mental, and psychosocial well-being. Findings: 1. During a concurrent interview and record review on 10/2/24 at 3:44 p.m., with the Staffing Coordinator (SC), the September 2024 staffing spreadsheet was reviewed, the SC stated she writes a schedule to ensure each resident receives a minimum 3.5 hours per patient day (PPD) of direct nursing care. The SC presented the September 2024 staffing spreadsheet which had two columns: projected PPD and actual PPD. The SC confirmed that the projected column indicated how many nursing hours she scheduled and acknowledged 17 of the 29 days on the spreadsheet indicated she scheduled under the goal of 3.5 hours PPD. The SC…

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 food that was palatable when one of 20 sampled residents (Resident 60) was served a burnt cookie. This failure had the potential for Resident 60 to experience dissatisfaction with food served, leading to decreased intake with possible weight loss. Findings: During a concurrent interview and observation on 10/1/24 at 10:35 a.m., in Resident 60's room, Resident 60 stated the food served in the facility is sometimes served burnt. Resident 60 showed a cookie the facility had served her that was black on the bottom. During a concurrent interview and observation on 10/1/24 at 10:45, in Resident 60's room, the [NAME] Clerk 1 (WC 1) confirmed Resident 60's cookie was burnt and stated she would not eat a burnt cookie like that. During an interview on 10/1/24 at 12:51 p.m., Resident 10 stated food provided by facility is sometimes served burnt. An interview on 10/4/24 at 11:08 a.m., the Registered Dietician (RD) stated she was aware the facility had an issue with an oven affecting the foods not being cooked…

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 infection prevention and control practices designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections when: 1. The Treatment Nurse (TN) did not perform hand hygiene (handwash with soap and water or alcohol-based hand rub) in between glove change during the wound dressing change to Resident 70; and, 2. A blood glucose machine was not sanitized after use. These failures had the potential to result in infection and spread of infection among census of 80. Findings: 1. A review of Resident 70's admission Record dated 10/4/24 (print date), indicated resident 70 was admitted to the facility in Summer of 2024 with diagnoses including orthopedic aftercare following surgical amputation, osteomyelitis (bone infection) and diabetes (inability to properly process blood sugar). A review of Resident 70's Order Summary Report (OSR) dated 10/4/2024 indicated, [order start date 8/6/24] right 2nd side MASD [Moisture…

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 antibiotics stewardship program for one (1) of 20 sampled residents (Resident 25) when infection screening evaluation was not conducted for Resident 25's two newly prescribed antibiotics to treat osteomyelitis (bone infection). This failure had the potential for antibiotics to be used when it was not indicated and the development of antibiotic-resistant bacteria. Findings: The following documents were reviewed in Resident 25's medical record: - admission Record, dated 10/1/24 (print date), indicated Resident 25 was admitted to the facility in August of 2024 with diagnoses including pneumonia (a lung infection) and type 2 diabetes (inability to properly process blood sugar). - Order Summary Report (OSR) dated 10/4/24, indicated that on 9/30/24 Resident 25 was started on two different antibiotic prescriptions for right foot osteomyelitis: Trimethoprim/Sulfamethoxazole and Cefalexin. - Review of assessments history indicated latest infection screening evaluation was completed on 8/13/24 [admission…

