Mid-Town Oaks Post-Acute

Based on observation, interview, and record review, the facility failed to ensure medications were safely stored and secured for a census of 96 residents, when:A medication refrigerator temperature log for December 2025 was found incomplete in the medication room at station-3;An expired and discontinued medication was found inside a medication refrigerator in the medication room at station-3;Eight loose tablets and three loose bubble packs were found in and behind medication cart 2's drawers at station-2; andFour over the counter (OTC) medications were stored insecurely inside Resident 89's room.These failures decreased the facility's potential to safely store and secure medications for its residents. Findings: 1- During a concurrent observation and interview on 12/3/25 at 11:22 a.m. with Licensed Nurse (LN) 3 in the medication room at station-3, an incomplete temperature log was observed posted at the door of a medication refrigerator. LN 3 confirmed the refrigerator temperature was not recorded for three days from 12/1/25 to 12/3/25 for the morning shift. 2- 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 observation, interview, and record review, the facility failed to provide a clean environment for a census of 96 residents, when one out of four garbage dumpsters located outside the facility was not closed securely due to a gap between the lids.This failure decreased the facility's potential to maintain a safe environment and prevent pest infestation.Findings:During a concurrent observation and interview on 12/2/25 at 10 a.m. with the Dietary Services Supervisor (DSS), four dumpsters used by the facility were inspected. One dumpster's lids did not fully cover the dumpster and had a two-inch gap in the middle. DSS stated the dumpster lid should be replaced.During an interview on 12/3/25 at 2 p.m. with the Director of Nursing (DON), DON stated the dumpsters where all the trash was disposed should always be kept closed by ensuring the lids fit properly. DON further stated it was necessary to maintain such a safe practice to prevent pests from entering and potentially spreading disease.A review of the facility's undated policy titled, Food-Related Garbage and Rubbish Disposal,…

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 administer a medication according to professional standards of quality for one of 31 sampled residents (Resident 86), when Resident 86's metoprolol succinate (a medication used to treat high blood pressure and heart failure) was not administered as ordered by the physician.This failure decreased the facility's potential to follow physician's orders and safely administer medications to residents as prescribed.Findings:A review of Resident 86's admission Record, indicated Resident 86 was admitted to the facility in July 2023 with a diagnosis of hypertensive heart disease with heart failure (a long-time high blood pressure weakens the heart and reduces its ability to pump blood effectively).During a concurrent observation and interview on 12/2/25 at 8:55 a.m. with Licensed Nurse (LN) 2, LN 2 was observed preparing and administering Resident 86's morning medications. LN 2 stated metoprolol succinate tablet was withheld because Resident 86's blood pressure (BP) and heart rate (HR) were lower than the physician's…

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

Based on observation, interview, and record review, the facility failed to ensure two out of 31 sampled residents (Resident 9 and Resident 61's) environment was safe and free of accident hazards, when: 1. Licensed Nurse (LN) 5 did not check Resident 61's wanderguard (a device that activates sensors on doors to alarm, alerting staff to intervene when wandering residents attempt to elope) functionality; and2. Resident 9 was smoking without supervision.These failures decreased the facility's potential to maintain residents' safety.Findings: 1- A review of Resident 61's admission Record, indicated she was admitted to the facility in October 2022 with diagnoses including dementia (a progressive state of decline in mental abilities) with agitation and history of falling. During an observation on 12/2/25 at 2:49 p.m., Resident 61 was observed pacing up and down the hallway going to the nurses' station. Resident 61 was redirected by staff to keep her from wandering to other residents' rooms. During a concurrent observation and interview on 12/2/25 at 3:49 p.m. with LN 5 inside Resident 61's…

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

Based on observation, interview, and record review, the facility failed to ensure respiratory care was consistent with professional standards of practice for one of 31 sampled residents (Resident 42), when Resident 42's nasal cannula (NC- a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was not changed weekly.This failure decreased the facility's potential to prevent the risk of lung infection for Resident 42. Findings:A review of Resident 42's admission Record, indicated Resident 42 was admitted to the facility in October 2024 with diagnoses including chronic obstructive pulmonary disease (a chronic lung disease causing difficulty breathing) and respiratory failure.During an observation on 12/1/25 at 10:40 a.m. in Resident 42's room, Resident 42 was wearing NC. The NC was labeled with a date of 11/18.A review of Resident 42's Order Summary Report, dated 12/4/25, indicated Resident 42 had an active order for continuous oxygen at one liter (a unit of measurement) per minute via NC and to change NC every Sunday and as needed.During 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 safely store food for a census of 96 residents, when an expired food item was available for use in the facility's kitchen.This failure decreased the facility's potential to prevent foodborne illness among residents.Findings:During a concurrent observation and interview on 12/1/25 at 8:12 a.m. with the Dietary Services Supervisor (DSS) in the kitchen, DSS confirmed a loaf of bread with expiration date of 11/30/25 was stored on the bread rack.During an interview on 12/3/25 at 2 p.m. with the Director of Nursing (DON), DON stated kitchen staff should not store expired food items that can be served to residents which might make them sick.A review of the facility's undated policy titled, Food-Related Garbage and Rubbish Disposal, indicated, Foods shall be received and stored in a manner that complies with safe food handling practices.

