Royal Vista Care Center

Based on observation, interview, and record review, the facility failed to ensure proper food handling practices and maintain the food service area in a clean and sanitary manner in accordance with the facility's policies and procedures (P&P) by failing to ensure:1. All personnels in the kitchen wore hair and or beard nets.2. Multiple food items were stored in a manner that prevents foodborne illness (illness that comes from eating contaminated food) for residents.3. Staff personal items were not placed inside the kitchen refrigerator. 4. Kitchen staff did not touch the rim of multiple glasses of water with bare hands during tray line preparation. These deficient practices have the potential to result in foodborne illness in a population of 80 residents who consume the food prepared by the facility every day.Findings:1. During an observation on 2/9/2026 at 7:35 AM, [NAME] 1 (CK 1) was observed without a hair net and was wearing a hat while his hair on the back of his head was exposed. During a concurrent observation and interview on 2/9/2026 at 8:11 AM, the Dietary Service…

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 the standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) in accordance with the facility's policy and procedure when:1.a Licensed Vocational Nurse 2 (LVN 2) failed to change gloves and perform hand hygiene during medication administration to Resident 2.1.b LVN 3 failed to sanitize medication tray (equipment includes durable plastic, divided trays designed to organize, transport, and dispensing pills and syringes in clinical or home settings) after putting in the dirty lancet (a small, disposable, double-edged needle or blade used to prick the skin-usually on the finger-to obtain a tiny blood sample for checking blood sugar levels) and failed to perform hand hygiene in between tasks during medication administration to Resident 2.2. The facility failed to ensure the facility linens (bed sheets, pillowcases and blankets) were washed…

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 two (2) of five (5) sampled residents (Residents 72 and 4), in the infection control care area, were provided education or a Vaccine Information Statements (VIS- information sheets produced by the Center of Disease Control and Prevention [CDC] that explain both the benefits and risks of a vaccine [medications used to prevent diseases usually given by injection or by mouth] to vaccine recipients) for influenza (the flu- a contagious respiratory virus) and pneumococcal (a serious, often fatal infection caused by Streptococcus pneumoniae bacteria) vaccinations per facility policy. This failure had the potential for Residents 72 and 4 (or their responsible party [RP]) to accept or decline the influenza and/or pneumococcal vaccinations without the proper understanding of risks and benefits to make an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives…

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 two (2) of five (5) sampled residents (Residents 72 and 4), in the infection control care area, were provided education or a Vaccine Information Statements (VIS- information sheets produced by the Center of Disease Control and Prevention [CDC] that explain both the benefits and risks of a vaccine [medications used to prevent diseases usually given by injection or by mouth] to vaccine recipients) for the Covid-19 (a highly contagious respiratory illness caused by the SARS-CoV-2 virus) vaccine per the facility's policy and procedure. This failure had the potential for Residents 72 and 4 (or their responsible party [RP]) to accept or decline the Covid-19 vaccine without the proper understanding of risks and benefits to make an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered).Findings:1. During a review of Resident 72's admission Record, 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 residents' medical records were updated to show documentation that advance directives (a legal document indicating resident preference on end-of-life treatment decisions) were discussed upon admission and written information were provided for one (1) of two (2) sampled residents and/or responsible party (Resident 78), in the advance directive care area. This deficient practice violated Resident's 78 and/or the responsible party's (RP) right to be fully informed of the option to formulate their advanced directives and had the potential to cause conflict with the residents' wishes regarding health care.Findings:During a review of Resident 78's admission Record, the admission Record indicated Resident 78 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included wedge compression fracture (an injury of the spine where the front part of a vertebra [a small bone in the spine] collapses, creating a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a safe, comfortable wheelchair for one (1) of two (2) sampled residents (Residents 38) reviewed for environmental concerns by failing to ensure the resident's wheelchair's left armrest pad was free from peeling and cracks and the wheelchair had a right padded armrest. This deficient practice had the potential to affect Resident 38's safety and comfort when sitting in the wheelchair. Findings:During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included difficulty in walking and lack of coordination. During a review of Resident 38's Minimum Data Set (MDS- a resident assessment tool), dated 1/13/2026, the MDS indicated Resident 38 had an intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 38 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 monitor signs and symptoms of hypoglycemia (an abnormally low level of sugar [glucose] in the blood) and hyperglycemia (a condition where the blood glucose [sugar] levels are abnormally high) from 5/3/2025 up to 2/11/2026 for one (1) of 18 sampled residents (Residents 3) on Insulin aspart (Novolog, is a rapid-acting, man-made version of human insulin), as indicated on the care plan (CP). This deficient practice had the potential for Residents 3 not to receive treatment in the event of a hypoglycemic and hyperglycemic episode, which could lead to complications, harm, hospitalization, or death.Findings:During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] and re-admitted on [DATE]. The admission record indicated Resident 3's diagnoses included spinal stenosis (happens when the space inside the backbone is too small) lumbar (lower back bone) region, peripheral…

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 of one sampled resident (Resident 72) from the vision/hearing care area, maintained a scheduled ophthalmology (the specialized field of medicine that focuses on the health of the eye appointment).This failure resulted in a delaying preoperative appointment with the potential risk for a delay in necessary treatment and evaluation including surgery.Findings:During a review of Resident 72's admission Record, the admission Record indicated Resident 72 was originally admitted to the facility on [DATE] with diagnoses that included fusion of the spine (a surgical procedure that permanently connects two or more vertebrae [a small bone in the spine] in the spine), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and difficulty in walking. During a review of Resident 72's Opthalmaology Consultation, dated 10/7/2025, the Opthalmaology Consultation indicated complaints of cataract (the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a fall risk identifier, frequent visual checks and caregiver education were implemented for one (1) of 1 sampled resident (Resident 78), for the accidents care area, as indicated in Resident 78's care plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) and the facility's policy and procedure.This failure had the potential for Resident 78 to experience preventable falls, injury or accident hazards.Findings:During a review of Resident 78's admission Record, the admission Record indicated Resident 78 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included wedge compression fracture (an injury of the spine where the front part of a vertebra [a small bone in the spine] collapses, creating a wedge-shaped bone) of first lumbar (lower part of the back) vertebra, spinal stenosis (a narrowing of the spaces within your…