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

Based on interview and record review, the facility failed to ensure one of five residents reviewed for immunizations (Resident 25) received the pneumococcal vaccine (a medical treatment that helps to prevent or reduce severity of pneumonia, a lung infection). This failure had the potential for the Resident 25 to be at higher risk for pneumonia and related complications. Findings: The following documents were reviewed in Resident 25's medical record: - admission Record, dated 10/1/24 (print date), indicated Resident 25 was admitted to the facility in August of 2024 with diagnoses including pneumonia (a lung infection) and type 2 diabetes (inability to properly process blood sugar). - Informed consent form signed by resident on 8/13/24 indicated that resident consented to receive pneumococcal vaccination. - Order Summary Report (OSR) dated 10/4/24, contained no orders for pneumococcal vaccine administration. - No records of prior pneumococcal vaccination history were found or provided by the facility. In an interview on 10/3/24 at 12:01 p.m. Infection Preventionist stated that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a correct discharge notice to one of three sampled residents (Resident 1), when Resident 1 received a Discharge Notice for a facility-initiated discharge that did not contain the discharge location, or the updated date of discharge. This failure had the potential to result in an unsafe discharge for Resident 1. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in March 2023 for multiple diagnoses including multiple polyneuropathies (disease affecting nerves causing weakness or numbness), paraplegia (paralysis of the legs), right foot drop (difficulty lifting the front part of the foot), and protein calorie malnutrition (inadequate intake of food). A review of Resident 1's Minimum Data Set (MDS-an assessment tool), Cognitive Patterns, dated 6/1/24, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 15 out of 15 which indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that nursing staff had the necessary competencies and skill sets to meet the care and services for two out of five sampled residents (Resident 2 and Resident 4) when: 1. Certified Nursing Assistant (CNA) 3 transferred Resident 2 using a mechanical lift by herself 2. Nursing staff did not answer resident call lights 3. Resident 4 had to wait for about 15 minutes or longer to get changed. These failures resulted to Resident 2 sustaining a fall and had the potential to result in Resident 4's physical and psychosocial harm. Findings: 1. During a review of Resident 2's MDS (an assessment and care screening tool), Section GG-Functional Abilities and Goals (measures resident's performance and independence in various functional tasks related to self-care and mobility), dated 7/24/24, the MDS Section GG indicated, Resident 2 needed the assistance of two or more staff for her chair/bed-to-chair transfer (the ability to transfer to and from 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 interview and record review, the facility failed to provide a safe and homelike environment for one of five sampled residents (Resident 2) when the Resident's personal property was not protected from theft or loss, and it was not promptly investigated. This failure resulted in Resident 2 losing her personal property. Findings: During a review of Resident 2's admission Record, the admission Record indicated, Resident 2 was admitted initially on 6/13/23, with diagnoses that included Hemiplegia (condition where one side of the body is paralyzed), Type 2 Diabetes Mellitus (condition where the body has high blood sugar levels), hypertension (condition where the blood pressure is high) and hyperlipidemia (condition where there is too much fat in the blood.) During a review of Resident 2's Minimum Data Set (MDS, an assessment and care screening tool), dated 7/24/24, the MDS indicated Resident 2 had a Brief Interview Mental Status (BIMS-test to check someone's memory and thinking abilities) score of 15 (score of 15 means a person has no memory problem.) During a concurrent…

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 effective pain management was provided for one of three sampled residents (Resident 1), when the facility's licensed staff did not notify Resident 1's physician that the resident's pain medications were not effective. This failure resulted in unnecessary pain for Resident 1, affected his sleep, and had the potential to result in further decline in the resident's overall health condition. Findings: A review of the facility's policy and procedure titled, Pain Assessment and Management, with the revision date of 10/22, indicated that the facility was committed to appropriate assessment and treatment of pain based on professional standards of practice, the comprehensive care plan, and the resident's choices. The policy indicated the facility shall assess for pain on admission, during ongoing assessments, and if the resident experiencing worsening of the pain. The licensed staff should assess the resident's pain, including location, severity, alleviating and exacerbating (increasing intensity) factors, current treatment,…

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 adequate supervision to ensure the safety for one resident (Resident 1) of four sampled residents, when Resident 1 eloped from the facility unaccompanied via unmonitored sliding doors and was found in the adjacent office building. This failure decreased the facility's potential to prevent physical injury and psychosocial harm to Resident 1 during her unsupervised time away from the facility. Findings: A review of an admission record indicated Resident 1 was readmitted to the facility in October of 2023 with diagnoses which included encephalopathy (a group of conditions that cause brain dysfunction). This admission record also indicated Resident 1 was not her own Responsible Party (RP). A review of Resident 1's discharge paperwork from a recent hospital stay, dated 10/2/23, indicated Resident 1 lacked capacity and had a designated decision maker. A review of a Minimum Data Set (MDS, an assessment tool), dated 10/6/23, indicated Resident 1 had severe cognitive impairment. A review of the facility's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure sufficient staffing was provided for a census of 77 residents when: 1. Multiple residents reported long call light response times from facility staff; and 2. Multiple staff stated the facility was insufficiently staffed. These failures decreased the facility's potential to provide residents with timely, necessary care and services to maintain their highest practicable physical, mental, and psychosocial well-being. Findings: 1. A review of Resident 1's Minimum Data Set (MDS: an assessment tool), dated 7/21/23, indicated Resident 1 was admitted to the facility in January of 2023, had a brief interview for mental status (BIMS: an assessment for cognition and orientation) score of 13 (indicated cognitively intact), had diagnoses that include Parkinson's disease (causes uncontrollable movements and difficulty with coordination), cervical spinal stenosis (a narrowing of spinal canal in the neck that puts pressure on the spinal cord and…

