Pine Grove Healthcare & Wellness Centre, LP

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent sexual abuse (non-consensual sexual contact of any type with a resident) for one of two sampled residents (Resident 1) on 2/11/2026 in the facility's hallway. On 2/11/2026, Visitor (Visitor 1) witnessed Resident 2's hand was inside Resident 1's pants. This failure can result in Resident 1 and 2 experiencing emotional trauma (response to deeply distressing or disturbing events) or psychological trauma (damage to the mind that occurs as a result of a severely distressing event).Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE]. Resident 1's diagnoses included dementia (progressive brain disorder that slowly destroys memory and thinking skills), hyperlipidemia (a condition in which there are high levels of fat particles in the blood), and hypertension (high blood pressure). The admission Record indicated Resident 1 was not self- responsible and 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 interviews and record review, the facility failed to provide adequate intervention such as bed alarm (a safety device, often for the elderly or those with dementia, that alerts caregivers when a person tries to get out of bed), to monitor/document sleeping pattern and inform the resident's physician of any insomnia (trouble falling asleep or staying asleep) or anxiety (natural feeling of worry, fear, or unease, often a physical and emotional reaction) for one (1) of two (2) sampled residents (Resident 1) who was assessed as at risk for fall. This deficient practice resulted in Resident 1 sustaining a fall in the resident's room on 12/31/2025 around 5:30 AM. Resident 1 was found on the floor on the right side of the bed and was assessed to have a small abrasion (a superficial skin injury, also known as a scrape) measuring 2 centimeters (cm, unit of measurement) on the left forehead.Findings: During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted 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 interview and record review, the facility failed to ensure an antibiotic time- out (ATO-a structured process where healthcare providers review and assess the need for ongoing antibiotic therapy) was completed within 48 to 72 hours for two (2) of three (3) sample residents (Residents 1 and 3), sampled for antibiotic use, as indicated in the facility's policy. These failures had the potential to result in Residents 1 and 3 to receive unnecessary antibiotic therapy with the risk of creating antibiotic resistance (bacteria develop and resist the effects of the antibiotics used to kill them).Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease (CKD - longstanding disease of the kidneys leading to renal failure), urinary tract infection (UTI- an infection in any part of the urinary system) and enterocolitis (inflammation [the body's response to an illness, injury 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 maintain residents' room temperature level between 71 to 81-degree Fahrenheit (° F-a unit of temperature measurement on the Fahrenheit scale, where water freezes at 32 degrees Fahrenheit and boils at 212 degrees Fahrenheit) for three (3) of eleven (11) sampled residents (Resident 126, Resident 63, and Resident 36). This deficient practice resulted in the resident's increased level of discomfort and had the potential to negatively impact the resident's quality of life. Findings: 1. During a review of the admission record, the admission record indicated Resident 126 was initially admitted to the facility on [DATE], with diagnoses that included but not limited to nondisplaced fracture (a broken bone where the pieces of the bone remain aligned) of greater trochanter (a bony projection on the upper part) of right femur (thing bone), subsequent encounter for closed fracture with routine healing (encounters after the patient has received active…

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 food service area was maintained in a clean and sanitary manner and proper food handling was provided in accordance with the facility's policy and procedure(P&P) by failing to: 1.Ensure one can opener was sanitized and was not rusted (a reddish-brown substance that forms on the surface of iron and steel as a result of reacting with air and water) according to the facility's P&P titled, Can Opener Use and Cleaning. 2.Ensure [NAME] non- stick spray oil was properly covered with a lid. 3. Ensure cheese stored in the refrigerator was labeled with an open date or use by date (a calendar date that indicates when a product is best quality) and in a sealed container. These deficient practices have the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness ([food poisoning] with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever) and can lead to other serious medical complications and…