Based on observation, interview, and record review, the facility failed to ensure one of 31 sampled residents (Resident 87's) call light was within reach, when Resident 87 was in bed and could not reach the call light.This failure decreased the facility's potential to provide Resident 87 with assistance when needed.Findings:A review of Resident 87's admission Record, indicated Resident 87 was admitted to the facility in 2025 with diagnoses including anxiety and inability to sleep.A review of Resident 87's Minimum Data Set (MDS, a federally mandated assessment tool), dated 10/27/25, indicated Resident 87 had moderate memory impairment.During a concurrent observation and interview on 12/1/25 at 9:27 a.m. with Resident 87 inside his room, Resident 87 stated he could not reach the call light and could not find it. The call light was hanging off the left side of bed. During a concurrent observation and interview on 12/1/25 at 9:34 a.m. with the Director of Nursing (DON) inside Resident 87's room, DON confirmed the call light was hanging off the bed and stated it should have been within…

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 accurately document and replace emergency medication kits (E-Kit: a kit/box containing medications and supplies for immediate use during a medical emergency) for a census of 95. This failure decreased the facility's potential for having accurate accountability of emergency medications, availability of emergency medications when needed, and meeting the residents' therapeutic needs. Findings: During a concurrent observation and interview on 11/4/24 at 9:35 a.m. with Licensed Nurse 3 (LN 3) in the medication room on the second floor, it was observed that an intravenous (IV; Injectable medication to be administered into the vein) E-kit was found to be opened on 10/16/24 at 10:25 p.m. LN 3 stated, one liter (L, a unit of measure) of dextrose (a type of sugar solution) was taken out of the E-kit and was not replaced. LN 3 further stated the medication sticker should have been faxed on 10/16/24 to the pharmacy to replace the E-kit and the faxed order should have been documented in a binder in 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 ensure that medications and medical supplies were labeled, stored, and disposed of consistently according to the facility's policies and procedures for a census of 95, when: 1. A medication refrigerator was not properly locked in the medication room, 2. Expired pharmaceutical products were found in a medication refrigerator, medication carts, and treatment carts, 3. Prescription pharmaceutical products did not have resident specific labels, and 4. Open date labels were not used to determine expiration dates. These failures had the potential for residents' medication misuse, drug diversion and medication errors and ineffectiveness. Findings: 1. During an observation on 11/4/24 at 9:35 a.m. in the second-floor medication room, the medication room refrigerator was found to be unlocked. During an interview on 11/4/24 at 9:35 a.m. with Licensed Nurse 3 (LN 3), LN 3 stated the refrigerator was normally locked, and if not, then someone could have taken the medications and therefore became unavailable for residents…

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

Based on observation, interview, and record review, the facility failed to ensure the menu was followed during lunch for a therapeutic diet (a modification of a regular diet to fit a person's particular nutritional needs, which could be related to a medical condition - usually prescribed by a physician), when 10 residents on a pureed diet for a census of 95 were served food that was not consistent with the recipe. This failure had the potential to compromise the residents' nutritional status. Findings: During a concurrent observation and interview on 11/6/24 at 10:45 a.m. with Dietary [NAME] 1 (DC 1), DC 1 started preparing the pureed diet for 10 residents for a total of 12 servings, with the two extra servings for double portions and a test tray. After boiling the diced carrots, DC 1 confirmed she added 1 ½ cups of chicken broth to the carrots for 12 half-cup servings, which were pureed in a blender. DC 1 acknowledged the consistency of the pureed carrots was runny and stated the mixture would thicken when heated on the steam tray and the consistency of the pureed carrots would be…

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

Based on observation, interview, and record review, the facility failed to serve pureed food (cooked food that has been processed in a blender) that was suitable to consume, when the kitchen prepared food items with inadequate textures for 10 residents on a pureed diet for a census of 95. This failure had the potential to compromise the residents' medical and nutritional status. Findings: During a concurrent observation and interview on 11/6/24 at 10:45 a.m. with the Dietary [NAME] 1 (DC 1), DC 1 confirmed she added 1 ½ cups of chicken broth for 12 ½ cup servings (with two extra servings for double portion requests and test tray) of cooked carrots and ran the ingredients through a blender. DC 1 stated the carrot mixture was runny because she expected it to thicken up while placed on the hot steam tray and the consistency would be like mashed potatoes. The carrot mixture was put in a metal serving pan on the steamer tray at 10:50 a.m. and no further ingredients were added before serving. During a concurrent observation and interview on 11/6/24 at 11:11 a.m. with DC 1, DC 1 pureed 12…

