Medical Center Convalescent Hospital

Based on the observation, interview, and record review, the facility failed to ensure safe medication labeling practices and medications were stored at the proper temperature range in accordance with accepted standards of practice and/or manufacturer's instructions when:1. One of one opened inhaler mouthpiece for Resident 36 was not properly labeled with sufficient information to clearly identify the specific resident.This failure had to potential to cause medication errors and preventable infections from cross-contamination (transfer of germs) if accidently mixed up with other residents' similar or same drugs.2. Medications were observed stored at the incorrect temperature.a. An undated insulin (drug to manage high blood sugars) pen (portable device) for Resident 39 in one of three medication carts.b. Two medication cartons containing bisacodyl (laxative drug to manage constipation) in one of two medication rooms refrigerators.This failure had the potential for residents to be given deteriorated (reduced quality) medications if stored outside the temperature range specified by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to maintain an accurate Medication Administration Record ([MAR] - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for one of one sampled resident (Resident 17) when the facility indicated Resident 17 was hospitalized , while the resident was out on pass ([OOP] - a temporary, authorized absence from a medical facility for social, family, or therapeutic reasons, with the explicit requirement that they return for continued treatment from the facility).This failure had the potential for omission of necessary medications.Findings:A review of Resident 17's admission Record, (a document showing a summary of the resident's information) dated 2/24/26, indicated Resident 17 was admitted to the facility on [DATE].A review of Resident 17's Release for Temporary Absence form undated, indicated Resident 17 departed the facility on 2/24/26 at10:08 AM.During an observation on 2/25/26 at 8:10 AM Resident 17 was not in the room and the bed was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper and safe infection control practices were followed when: 1. In the laundry room, two dryers were set below the facility policy requirement of 180 degrees Fahrenheit (°F- unit of measurement), to comply with infection control, on February 5, 2025. 2. Resident 192's Intravenous (IV- flexible tube used to give fluids, medicine, or nutrients through a vein) tubing was not dated as per facility policy. These failures had the potential to result in cross-contamination (the transfer of harmful bacteria) causing a preventable infection to 71 highly vulnerable residents whose health conditions are already compromised. Findings: 1. During an observation on February 5, 2025, at 2:45 PM, with the Maintenance Director (MD), in the laundry room, the facility's two dryers were inspected. Both dryers were set to a medium setting (range of 140°F to 170°F). The temperature of each dyer was measured using an infrared thermometer (also known as…

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

Based on observation, interview, and record review, the facility failed to ensure proper management and disposal of expired medications was being implemented when: 1. One expired bisacodyl (used to treat constipation- when a person cannot poop) suppository (solid form of medications that dissolve inside the body) was found in the medication storage room and was available for use. 2. One expired alginate dressing (absorbent wound care product) was found in the treatment cart and was available for use. These failures had the potential for the dressing and medication to not be effective or safe for resident use in 71 highly susceptible medically compromised residents. Findings: 1. During a concurrent observation and interview, with Licensed Vocational Nurse (LVN 5), on February 2, 2025, at 10:37 AM, the medication storage room was inspected. One bisacodyl suppository dated January 2025 was found inside the medication refrigerator. (One month expired) LVN 5 confirmed it was expired and stated it should not have been available for use. 2. During a concurrent observation and interview,…

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

Based on observation, interview, and record review, the facility failed to follow their policy to store food in a way that conserves nutritive value, flavor, and appearance, when cups of pudding, which were designated to be used during medication pass (process of delivering and administering medications to residents at scheduled times) were not accurately dated to reflect when it was prepared. This failure had the potential for staff to serve outdated pudding to residents, which could lead to dissatisfaction. (Each day, two residents receive pudding as a snack, while 68 residents potentially receive pudding during the medication pass.) Findings: During a concurrent observation and interview, with the Dietary Supervisor (DS), on February 3, 2025, at 8:05 AM, in the kitchen, a tray containing 18 cups of 4-ounce (oz- unit of measurement) servings of pudding was inside the kitchen refrigerator. A piece of paper taped on the tray indicated, 2/2/25 [February 2, 2025]. The individual cups of pudding were not dated. The DS explained the date on the tray indicates when an item was prepared…