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

Based on observation, interview, and record review the facility failed to provide adequate supervision and required assistance for one resident (Resident 4) of five sampled residents when nursing staff did not respond to Resident 4's request for assistance to use the restroom in a timely manner and Resident 4 fell attempting to transfer herself from the toilet to the wheelchair (WC). This failure resulted in Resident 4's fall while attempting to transfer herself from the toilet to the wheelchair. Findings: A review of Resident 4's admission record, indicated Resident 4 was admitted to the facility in March of 2023, and diagnosed with hemiparesis (weakness or the inability to move on one side of the body), and right below the knee leg amputation (surgical removal of a limb). A review of Resident 4's Minimum Data Set (MDS: an assessment tool), dated 9/30/23, indicated Resident 4 had no memory problems with a Brief Interview for Mental Status (BIMS: an assessment for cognition and orientation) score of 15, was occasionally incontinent (lack of voluntary control over urination and/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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Resident 1's use of medical transport service was properly coordinated ahead of time by the Social Services Department. This failure resulted in Resident 1 experiencing anxiety and missing her doctor's appointment. Findings: A review of Resident 1's facesheet (FS) indicated, Resident 1 was last re-admitted to the facility on [DATE] with diagnoses which included epilepsy (a neurological disorder that results from abnormal activities in the brain with symptoms which include temporary confusion, episodes of staring blankly, jerking and/or twitching of arms and legs) and stiff-man syndrome (a rare and mysterious disorder that makes muscles rigid and painful, especially in the trunk and limbs). A review of Resident 1's interfacility transfer order (IFTO) dated 8/7/23, the IFTO indicated, .General Orders/ Treatment Orders .Follow-up with [Physician's Name (Neurology specialist)] in next 1 month . A review of Resident 1's physician…

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

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of the residents for a census of 63 when: 1. The narcotic (medication that may be abused or cause addiction) count sheet for Resident 24 was not filled out after medication administration; 2. Emergency Kit (E-Kit, limited number of medications for use in an emergency) log was not properly filled out for two opened refrigerator E-Kits (E-Kit number 086 and 052) which was missing six vials of lorazepam (a controlled medication used to treat anxiety); and, 3. Opened E-Kits (E-Kit number 067 and 056) were not properly sealed, logged, and replaced within 72 hours. These failures increased the potential for abuse, misuse, or diversion of the controlled substances and not have the needed medications available during emergencies that could jeopardize resident's health and safety. Findings: 1. During an inspection of the Station 3 Medication Cart 2 on 11/1/22 at 11:01 a.m. with Licensed Nurse 2 (LN 2), the narcotic sheet for Resident 24's oxycodone (pain medication) 10…

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

Based on observation, interview, and record review the facility failed to maintain a sanitary kitchen for a census of 63 residents when there were multiple brown spots on the ceilings and walls near the food preparation area. This failure increased the potential for food contamination from the brown spots dropping onto resident trays. Findings During the initial tour of the kitchen on 11/1/22 at 8:38 a.m. multiple brown areas were observed on the ceiling near the dishwashing station and steam table (tables which keep ready-to-serve food at set temperatures). In an interview on 11/1/22 at 8:40 a.m., the Dietary Manager (DM) confirmed the presence of brown spots on the ceilings by the dishwashing machine and the steam table. The DM stated she did not know what the brown spots were composed of, but they should not be there. During an observation and concurrent interview on 11/1/22 at 8:45 a.m., an inspection of the kitchen near the oven revealed round brown spots on the wall approximately the size of the quarter. The DM stated the Maintenance Director (MD) had installed insulating foam…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper infection prevention and control practices were followed for a census of 63 when: 1. A reusable blood pressure device was not disinfected between resident use; 2. Hand hygiene was not performed during medication administration; 3. Resident 8's oxygen tubing was undated and unlabeled; and, 4. The facility's water management for the prevention of Legionella disease was not conducted. These failures had the potential to transmit infectious disease among residents. Findings: 1. During a medication administration observation on 11/1/22 starting at 8:14 a.m., the Licensed Nurse 1 (LN 1) was observed preparing medications for Resident 86 which included blood pressure medications. The LN 1 was observed taking Resident 86's blood pressure prior to giving Resident 86's medications. The LN 1 did not clean the blood pressure machine after using it with Resident 86. After giving resident 86 his medications, the LN 1 proceeded to prepare…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the required minimum square footage of 80 square feet per resident for a census of 63. This failure had the potential to affect residents' safety due to the reduced space for staff to deliver care. Findings: The facility submitted a letter titled, Request for Continuation of Facility Room Waiver, dated 2/19/19 for rooms 1, 2, 4, 6, 8, 14, 15, 17, 18, 19, 20, 21, 22, 23, 24, 26, 228, 30, 31, 33, 34, and 35. During general observation of the facility on 11/1/22 and 11/2/22 respectively, the above listed rooms were identified as deficient in square footage. During an interview on 11/3/22, at 11 a.m., with the Registered Nurse Consultant (RNC) and Maintenance Supervisor (MS), the RNC and MS confirmed that rooms 1, 2, 4, 6, 8, 14, 15, 17, 18, 19, 20, 21, 22, and 23 are identical in room size and square footage, rooms [ROOM NUMBER] were identical in room size and square footage, rooms 30, 31, 33, 34, and 35 were identical in room size…