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 of 18 sampled residents (Resident 78) who was incontinent (loss of control) of bladder, was provided a bladder retraining and/or toileting program (helps manage incontinence [involuntary loss of urine or stool] by training the bladder to hold more urine and reducing the frequency of bathroom visits) in accordance with the resident care plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) and the facility's policy and procedure titled Bowel and Bladder Program. This deficient practice had potential to result in Resident 78's inability to regain control of bladder function, continued urinary incontinence, and development of urinary tract infection (UTI- an infection in any part of the urinary system, the kidneys, bladder or urethra), and/or another occurrence of fall.Findings:During a review of Resident 78's admission Record, the admission Record indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store the nebulizer (a small device that turns liquid medicine into a mist or fine spray) mask in a clean plastic bag when not in use for one (1) of 1 sampled resident (Resident 55) reviewed for respiratory care services, as indicated on the facility policy and procedure (P&P). This deficient practice had the potential to contaminate the nebulizer and place Resident 55 at risk for respiratory infectionFindings:During a review of Resident 55's admission Record, the admission Record indicated Resident 55 was admitted to the facility on [DATE] with diagnosis that included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing). During a review of Resident 55's Minimum Data Set (MDS, a resident assessment tool), dated 11/17/2025, the MDS indicated Resident 55 had moderate impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making.…

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 manage the pain timely and effectively for one of two sampled residents (Resident 4) reviewed for pain by not administering Cyclobenzaprine (is a medication used to treat muscle spasms) on 1/13/2026 and 1/20/2026 as indicated on the physician's order and facility policy. This deficient practice had the potential for unmanaged pain in Resident 4's left thigh which could negatively affect the resident's overall well-being and quality of life. Findings:During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] and re-admitted on [DATE]. The admission record indicated Resident 4's diagnoses included chronic respiratory failure (a condition in which the blood does not have enough oxygen or has too much carbon dioxide) with hypoxia (low levels of oxygen in the body tissues), open reduction and internal fixation (ORIF, is surgery to repair broken bones) of the left hip…

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 monitor the fluid intake for one (1) of 1 sampled resident (Resident 92) reviewed for dialysis in accordance with the care plan and facility policy. This deficient practice had the potential to place the resident at risk for fluid overload (a condition where the body has too much fluid) or dehydration (condition that occurs when the loss of body fluids, mostly water, exceeds the amount that is taken in).Findings:During a review of Resident 92's admission Record, the admission Record indicated Resident 92 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease (ESRD, irreversible kidney failure) and dependence on renal dialysis (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 the Resident 92's Physician's Order, dated 2/4/2026 at 10:29 PM, the Physician's Order indicated 1500 cc/day fluid restriction broken…

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

Based on interview and record review, the facility failed to ensure appropriate competencies and skills sets to provide nursing and related services were completed for one (1) of four (4) sampled employees in accordance with the facility assessment when Licensed Vocational Nurse 3 (LVN3) did not have a medication administration competency completed upon hire. This deficient practice has the potential to cause improper medication administration causing medication errors which could result in resident harm. Findings:During a review of LVN 3's Application of Employment, dated 2/28/2025, the application indicated LVN 3 was hired on 3/10/2025.During a concurrent interview and record review on 2/12/2026 at 3:13 PM with ADON, the Employee Competency Folder for LVN 3 was reviewed. There was no documentation that the new hire competency pre-checklist skills form was completed for LVN 3. The ADON stated LVN 3 was hired on 3/10/2025 and the competency folder should have the competency pre- checklist form during the start of LVN 3's floor orientation. The ADON stated they should have kept all…

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 promptly provide dental services for one (1) of 1 sampled resident (Resident 3) reviewed for dental care as indicated in the facility's policy and procedure. This deficient practice had the potential to result in Resident 3's inability to effectively chew food, weight loss, discomfort, and develop infection in the oral cavity.Findings:During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] and re-admitted on [DATE]. The admission record indicated Resident 3's diagnoses included spinal stenosis (happens when the space inside the backbone is too small) lumbar (lower back bone) region, peripheral vascular disease (reduced circulation of blood to arms or legs due to a narrowed or blocked blood vessel), and diabetes mellitus (DM, is a metabolic disease, involving inappropriately elevated blood glucose levels) During a review of Resident 3'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 observation, interview, and record review the facility failed to maintain accurate medical records for one of 18 sampled residents (Resident 2) in accordance with the facility's Policy and Procedure (P&P).This deficient practice had the potential to result in miscommunication, improper delivery of wound management and inaccurate information of the care provided, which could result in skin breakdown to Resident 2. Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest in life) . During a review of Resident 2's Order Summary Report,…

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 implement their protocol for Antibiotic Stewardship (the ongoing effort by a provider and clinical caregivers to optimize and minimize the use of antimicrobial medicines) for one (1) of two sampled residents (Resident 72), after being prescribed an antibiotic (drug used to prevent and treat bacterial infections) without meeting the criteria for cellulitis (bacterial skin infection that may appear as a red, swollen area, feeling hot and tender to the touch), soft tissue or wound infection. This deficient practice had the potential for Resident 72 to develop antibiotic resistance (when bacteria change so antibiotic medicines cannot kill them or stop their growth) from unnecessary or inappropriate antibiotic use.Findings:During a review of Resident 72's admission Record, the admission Record indicated Resident 72 was originally admitted to the facility on [DATE] with diagnoses that included fusion of the spine (a surgical procedure that permanently…

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 facility exit doors and hallways were free from obstruction and clutter. This deficient practice had the potential to place residents and facility staff at risk for accidents, such as tripping and falling, and impede or hinder immediate evacuation from the facility in cases of emergency. Findings: During an observation of the facility on 3/13/2025 at 7:36 AM, one wheelchair was observed on the left side of the hallway and one wheelchair was observed on the right side of the hallway blocking the exit doors by rooms [ROOM NUMBERS]. During an observation of the facility on 3/13/2025 at 7:38 AM, one wheelchair was observed on the right side of the hallway blocking the exit doors by rooms [ROOM NUMBERS]. During an observation of the facility on 3/13/2025 at 7:40 AM, one wheelchair was observed on the left side of the wall and two soiled linen bins were observed on the right side of the wall blocking the exit doors by rooms [ROOM…

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 to the State Agency (SA) within 24 hours after an unusual occurrence (events or situations that do not happen daily or that may have had an impact on the residents) for one of two sampled residents (Resident 1) when the facility was made aware on 2/3/2025 of Resident 1's sustained a fracture (complete or partial break in the bone) from a fall in accordance with the facility's policy and procedure titled Unusual Occurrence Reporting. This deficient practice had a potential for ongoing/ another unusual occurrence for Resident 1 or other residents in the facility. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the following diagnoseof dementia (a progressive state of decline in mental abilities), muscle weakness and fracture of the left ilium (the large broad bone forming the upper part of the pelvis). During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement a care plan for one of two sampled residents (Resident 1) by not ensuring a floor mat (a cushioned floor pad designed to help prevent injury should a person fall) was placed at Resident 1's bedside after an unwitnessed fall on 1/26/2025 wherein the resident sustained a fracture (the cracking or breaking of the bone). This deficient practice has the potential for Resident 1 to have further falls with injury. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the following diagnoses of dementia (a progressive state of decline in mental abilities), muscle weakness and fracture of the left ilium (the large broad bone forming the upper part of the pelvis). During a review of Resident 1's SBAR (situation, background, assessment, recommendation - a communication tool used by healthcare workers when there…

