Ivy Creek Healthcare & Wellness Centre

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide two (2) of three (3) sampled residents (Residents 37 and 43) on dialysis (a lifesaving treatment for residents with kidney failure) treatment, a safe and appropriate care in accordance with the facility's policy by failing to ensure: 1a. Resident 37's fluid intake was restricted to 1200 milliliters (ml, unit of volume) per day as indicated on the physician's orders and care plan. 1b. A current Interdisciplinary Team (IDT, group of healthcare professionals from diverse fields who work in a coordinated manner toward a common goal for the resident) meeting was conducted for Resident 37's fluid restriction noncompliance. 2. Resident 43's fluid intake was restricted to 1000 ml per day as indicated on the physician's order and care plan. This deficient practice had the potential to result in overloading (harmful amount of fluid in the body) Resident's 37 and 43 with fluid which could cause complications such as swelling, high blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to administer medications as indicated on facility policy for three (3) of four (4) sampled residents (Resident 245, 4 and 11), by failing to administer: 1. Resident 245's cyclobenzaprine (a muscle relaxer that treats muscle spasms) between 7 AM and 9 AM. 2. Resident 4's bethanechol (medication that stimulates the bladder to urinate), metoprolol (medication that lowers blood pressure), verquvo (medication that reduces risks of death or hospitalization with heart failure), eliquis (medication that reduces blood clotting), entresto (medication that reduces stress on the heart and strengthens the heart's pumping action) between 8 AM and 10 AM. 3. Resident 11's amlodipine (medication to lower blood pressure) and clopidogrel (medication that prevents blood platelets from sticking together) between 8 AM and 10 AM. This deficient practice had the potential to result in adverse reactions (an undesired harmful effect resulting from a medication or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five (5) percent (%). Eight (8) medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/ manufacturer's specifications/accepted professional standards and principles) out of 26 opportunities (observed administered medications) for error, which yielded a facility medication error rate of 30.77% for three (3) of four (4) sampled residents (Residents 245, 4 and 11) observed during medication administration (med pass). The medication errors were as follows: 1. Resident 245's cyclobenzaprine (a muscle relaxer that treats muscle spasms) was not administered between 7 AM and 9 AM. 2. Resident 4's bethanechol (medication that stimulates the bladder to urinate), metoprolol (medication that lowers blood pressure), verquvo (medication that reduces risks of death or hospitalization with heart…

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 three (3) of 3 dumpsters (a movable waste container designed to be brought and taken away) were closed and not overflowing, in accordance with the facility's Policy and Procedure (P&P) titled, Waste Management. This deficient practice had a potential to attract vermin (animals that are believed to be harmful, carry diseases such as rodents, parasitic worms, or insects), pests (any living thing that has a negative effect on humans), and wildlife (undomesticated animal species) and may cause disease and other health issues to residents, staff, and the community. Findings: During an observation on 4/7/2025 at 7:34 AM at the west side of the facility building, 3 dumpsters located outside the facility building, near the facility entrance and parking area were observed overflowing with empty boxes and clear plastic bag containing kitchen trash. During a concurrent observation of the 3 dumpsters outside the facility and interview on 4/7/2025 at 7:54 AM with the Dietary Service Supervisor (DSS), the DSS 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 observation, interview, and record review, the facility staff failed to obtain an accurate water temperature reading and ensure the water used to wash two loads of soiled linens in two (2) of 2 washing machines had the correct temperature in accordance with the facility policy. This deficient practice had the potential to compromise infection control measures to eliminate disease causing bacteria, germs, and viruses on linens which could get residents sick and potentially spread infection in the facility. Findings: During a concurrent observation and interview on 4/9/2025 at 9:27 AM in the laundry room with Laundry 1 (LD 1), LD 1 stated LD 1 did not check the thermometer for the water temperature in the washing machine. LD 1 stated there were 2 loads of white linens currently being washed in washing machines 1 and 2. During a concurrent observation and interview on 4/9/2025 at 9:34 AM with Maintenance Supervisor (MS), MS stated the thermometer to check for the water temperature of the washing machine was broken. MS stated the reading on the thermometer was between 70-80…