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

Based on observation, interview, and record review, the facility failed to 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 Waste Management.Policy and Procedure. 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 a concurrent observation and interview on 2/5/2025 at 6:40 AM with the Dietary Supervisor (DC), in the facility's parking lot, 3 dumpsters were observed. The dumpsters were overflowing with personal protective equipment (PPE- is equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) and kitchen trash. During a concurrent observation and interview on 2/6/2025 at 8:50 AM with DC, DC stated one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to observe infection control measures as indicated on the facility policy when facility failed to establish and maintain an effective water management program to prevent the development and transmission of Legionnaire's disease (LD, a serious and often deadly form of lung infection [pneumonia, lung inflammation usually caused by infection], acquired by breathing in water droplets caused by the bacteria, legionella [the bacteria that causes LD]). This failure had the potential to place the residents at risk for developing severe respiratory infection (pneumonia). Findings: During an interview on 2/6/2025 at 10:26 AM with Maintenance Supervisor (MS), MS stated that the way the facility control legionella at the facility is through their control measures and that to his knowledge, the facility does not do any sort of testing for legionella. During an interview on 2/6/2025 at 10:56 AM with MS, MS stated that they do not test for legionella. MS stated that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain safe, clean, comfortable sanitary and home like environment for two (2) of 11 sampled residents (Residents 15 and 23) by failing to: 1. Ensure the bedside control (used to adjust the bed height, head of bed and/ or foot of the bed) wires for Residents 15 and 23 were not exposed (occur when the insulation around electrical cords and cables is frayed or damaged, revealing the wires within). 2. Facility failed to ensure the trash cans were not overflowing for Rooms A, B and C. These deficient practices caused an unsanitary and had a potential for residents to be placed at risk for serious illness and/ or injury. Findings: 1.During a review of Resident 23's admission Record, the admission Record indicated Resident 23 was initially admitted to the facility on [DATE] with diagnosis which included muscle weakness, anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells), history 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 and interview and record review, the facility failed to provide reasonable accommodations for Resident 36's needs and preferences with a wheelchair that was comfortable for his size, was not damaged, ripped, dusty and old. This failure had the potential for Resident 36 to be placed at risk for negative impact of his psychosocial wellbeing, result in delayed provision of services and/or risk for injury. Findings: During a review of the admission record, the admission record indicated Resident 36 was initially admitted to the facility on [DATE] and re admitted on [DATE], with diagnoses that included but not limited to polyneuropathy (damage or disease affecting peripheral nerves in roughly the same areas on both sides of the body, featuring weakness, numbness, and burning pain), type 2 diabetes mellitus with diabetic polyneuropathy (a chronic condition where the body has trouble using sugar [glucose] from food properly and as a complication of the diabetes, there is nerve damage affecting…

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 five (5) sampled residents (Residents 66 and 225) were provided a communication board (a device that displays photos, symbols or illustrations to help people with limited language skills express themselves) that was readily accessible in the language the residents understood. This failure had the potential to result in Residents 66 and 225 experiencing a delay in receiving appropriate care and treatment and feeling misunderstood due to the staff not being able to properly communicate with the resident. Findings: 1.During a review of Resident 66's admission Record, admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of dementia (a group of brain disorders that cause a gradual decline in cognitive abilities such as memory, thinking, reasoning and judgement) and muscle weakness (lack of muscle strength that makes it hard to move muscles). During a review of Resident 66'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 provide grooming services for two (2) of five (5) sampled residents (Resident 53 and Resident 57) who were dependent with activities of daily living (ADLs- are activities related to personal care that include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating), in accordance with the facility's policy. This deficient practice resulted in Resident 53 and 57's unkempt and dirty fingernails potentially leading to skin injury, infection, and scarring. Findings: 1.During a review of Resident 53's admission Record, the admission Record indicated Resident 53 was initially admitted to the facility on [DATE] with diagnosis which included sepsis (a serious condition in which the body responds improperly to an infection), dysphagia (swallowing difficulties) and muscle weakness. During a review of Resident 53's Annual History and Physical (H&P) dated 1/17/2025, the H&P indicated Resident 53…

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 pharmaceutical services to meet the needs of one of six sampled residents (Resident 64) by failing to administer the resident's amlodipine 5 mg (milligrams - unit of measure, used to treat high blood pressure) one tablet and Vitamin C 500 mg one tablet, as indicated on the physician order. This deficient practice had the potential to place Resident 64 at risk of uncontrolled blood pressure, heart attack, or death. Findings: During a review of Resident 64's admission Record, the admission Record indicated Resident 64 was admitted to the facility on [DATE], with diagnoses including, cardiomegaly (an enlarged heart), heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), and diabetes (a group of diseases that result in too much sugar in the blood [high blood glucose]. During a review of Resident 64's Minimum Data Set (MDS- resident assessment tool), dated 11/27/24, indicated Resident 64 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.