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 facility staff performs hand hygiene (an action of hand cleansing such as with soap and water or applying alcohol based handrub to the surface of the hands) according to the facility's policy for one (1) of 4 sampled residents. This deficient practice had the potential to spread infection to staff and residents. Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the following diagnoses of chronic kidney disease (CKD - progressive damage and loss of function in the kidneys), urinary tract infection (UTI - an infection in the bladder/urinary tract), and diabetes mellitus (metabolic disease, involving inappropriately elevated blood glucose levels). During a review of Resident 3's History and Physical (H&P), dated 1/30/2025, the H&P indicated Resident 3 has the capacity to understand and make…

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 implement the comprehensive care plan related to alleged rough handling by staff for one of one sampled resident (Resident 1) in accordance with the facility policy. This deficient practice had the potential to result in delay or lack of delivery of care and services to Resident 1 which could affect resident's overall wellbeing. Findings: During a review of Resident 1's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission record indicated Resident 1 was originally admitted to the facility on [DATE]. Resident 1's diagnoses included dysphagia (difficulty swallowing), pneumonia (an infection/inflammation in the lungs), and hypertension (HTN-high blood pressure). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 10/9/2024, the MDS indicated Resident 1 was moderately impaired (decisions poor; cues/supervision required) with cognitive (processes 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 follow its infection control policy for one (1) of two (2) sampled residents (Resident 1) by failing to ensure staff were using a gown while rendering diaper change and administering medication via gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for residents with swallowing problems) tube to Resident 1 who was on enhanced barrier precaution (EBP, an infection control practice that involves wearing gowns and gloves during high-contact activities with residents in nursing homes). This deficient practice had the potential to result in Resident 1 developing an infection and spread of infection among staff and residents. Findings: During a review of Resident 1's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated Resident 1 was originally admitted to the facility on [DATE]. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide care consistent with the professional standards of practice (the set of guidelines, principles, and expectations that govern the conduct and performance of nursing professionals) to prevent worsening of the pressure ulcer (PU, a localized area of skin damage caused by prolonged pressure on the skin) for one of two sampled residents (Residents 1) by failing to: 1. Assess and document detailed observations in SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) of Resident 1's change with skin condition and/ or wound condition on the resident's sacral area (lower back region specifically triangular- shaped bone called the sacrum) and/ or left buttocks on 10/17/2024, 10/24/2024, 11/14/2024 and 11/30/2024. 2. Monitor Resident 1's change with wound condition on the resident's left buttock of foul odor noted on 11/25/2024 every shift from…

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 licensed nurses document accurate information of Resident 1's skin condition and wound care treatment in the resident's Skilled Nursing Assessment form on 9/11/2024 and 10/25/2024 and in the Weekly Summary form on 9/18/2024, 10/11/2024, and 10/18/2024, This deficient practice had the potential to result in miscommunication, improper delivery of care and delayed communication of the progression of Resident 1's pressure ulcer. Findings: During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should) and lack of coordination. During a review of Resident 1's Minimum Data Set (MDS, a federally mandated assessment tool), dated 11/1/2024, the MDS indicated Resident 1 had moderately impaired cognitive…

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 treat resident with respect and dignity, and maintain privacy for five (5) of 23 sampled residents (Residents 47, 59, 73, 75, and 25) in accordance with the facility policy by failing to ensure: 1. Resident 47 was fed at eye level. 2. Resident 59's curtain or door was closed when staff changed the resident. 3. Resident 73's curtain or door was closed when staff changed the resident. 4. Failing to address Resident 25 by her name. 5. Resident 75 was fed at eye level. These deficient practices had the potential to negatively affect Residents 47, 59, 73, 75, and 25's self-worth, self-esteem, and psychosocial well-being. Findings: 1. During a record review of Resident 47's admission Record, the admission Record indicated Resident 47 was admitted to the facility on [DATE], with diagnoses of metabolic encephalopathy (abnormalities of water, electrolytes, vitamins, and other chemicals that adversely affect the brain function), schizoaffective…

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 comfortable and homelike environment (one that de-emphasizes the institutional character of the setting and is as close to that of the environment of a private home as possible) for five of seven sampled residents (Resident 8, 22, 43, 44, and 72) who were in attendance during the Resident Council (a group of residents who meet regularly to discuss concerns, suggest improvements, and plan activities related to their living situation within the facility) meeting by the facility failing to provide communal dining to their residents. This deficient practice had the potential to result in decreased social interactions, decreased psychosocial wellbeing, and weight loss in residents. Findings: 1. During a review of Resident 8's admission Record indicated Resident 8 was admitted to the facility on [DATE] and re admitted on [DATE], with diagnoses that included acute respiratory failure with hypoxia (the lungs are…

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 three (3) of four (4) sampled residents (Residents 41, 42 and 63) readily accessible with the language the residents were able to understand in accordance with the facility's policy. This failure had the potential for the residents 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 41's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) cerebral infarction (refers to damage to tissues in the brain due to a loss of oxygen to the area) affect the left non- dominant…

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 of two sampled residents (Residents 78 and 22) were provided activities, based on comprehensive assessment and resident's preferences and interests in accordance with the facility policy. This deficient practice had the potential to negatively affect Residents 78 and 22's physical, mental, and psychosocial well-being. Findings: 1. During a review of the Resident 78's admission Record, the admission Record indicated Resident 78 was admitted to the facility on [DATE], with diagnoses of malignant neoplasm of nasopharynx (cancer that starts in the tissue connecting the back of the nose to the back of the mouth), sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood), adult failure to thrive (refers to a state where resident experiences a substantial decline in overall health and functional abilities), gastrotomy status (a surgical procedure for inserting a tube through the abdomen wall and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed ensure resident's drug regimen was free from unnecessary medication use for four (4) of five (5) sampled residents (Residents 47, 62, 33, and 45) in accordance with the facility policy by failing to ensure: 1.a. Resident 47 was free from taking two anxiety (a feeling of nervousness, panic, and fear) medications, Clonazepam (drug used to treat anxiety) and Lorazepam (drug used to relieve anxiety [fear characterized by behavioral disturbances] and treat insomnia caused by anxiety or temporary situational stress) 1.b. A specific indication for use/behavior was monitored for Resident 47's use of Clonazepam and Lorazepam. 1.c. Resident 47's behavior of crying for the use of Cymbalta (drug used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest] and anxiety) was monitored via hashmark from 10/21/2024 to 10/31/2024 1.d. Resident 47's behavior of paranoid delusions (fears, anxieties, and suspicions that someone…