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 promote respect and dignity for one (1) of 1 sampled resident (Resident 56) by not providing privacy during brief change. This deficient practice had the potential for Resident 56 to experience loss of dignity, self-esteem, and affect resident's psychosocial well-being. Findings: During a review of Resident 56's admission Record, the admission Record indicated Resident 56 was initially admitted to the facility on [DATE] with diagnosis which included history of falling, adult failure to thrive (adults whose independence is declining), bed confinement status (unable to get up from bed without assistance, unable to ambulate, and unable to sit in a chair or wheelchair). During a review of Resident 56's Minimum Data Set (MDS, a resident assessment tool), dated 3/21/2025, the MDS indicated Resident 56 cognitive skills (processes of thinking and reasoning) for daily decision making was severely impaired (never/rarely made decisions). 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 2. During a review of Resident 245's admission Record, the admission Record indicated resident 245 was admitted to the facility on [DATE] with diagnoses that included osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), gastro esophageal reflux disease (GERD - chronic digestive disease where the contents of the stomach refluxes and irritates the esophagus) and fusion of thoracic spine (a surgical procedure where two or more bones in the mid-back are joined together to eliminate movement between them). During a review of Resident 245's MDS, dated [DATE], the MDS indicated Resident 245 was moderately impaired with cognitive skills for daily decision making. The MDS also indicated Resident 245 was dependent (helper does all effort needed to complete activity) with toileting hygiene and dressing, required substantial/maximal assistance (helper does more than half the effort needed to complete the activity) with bathing, and required partial/ moderate assistance (helper does…

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 interview and record review, the facility failed to ensure the dental care plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) was reviewed and revised for one (1) of 19 residents (Resident 28) after the completion of the Minimum Data Set (MDS - a resident assessment tool) on 2/19/2025 and based on the assessed needs of the resident as indicated in the facility's policy. This failure had the potential for Resident 28 to receive inappropriate care and/or inadequate services, negatively affecting Resident 28's well-being. Findings: During a review of Resident 28's admission Record, the admission Record indicated Resident 28 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (inability to move one side of the body), dysphagia (difficulty swallowing foods or liquids) following cerebral infarction (also known as a stroke;…

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 apply Geri sleeves (protective sleeves that prevent tearing, bruising, and abrasions of the skin) for one (1) of two (2) sampled residents (Resident 4) as indicated on the physician's order. This failure had the potential for Resident 4 to acquire additional skin tears (traumatic wounds caused by friction when the upper layer of the skin becomes torn from the underlying layers) to the arms and a lack of services to attain or maintain his highest practicable physical well-being. Findings: During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure (a sudden condition in which not enough oxygen passes from the lungs into the blood), muscle weakness, and dementia (a progressive state of decline in mental abilities). During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool), dated 3/10/2025, 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 interview and record review, the facility failed to accurately document the site of blood pressure measurement for one of 19 sampled residents (Resident 20), for consistent monitoring and clinical interpretation. This deficient practice had the potential to affect the accuracy of clinical assessments and medical management of Resident 20. Findings: During a review of Resident 20's admission Record, the admission Record indicated Resident 20 was admitted on [DATE] with diagnosis of End Stage Renal Disease (ESRD- Condition in which the kidneys cease functioning on a permanent basis leading to the need for regular course of long-term dialysis or kidney transplant to maintain life) and required hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). During a review of Resident 20's Order Summary, dated 3/9/2025, indicated no Blood Pressure checks, no blood draw on left arm as appropriate, dialysis (hemodialysis) access site:…