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 percent (5%). There were two (2) 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 25 opportunities (observed administered medications) for error which yielded a facility medication error rate of 7.69% for one (1) of six (6) sampled residents (Resident 64) observed during medication administration (med pass). 2 medications were not given within one hour from the scheduled 9 a.m. time. This deficient practice had the potential to place Resident 64 at risk of uncontrolled blood pressure, heart attack, or death. Findings: During a review of Resident 64's admission Record, the admission Record indicated Resident 64 was admitted to the facility on [DATE], with diagnoses including, cardiomegaly (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to remove expired Osmolite 1.5 Cal (therapeutic nutrition that provide complete balanced nutrition for long- or short-term tube feeding for residents with increased calorie and protein needs.) from one (1) of two (2) Medication Rooms (Medication room [ROOM NUMBER]) located at nurse station 2. This deficient practice increased the risk for residents to receive nutrition that had become ineffective or toxic due to improper storage which could possibly lead to health complications resulting in harm and hospitalization. Findings: During an observation of the medication room with the Director Staff Development (DSD) on [DATE] at 2:23 PM, one (1) bottle of Osmolite 1.5 Cal was observed with the expiration date of [DATE]. During the same concurrent observation and interview on [DATE] at 2:43 PM, DSD stated, There should not be any expired enteral feeding bottle left in the medication room because if a licensed staff accidently administered it 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 interview and record review the facility failed to ensure a coordination of care between the facility and hospice (a program that provides are and support for people who are nearing the end of their life) staff for one (1) of 1 sampled resident (Resident 64) in accordance with the facility's hospice program by not ensuring: a. Hospice staff visit progress notes were maintained in Resident 64's medical record. b. Hospice staff were signing in on their flow sheet in Resident 64's hospice binder. This failure resulted in Resident 64's medical record being inaccurate which had the potential for Resident 64 to not receive the required hospice care and services necessary to promote comfort and quality of life. Findings: During a review of Resident 64's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of dissection of ascending aorta (a life-threatening condition where the inner layer of the ascending aorta [the part of heart that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure two (2) of 17 sampled residents (Residents 8 and 44) had their call light (device used by residents to call staff) within reach. This failure placed Residents 8 and 44 at risk for experiencing a delay in receiving assistance from facility staff which could lead to a fall or accident. Findings: 1. During a review of Resident 8's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of type 2 diabetes (DM2; a disease in which one's blood sugar levels are too high) and dementia (a group of brain disorders that cause a gradual decline in cognitive abilities such as memory, thinking, reasoning and judgement). During a review of Resident 8's History and Physical Examination (H&P), dated 11/20/2024, the H&P indicated the resident does not have the capacity to make their own decisions. During a review of Resident 8's Minimum Data Set (MDS - a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) was free from the use of physical restraints (any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body) in accordance with the facility policy. On 10/3/24, Certified Nurse Assistant (CNA) 3 wrapped Resident 1's torso (the main part of the body that contains the chest, stomach, pelvis, and back) with a white sheet as an abdominal binder (a wide compression belt that encircles the stomach) preventing resident's normal access to his torso. This deficient practice had the potential to negatively affect Resident 1's physical and psychological wellbeing and quality of life. Cross reference with F609. Findings: During a review of Resident 1's admission Records indicated the resident was admitted to the facility on [DATE] and re-admitted on…

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 the suspected abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) and physical restraint (any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body) of resident to the long-term care (LTC) ombudsman (advocates for residents of nursing homes), Law Enforcement, and State Survey Agency State Survey Agency within 2 hours after the allegation oh physical restraint occurred for one of two sample residents (Resident 1) in accordance with the facility's Restraint prevention policy by failing. This deficient practice had the potential to place Resident 1at risk for further abuse and delay of investigation. Cross reference with F604. Findings: During a review of Resident 1's admission Records…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide the Resident's/ Resident's responsible parties' right to have a written information on how to formulate an Advanced Directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for two (2) of 2 sampled residents (Resident 4 and 12) for advance directive care area. 1. Resident 4 did not have an advanced directive or a signature declining information on how to obtain an advanced directive. 2. Resident 12 did not have a copy of advance directive filed under the advance directive tab in the resident's physical medical chart where staff can access during a medical emergency. This deficient practice had the potential for violating Residents 4 and 12 choices about their medical care. Findings: 1. A review of the facility's face sheet indicated Resident 4 was admitted on [DATE] with diagnoses…