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 (%). Four (4) medications 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 and yielded a facility medication rate of 16% for two (2) of 5 sampled residents (Resident 31 and Resident 284) observed during medication administration (med pass). 1. Licensed Vocational Nurse 5 (LVN 5) failed to ensure Resident 31 received the full dose of Humulin R insulin (a hormone that removes excess sugar from the blood) by not waiting approximately 5 seconds before removing the needle after injection. 2.a Infection Preventionist Nurse (IPN), failed to administer Letrozole (a medication used to treat certain types of breast cancer) for 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review, the facility failed to label and store drugs in locked compartments when the facility failed to: 1. Ensure safe drug storage by leaving two medications unattended on top of the medication cart. This deficient practice had the potential to result in other residents having access to medications causing adverse consequences or possible hospitalization if ingested. 2. Ensure the unopened insulin (a hormone that works by lowering levels of sugar in the blood) pens of Residents 75 and 48 were stored inside the refrigerator instead of inside the medication cart per manufacturer's guidelines. This deficient practice had the potential for loss of efficacy of the insulin injection. 3. Ensure the opened Resident 37's Ipratropium-Albuterol Solution (a medication that treats chronic obstructive pulmonary disease [COPD- a long-term lung disease causing difficulty breathing]) box, which expires 7 days after opening, was labeled with date opened for Resident 37. This deficient…

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

Based on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with their policy and procedure by failing to: 1. Discard expired food and label food in the dry storage room, refrigerators, and freezers in the kitchen with item name, date opened and expiration date, and failed to 2. Ensure kitchen equipment and food carts were clean and free of food debris (leftover food particles). 3. Ensure electric fans were free form dust and were not stored in the kitchen dry storage room. 4. Ensure dietary staff (Cook 1 and Chef 1) perform hand hygiene (is the act of cleaning the hands with soap or handwash and water to remove viruses/bacteria/microorganisms, dirt, grease, or other harmful and unwanted substances stuck to the hands) and change gloves during cooking and tray line assembly. (the dates that are placed on food labels to ensure foods maintain best texture or taste and prevent food spoilage) These deficient practices had the potential to result in pathogen (germ) exposure to residents, which could place the residents at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to observe infection control measures in accordance with the facility policy by failing to : 1. Handle soiled linens in a safe and sanitary method while changing Resident 16's soiled bedding. 2. Clean and disinfect the glucometer (an instrument for measuring the concentration of glucose [sugar] in the blood) after use with Resident 31 and before returning it in the medication cart drawer. 3. Post an enhanced barrier precautions (set of infection control measures that use personal protective equipment [PPE] to reduce the spread of multi drug resistant organisms [MDRO, microorganisms that are resistant to multiple classes of antibiotics and antifungals, which could be difficult to treat and spread quickly]) signage by Resident 63's room who was on isolation precautions. 4. Licensed Vocational Nurse 4 (LVN 4) failed to perform hand hygiene before and after administering medications to Resident 40. 5. Infection Preventionist Nurse (IPN)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe environment for one of 23 sampled residents (Resident 43) by: 1. Failing to ensure the designated exit door was not blocked by a wheelchair. This deficient practice had the potential for residents to be placed at risk for injury by not allowing a rapid evacuation in case of an emergency. 2. Failing to ensure the hallway for Resident 43 to pass through back and forth from the resident's room to the activity room was not cluttered with multiple parked wheelchairs and equipment (such as Hoyer lift [mechanical device that helps transfer people with limited mobility from one place to another. It allows a person to be lifted and transferred with a minimum of physical effort], walker and clean linen cart). This deficient practice placed Resident 43 at risk for accident, tripping, or fall. Findings: 1. During an observation of the facility, on 11/18/2024, at 10:54 AM, a wheelchair was observed in the middle of the hallway in front…

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 fully inform the resident in advance, of the risks and benefits of proposed care for two of 23 sampled residents (Resident 185 and 62) in accordance with the facility policy when: 1. Resident 185's admission Consent Forms (consent for treatment, disclose medical record, and photograph) were not completed and signed upon admission on [DATE]. 2. An informed consent was not obtained prior to Resident 62's use of psychoactive medication (drug that changes brain function and results in altercations in perception, mood, consciousness or behavior) Seroquel (an antipsychotic drug to treat certain mental conditions). This deficient practice had the potential for Residents 185 and 62 not to be able to exercise their right to choose their treatment plan. Findings: 1. During a review of Resident185's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses which included dementia (a mental…

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 on Self-administration of Medications for one (1) of 23 sampled residents (Resident 20) by failing to obtain a physician order and conducting an assessment to determine if the resident was capable to self-administer medications. This deficient practice had the potential to result in unsafe medication administration, omission, and/or duplication of medications, which can result to complications. Findings: During a review of Resident 20's admission Record, the admission Record indicated Resident 20 was admitted to the facility on [DATE] with diagnoses that included calculus of gallbladder with acute cholecystitis without obstruction (a condition where gallstones build up in the gallbladder and cause inflammation), lack of coordination, and unspecified glaucoma (a chronic eye disease that occurs when fluid builds up in the eye damaging the optic nerve and causing increased pressure in the eyeball). During a review 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 ensure the call light (device used by residents to call staff) was in reach for one (1) of 23 sampled residents (Resident 185) in accordance with the facility policy and procedure for Residents'Call System. This failure had the potential for Resident 185 to not be able to call for assistance, which could result in untimely delivery of care and services. Findings: During a review of Resident 185's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses which included adult failure to thrive (FTT, a syndrome of weight loss, decreased appetite and poor nutrition, and inactivity), benign prostatic hyperplasia (BPH, also known as an enlarged prostate, is a noncancerous condition in which the prostate gland becomes larger than normal), syncope (fainting or passing out), and fall (unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of 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 interview and record review, the facility failed to inform and provide a written information for one (1) of four (4) sampled residents (Resident 21) on the option to formulate an advance directive (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law relating to the provision of health care when the resident is incapacitated [clinical state in which a resident is unable to participate in a meaningful way in medical decisions]) as indicated on the facility's policy. This deficient practice violated the resident's and/or the representative's right to be fully informed of the option to formulate their advance directives and had the potential to unwanted treatment with the resident's wishes regarding health care. Findings: During a review of Resident 21's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses which included heart failure (a lifelong condition in which the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility 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 for one of 23 sampled residents (Resident 71). This deficient practice had the potential to expose Resident 71's records to others and violated the resident's right for privacy and confidentiality. Findings: During a record review of Resident 71's admission Record, the admission Record indicated Resident 71 was admitted to the facility on [DATE], with diagnoses of nontraumatic intracerebral hemorrhage (bleeding into the substance of the brain in the absence of trauma or surgery), encephalopathy (brain disease, damage, or malfunction that results in an altered mental state), and acute kidney failure (when the kidneys suddenly become unable to filter…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the preadmission screening and annual resident review assessment (PASARR, preventing individuals with mental illness, developmental disability, intellectual disability, or related conditions from being inappropriately placed in nursing homes for long term care) form was accurately completed for a resident who had a mental illness for one of four sampled residents (Resident 62). This deficient practice led Resident 62 to not receive the necessary and appropriate psychiatric (of or relating to the study of mental illness) level of treatment and evaluation in the facility. Findings: During a review of the Resident 62's admission Record, the admission Record indicated Resident 62 was admitted to the facility on [DATE], with diagnoses of psychosis (a mental disorder characterized by a disconnection from reality) and dementia (progressive brain disorder that slowly destroys memory and thinking skills). During a record review of Resident 62's Minimum…