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 food and maintain proper sanitizing procedures in accordance with professional standards for food service safety for a total of 95 residents, when: 1. Expired food was found in dry storage, 2. Metal serving containers were stacked wet in storage, 3. [NAME] sticky residue was found on the bottom surface of a metal serving container, and 4. Two of three sanitizer buckets contained sanitizers not within required disinfecting ranges. These failures had the potential to lead to contamination and food borne illness among residents. Findings: 1. During a concurrent observation and interview on 11/4/24 at 9 a.m. with the Dietary Services Supervisor (DSS), one opened package and two unopened packages of hamburger buns were found expired on the bread rack. The opened bread had an open date of 10/15/24 (the date the bread was taken out of the freezer) with no expiration date written on the label (bread was in dry storage for 20 days). Two unopened hamburger bun packages had open dates of 10/27/24 and expiration…

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 control for a census of 95 residents, when: 1. Staff members did not use gowns in rooms with enhanced barrier precautions (EBP, an infection control method that involves wearing gowns and gloves during high-contact interactions); 2. Certified Nursing Assistant 5 (CNA 5) did not use personal protective equipment (PPE) while providing care to Resident 21 in an EBP room; and 3. A clean-linen cart was stored uncovered in the basement. These failures had the potential for the spread and transmission of a communicable disease among residents. Findings: 1. During a concurrent observation and interview on 11/4/24 at 9:45 a.m. and 9:55 a.m. with a physical therapist (PT) inside an EBP room, the PT was assisting a resident to transfer from bed to wheelchair without wearing a gown. The PT confirmed he should have used a gown and gloves while in the EBP room. During a concurrent observation and interview on 11/4/24 at 9:58 a.m. and 10:01 a.m. with CNA 2 inside an EBP room, CNA 2 was changing the old…

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 person-centered care plan for one of 26 sampled residents (Resident 141), when the care plan did not address Resident 141's catheter (permanent catheter, a flexible tube inserted into a blood vessel) treatment services and interventions. This failure decreased the facility's potential to address the residents' individualized and specific needs. Findings: A review of an admission record indicated Resident 141 was admitted to the facility in 2024 with a diagnosis of chronic kidney disease (a condition when the kidneys gradually lose its ability to filter blood properly). During a concurrent observation and interview on 11/4/24 at 9:45 a.m. inside Resident 141's room, Resident 141 stated staff did not do any dressing change and monitoring for her right upper chest catheter since she was admitted on e week ago. A review of Resident 141's Order Summary Report, dated 11/5/24, indicated there was no order for catheter care and dressing monitoring on the right upper chest. A review of Resident…

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

Based on observation, interview, and record review, the facility failed to provide services according to professional standards for one of 26 sampled residents (Resident 2), when an anticoagulant (medication that prevent or reduce blood clotting) monitoring was not in place for Resident 2. This failure had the potential to put Resident 2 at risk for having complications due to excessive bleeding. Findings: A review of an admission record indicated, Resident 2 was admitted to the facility in October 2024 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and cerebral infarction (occurs when blood flow to the brain is blocked). A review of Resident 2's Medication Administration Record, dated 11/6/24, indicated Resident 2 was receiving apixaban (medication that decreases the clotting ability of the blood) tablet twice a day. The record did not indicate an order to monitor side effects such as excessive bleeding or bruising. During a concurrent interview and record review on 11/6/24 at 12:10 p.m. with Licensed Nurse 4 (LN 4),…