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 Low Air Loss mattress (LAL mattress, designed to prevent and treat pressure injury/ ulcer [localized damage to the skin and underlying soft tissue caused by prolonged pressure]) was set up accurately for two (2) of three (3) sampled residents (Resident 12 and Resident 16) for pressure ulcer care area. This deficient practice had the potential for the resident to worsen or develop new pressure injury. Findings: 1. A review of the admission record indicated Resident 12 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus (high blood sugar), gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection), peripheral vascular disease (the reduced circulation of blood to a body part other than the brain or heart), pressure ulcer (an injury that breaks down the skin and underlying tissue) of sacral region (tailbone). A review of Resident 12'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 and interview the facility failed to maintain a clean [NAME] Valve (a stopcock-like device, which allows the health care worker to access enteral systems without breaking open the lines) for gastrostomy tube (G-tube, a tube inserted through the wall of the abdomen directly into the stomach) for one of two sampled residents (Resident 34). This deficient practice had the potential to result in complications including infections and stomach discomfort. Findings: A review of Resident 34's admission Record indicated the facility admitted Resident 34 on 2/12/2019 with diagnosis which include muscle weakness, sepsis (a serious condition in which the body responds improperly to an infection) and dysphagia (swallowing difficulties). A review of Resident 34's Minimum Data Set (MDS, standardized care and screening tool), dated 2/2/2024, indicated Resident 34 was severely impaired with cognitive (processes of thinking and reasoning) skills for daily decision making. The MDS indicated Resident 34 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 provide oxygen therapy (treatment that provides supplemental, or extra oxygen) and necessary respiratory care services for three (3) of 3 sampled residents (Resident 4, 125, and 224) for oxygen care area in accordance with the facility's policy and procedure when: 1. Resident 4's oxygen humidifier (medical device used to humidify supplemental oxygen) and nasal cannula (a device that delivers extra oxygen through a tube and into your nose) tubing were not on the floor. Resident 4's oxygen concentrator was also left on when Resident 4 was not on oxygen therapy. 2. Resident 125 did not receive oxygen as indicated on the physician's order. 3. Resident 224's nasal cannula tubing and humidified sterile water was not properly labeled. These deficient practices had the potential to cause complications associated with oxygen therapy and increase the risk of infection to Residents 4, 125, and 224. Findings: 1. A review of the facility's admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent food contamination and the spread of foodborne illness as indicated on the facility policy when the facility failed to ensure: 1. The sanitary storage and disposal of expired food. These deficient practices have the potential to result to pathogen (germ) exposure and place residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to hospitalizations. 2. Seven (7) of 32 kitchen mounted ceiling lights have a protective plastic cover. This deficient practice had the potential of breakage with particles of glass potentially landing on food preparation areas or residents' trays. Findings: During observation on 2/12/2024 at 07:52 AM., in the kitchen were multiple food containers noted with expired date labels. a. A partially covered silver color pan with partially defrosted chicken with expired used by label was observed…

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 dispose garbage and refuse (disposable material, which includes both recyclable and non-recyclable material) from the kitchen properly when Dietary Aid was observed dumping four(4) clear bags of kitchen trash on top of the regular facility trash at the the facility's parking area on the North/East side of the facility building on 2/14/2024 This failure had the potential to result in the attraction and spread of vermin (animals that are believe to be harmful, or that carry diseases, e.g., rodents parasitic worms or insects) that could potentially infiltrate the facility, affect the resident care areas and pose a disease threat to residents of the facility. Findings: During an observation on 2/14/2024 at 11:19 A.M. in the kitchen, Dietary Aid (DA) was observed taking out 4 bags of kitchen trash to the the facility's parking area on the North East side of the facility building. DA was observed dumping the trash bags from the kitchen on the ground with the rest of the facility's regular trash that were also pile…