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 develop a resident-centered comprehensive care plan (a care plan developed and implemented to meet the resident's preferences and goals, and addresses the resident's medical, physical, mental, and psychosocial needs) with individualized interventions for one (1) of 23 sampled residents (Resident 8) who was hard of hearing and refused to wear his hearing aid. This deficient practice had the potential to negatively affect and delay the delivery of care and services for Resident 8. Findings: During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included acute respiratory failure with hypoxia (condition where there's not enough oxygen or too much carbon dioxide in the body), pneumonia (an infection that affects one or both lungs), and type 2 diabetes mellitus without complications(DM- a disorder characterized by difficulty…

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 staff failed to ensure one (1) of 23 sampled residents (Resident 8) received treatment and care in accordance with professional standards (the guidelines, policies, and procedure that define the expected behaviors and performance level for specific profession) of practice by failing to perform appropriate laboratory tests and monitor Resident 8's blood sugar (concentration of glucose in the blood). This deficient practice had the potential to result in a lack of or delay in assessing for possible complications of hypoglycemia (when the blood sugar is lower than normal) and hyperglycemia (high blood sugar) for Resident 8 which can lead to hospitalization. Findings: During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included acute respiratory failure with hypoxia (condition where there's not enough oxygen or too much carbon…

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 of two sampled resident (Resident 70), who was assessed at moderate to high risk for falls, had a floor matt placed in Resident 70's room as ordered by facility physician. This deficient practice had the potential to result in injury to Resident 70. Findings: During a review of Resident 70's admission Record (a document containing diagnostic and demographic information), dated 11/20/2024, the record indicated Resident 70 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of lumbar (the lower back region of the spine) fracture (a partial or complete break in the bone), osteoarthritis (OA- is a degenerative joint disease that causes the cartilage in your joints to break down over time. It's the most common type of arthritis and can affect the hands, hips, knees, neck, and lower back), and history of falling. During a review of Resident 70's History and Physical (H&P- a term used to describe a physician's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide and accurately monitor fluid intake for one of one sampled resident (Resident 75) with fluid restrictions. This deficient practice had the potential to cause fluid overload (too much fluid in the body) or increase Resident 75's risk for dehydration (condition that occurs when the loss of body fluids, mostly water, exceeds the amount that is taken in). Findings: During a review of Resident 75's admission Record, the admission Record indicated Resident 75 was admitted to the facility on [DATE], with diagnoses that included end stage renal disease (a permanent condition that occurs when the kidneys are no longer able to function and require dialysis or a kidney transplant to survive), chronic kidney disease (a condition where the kidneys are damaged and can't filter blood properly), unspecified intellectual disabilities (a diagnosis given when it's difficult or impossible to assess the degree of intellectual disability in someone…

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 implement the order for gastrostomy tube (GT, a tube inserted through the belly that brings nutrition directly to the stomach) feeding for one of two sampled residents (Resident 78) in accordance with the facility's policy. This deficient practice resulted in Resident 78 to not receive the volume of tube feeding formula ordered which could lead to weight loss and worsening malnutrition (serious condition that occurs when a resident's diet does not contain the right amount of nutrients). Findings: During a review of the Resident 78's admission Record, the admission Record indicated Resident 78 was admitted to the facility on [DATE], with diagnoses of malignant neoplasm of nasopharynx (cancer that starts in the tissue connecting the back of the nose to the back of the mouth), sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood), adult failure to thrive (refers to a state where resident experiences a substantial…

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 treatment and care to manage pain of one of two sampled residents (Resident 64) by failing to: a. Administer Resident 64's methadone (medication used to treat moderate to severe pain. It can also treat narcotic drug addiction) on 11/18/2024 at 9 AM as ordered by the physician. b. Reassess Resident 64's pain level after administering pain medication (methadone and Percocet [medication to treat moderate to severe pain]) on 11/21/2024 at 10 AM, to ensure pain medication was effective. These deficient practices resulted in Resident 64 experiencing severe pain reporting a pain score of nine out of ten (9/10) on 11/18/2024 from 10 AM to 12:01 PM (2 hours and 1 minute). In addition, Resident 64 experienced pain with a score of eight out of ten (8/10) on 11/21/2024 from 10 AM to 1:09 PM (3 hours and 9 minutes) which resulted in physical distress to Resident 64. Findings: During a review of Resident 64's admission Record (a document containing…

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 including procedures to ensure the accurate acquiring, administering of all drugs and biologicals to meet the needs of two (2) of five sampled residents (Resident 31 and Resident 284) in accordance with the facility's policy and procedure (P&P) by failing to: 1. Ensure Resident 31 received the full dose of Humulin R insulin (a hormone that removes excess sugar from the blood) by not waiting approximately five (5) seconds before removing the needle after injection as indicated in the facility's policy and procedure (P&P). This deficient practice placed Resident 31 at risk of inadequate blood sugar management which can cause hyperglycemia (elevated blood sugar level) or hypoglycemia (low blood sugar level) 2.a. Administer Letrozole (a medication used to treat certain types of breast cancer (cells begin to grow out of control) for Resident 284 as ordered daily. 2.b. Administer clopidogrel bisulfate (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 relay to the doctor the recommendations form the pharmacist indicated in the Medication Regimen Review (MRR, a monthly thorough evaluation by the consulting pharmacist of a resident's medication regimen, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) for the month of September 2024 for two of five sampled residents (Resident 45 and 55). The MRR indicated to consider a gradual dose reduction (GDR - a periodic attempt to manage a resident's behavioral issues with a lower dose of medication) related to the use of Seroquel (an antipsychotic medication used to treat a severe mental condition in which thought, and emotions are so affected that contact is lost with external reality also called psychosis) for Resident 55 and 45. This deficient practice had the potential to result in adverse reaction (unwanted, uncomfortable, or dangerous effects that a drug may have) to 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.