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 call light was functioning for one of 26 sampled residents (Resident 37), when Resident 37 pushed the button for assistance and the call light did not turn on. This failure decreased the facility's potential to assist Resident 37 when needed. Findings: A review of Resident 37's admission record indicated Resident 37 was admitted to the facility in April 2024 with diagnoses including malignant breast neoplasm (a cancerous breast tumor likely to spread to other body parts) and generalized muscle weakness. A review of Resident 37's Minimum Data Set (MDS-an assessment tool), dated 10/15/24, indicated Resident 37 needed partial to moderate assistance to roll from side to side in the bed. During a concurrent observation and interview on 11/4/24 at 10:51 a.m. with Resident 37, Resident 37 was lying on her back at the left edge of the bed and pressing the call light button. Resident 37 stated she had been pressing the call button for few minutes and did not get any response. Resident 37 further 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 ensure one of four sampled residents (Resident 1) right to self-determination was maintained, when the facility canceled Resident 1's medical appointment without confirming with the resident or their family. The failure had potential to result in resident not receiving medical treatment and negatively impacting the resident's psychosocial well-being. Findings: During a review of Resident 1's face sheet (a document containing patient information), the face sheet indicated, Resident 1 was admitted to the facility August 2024 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 an interview on 10/24/24 at 1:09 p.m., with Resident 1's daughter, Resident 1's daughter stated the facility canceled the resident's medical appointment on 9/20/24. Resident 1's daughter further stated the facility did not consult with 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 record review and interview, the facility failed to ensure one of four sampled residents (Resident 1), received treatment and care in accordance with professional standards of practice, when Resident 1's episode of low blood sugar was not addressed as directed by the management of hypoglycemia (low blood sugar) policy and procedure. The failure had the potential to result in Resident 1's hospitalization or death. Findings: During a review of Resident 1's face sheet (a document containing patient information), the face sheet indicated, Resident 1 was admitted to the facility August 2024 with multiple diagnoses which included type 2 diabetes mellitus (a disease where blood sugar is too high). During a review of Resident 1's Minimum Data Set (MDS- an assessment tool), dated 9/21/24, the MDS indicated Resident 1 was taking high risk medications which could cause hypoglycemia. During a review of Resident 1's active orders in the Orders Summary Report, initiated 9/12/24, indicated, .Finger Stick Blood Glucose (sugar) Testing as needed for Hypo/Hyperglycemia (low blood sugar/high…

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 protect the resident's right to be free from sexual abuse by a resident for one of four sampled residents (Resident 2) when facility staff witnessed Resident 1's hand underneath Resident 2's shirt. This failure resulted in Resident 2 not being free from abuse and had the potential for Resident 2 to feel afraid and scared. Findings: Resident 1 was admitted [DATE] with diagnoses that included altered mental status and post-traumatic stress disorder (persistent mental and emotional stress occurring as a result of injury or severe psychological shock). A review of the Minimum Data Set (MDS, an assessment tool), dated 8/23/24, indicated Resident 1 had severe impairment in cognition. Resident 1's Face Sheet (a document that has patient information), indicated Resident 1's son was listed as the responsible party. Resident 2 was admitted [DATE] with diagnoses that included dementia (impaired ability to remember, think, or make decisions). A review of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to report an incident of an injury of unknown origin for one of three sampled residents (Resident 1) as required by the regulations. This failure resulted in a delay in the abuse investigation process and decreased the facility's potential to protect patients from physical and psychosocial harm. Findings: During a review of Resident 1's admission records, the records indicated Resident 1 was admitted [DATE] with diagnoses that included dementia (memory loss), history of falling, and osteoporosis (bones become weak and brittle). Resident 1's Minimum Data Set (MDS, an assessment tool) indicated Resident 1 had severe cognitive impairment and did not exhibit physical and verbal behaviors towards self and other people. During a review of Resident 1's SBAR [Situation, Background, Assessment, Recommendation] Communication Form, dated 9/1/24, the form indicated Resident 1 had a fall on 9/1/24. The notes further indicated, With small scrape to 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, interviews, and record review the facility failed to ensure the residents' shower room on the second-floor was sanitary. This failure decreased the facility's potential to provide residents with a sanitary bathroom and a homelike environment for a census of 35. Findings: During an observation on 1/12/24 at 10:06 a.m., in the shower room on the second-floor, the following was observed: · Black and brown colored substance around the shower drain. · Black and brown colored substances in the grout between tiles on the floor and walls. · Missing grout in between tiles. · Cracked, broken and missing tiles. During an interview on 1/12/24 at 10:14 a.m. with Resident 3, when asked about the cleanliness of the second-floor shower room, Resident 3 stated, It's disgusting. I don't think it ever gets cleaned .the floor is slimy. During an interview on 1/12/24 at 10:45 a.m. with Resident 5, Resident 5 stated, That shower room could use a good scrub, there's lots of mildew on the tiles. It doesn't look good. During an interview on 1/12/24 at 2:15 p.m. with the Janitor, photos…