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 call light (a visible and audible alarm activated by a call button) for one of 19 of sampled residents (Resident 3) was within reach as indicated on care plan and facility's policy. This failure had the potential to result in the inability for Resident 3 to obtain necessary care and services which could result to harm/injury to the resident. Findings: During a record review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with the diagnoses including but not limited to metabolic encephalopathy (abnormalities of water, electrolytes, vitamins, and other chemicals that adversely affect the brain function), chronic obstructive pulmonary disease (COPD, disease that causes obstructed airflow from the lungs), and cerebral infarction (a stroke, damage to tissue in the brain due to loss of oxygen to the area). During a record review of Resident 3's Minimum Data Set (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 maintain safe, clean, comfortable sanitary and home like environment for one (1) of (3) three sampled residents (Resident 56) for the environment care area by failing to ensure the linen bin was not overflowing in Room A. This deficient practice caused an unsanitary environment and had a potential for residents to be placed at risk for serious illness and/ or injury. Findings: During a review of Resident 56's admission Record, the admission Record indicated Resident 56 was initially admitted to the facility on [DATE] with diagnosis which included history of falling, adult failure to thrive (adults whose independence is declining), bed confinement status (unable to get up from bed without assistance, unable to ambulate, and unable to sit in a chair or wheelchair). During a review of Resident 56's Minimum Data Set (MDS, a resident assessment tool), dated 3/21/2025, the MDS indicated Resident 56 cognitive skills (processes of thinking 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 document the administration of the two (2) doses of intravenous (IV, directly into the blood stream) antibiotics (medicines that treat bacterial infections by killing or stopping the growth of bacteria0 medication on to the Medication Administration Record (MAR) for one (1) of five (5) sampled residents (Resident 4) in accordance with the Medication Administration policy. This deficient practice had the potential to result in the doubling up of medications (taking the dose twice). Findings: During a review of Resident 4's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses of pneumonia (an infection/inflammation in the lungs). During a review of the Physician ' s Order dated 2/6/2024 at 8 PM, the Physicians order indicated cefepime HCL (antibiotics used to treat pneumonia) 1 gram (gm, unit of measurement), IV to be given 2 times a day until 2/10/2025 10:24 PM. During a review…

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 and interview, the facility failed to provide a communication board (a device that displays photos, symbols, or illustrations to help people with limited language skills express themselves) for two (2) of three (3) sampled residents (Residents 1 and 2) that was readily accessible with the language the residents were able to understand in accordance with the facility's policy. This failure had the potential for Residents 1 and 2 to experience a delay in receiving appropriate care and treatment and feeling lonely and isolated due to the staff not being able to properly communicate with the residents. Findings: 1. During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE] and re- admitted on [DATE]. Resident 1's diagnoses included metabolic encephalopathy (ME, occurs when problems with your metabolism cause brain dysfunction), diabetes mellitus (DM, is a metabolic disease, involving inappropriately elevated blood glucose…

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 report an allegation of physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) on 1/23/2025 for one (1) of three (3) sampled residents (Residents 1) within two (2) hour timeframe to the State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities), the state ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement. This deficient practice had the potential to compromise or impede the protection of Resident 1, which could affect the resident's emotional and mental wellbeing. Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE] and re- admitted on [DATE]. Resident 1's diagnoses included metabolic encephalopathy (ME, occurs when problems with your metabolism…