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 sampled residents (Resident 31 and Resident 284) were free from significant medication errors by failing to: 1. Administer Resident 31's of Humulin R insulin (a hormone that removes excess sugar from the blood) 4 units as indicated in the facility's policy and procedure (P&P) and manufacturer's guidelines. This deficient practice placed the resident at risk of inadequate blood sugar management, which can cause hyperglycemia (high blood sugar) and untreated can lead to complications, such as eye, kidney, or heart disease or nerve damage. 2.a. Ensure Resident 284's Mometasone spray (medication used to treat and prevent the symptoms of seasonal and year-round allergy symptoms) 50 micrograms (mcg- unit of measurement) was not expired when administered on [DATE] to [DATE]. 2.b. Ensure Resident 284's Clopidogrel Bisulfate (a medication used to prevent blood clots) 75 mg Metoprolol (a medication used to treat 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 provide appropriate food preferences for one of 23 sampled residents (Resident 284). This deficient practice had the potential to result in decreased meal intake and can lead to weight loss and malnutrition (the condition that develops when the body is deprived of vitamin, minerals, and other nutrients it needs to maintain healthy tissue and organ function). Findings: During a review of Resident 284 admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses which included malignant neoplasm of the breast (a cancerous tumor that originates in the breast tissue, meaning it is a form of breast cancer), chronic obstructive pulmonary disease (COPD- is a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and peripheral vascular disease (is the reduced circulation of blood to a body part other than the brain or heart caused by a narrowed or blocked 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 ensure one of 23 sampled residents (Resident 286) was provided mechanically altered (texture of a diet is altered) diet as indicated on the physician's order. This deficient practice had the potential to cause Resident 286 to choke (severe difficulty in breathing because of a constricted/obstructed throat) which could lead to death. Findings: During a review of Resident 286's admission Record, the admission Record indicated Resident 286 was admitted to the facility on [DATE], with diagnoses that included type two diabetes mellitus (a chronic disease that occurs when the body doesn't produce enough insulin or doesn't use it properly, resulting in high blood sugar levels), dysphagia ( difficulty swallowing) and depression (a serious medical illness that negatively affects how you feel, the way you think and how you act). During a review of the Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 11/11/2024, 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 interview and record review, the facility failed to ensure two of 23 sampled residents (Residents 21 and 185) medical record is complete by failing to ensure Residents 21 and 185's Resident's Clothing and Possessions Form we're signed by the resident/ resident representative. This deficient practice placed Resident 21 and 185 at risk for loss or theft of belongings. Findings: 1. During a review of Resident 21's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses which included heart failure (a lifelong condition in which the heart muscle cannot pump enough blood to meet the body needs for blood and oxygen), chronic kidney disease (is a condition in which the kidneys are damaged and cannot filter blood as well as they should) and hypertensive heart disease (a long-term condition that develops over many years in people who have high blood pressure) During a review of Resident 21's Minimum Data Set (MDS, a resident assessment tool) dated…

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 device used by a resident to signal his or her need for assistance) was functioning to alert the staff that assistance was needed as for one (1) of 23 sampled residents (Resident 25). This deficient practice had the potential to result in delay in meeting Resident 25's needs for hydration, toileting, and activities of daily living (ADL) which can lead to falls and/ or accidents. Findings: During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included epilepsy (a brain disorder that causes recurring , unprovoked episodes of abnormal electrical activity in the brain), personal history of transient ischemic attack (TIA- a brief stroke that occurs when blood flow to the brain is temporarily blocked) and cerebral infarction (a condition that occurs when blood flow to the brain is…

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 a copy of the medical records for one of one sampled resident (Resident 1) within 48 hours (excluding weekends and holidays) from when the written request was received from the resident's representative on 10/3/2024. This deficient practice has resulted in the delay of access to Resident 1's medical records in a timely manner. Findings: During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and was transferred to the emergency room (ER) in General Acute Hospital (GACH) on 9/18/2024 via ambulance. During a review of Resident 1's History and Physical (H&P), dated 11/16/2022, with diagnosis of Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) 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 create a resident- centered care plan for one (1) of three (3) sampled residents (Resident 1) with interventions to prevent future fall (to drop suddenly or collapse) after the resident's fall incidents on 5/22/2024, 7/26/2024 and 9/27/2024. This failure resulted in Resident 1 had another fall on 7/26/2024 and 9/27/2024 and place resident at risk for another incident of fall. Findings: During a review of Resident 1's admission Record, admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks) and muscle wasting and atrophy (decrease in size or wasting away of a body part or tissue). During a review of Resident 1's History and Physical Examination (H&P), dated 2/2/2024, H&P indicated the resident does not have the capacity to understand and make…

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 treatment and care in accordance with the professional standards of practice for ne (1) of two (2) sampled residents (Resident 1) by: 1. Failing to record Resident 1's bowel movement (BM) pattern each day on 7/9/24-7/11/24, 7/15/24-7/16/24 and 7/19/24-7/22/24 as indicated in the resident's care plan for constipation (a condition where it's difficult or infrequent to have a BM usually resulting in hard, dry stools). 2. Failing to monitor/document/report to physician (MD) as needed for complications related to constipation when the resident did not have documented evidence of BM from 7/5/2024 to 7/23/2024 (19 days). This failure resulted to Resident 1 being transferred to the General Acute Care Hospital (GACH) on 8/2/2024 due to persistence of abdominal bulge in the resident's right lower quadrant (area) of abdomen. Resident 1 was found to have severe fecal impaction (a serious condition that occurs when a large, hard, dry stool mass blocks the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to safeguard one of two sampled residents (Resident 1) personal privacy and confidentiality of the medical records. This failure had the potential to result in Resident 1's personal information and medical records disclosed without Resident 1's permission, this will compromise the security or privacy of Resident 1's protected health information. Findings: During a review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included type 2 diabetes mellitus diabetic with chronic kidney disease (high blood sugar level in the blood stream lead to a gradual loss of kidney function over time), dependence on renal dialysis (a person requires technology to sustain their life due to kidney failure), and end stage renal disease (a permanent condition where the kidneys stop working, requiring dialysis or a kidney transplant to survive). During a review of Resident 1's History 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 safe provision of pharmaceutical services by failing to store unused insulin (used to help manage blood sugar levels on adults with diabetes [high blood sugar level]) injectable medications in the refrigerator and dispose of expired medications from two (2) of 2 sampled medication carts (Medication Cart one [1] and 3). These deficient practices had the potential for adverse reactions if these improperly stored medications were administered to the residents. Findings: During a concurrent observation and interview with Licensed Vocational 3 (LVN 3) on 9/23/24 at 2:25 PM, Medication Cart 1 was noted to have the following items: 1) 3 unopened Novolin R insulin (a short-acting insulin that starts to work in about 30 minutes and lasts for several hours to help lower blood sugar levels in the blood) Flex Pen injection 100 units labeled with name of 3 different residents. 2) 1 unopened Basaglar Insulin (a long-acting insulin that is slowly absorbed after being administered and maintains its effects over a long…