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 their restorative nursing services (RNS; also known as RNA program; nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible; generally initiated when a resident is discharged from formalized rehabilitation therapy) policies and procedures were being implemented for one of three residents reviewed for position and mobility (Resident 61) when Resident 61 was not placed on the RNS program after his Physical Therapy (PT- medical treatment that uses physical techniques to help people regain movement and function after an injury or disease) treatment was completed. This failure had the potential for Resident 61 to be at risk for falls, further decline in ambulation, and a loss of independence. Findings: During a review of Resident 61's health record, the admission Record (which contains demographic and medical information) indicated that Resident 61 was admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the observation, interview, and record review, the facility failed to meet the regulatory requirement to ensure the resident environment remains as free of accident hazards as possible when a resident (Resident 1) accidentally released a bear spray ( a spray which is twice as concentrated as pepper spray, a chemical can cause burning pain, watery eyes, and coughing upon contact with skin or eyes) which affected five other residents (Residents 2 , 3, 4 ,5 and 6) on July 23, 2024. This failure resulted in Residents 2 , 3, 4, 5 and 6 to experience red, watery eyes and coughing. Residents 2, 3, 5, and 6 required hospitalizations. Findings: 1. During a review of Resident 1's admission Record (clinical record with demographic information), indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included anxiety disorder (mental health conditions that cause excessive fear or worry), restlessness and agitation (mean feeling uneasy or upset, making it hard to stay still or calm down). 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 have a full-time qualified Dietary Services Supervisor, who was responsible for overseeing daily food production for breakfast, lunch, and dinner. This failure led to sanitation issues in the kitchen (cross-reference F-tag 812), staff who were not competent (cross-reference F-tag 802), deficiencies with food palatability when kitchen staff were using disposable dishware for resident meals (cross reference F-tag 804), and had the potential to affect 92 medically compromised residents at nutrition risk who received food from the kitchen. Findings: During an initial kitchen tour observation and interview, on May 2, 2023, at 8:50 AM, with [NAME] 1, [NAME] 1 stated the facility did not have a Dietary Services Supervisor. During an interview, with the Director of Nursing (DON), on May 2, 2023, at 11:35 AM, the DON stated the former Dietary Services Supervisor quit on April 24, 2023, via text message. During a review of an undated facility provided copy of a printed text message, it indicated, Good morning,…

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

Based on observation, interview, and record review the facility failed to store and serve food that conserved flavor and appearance and was an appetizing temperature when: 1. A 20-pound box of carrots was stored in the freezer, open and unsealed, and was available for use. 2. In the cooking area, there was a container with onions sprouting and growing mold, and potatoes that were sprouting, and was available for use. 3. Residents were served lunch on May 2, 2023, on Styrofoam take-out containers and with plastic utensils These failures had the potential to cause 92 medically compromised residents who received food from the kitchen not to enjoy their food which could affect their nutrition status. Findings: 1. During an initial kitchen tour observation, on May 2, 2023, at 8:33 AM, there was a 20-pound open box of frozen carrots in the freezer. It was open, unsealed, and was available for use. During an interview with the Registered Dietitian (RD), on May 4, 2023, at 12:25 PM, the RD stated all food should be sealed before being placed in the freezer. During 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.

Based on observation, interview, and record review, the facility failed to maintain a sanitary condition in the kitchen in accordance with professional standards for food safety when: 1. Three-compartment sink was not sanitizing dishes. It required 200 ppm (part per million- unit of measurement) of quaternary ammonia (chemical used to kill bacteria, viruses, and mold). The test was conducted and resulted to 100 ppm of quaternary ammonia. 2. The stainless steel shelf, used to store clean metal pans, had a sticky residue and food crumbs. 3. The floor, under the stainless steel shelves, had dirt, food crumbs, and black grime. 4. Three cupcake pans, stored on a shelf, had black burn residue and were available for use. These failures had the potential for microorganism growth that could be inadvertently transferred to the food of 92 medically compromised residents who received food from the kitchen. Findings: 1. During an observation and concurrent interview, in the kitchen, on May 2, 2023, at 8:55 AM, the three-compartment sink was inspected. A Dietary Aide 1 (DA 1) tested its'…

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 infection (establishment of an infective agent in or on a suitable host, producing clinical signs and symptoms) control practices were being implemented when: 1. The facility did not follow their policy and procedure for Legionella (bacteria that can cause a lung infection) water management program when the last results found were from March 25, 2020 (approximately 25 months ago). 2. Licensed Vocational Nurse (LVN 4) did not perform hand hygiene after checking Resident 44's blood sugar level. 3. LVN 1 did not perform hand hygiene when she provided Residents 26's wound care treatment. 4. LVN 1 did not perform hand hygiene when she provided Resident 289's wound care treatment. 5. Resident 290's oxygen tubing was found on the floor of her room. These failures had the potential to result in the spread of infection to 92 highly vulnerable residents whose health conditions were already compromised. Findings: 1. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an accurate completion of a Preadmission Screening and Resident Review (PASARR - a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) for one resident (Resident 3) reviewed for PASARR . This failure had the potential for Resident 3 not to receive the care and services she needs due to her not being evaluated further. Findings: During a review of Resident 3's clinical record, the admission Record (contains personal demographic and medical information) indicated Resident 3 was initially admitted to the facility on [DATE], with diagnoses that included bipolar disorder (a mental disorder), and schizoaffective disorder (a mental disorder). During a concurrent interview and record review, with the Registered Nurse (RN), on May 4, 2023, at 2:44 PM, the RN reviewed Resident 3's PASARR Status Change Level 1 screening,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the physician was notified of wound care treatment refusals for one of four residents (Resident 82) reviewed for skin conditions when Resident 82 refused his treatments for three consecutive days (May 1, 2023 through May 3, 2023). This failure had the potential for Resident 82 to be at risk of increased infection, poor wound healing, hyperglycemia (elevated sugar levels in blood), and/or re-hospitalizations. Findings: During a review of Resident 82's clinical record, the admission Record (contains demographic and medical information indicated Resident 82 was admitted to the facility on [DATE], with diagnoses of burn of second degree of left foot (involves the top skin and parts of the dermis layer of skin), second degree of right foot (involves the top skin and parts of the dermis layer of skin), diabetes mellitus (an abnormal level of blood sugar), and pain. During a concurrent observation and interview, on May 3, 2023, at 2:30…