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 residents were provided a homelike environment for three (3) of four (4) sampled residents (Residents 19, 81, and 20) for the environment care area by: 1. and 2. Failing to provide Residents 19 and 81 a room without unfinished and peeling paint on the walls and unmaintained baseboards (wooden or plastic board covering the lowest part of a wall). 2. Leaving a plastic cup of frozen beverage, owned by staff, on top of Resident 20's hand sanitizer dispenser. These deficient practices have the potential for an unsafe and unsanitary resident's environment which had the potential to negatively affect the resident's quality of life. Findings: 1. A review of Resident 19's admission Record indicated Resident 19 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (damage or disease that affects the brain), chronic obstructive pulmonary disease (COPD, a lung disease characterized by long term poor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow its policy to ensure licensed nurses administer oxygen to two (2) of 2 sampled residents (Resident 143 and 85) for Respiratory Care area, as indicated on the care plan. This deficient practice had the potential for Residents 143 and 85 not to receive the appropriate respiratory care and services, which can affect the residents' overall wellbeing. Findings: 1. A review of Resident 143's admission Record indicated resident was originally admitted on [DATE] and was readmitted on [DATE] with the diagnoses of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and chronic kidney disease (long standing disease of the kidneys [organs that filter waste and excess fluid from the blood] leading to renal failure [a condition in which the kidneys lose the ability to remove waste and balance fluids]). A review of Resident 143's History and Physical (H&P), dated 4/8/24, indicated 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 the storage, preparation and distribution of food were done under sanitary conditions by failing to ensure: 1. One red fruit Jello was labeled with use by date and expiration date. 2. Apple sauce tray cups were labeled with a use by date. 3. [NAME] noodles and garlic bag were labeled with received, use by, and expiration date. 4. Expired cilantro bag was not mixed in with carrots in same container. 5. Chorizo container labeled as Chorizo, contained a bacon and not a chorizo. These deficient practices have the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever, which could lead to hospitalization. Findings: 1. 2. and 3. During concurrent observation and interview with the Dietary Staff Supervisor (DSS) on 4/9/24 at 8:30 AM, DSS confirmed there was no use by date on a red fruit Jello container in the walk in freezer. DSS also…

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 care in a manner that maintained or enhanced dignity and respect in full recognition of the resident's individuality for two (2) of 19 sampled residents (Resident 11 and 37). The facility staff was observed standing above the resident's eye level while assisting the resident during a meal. This deficient practice had the potential to affect Resident 11's and 37's self-esteem and self-worth. Findings: 1. A review of Resident 11's admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnosis of, but not limited to, dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning), dysphagia oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat). A review of Resident 11's History and Physical (H&P) dated 3/3/24 indicated Resident 11 does not have the capacity 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 observation, interview and record review, the facility failed to reasonably accommodate the needs of three (3) of 19 sampled residents (Resident 37, 73, and 3) by failing to have residents call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) within reach. This deficient practice had the potential for the residents not to be able to call the staff for assistance, which could result to not receiving or delayed needed care or services necessary for the residents' well-being. Findings: 1. A review of Resident 37's admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with the following diagnosis of dysphagia (difficulty swallowing) and protein-calorie malnutrition (lack of proper nutrition caused by not eating enough). A review of Resident 37's History and Physical (H&P), dated 2/29/24, indicated resident does not have the capacity to understand and make decisions. A review of Resident 37's Minimum Data Set…

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 nursing staff failed to provide privacy and confidentiality (safeguarding the content of information including video, audio, or other computer stored information from unauthorized disclosure without the consent of the resident and/or the individual's surrogate or representative) of the resident's medical records by not closing the unattended computer screen for one (1) of 19 sampled residents (Resident 11). This deficient practice violated Resident 11's right for privacy and confidentiality. Findings: A review of Resident 11's admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnosis of, but not limited to, dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning), dysphagia, oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat). A review of Resident 11's History and Physical…