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 an interview and record review, the facility failed to ensure the resident's environment was free from accident hazards for one (1) of two (2) sampled resident (Resident 1) by failing to ensure the resident head did not get injured while using the Hoyer lift (a patient lift used by caregivers to safely transfer patients) during transfer. This deficient practice resulted to a 1.5 cm laceration (deep cut or skin tear in the skin) and a small bump to Resident 1's left front part of his head. Resident 1 was also sent to General Acute Care Hospital 1 (GACH 1) on 8/27/24 and was found to have a scalp cephalohematoma (accumulation of blood under the scalp) Findings: During a review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis of dementia (loss of cognitive functioning such as thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities) and Alzheimer (a brain disorder that slowly destroys…

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 observations, interview and record review, the facility failed to report the resident- to- resident altercation to the State Survey Agency (SSA), the state ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement (Local PD) within two (2) hours after the allegation of physical abuse (intentional bodily injury to a person, for example slapping, pinching, choking, kicking, shoving) for one of three sample residents (Resident 1) in accordance with the facility's policy and procedure. This deficient practice had the potential to place Resident 1 for further abuse and placed other residents at risk for elder abuse. Findings: During a review of Resident 1's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included but not limited to bilateral primary osteoarthritis of knee (a degenerative joint disease that affects both knees, causing pain,…

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 supervise and ensure the safety of three of three sampled residents (Residents 1, 2 and 3) in accordance with the facility's policy and procedure by: 1. Facility failed to provide sitter (one staff- to- one resident to provide monitoring) for Resident 1 who is at risk for elopement (leaving the facility without the staff's knowledge and/ or supervision). 2. Facility failed to supervise Resident 2 and ensure the resident signed out and followed the facility's out on pass (OOP; a non-medical visit outside of the facility mostly used for visits with family or friends) procedure when the resident left the faciity on 1/30/2024. 3. Facility failed to supervise Resident 3 who left the facility without signing OOP on 2/2/2024. These deficient practices resulted in Resident 1 eloped on 1/20/2024 at 5:45 AM and was brought back by the local police department to the facility on 1/20/2024 at 6:20 PM. Resident 2 left the faciity on 1/30/2024 and is not…

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 and interventions for wandering (moving from place to place without a fixed plan)/elopement (leaving the facility without the staff's knowledge and/or supervision) for one of two sampled residents (Resident 2). This failure resulted in Resident 2 eloped on 1/30/2024 and placed resident at risk for illness or serious injury. As of 2/2/2024, facility staff have no knowledge of the resident's where about. Findings: During a review of Resident 2's admission Record, admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of cord compression (a condition that puts pressure on your spinal cord) and osteomyelitis (swelling of the bone or bone marrow, usually due to infection). During a review of Resident 2's History and Physical Examination (H&P), dated 5/26/23, H&P indicated the resident has the capacity to understand and make decisions. During a review of Resident 2'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.

Based on observation, interview, and record review, the facility failed to ensure the facility's Falling Star Fall Prevention Program policy was implemented for one (1) of three (3) sampled Residents (Resident 1). This deficient practice had the potential to result in repeated falls, which could cause harm and injury to Resident 1. Findings: A review of the admission Record indicated the facility admitted Resident 1 on 11/27/23, with diagnoses including displaced intertrochanteric fracture (a type of hip fracture where points of the muscles of the thigh and hip attach) of the left femur, subsequent encounter for closed fracture with routine healing (used for encounters after the resident has received active treatment of the injury and is receiving routine care for the injury during the healing or recovery phase), wedge compression fracture (the front of the vertebral body collapses but the back does not) of thoracic (thorax is in the chest: the area between the neck and abdomen) T11 to T12 (nerves responsible for the lower abdomen ) vertebra (backbone), subsequent encounter for…

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

Based on interview and record review, the facility failed to ensure the Payroll Based Journal (PBJ, a system for healthcare facilities to submit staffing information. This system allows staffing information to be collected on a regular and more frequent basis than previously collected) report was completed. This deficient practice had the potential for the facility to not be adequately staffed and/or have the necessary staff to provide care to meet the needs of all the residents in the facility. Findings: A review of Centers for Medicare & Medicaid Services (CMS, the federal agency that provides health coverage) PBJ Staffing Data Report, dated 11/30/23, indicated facility did not submit staffing data for the fiscal quarter four (7/1/2022 to 9/30/2022). During an interview on 12/8/23 at 3:03 p.m., the Administrator stated, the facility's PBJ was not completed for the fiscal quarter four (7/1/2022 to 9/30/2022). A review of the facility's policy and procedure, title Reporting Direct Care Staffing Information-Payroll-Based Journal) revised 08/2022, indicated the following: 1. Complete…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the advance directive (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law [whether statutory or as recognized by the courts of the State], relating to the provision of health care when the resident is incapacitated ) or advance directive acknowledgement form (information about advance health care directives and the residents rights to make decisions about their medical treatment) was placed in the residents chart for seven (7) of 12 sampled residents (Resident 38, 40, 49, 57, 66, 70, and 73) as indicated in the facility policy. This deficient practice had the potential not to carry out Residents 38, 40, 49, 57, 66, 70, and 73's wishes regarding health care decisions during an emergency. Findings: 1. A review of Resident 38's admission Record indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE] with a diagnosis that included dementia (a mental…

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 complete the annual minimum data set (MDS, standardized assessment and care screening tool) timely for two (2) of four (4) sampled residents (Resident 70 and 78) as indicated in the facility policy. This deficient practice resulted to an incomplete MDS which had the potential for Residents 70 and 78 not to have an individualized care plan in accordance with the MDS, which could affect the resident's overall well-being. Findings: 1. A review of Resident 70's admission Record indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE] with a diagnosis that included malignant neoplasm of the pancreas (cancerous tumors of the long, flat gland that lies in the abdomen behind the stomach that produces enzymes that are released into the small intestine to help with digestion) and end stage renal disease (a medical condition in which a resident's kidneys cease functioning on a permanent basis leading to the need for a 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.