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 complete and accurate maintenance logs for the kitchen dish machine. These failures decreased the facility's potential to ensure sanitation of dishes for a census of 63 residents. Findings: During the initial kitchen tour accompanied by the Dietary Manger (DM) on 11/1/22 at 8:15 a.m., a review of the kitchen's dish machine temperature log for October 2022 indicated there were no entries for 10/26/22, 10/27/22, 10/29/22, and 10/30/22. In a concurrent interview, the DM confirmed the dish machine temperature log was incomplete. A review of the facility's policy titled Dish Washing dated 2018 indicated, .All dishes will be properly sanitized through the dish washer. The dish washer will be kept clean and in good working order .A temperature log (a chlorine log for low-temperature machines) will be kept and maintained by the dishwashers to assure that the dish machine is working properly. This log will be completed each meal prior to any dish washing.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to update and revise the care plans for four residents (Resident 31, Resident 124, Resident 75, Resident 22) of 19 sampled residents. These failures resulted in residents' person-centered plan of care not reviewed and revised timely to meet the residents' needs. Findings: A review of a face sheet indicated Resident 31 admitted to the facility in June 2021 with multiple diagnoses which included stroke, hemiplegia (one-sided paralysis due to a brain or spinal cord injury or condition), hemiparesis (weakness on one side of the body) affecting the left side, contracture of the muscle on the left hand, osteoarthritis (wear and tear joint disease), and depression. A review of a Minimum Data Set (MDS, a comprehensive assessment tool) dated 10/12/22, indicated Resident 31 had a mild memory problem. During a concurrent observation and interview on 11/1/22 at 11:50 a.m., Resident 31's four fingers were contracted (curled toward the palm) on the left…

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 nursing standards of practice were practiced for two residents (Resident 31 and Resident 22) of 19 sampled residents when: 1. Licensed Nurses did not follow Resident 31's physician order for a left-hand contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff); and, 2. Licensed Nurses did not monitor Resident 22's use of a boot to prevent pressure injury of the lower extremities. These failures decreased the facility's potential to meet residents' needs and prevent further decline in the use of their upper and lower extremities. Findings: 1. A review of a face sheet indicated Resident 31 admitted to the facility in June 2021 with multiple diagnoses which included stroke, hemiplegia (one-sided paralysis due to a brain or spinal cord injury or condition), hemiparesis (weakness on one side of the body) affecting the left side, contracture of the muscle on the left hand, osteoarthritis (wear and tear joint disease), and…

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

Based on observation, interview, and record review, the facility failed to provide a communication binder for one resident (Resident 22) of 19 sampled residents for use during the provision of care. This failure decreased the facility's potential to meet Resident 22's ability to communicate her basic needs. Findings: A review of a face sheet indicated Resident 22 was admitted in June 2014 with diagnoses including aphasia (the inability to comprehend or formulate language) and dementia (a group of thinking and social symptoms that interferes with daily functioning). A review of a Minimum Data Set (MDS, an assessment tool) dated 8/24/22 indicated Resident 22's cognition was severely impaired, was non-verbal, was rarely understood, and sometimes understands. A review of Resident 22's communication care plan indicated, At risk for altered communication related to dementia, Alzheimer's disease [a type of dementia that affects memory, thinking and behavior], depression, and or language barrier speaks, hearing [manifested by]: may miss part or most of message(s) sent. A listed intervention…