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

Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1's), dignity and safety was protected when Certified Nurse Assistant (CNA) 1 threw a juice carton that hit the resident's water bottle, knocking it onto Resident 1. This failure resulted in Resident 1 to feel disrespected when the juice carton hit the resident's water bottle on the bedside table and fell onto Resident 1 in bed. Findings: Resident 1 was a long-term resident in the facility with diagnoses that included a mental disorder with behaviors. Review of Resident 1's most recent MDS (Minimum Data Set, an assessment tool) indicated the resident was cognitively intact with a score of 14/15 in the BIMS (Brief Interview for Mental Status) assessment. In an interview on 1/3/24 at 10:26 a.m., the Director of Nursing (DON) stated there was an incident in Resident 1's bedroom during the holidays when CNA 1 stated that she threw a carton of juice into the garbage can but it hit the resident's water bottle instead and fell onto the resident in bed. The DON 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 and interview, the facility failed to follow infection control guidelines for 14 residents for a census of 96 when infection control precautions signs were not posted for five out of nine COVID positive rooms, doors were left open, garbage containers were outside of the rooms for nine out of nine COVID positive rooms,and two out of the nine rooms had broken garbage cans, causing staff to touch the lid with gloved contaminated hands to throw away contaminated PPE. These failures had the potential to spread infection and disease among residents, staff, and visitors. Findings: During an observation on 12/13/23 at 10:35 AM, six first-floor rooms that contained COVID positive residents were seen with all their doors opened and garbage cans outside of the rooms contained used PPE. During an observation on 12/13/23 at 10:35 AM, four out of six COVID positive rooms on the first floor were seen not having infection control signs outside the rooms. During an observation on 12/13/23 at 12:44 PM, one out of three COVID positive rooms on 2nd floor were observed not having an…

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

Based on observation, interview, and record review, the facility failed to ensure pharmacy services were maintained for 95 residents when: 1. Loose pills and pharmaceutical products were found at the back of bottom drawers of two medication carts, which could result in diversion of the loose medications; 2. An expired medication was available for Resident use in the medication cart, which put Residents at risk of receiving expired or outdated medications; 3. The facility failed to properly label and store all drugs and biological as per manufactures instructions, including expiration dates which put Residents at risk of receiving expired or outdated medication; and, 4. The facility failed to properly storage medications and left medications at the resident's bedside. These failures had the potential to contribute to medication error, unsafe medication use and storage, and diversion. Findings: 1. During an inspection of medication cart 1 on 9/11/23 at 2:56 p.m., 10 loose pills were found in the bottom of the medication cart drawers as well as multiple pharmacy products were found at…

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

Based on observation, interview and record review, the facility failed to implement measures to provide a homelike environment for a census of 95 when: 1. The shower room for Nursing Station 1 had discolored grout along several tiles, had broken and missing tiles and was dirty; and, 2. Resident 10's clothing was lost and staff did not follow up in a timely manner to replace them. These failures had the potential to result in residents experiencing an environment that was not homelike. Findings: 1. In a concurrent observation and interview, on 9/11/23 at 9:24 a.m., the Nursing Station 1 shower room had an area with missing tiles on the floor, an area with cracked tiles and the grout around the tiles was brown in color. The floor was dirty and the shower drain was covered with a thick layer of hair. The Director of Staff Development (DSD) confirmed the shower room was dirty, the tiles were in need of repair and stated she would not want to take a shower in the room. In an interview, on 9/14/23 at 11:35 a.m., the Director of Nursing (DON) agreed the shower room tiles needed to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain resident safety for a census of 95 when: 1. Electrical equipment was in use near water; and 2. Residents were smoking unsupervised and smoking materials were not stored properly. These failures had the potential to jeopardize the health and safety of the residents. Findings: 1. In a concurrent observation and interview, on 9/11/23 at 8:35 a.m., the left side of a large two basin sink in the kitchen contained several tubes of ground turkey thawing in a bus pan with cold water running over the them. A large fan was placed to the left of the sink and was plugged into an extension cord which was kept off the floor by being run through a closed drawer with the plugs hanging in the air. The remainder of the extension cord was extended over to the right of the sink, coiled on the shelf next to the right sink and plugged into the wall outlet. Water was coming from under the sink and pooling on the floor. The Dietary Manager (DM) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement its pharmaceutical policies and procedures for a census of 95 when an expired E-Kit (Emergency-Kit, storage box containing emergency supplies of medication) was not removed and replaced according to facility policy. This failure had the potential to allow administration of expired and ineffective emergency medications. Findings: During a concurrent inspection of medication room [ROOM NUMBER] and interview with Licensed Nurse (LN) 1 on [DATE] at 2 p.m., e-kit #30 was found to have been opened on [DATE] at 9 a.m. LN 1 confirmed that e-kit in the medication room was used and needed to be replaced by the pharmacy. A review of documentation found in the e-kit indicated one vial of heparin (medication used to prevent blood cloths) 5000 units (a unit of measure) had been removed on [DATE] at 9 a.m. Other documentation located in the e-kit indicated the LN 2 had not faxed the documentation nor notified the pharmacy, that e-kit #30 had…