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 a Registered Nurse (RN) signed and certified the Minimum Data Set (MDS, standardized assessment and care screening tool)/ Care Area Assessment (CAA, provides guidance to focus on key issues identified in the comprehensive MDS) for one (1) of two (2) sampled residents (Resident 84), for Resident Assessment Care Area, in accordance with the facility's policy. This deficient practice had the potential to result in an incomplete assessment and inaccurate depiction of resident specific issues affecting the development of an individualized care plan. Findings: A review of Resident 84's admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnosis that included type 2 diabetes mellitus (DM, body's failure to regulate and use sugar as a fuel). A review of Resident 84's History and Physical (H&P), dated 11/10/23, indicated Resident 84 had the capacity to understand and make decisions. A review of Resident 84's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement the care plan for one (1) of two (2) sampled residents (Resident 18) to ensure the head of bed (HOB) was elevated while resident was on oxygen. This deficient practice had the potential to result in complications from hypoxia (lack of sufficient oxygen in the body) and can lead to shortness of breath, rapid breathing, confusion, and loss of consciousness, and irregular heartbeat. Findings: A review of Resident 18's admission Record indicated Resident 18 was admitted to the facility on [DATE] with diagnoses that included COVID -19 (Coronavirus, a respiratory illness caused by a virus that can spread from person to person), pneumonia (an infection that affects one or both lungs) due to Coronavirus disease 2019, and respiratory failure. A review of Resident 18's History and Physical Examination (H&P), dated 1/5/24, indicated Resident 18 did not have capacity to make decisions due to dementia. A review of Resident 18's Minimum Data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one (1) of 1 sampled resident (Resident 17) for the activities of daily living (ADL) care area, who was unable to carry out ADL received the necessary services to maintain good personal hygiene. This deficient practice resulted in Resident 17 having white crust on the eyelids and brownish stains around the mouth. Findings: A review of Resident 17's admission Record indicated resident was originally admitted on [DATE] and was readmitted on [DATE] with the following diagnosis of dementia (Impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and encounter for palliative care (interdisciplinary [combination of multiple academic disciplines into one activity] medical caregiving approach aimed at optimizing quality of life and mitigating suffering among people with serious, complex, and often terminal illness). A review of Resident 17's History and Physical (H&P), dated 5/1/23, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two (2) of 19 sampled residents (Residents 3 and 30) received treatment and care in accordance with the physician's order, care plan, and professional standards of practice by failing to: 1. Ensure facility staff applied Resident 3's abdominal binder (a wide compression belt that wraps around the abdomen) to prevent the gastrostomy tube (g-tube, a flexible tube surgically inserted through the wall of the abdomen directly into the stomach for feeding, fluid, and medication administration) dislodgement as ordered by the physician. This deficient practice had the potential to result in Resident 3 pulling her g-tube and suffer complications and hospitalization. 2. Reassess and monitor Resident 30's right big toe as indicated in the resident's care plan. This deficient practice had the potential to result in the recurrence of Resident 30's diabetic foot ulcer (an open wound that occurs in approximately 15 percent of residents 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 interview and record review, the facility failed to ensure there was a coordination of care between facility and hospice (care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure) staff for one (1) of 1 sampled resident (Resident 79), for hospice care area, by failing to ensure Hospice nursing/ visitation notes were maintained in the resident's medical record, in accordance with the hospice policy. This deficient practice had the potential to result in a delay or lack of coordination in delivery of hospice care and services to Resident 79. Findings: A review of Resident 79's admission Record indicated Resident 79 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and eventually the ability to carry out the simplest tasks), iron deficiency anemia (a condition in which the blood does not have enough healthy red…

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 enforce its policy and procedure on infection control by : 1. Certified Nursing Assistant 6 (CNA 6) did not perform hand hygiene after doffing (remove) dirty gloves and donning (put on) clean gloves during resident care. 2. CNA 7 picked up resident's nasal cannula tubing (device used to deliver supplemental oxygen from the tube to nose) off the floor and connecting it to the oxygen concentrator (a device that concentrates oxygen by removing nitrogen giving a supply of 95% oxygen) from the floor and attached it to the resident's oxygen concentrator. 3. Failing to disinfect the laundry washers after every use. These deficient practices have the potential to transmit infectious microorganisms and increase the risk of infection for the residents. Findings: 1. and 2. A review of Resident 143's admission Record indicated resident was originally admitted on [DATE] and was readmitted on [DATE] with the following diagnoses of dementia (impaired…