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 activity care plan approaches were consistently implemented for three residents (Resident 75, Resident 90, and Resident 22) of 19 sampled residents. These failures increased the risk of deterioration of social and psychological well-being among residents. Findings: A review of a face sheet indicated Resident 75 was admitted in May 2022 with diagnoses including major depressive disorder, Post Traumatic Stress Disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), and schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly). A review of Resident 75's activity care plan regarding the risk of decreased participation in activities indicated staff was supposed to implement the following, .offer in room [ROOM NUMBER]:1 [one-to-one, when one staff member works with one resident] programming at least three times per week as 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 ensure the medication error rate did not exceed 5% for two of 19 sampled residents (Resident 86 and Resident 124) during observation of medication administration when: 1. A wrong medication of Vitamin D3 (a vitamin needed to build and maintain healthy bones) was administered to Resident 86; and, 2. A wrong dose of amlodipine (a medication to treat high blood pressure and heart disease) was administered to Resident 124. These failures resulted in two medication errors out of 27 opportunities which resulted in the facility having a medication error rate of 7.41%. Findings: 1. Resident 86 was admitted to the facility early 2022 with multiple diagnoses which included Guillain-Barre syndrome (a rare disorder in which the body's immune system attacks the nerves causing weakness and tingling in arms and legs). During a medication administration observation on 11/1/22 starting at 8:14 a.m., with Licensed Nurse 1 (LN 1), the LN 1 was observed administering one tablet of vitamin D3, 125 mcg (microgram, a unit of…

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

Based on observation, interview and record review, the facility failed to ensure medications were labeled, stored, and disposed of consistently according to standards of practice for a census of 63, when: 1. Expired medications were not removed from the medication cart and the medication storage room; 2. Resident's medications were found in medication cups on top of the medication cart; 3. Loose pills were found in the first drawer of the medication cart; 4. Pharmaceutical products were found in the medication cart without an opened date; 5. A bottle of antifungal powder with an unclear and torn label was found in the treatment cart; and, 6. discharged resident's medications were not removed from the treatment cart. These failures had the potential to result in the lack of effectiveness of the medications, increase the potential for medication administration errors and jeopardize residents' health and safety. Findings: 1. During an inspection of the Station 3, medication cart 2 on 11/1/22 at 11:01 a.m. with Licensed Nurse 2 (LN 2), one bottle of vitamin B 12 100 mcg (microgram, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one resident (Resident 42) of 19 sampled residents received assistance to obtain Resident 42's full dentures. This failure decreased the facility's potential to ensure Resident 42 was able to properly chew her food. Findings: A review of a face sheet indicated Resident 42 was admitted on [DATE] with diagnoses including mild protein-calorie malnutrition, cognitive communication deficit, and aphasia (the loss of the ability to understand or express speech). A review of a social service note dated 5/6/22, indicated Resident 42 verbalized both of her dentures were left at her home. A review of a physician's order dated 5/22/22, indicated Resident 42 was on a regular diet with mechanical soft texture and thin liquids due to the diagnosis of aphasia. A review of a Minimum Data Set (MDS, an assessment tool), dated 6/9/22, indicated Resident 42's thought process was mildly impaired, she did not have natural teeth, and required…

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 timely replacement for one resident's missing clothing (Resident 338) of five sampled residents. This failure resulted in residents' expression of discontent with the facility's quality of care and negatively impacted his dignity and quality of life. Findings: A review of a face sheet indicated Resident 338 was admitted to the facility in October 2022 with multiple diagnoses which included cerebral infarction without residual effect (stroke) and major depressive disorder. A review of a Minimum Data Set (MDS, an assessment tool), dated 10/16/22, indicated, Resident 338 had moderate cognitive impairment. During a concurrent observation and interview on 11/2/22 at 8:11 a.m., Resident 338 stated four sets of clothes his family brought him were missing. During a concurrent interview and record review on 11/3/22 at 8:15 a.m., the Licensed Nurse 5 (LN 5) stated resident belongings are accounted for on the resident belongings document in the paper chart. A review of a personal items inventory 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 ensure one resident (Resident 42) of 19 sampled residents was assessed within 14 calendar days of admission to determine her dental needs. This failure decreased the facility's potential to ensure Resident 42 was able to properly chew her food and independently feed herself. Findings: A review of a face sheet indicated Resident 42 was admitted in May 2022 with diagnoses including mild protein-calorie malnutrition, cognitive communication deficit, and aphasia (the loss of the ability to understand or express speech). A review of a social service note dated 5/6/22, indicated Resident 42 verbalized both of her dentures were at her home. A review of a physician's order dated 5/22/22, indicated Resident 42 was on a regular diet with mechanical soft texture and thin liquids due to the diagnosis of aphasia. A review of a Minimum Data Set (MDS, an assessment tool), dated 6/9/22, indicated Resident 42's thought process was mildly impaired, she did not have natural teeth, and required supervision/cueing with 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 develop a comprehensive care plan regarding Post-Traumatic Stress Disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) for one resident (Resident 75) of 19 sampled residents. This failure decreased the facility's potential to address Resident 75's mental and behavioral care needs. Findings: A review of a face sheet indicated Resident 75 was admitted in May 2022 with diagnoses including major depressive disorder, PTSD, and schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly). A review of all care plans indicated no documented evidence a comprehensive care plan was developed to address Resident 75's PTSD. In an interview and record review on 11/2/22 at 3:02 p.m., the Social Services Director (SSD) validated there should have been a comprehensive care plan developed to address Resident 75's PTSD diagnosis but there was none. A review of the facility's policy and procedure titled, Care…