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 environment when multiple piles of trash bags were observed on the ground near the facility's parking area on the North/East side of the facility building. This failure had the potential to result in the attraction and infestation of vermin (wild animals that are believed to be harmful such as rodents, parasitic worms or insects) that could potentially infiltrate the facility, affect resident care areas and pose a direct disease and infection threat to residents. Findings: During an observation on 2/14/2024 at 11:19 A.M., multiple piles of trash bags along with other miscellaneous trash such as a broken folding chair, plastic bucket, two wooden crates, empty cardboard boxes, and a gurney were observed on the ground near the facility's parking lot area on the North/East side of the facility building. There were no trash garbage and refuse (disposable material, which includes both recyclable and non-recyclable material) containers noted at the site. The trash bags were a mixed of regular…

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 promote respect and dignity for one (1) of 1 sampled resident (Resident 34) for dignity care area when resident was left in bed sleeping with food around his mouth and on the resident's gown. This deficient practice had the potential to result in Resident 34's feelings of decreased self-esteem and self-worth. Findings: A review of Resident 34's admission Record indicated the facility admitted Resident 34 on 2/12/2019. Resident 34's diagnoses included muscle weakness, sepsis (a serious condition in which the body responds improperly to an infection), and dysphagia (swallowing difficulties). A review of Resident 34's Order Summary Report, dated 4/1/2022, indicated, May have 1:1 feeding assistance with all meals. A review of Resident 34's Minimum Data Set (MDS, standardized care and screening tool), dated 2/2/2024, indicated Resident 34 was severely impaired with cognitive (processes of thinking and reasoning) skills for daily decision making. The MDS indicated Resident 34 required partial /moderate assistance…

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 baseline care plan was developed and implemented for one of 20 sampled residents (Resident 174). This deficient practice placed Resident 174 at risk of not having goals and interventions to fulfill resident's needs which had the potential to negatively affect Resident 174's well-being. Findings: A review of Resident 174's admission Record, indicated resident was admitted to the facility on [DATE] with admitting diagnoses of urinary tract infection (UTI), bacteremia, and Klebsiella Pneumoniae (infections commonly occur among sick patients in healthcare settings who are receiving treatment for other conditions). A review of Resident 174's History and Physical, dated 2/08/24, indicated the resident had the capacity to understand and make decisions. During a concurrent interview and record review of Resident 174's electronic medical records on 2/13/2024 at 3 PM, with Minimum Data Set Nurse 2 (MDSN 2), MDSN 2 stated Resident 174 did not have…

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 revise the care plan (a formal process that correctly identifies existing needs and recognizes a resident's potential needs or risks to achieve healthcare outcomes) for two (2) of 20 sampled Residents (Resident 4 and 18) as indicated on the facility's policy. 1. Resident 4's oxygen therapy order was not revised on 2/12/2024 when order was changed to as needed from continuous use. 2. Resident 18's care plan to prevent injury was not revised when Resident 18 was non compliant with the use of soft helmet (a special kind of protective headgear that is designed to reduce the risk or severity of head injuries for residents with epilepsy (a disorder of the brain characterized by repeated seizures [abnormal brain activity]). This deficient practice had the potential for inconsistency of care being rendered for Residents 4 and 18, which could affect over all well-being. Findings: 1. A review of the facility's face sheet indicated Resident 4 was admitted on…