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

Based on observation, interview and record review, the facility failed to ensure the medication error rate did not exceed 5% for 2 of 4 sampled residents (Resident 9, and 148). 1. For Resident 148, Licensed Nurse (LN) 1 administered Resident's losartan potassium, a medication to treat high blood pressure, not in accordance with the Physicians Order. 2. For Resident 9, LN 2 administered Resident's fluticasone furoate 100 mcg (microgram, unit of measure), umeclinium 62.5 mcg, and vilanterol-25 mcg, a combination of three medications used to treat breathing issues, not in accordance with the Physicians Order. As a result, 2 errors were identified out of 31 opportunities for error during observation of medication administration; the facility medication error was 6.45%. Findings: 1. During an observation of medication administration on 9/11/23 at 8:41 a.m. LN 1 was observed to prepare and administer Resident 148's blood pressure medication. On 9/11/23 at 8:41 a.m. LN 1 administered 50 mg (milligram, unit of measure) of losartan potassium. During an interview on 9/11/23 at 1:45 p.m. with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to properly store, prepare, and serve food and maintain kitchen equipment and sanitary conditions in accordance with professional standards for food safety for a census of 95, when: 1.The Certified Nursing Assistant 3 (CNA 3) used a non-microwaveable base and dome to reheat Resident 21's food plate; 2. Undated food products were stored in the freezer and dry storage area; and, 3. Kitchen equipment and floor were not clean and in disrepair. These failures increased the potential for food-borne illnesses among the residents. Findings: 1. A review of an admission record indicated Resident 21 was admitted to the facility on [DATE]. During a concurrent observation and interview on 9/14/23 at 8:20 a.m. with CNA 3, Resident 21 asked CNA 3 to warm her food in the microwave. CNA 3 took Resident 21's food to the staff's break room, covered the food plate with an insulated dome, placed it in the microwave with an insulated base underneath it, reheated…

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

Based on observation, interview and record review, the facility failed to ensure infection control measures were followed for two of 27 sampled resident (Resident 65 and Resident 5) when: 1. Resident 65's privacy bag was placed on his indwelling catheter (a flexible plastic tube inserted in the bladder to constantly drain urine) after being on the floor; and, 2. No hand hygiene was completely during wound care for Resident 5. These failures had the potential to increase the chance of an infection. Findings: 1. A review of the admission Record, Resident 65 was admitted to the facility in April 2023 with diagnosis that included retention of urine. A review of a facility document titled care plan dated 4/17/23 indicated Resident 65 had an indwelling catheter related to urinary retention at risk for developing complications related to catheter use. During an observation on 9/12/23 at 12:32 p.m. Resident 65 was observed being assisted into a wheelchair. Occupational Therapist (OT) was observed picking up a blue privacy bag from the floor and placed Resident 65's indwelling catheter in…