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 observation, interview, and record review, the facility failed to ensure their urinary catheter (a flexible tube used to empty the bladder) removal policy and procedure was implemented for one of three residents reviewed for urinary care when Resident 76's urinary catheter was removed without a physician's order. This failure had the potential for Resident 76 to be at risk of urinary retention (inability to completely empty the urinary bladder by urinating.) Findings: During a review of Resident 76's clinical record, the admission Record (contains demographic and medical information), indicated Resident 76 was admitted to facility on October 1, 2022, with diagnoses of obstructive and reflux uropathy (occurs when urine cannot drain through urinary tract, and presence of urogenital implants (a way to help treat stress incontinence due to a weak sphincter). During a review of Resident 76's physician's order, dated April 10, 2023, it indicated Resident 76 had an order for Indwelling catheter (a type of urinary catheter) . attached to gravity drainage bag for obstructive reflux…

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 did not maintain acceptable parameters of nutritional status (factors that reflect that an individual ' s nutritional status is adequate, relative to his/her overall condition and prognosis, such as weight, food/fluid intake, and pertinent laboratory values) for one of six residents (Resident 51) reviewed for nutrition, when the nutrition interventions recommended by the Registered Dietitian were not implemented for Resident 51. This failure had the potential for Resident 51, a medically compromised individual, to be at risk of impaired wound healing and weight loss. Findings: During a review of Resident 51's clinical record, the admission Record indicated Resident 51 was admitted in April 25, 2023 with diagnoses of end stage renal disease (medical condition in which person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis), pressure ulcer of sacral region stage four (deep wound reaching the muscles, ligaments, and/or bones), and pressure induced deep tissue…

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 oxygen administration were provided for one of three residents (Resident 32) reviewed for respiratory care when: 1. Resident 32's oxygen therapy order was not carried out as prescribed by the physician. 2. Resident 32's oxygen tubing (a device which facilitates oxygen delivery) was not labeled to indicate the date when it was changed. These failures had the potential to result in a decline in Resident 32's oxygen status, causing shortness of breath, oxygen toxicity (too much oxygen), respiratory infection, and lung damage. Findings: 1. During a review of Resident 32's clinical records, the admission Record (containing demographic information), indicated Resident 32 was admitted on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD- lung disease that causes obstructed airflow from the lungs), dependence on supplemental oxygen (additional oxygen), and pneumonia (inflammation in the lungs that makes…

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 medications were administered according to the facility's policies and procedures for two of 13 residents (Resident 33 and 77) reviewed for medication administration observation when: 1. Resident 33 had an order to receive Sevelamer (medication to treat high levels of phosphorus). The medication was not available for administration. 2. Resident 77 refused to receive Pantoprazole (a medication to treat acid reflux). It was documented as administered. These failures had the potential for Residents 33 and 77 to not be administered prescribed medication and increased the resident's risk for adverse reactions and side effects. Findings: 1. During a review of Resident 33's clinical record, the admission Record (contains demographic and medical information), indicated Resident 33 was admitted to the facility on [DATE], with diagnoses which included, end stage renal disease (condition in which kidneys cannot longer function on their own)…