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

Based on interview and record review, the facility failed to provide one (1) to 1 feeding assistance (help residents in a nursing facility eat and drink) while eating for 1 of 1 sampled resident (Resident 34) for ADL care area, as indicated on the physician's order. This deficient practice had the potential for Resident 34's functional ability to decline, suffer a weight loss, and risk for accident such as choking, which coould result to harm. Findings: A review of Resident 34's admission Record indicated the facility admitted Resident 34 on 2/12/2019. Resident 34's diagnoses included muscle weakness, sepsis (a serious condition in which the body responds improperly to an infection), and dysphagia (swallowing difficulties). A review of Resident 34's Minimum Data Set (MDS, standardized care and screening tool), dated 2/2/2024, indicated Resident 34 was severely impaired with cognitive (processes of thinking and reasoning) skills for daily decision making. The MDS indicated Resident 34 required partial /moderate assistance (helper does less than half the effort) with eating. 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 nursing staff failed to elevate bilateral lower extremities (BLE, everything from your hip to your toes, including your hip, thigh, knee, leg, ankle, foot, and toes) and implement care plan for one of 20 sampled (Resident 224). This deficient practice had the potential to result in a delay in reducing the swelling in the affected extremities. Findings: A review of Resident 224's admission Record indicated the facility admitted Resident 224 on 2/1/2024 with diagnosis which include muscle weakness, difficulty in walking and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 224's Minimum Data Set (MDS, standardized care and screening tool), dated 2/8/2024, indicated Resident 224 was moderately impaired with cognitive (processes of thinking and reasoning) skills for daily decision making. The MDS indicated Resident 224 was substantial/ maximal assistance (helper does more than half the effort. Helper lifts or hold trunks or limbs and provide more than half 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 nursing staff failed to ensure the safety of one of two sampled residents (Resident 18) by not ensuring Resident 18 was wearing a soft helmet (a special kind of protective headgear that is designed to reduce the risk or severity of head injuries for people with epilepsy [uncontrolled shaking] ) and that had side rails remained padded (provides added cushioning to help reduce injuries). This failure had the potential to cause injury to Resident 18 during seizures (uncontrollable shaking). Findings: A review of Resident 18's admission Record indicated the facility admitted Resident 18 on 5/1/2023 with diagnosis which include muscle weakness, epilepsy and lack of coordination. A review of Resident 18's Minimum Data Set (MDS, standardized care and screening tool), dated 10/22/2023, indicated Resident 18 was severely impaired with cognitive (processes of thinking and reasoning) skills for daily decision making. The MDS indicated Resident 18 required partial /moderate assistance (helper does more than half of the effort) on oral…

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 remove an intravenous (IV, within the vein) catheter saline lock (a thin plastic tube that is threaded into a vein, flushed with saline, and then capped off for later use) used in the administration of parenteral fluid (delivery of fluid or medication through an IV, subcutaneous [beneath, or under, all the layers of the skin], intramuscular [within or into the muscle] or mucosal [the moist, inner lining of some organs and body cavities] route to maintain adequate hydration, restore and/or maintain fluid volume, establish lost electrolytes [minerals in your blood and other body fluids that carry an electric charge], or provide nutrition which includes total parenteral nutrition [TPN, IV administered nutrition]) and left it inserted for more than 96 hours for one (1) of 20 sampled residents (Resident 174), in accordance with facility's policy and procedure. This failure had the potential to put Resident 174 at risk for developing 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident who required adaptive feeding equipment (modified utensils, accessories, glasses, and plates to help improve residents comfort and independence), utilize a plate guard (unique spill guard which prevents food from accidentally being pushed off the plate) and built up spoon (specialized utensil with built up handle designed to assist residents with limited or weakened grasping strength) during meal, as indicated on the physician's order, for one of one sampled resident (Resident 39) in Activities of Daily Living care area. This deficient practice placed Resident 39 at risk for further decline in physical functioning and decline to perform self-feeding skills. Findings: A review of Resident 39's admission Record indicated the resident admitted to the facility on [DATE] and got readmitted on [DATE], with diagnoses including but not limited to cerebral infarction (stroke, refers to damage to tissues in the brain due to a loss…

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.

Revised with comments/ questions: Based on observation, interview, and record review, the facility failed to ensure the call light device (one of the major communication technologies that link nursing home staff to the needs of residents) was within reach (an arm's length) for one of four sampled residents (Resident 1). This had the potential to result in a delay in care for Resident1 not to receive the necessary care and services which can lead to illness or serious injury. Findings: A review of Resident 1's admission record indicated the facility admitted Resident 1 on 10/10/2023 with diagnosis which include difficulty in walking, lack of coordination and history of falling. During a review of Resident 1's care plan, titled Care Plan Detail initiated on 10/11/2023, indicated Focus: Potential for injury related to the use of bed rails and one of the interventions was to keep call light within reach. A review of Resident 1's Minimum Data Set (MDS, standardized care and screening tool), dated 10/17/2023, indicated Resident 1 was severely impaired with cognitive (processes of thinking…

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.