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 resident call light system was properly functioning for seven residents (Resident 19, Resident 24, Resident 33, Resident 35, Resident 44, Resident 70 and Resident 75) of a census of 95 when their call lights were malfunctioning. This failure had the potential to unneccesarily extend the time residents waited to have their call lights answered. Findings: In a concurrent observation and interview, on 9/11/23 at 9:56 a.m., Resident 33 stated his call light was not working properly and that it had been turning on without him pushing it. Resident 33 stated he had been complaining about it for 3 weeks, staff did not know if he really needed something or not and after a while staff just did not come when his light was on. Resident 33 further stated he was diabetic (living with diabetes mellitus, a chronic condition that affects the way the body processes blood sugar) and worried his blood sugar could drop and he would not be able to get assistance. In a concurrent observation and interview, on 9/11/23 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. A review of an admission record indicated Resident 300 was admitted to the facility on [DATE]. A review of Resident 300's MDS, dated [DATE], indicated Brief Interview of Mental Status (BIMS) score was 13 with good memory. A review of an admission record indicated Resident 297 was admitted to the facility in August 2023 with diagnoses including metabolic encephalopathy (problem in the brain), cognitive communication deficit (difficulty with thinking and using language), and bipolar disorder (mental illness). A review of Resident 297's MDS, dated [DATE], indicated BIMS score was 5 with memory problems. During a concurrent observation and interview on 9/11/23 at 9:55 a.m. with Resident 300, Resident 300 stated Resident 297 went into her room five times using the shared restroom, kept the restroom's door open while using it, and came naked to her room one time. Resident 300 further stated she felt uncomfortable about Resident 297 continuously coming into her room, got anxious thinking about if he was going 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 observation, interview and record review, the facility failed to effectively implement its grievance policy and procedure for a census of 95 when: 1. The grievance policy was not prominently posted in the facility; 2. The Resident Council President was not aware of how to file a grievance; and, 3. The grievance process was not thoroughly explained to newly admitted residents. These failures had the potential to result in residents not having a process to report concerns related to their care and treatment without fear of threat or reprisal. Findings: 1. In a concurrent observation and interview, on 9/12/23 at 12:51 p.m., the Director of Staff Development (DSD) was asked where the grievance policy was posted and was initially unable to locate it. After speaking to someone on the phone, the DSD located the grievance policy in the top left corner of a locked bulletin board next to the facility's front door. In a concurrent observation and interview, on 9/12/23 at 1:51 p.m., the Social Services Director (SSD) confirmed the grievance policy had not been prominently posted 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 observation, interview, and record review, the facility failed to complete a Significant Change in Status Assessment (SCSA, an assessment that indicates a major decline or improvement in the resident's status) for one of 27 sampled residents (Resident 15) when Resident 15 developed a stage 4 (deep wound reaching the muscles, ligaments, and bones) pressure ulcer (PU) to her sacrococcyx (tailbone). This failure decreased the facility's potential to develop a personalized plan of care to prevent a further decline. Findings: Resident 15 was admitted to the facility in mid-2022 with diagnoses that included right femur fracture (broken thigh bone), difficulty in walking, and pressure-induced deep tissue damage (purple or maroon localized area of discolored intact skin due to damage from pressure) to sacral region (tailbone area). During a review of Resident 15's Minimum Data Set (MDS, an assessment tool), dated 12/20/22, Section M, indicated Resident 15 had no pressure ulcer. During a review of Resident 15'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 ensure comprehensive care plans were developed timely for two of 27 sampled residents (Resident 15 and Resident 148) when: 1. Resident 15 developed a stage 4 Pressure Ulcer (PU-full thickness skin loss, wound can extend to muscle and bone) was identified; and, 2. Resident 148 did not have a PU care plan. These failures had the potential to result in inadequate care being provided to residents. Findings: 1. Resident 15 was admitted to the facility in mid-2022 with diagnoses that included right femur fracture (broken thigh bone), difficulty in walking, and pressure-induced deep tissue damage (purple or maroon localized area of discolored intact skin due to damage from pressure) to sacral region (tailbone area). During a review of Resident 15's Progress Notes, Type: Skin/Wound Note (PN), dated 1/6/23, the PN indicated, .The wound is now 99% intact black eschar [dead tissue]. The eschar is measuring 5cm [centimeter, a unit of measurement] X 3.8cm and is irregular shaped .Pt [patient] is reporting pain in the area . During 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 1. A review of an admission record indicated Resident 25 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD; chronic lung condition) and asthma (chronic lung disease). A review of Resident 25's Minimum Data Set (MDS; an assessment tool), dated 7/24/23, indicated Brief Interview of Mental Status (BIMS) score was 14 with good memory. During an interview on 9/11/23 at 10:58 a.m. with Resident 25, Resident 25 stated she received her inhaler late and if she did not receive it by 8 a.m., then she will start having chest tightness and wheezing. Resident 25 further stated she had a tight chest this morning because she received her inhaler at 10 a.m. A review of Resident 25's Order Summary Report, indicated Resident 25 started on 7/22/23, to inhale two puffs of budesonide-formoterol fumarate dihydrate (an inhaler used to treat COPD and asthma) two times a day at 8 a.m. and 6 p.m. for COPD. A review of Resident 25's Asthma Care Plan, dated 7/24/23, 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 bath/shower as scheduled for one out of 27 sampled residents (Resident 57) when Resident 57 did not get shower as scheduled. This failure had the potential to decrease cleanliness and comfort for the resident. Findings: A review of an admission Record indicated Resident 57 was admitted to the facility in January of 2021 with diagnoses including brain injuries affecting the left side of the body and need for assistance with personal care. A review of a Minimum Data Set (MDS, a standardized assessment tool), dated 8/12/23, indicated Resident 57 required total dependence for full-body bath/shower. A review of the Shower Schedule, Resident 57's shower schedule was on a Tuesday and Friday day-time shower schedule. Resident 57 should have gotten a shower/bath on August 15, 18, 22, 25, 28 and September 1, 5, 8, 12, and 15 of 2023. During an observation on 9/11/23 at 8:50 a.m., Resident 57 was in bed and noted with foul odor. During a concurrent observation and interview on 9/13/23 at 8:35 a.m., Resident 57…

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 resident centered care and services for two of 27 sampled residents (Resident 5 and Resident 71) when: 1. The facility did not follow the wound care order for Resident 5; and, 2. The facility did not have the call light within reach for Resident 71. These failures decreased the potential for the residents to receive effective treatment and necessary personal care. Findings: 1. A review of an admission Record indicated Resident 5 was admitted to the facility in July of 2023 with diagnoses including diabetes (the body's inability processes blood sugar) and lymphedema (swelling of the upper or lower limb). A review of Resident 5's clinical records included the following documents: A Minimum Data Set (MDS, an assessment tool), dated 8/28/23, indicated Resident 5 was cognitively intact. A physician order, dated 9/13/23, indicated, Treatment: left plantar [sole of the foot] 5th metatarsal [bone of the foot] diabetic wound cleanse with NS…