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 pharmacy recommendation identified from the Drug Regimen Review (DRR- thorough evaluation of a resident's medication regimen to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities) was followed up in accordance with federal regulations, for one of five residents (Resident 66) reviewed for unnecessary medications. Resident 66 had an order to receive Xanax (medication to treat anxiety) as needed. The Consultant Pharmacist reviewed her medications and recommended for it to be limited for 14 days. This failure had the potential for Resident 66 to receive unnecessary medication and had unrecognized adverse reactions. Findings: During a review of Resident 66's clinical records, the admission Record (contains demographic and medical information), indicated Resident 66 was admitted on [DATE], with diagnoses which included alzheimer's disease (progressive disease that destroy memory 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 ensure medication error rate was less than five percent. There were two medication errors identified out of 29 opportunities for errors, affecting two of 13 residents (Residents 33 and 77), resulting in an overall medication error rate of 6.9 percent when: 1. Resident 33 had an order to receive Sevelamer (medication to treat high levels of phosphorus). The medication was not available for administration. This failure had the potential for Resident 33 to have increased levels of phosphorus in the blood which could lead to low calcium which may cause muscle cramps. 2. Resident 77 refused to receive Pantoprazole (a medication to treat acid reflux). It was documented as administered. This failure had the potential for Resident 77's health care needs towards his acid reflux not being addressed. Findings: 1. During a review of Resident 33's clinical record, the admission Record (contains demographic and medical information), indicated 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 have dietary staff with appropriate competencies when: 1. Dietary Aide 1 (DA 1) did not know how to check the quaternary ammonia (chemical used to kill bacteria, viruses, and mold) level of the three-compartment sink (3 sinks, one for each step of the ware wash procedure, wash, rinse and sanitize) and the quaternary ammonia level was not the correct concentration. 2. Dietary Aide 2 (DA 2) did not know how to check the chlorine level of the dish machine. These failures had the potential to cause foodborne illness (illness caused by the ingestion of contaminated food or beverages) for a medical compromised population of 92 residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview, with Dietary Aide 1 (DA 1) and [NAME] 1, in the kitchen, on May 2, 2023, at 8:55 AM, (DA 1) checked the quaternary ammonia level of the three -compartment sink. DA 1 dipped the quaternary test strip in the water and immediately compared it to the vile color code, it was 100 ppm (parts per…

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 hospice (specialized end-of-life care for all patients with a terminal illness with a prognosis of 6 months or less) care was coordinated in accordance with the facility's policy and procedure for one of two residents (Resident 23) reviewed for hospice, when there was no current hospice recertification (the certification and recertification regulations require a physician certify the patient is terminally ill with a prognosis of 6 months or less) and current plan of care available in Resident 23's health record. This failure had the potential for Resident 23 not to receive hospice care services based on a comprehensive person-centered care plan. Findings: During a review of Resident 23's admission Record (contains demographic and medical information), it indicated Resident 23 was admitted to the facility on [DATE], with diagnoses of heart failure (a condition in which the heart is no longer able to pump oxygen-rich blood to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure their bed inspection policy were implemented for two of seven residents (Residents 12 and 69) reviewed for accidents when: 1. For Resident 12, her bed had a 10-centimeter (cm- unit of measurement) gap between the mattress bed and footboard. 2. For Resident 69, her bed had a 15-centimeter gap between the mattress and the footboard. These failures had the potential to place Residents 12 and 69 at risk for entrapment (being caught between the mattress and bed rail), falls, and injuries. Findings: 1. During a review of Resident 12's clinical record, the admission Record (contains demographic and medical information) indicated Resident 12 was admitted to the facility on [DATE], with the diagnoses of type 2 diabetes (a condition where the body does not produce enough insulin), delusional disorders (person cannot tell what is real from what is not), abnormalities of gait (walking) and mobility, and anxiety (feeling of fear or uneasiness).…

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 systems for two of three shower rooms (Shower Rooms A and B) were accessible and functional. This failure had the potential to place 92 residents at risk of harm, as residents experiencing an emergency or needing assistance would not be able to call for help. Findings: During a concurrent observation and interview, on May 5, 2023, at 10:58 AM, with the Infection Preventionist (IP), at Shower Room B (SRB- located in the southeast corner of the facility), SRB had one toilet and one shower. Both toilet and shower call lights were inoperable when pulled to activate, as no light indicator was visible over SRB doorway to alert staff. The call light cord in the shower was not accessible to a resident lying on the floor. The IP stated a resident on the floor would not be able to reach the call light for the shower. The IP further stated the expectation was that the call lights were accessible and working properly. During an observation, on May 5, 2023, at 11:07 AM, with the IP, at Shower Room A (SRA-…

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 an effective pest control program (measures to eradicate and contain common household pests e.g., bed bugs, lice, roaches, ants, mosquitoes, flies, mice, and rats) when the presence of pests in the facility within the last year were not reported to the Maintenance Supervisor as indicated in the facility's policy and procedure. This failure had the potential to negatively affect the health and safety of 92 highly vulnerable residents through the direct and indirect exposure to the contaminants the cockroach may carry. Findings: During a concurrent observation and interview on May 4, 2023, at 7:00 AM, in room [ROOM NUMBER], with a Licensed Vocational Nurse (LVN 4), a live cockroach jumped under Bed B. LVN 4 stated That [cockroach] was a big one I hate cockroaches. During an interview, on May 4, 2023, at 8:15 AM, with LVN 3, LVN 3 stated she has had seen a cockroach in the facility within the last year. During an interview, on May…

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.