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 maintain equipment in the kitchen in safe operating condition when the kitchen burners did not ignite when [NAME] turned knob on 4/9/24. This failure had the potential to cause the staff to burn their hands while igniting burners, which could result to hospitalization and death. Findings: During the initial tour observation and interview with DSS (Dietary Staff Supervisor) and [NAME] on 4/9/24 at 8:58 AM, [NAME] turned one of the kitchen burners on with a piece of paper. [NAME] stated he usually turns the burner on that way because the flame is small and that way, he can get the flame to be bigger. During an interview with DSS on 4/9/24 at 9:01 AM, DSS stated, The cook uses the paper to ignite the burners, he should not ignite them with paper it's dangerous, there's an igniter we use for that, maybe he misplaced it. During concurrent interview with [NAME] on 4/9/24 at 9:03 AM, [NAME] stated, I've burned myself before when igniting the burners. I do have an igniter, a lighter, but sometimes the staff will borrow it when they…

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 infection control (methods used to prevent, control, or stop the spread of infections) precautions by having expired alcohol hand sanitizer bottles available and used throughout the facility. This failure had the potential to result in the spread of bacteria, viruses and pathogens (harmful microorganisms) to residents, visitors and staff while increasing the risk of infections. Findings: During an observation on [DATE] at 12:28 pm at the front lobby, two visitors seen using bottled alcohol sanitizer with an expiration date of 6/2022. During a concurrent observation and interview on [DATE] at 12:31 pm with Central Supply Manager (CSM) at the indoor facility supply cabinet, seven bottles of alcohol hand sanitizer found with expiration dates of 6/2022. CSM stated these bottles should not be used and should have been thrown away. During a concurrent observation and interview on [DATE] at 12:36 pm with Licensed Vocational Nurse (LVN)…

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 facility supplies for resident care and treatment, including Personal protective equipment (PPE- equipment worn to minimize exposure and spread of illnesses) and gastrostomy tube (GT - a tube that is surgically inserted into the resident's stomach to allow access for food fluids and medications) feedings (nutritious and caloric supplements) were stored in a safe and sanitary environment. This failure had the potential for staff to use contaminated (the presence of an infectious agent on or inside) supplies during the care and treatments provided to the residents and increasing the possible spread of bacteria, viruses, and pathogens (harmful microorganisms). Findings: During a concurrent observation and interview on 1/24/2024 at 12:55 pm with Central Supply Manager (CSM- responsible for ordering, storing, inspecting and distributing supplies as needed for patient care) at the facility's supply storage shed, the following were observed: 1. Three stacked boxes of supplies damp to touch with a mixture of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement intervention to prevent falls (multiple factors that increases an older person's chance of falling) for two out of three sampled residents (Resident 1 2) by failing to place fall risk identifiers for Resident 1 and 2 in accordance with the facility's policy and procedure. This failure had the potential to result in Resident 1 and Resident 2 being at risk for falling and possibly sustaining a serious bodily injury. Findings: During a review of Resident 1's admission record indicated the resident was admitted in the facility on 11/7/22 with diagnoses that included other seizures (a burst of uncontrolled electrical activity between brain cells (also called neurons or nerve cells) that causes temporary abnormalities in muscle tone or movements (stiffness, twitching or limpness), behaviors, sensations or states of awareness), type 2 diabetes mellitus (DM, A group of diseases that result in too much sugar in the blood) without…

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 infection control practices (a set of practices that prevent or stop the spread of infections and or diseases in healthcare settings) were followed for six (6) of seven (7) sampled resident (Residents 1, 2, 3, 4, 5, and 6) in accordance with the facility's policy and procedure when: 1. The facility failed to ensure indwelling catheter (is a closed sterile system with a catheter and retention balloon that lets urine leave your bladder and your body to allow for bladder drainage) bag for Resident 1 was not touching the floor. 2. The facility failed to follow standard precautions (a set of infection control practices used to prevent transmission of diseases that can be acquired by contact with blood, body fluids, non-intact skin, and mucous membranes) by failing to remove soiled gloves and failed to perform hand hygiene (the act of cleaning one's hands with soap and water to remove viruses/bacteria/microorganisms, dirt, grease, or…

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