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

Based on observation, interview, and record review, the facility failed to provide necessary services to maintain grooming for one resident (Resident 31) of 19 sampled residents. This failure decreased the facility's potential to meet Resident 31's grooming needs. Findings: A review of a face sheet indicated Resident 31 admitted to the facility in June 2021 with multiple diagnoses which included stroke, hemiplegia (one-sided paralysis due to a brain or spinal cord injury or condition), hemiparesis (weakness on one side of the body) affecting the left side, contracture of the muscle on the left hand, osteoarthritis (wear and tear joint disease), and depression. A review of a Minimum Data Set (MDS, a comprehensive assessment tool) dated 10/12/22, indicated Resident 31 had a mild memory problem. During a concurrent observation and interview on 11/1/22 at 11:10 a.m., Resident 31's fingers on the left-hand were contracted. Both left and right fingernails were untrimmed, dirty with a dark, black substance underneath the fingernails. Resident 31 stated, I prefer them [his fingernails]…

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 resident (Resident 75) of 19 sampled residents was referred to psychiatry services. This failure increased Resident 75's risk for delayed psychiatry evaluations and interventions. Findings: A review of a face sheet indicated Resident 75 was admitted in May 2022 with diagnoses including major depressive disorder, Post Traumatic Stress Disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), and schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly). A review of a Minimum Data Set (MDS, an assessment tool) dated 5/30/22 indicated Resident 75's thinking process was intact, she had trouble falling/staying asleep or sleeping too much, felt tired, and had a poor appetite and overeating. A review of Resident 75's physician's progress notes dated 5/24/22 indicated [psychiatry follow-up]. A review of Resident 75's medical chart indicated no documented evidence Resident 75 was referred to psychiatry…

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 resident (Resident 86) of five sampled residents was provided a cock-up wrist splint with adaptive feeding handle (an assistive device enabling a resident with weak grasp to hold eating utensils). This failure decreased the facility's potential to ensure a resident's ability to reach their highest potential physical and psychosocial wellbeing. Findings: A review of a face sheet indicated Resident 86 was admitted to the facility in April of 2022 with multiple diagnoses which included Guillain-Barré syndrome (a condition in which person's own immune system harms their body's nerves causing muscle weakness and sometimes paralysis). A review of a Minimum Data Set (MDS, an assessment tool), dated 8/5/22, indicated Resident 86 was cognitively intact and required set up and one-person physical assist for meals. A review of an occupational treatment encounter note dated 4/29/22 at 3:06 p.m. indicated, .Skilled interventions to facilitate independence with Self Feeding abilities included adaptive equipment…

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

Based on observation, interview, and record review, the facility failed to protect resident health information when meal tickets were disposed of in the facility's regular trash. These failures decreased the facility's potential to protect sensitive health information for a census of 63 residents. Findings: During a tour of the kitchen on 11/4/22 at 1:36 p.m., the Dishwasher (DW) was seen removing trays from the soiled tray carts to prepare them to be washed. The DW sorted the tray contents and threw residents' meal tray tickets into the garbage can along with scraps of food. During a concurrent interview with the DW she stated residents' meal tickets are thrown into the garbage with food scraps. An observation of the contents of the garbage can included Resident 8, Resident 180, and Resident 181's meal tickets. The DW confirmed the name, room number, diet order, allergies, and likes and dislikes were visibly clear to read. The DW confirmed there were no locked confidential information bins for the disposal of residents' meal tickets. In a subsequent interview on 11/4/22 at 1:45…

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.