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 27 sampled residents (Resident 63) receive trauma-informed care when his Post-Traumatic Stress Disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) care plan did not include identified triggers and had not been revised at least quarterly. These failures had the potential to result in the re-traumatization of the resident and lead to unmet nursing needs. Findings: A review of Resident 63's admission record indicated he was admitted in 10/21 with diagnoses including altered mental status and PTSD. A review of Resident 63's Minimum Data Set (MDS, and assessment tool), dated 6/25/23, indicated he had severe memory impairment. A review of Resident 63's clinical record included the following documents: A Social History Assessment, dated 10/12/22, identified Resident 63's PTSD triggers as loud noises, closed doors and lack of sleep. A PTSD care plan, initiated on 10/28/22 and last revised 2/14/23, indicated nursing interventions/tasks to manage 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 perform an annual evaluation for two employees out of six sampled personnel files. These failures reduced the potential for the facility to evaluate staff performance effectively. Findings: During a concurrent interview and record review on 9/13/23 at 12:55 pm., the Director of Staff Development (DSD) reviewed the employee's file for Licensed Nurse 12 (LN 12) and Certified Nursing Assistant 8 (CNA 8) and confirmed the annual employee evaluation was past due. A review of an undated facility's policy titled, Performance Evaluations, indicated, A performance evaluation will be completed at least annually.

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 21) of 27 sampled residents was free from an unnecessary psychotropic medication (drug prescribed to affect the mind, emotions, or behaviors), when Resident 21's: 1. Indication/rationale for psychotropic medication was not documented and clinically justified; and 2. Behavioral symptoms were not monitored while receiving the psychotropic medication. This failure increased the facility's potential to administer unnecessary psychotropic medications to residents. Findings: 1. A review of an admission record indicated Resident 21 was admitted to the facility on [DATE] with diagnoses including depression and anxiety disorder. During an observation and interview on 9/11/23 at 10:43 a.m. with Resident 21, Resident 21 was smiling and talking with her roommate while lying comfortably in bed. Resident 21 did not express any episodes of sadness, depression, loneliness, or thoughts of feeling useless. A review of Resident…

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

Based on observation, interview and record review, the facility failed to ensure garbage was properly contained for a census of 95 when one out of five dumpsters was not closed and the surrounding area was littered with trash. This failure had the potential to expose the facility environment to odors, pests and diseases. Findings: During a concurrent observation and interview, on 9/12/23 at 7:50 a.m., one of five facility dumpsters was open, a sticky brown substance was on the ground surrounding the dumpster, several plastic cups, blue gloves, plastic bags, papers, a juice box and other litter were noted on the ground behind the dumpster. The Dietary Manager (DM) confirmed one dumpster had the lid propped open and confirmed there was trash on the ground around the dumpsters. The DM stated, the lid should have been closed and there should not have been trash around it or it can attract rodents and flies. During an interview on 9/14/23 at 8:28 a.m. with the Registered Dietician (RD), the RD confirmed, The lids of the trash should be closed and no debris around. During a review of the…

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

Based on observation, interview and record review, the facility failed to ensure dignity and respect was maintained for one resident (Resident 2) in a facility census of 89, when a registry (temporary contract employee) Certified Nursing Assistant (CNA) verbally demeaned her and did not provide her care properly and in a dignified manner. This caused Resident 2 to be tearful, afraid, and not wanting the CNA to assist in changing the soiled diaper This failure had the potential to diminish Resident 2's self-worth and self-esteem. Additionally, being left lying in urine or stool for an extended period increased the risks for compromising her skin integrity. Findings: During an interview on 8/14/23 at 12:39 p.m. with Resident 2, Resident 2 stated on the night shift of 8/9/23, a registry CNA was being rough with her during her diaper changes and pulling on her left arm which has limited use due to a stroke (a medical condition which can cause paralysis) on two occasions. On the second occasion, she stated the CNA spoke to her rudely and disrespectfully and said, I am not your maid!…

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 initiate life saving measures, Cardio Pulmonary Resuscitation (CPR) and call 911 (emergency personnel) immediately upon determining one of three sampled full code residents (Resident 1) was unresponsive and not breathing. This failure had the potential to contribute to Resident 1's death and put other residents who are full code at risk for delayed intervention in an emergency situation. Findings: Resident 1 was admitted to the facility in early 2023 with diagnoses that included polyneuropathy (weakness, numbness, and pain from nerve damage), generalized muscle weakness and type 2 diabetes (a disease that affects the way the body processes blood sugar). During a record review of Resident 1's Physician Orders for Life-Sustaining Treatment (POLST), dated [DATE], Resident 1's POLST indicated, Attempt Resuscitation/CPR .Full Treatment - primary goal of prolonging life by all medically effective means. During a review of Resident 1's Progress Notes (PN),…

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.