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 2 sampled residents (Resident 40 and Resident 49) were provided communication boards with the language that they were able to understand as indicated on the facility policy. This failure had the potential to result in Residents 40 and 49 experiencing a delay in receiving appropriate care and treatment due to the staff not being able to properly communicate with them. Findings: 1. A review of Resident 40's admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of low back pain and hypertension (when the pressure in the resident's blood vessels is too high). A review of Resident 40's History and Physical Examination, dated 1/18/23, indicated Resident 40 does not have the capacity to understand and make decisions. A review of Resident 40'S Minimum Data Set (MDS, a standardized resident assessment care screening tool), dated 10/24/2023, indicated the resident was moderately…

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 four (4) sampled residents (Residents 1 and 70) had their low air loss (LAL, operates using a blower based pump that is designed to circulate a constant flow of air through the mattress, commonly used to heal pressure ulcers [areas of damaged skin caused by staying in one position for too long]) mattresses set according to the residents' weight in accordance with the facility's policy and procedure (P&P). 1. Resident 1, who weighed 93 pounds (lbs., unit of measurement), was observed with the LAL mattress set at 250 lbs. 2. Resident 70, who weighed 155 lbs. was observed with LAL set between 175 to 210 pounds This deficient practice placed Residents 1 and 70 at risk for development of new pressure ulcer and progression of existing pressure ulcer. Findings: 1. A review of Resident 1's admission Record, indicated the resident was admitted to the facility on [DATE] with diagnoses that included aphasia (language disorder 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 that the facility was free of medication error rate of five percent (%) or greater as evidenced by the identification of nine (9) medication errors (any preventable event that may cause or lead to inappropriate medication use or resident harm while the medication is in the control of the health care professional) out of 32 opportunities (observed administered medications) for error, which yielded a cumulative medication error rate of 28 % for four sampled residents (Residents 39, 46, 51, and 54) observed during medication administration (med pass). This deficient practice had the potential to result in harm to Residents 39, 46, 51, and 54 by not administering medications as prescribed by the physician in order to meet their individual medication needs. Findings: 1. A review of Resident 39's admission Record indicated Resident 39 was admitted on [DATE] with diagnoses that included gastro-esophageal reflux disease (GERD- stomach acid…

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 was done under sanitary conditions by not ensuring: 1. Blender for mechanical soft diet was clean. 2. Opened food items were labeled and stored in resealable bags or tightly closed containers. 3. Window above the three (3) compartment sink was closed properly and was not broken. 4. Five (5) of 5 refrigerators were free from food build up from food residue. 5. Storage bin for clean water pitcher had a plastic lining and was free from dirt, scratches, calcification build up, and was properly closed. 6. Floor in the dishwashing area was not dirty and dishwasher did not have a calcium build up. 7. Ice machine was free from dirt and calcification. The Weekly Cleaning (Ice Machine) log was not signed from June 2023 to December 2023. 8. Food items that were past the best by date were discarded. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food…

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 the facility's policies and procedures on infection control by: 1. Failed to ensure all staff wear an N95 mask (National Institute for Occupational Safety and Health (NIOSH) N95 classification of air filtration, meaning that it filters at least 95% of airborne particles. A product that covers the wearer's nose and mouth that protects the wearer from inhaling particles that may be infectious) while in the facility. 2. Failed to ensure Resident 66's oxygen tubing (a long tube, used to deliver supplemental oxygen to a person in need of respiratory help) is not touching the floor. 3. Failed to change Resident 14's oxygen tubing every Wednesday as ordered. 4. Failed to label the Resident's 141 Intravenous (IV, a method of administering fluids and/or medications via the vein) tubing and IV site with a date of when it was placed and/or changed. 5. Failed to check the water for Legionella (a severe form of pneumonia [lung inflammation]…

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 have safe, clean, comfortable, sanitary, and home like environment in accordance with the facility policy by: by failing to ensure: 1. 10 of 36 rooms (Room H, I, J, K, L, M, N, O, P and Q) nightstands (bedside drawer) and dressers' paint and/ or vinyl panels were not peeled off. Facility also failed to ensure two (2) chairs in the resident's room were in good condition and leather seat cushions were not peeling off in Room P and Q. 2. Bed control (used by residents or facility staff to adjust position of the bed) wiring for Resident 85 was exposed. 3. Resident 54 ceiling was free from insects. 4. The glass window of Resident 60 was cracked (damaged and showing lines on the surface from having split without coming apart). 5. The toilet seat for Room F and G was free of fecal matter shared bathroom for Resident 25 and Resident 26. Findings: 1.a During an observation on 12/5/23 at 10:05 a.m. in Room O, 2 nightstands and one drawer were found…

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 (device used by residents to call staff) was in reach for one of 22 sampled residents (Resident 27) in accordance with the facility policy. This failure had the potential for Resident 27 to not be able to call for assistance, which could result in untimely delivery of care and services and fall resulting to serious injury or death. Findings: A record review of Resident 27's admission Record indicated Resident 27 was admitted to the facility on [DATE] with admitting diagnoses of Alzheimer's disease (a condition in brain that leads to memory loss, physical decline, and confusion) and repeated falls. A review of Resident 27's Minimum Data Set (MDS, a comprehensive standardized assessment and screening), dated 8/29/23, indicated Resident 27 required assistance with activities of daily living, including bed mobility (how resident moves while in bed such as turning from side to side), transferring, walking, dressing (how…

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 observation, interview, and record review, the facility failed to accurately assess the hearing status of one (1) of four (4) sampled residents (Resident 83) on the Minimum Data Set (MDS- an assessment and care screening tool) as indicated on the facility policy. This deficient practice had the potential to not develop and implement an individualized care plan for Resident 83, which could negatively affect the resident's overall wellbeing. Findings: A review of Resident 83's admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis that included Alzheimer's (a progressive disease that destroys memory and other important mental functions) and dementia (a mental disorder in which a resident loses the ability to think, remember, learn, make decisions, and solve problems). A review of Resident 83's MDS, dated [DATE], indicated Resident 83 had severe cognitive skills for daily decision making and was dependent (helper does all the effort) with shower/bathing self. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident specific care plan was developed for four (2) of 22 sampled residents (Resident 70 and 83) as indicated on the facility's care plan policy. 1. Resident 70's comprehensive care plan for bowel and bladder incontinence was not developed. 2. Resident 83's comprehensive care plan for hearing impairment was not developed. These deficient practices have the potential for Residents 70 and 83 not to receive interventions specific to their needs which could affect resident's overall wellbeing. Findings: 1. A review of Resident 70's admission Record indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE] with a diagnosis that included malignant neoplasm of the pancreas (cancerous tumors of the long, flat gland that lies in the abdomen behind the stomach that produces enzymes that are released into the small intestine to help with digestion) and end stage renal disease (a medical condition in which a resident'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, interviews, and record review, the facility failed to ensure inventory of all clothing and valuables were documented in the Resident's Clothing and Possessions (RCP, records the quantity of each item, description, and other identifying factors) and signed by the responsible personnel who completed the inventory list for two of five sampled residents (Resident 10 and 141). This deficient practice had the potential to cause misappropriation of property related to the lack of safekeeping of the residents' personal belongings. Findings: 1. A review of Resident 10's admission Record indicated Resident 10 was admitted on [DATE] and re-admitted on [DATE] with diagnoses that included sepsis (infection of the blood) of unspecified organism and hyperlipidemia (a condition in which there are high levels of fat particles (lipids) in the blood). A review of Resident 10's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 10/25/23, indicated Resident 10 had severely 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one (1) of four (4) sampled residents (Resident 10) under hospice care (provides medical services, emotional support, and spiritual resources for people who are in the last stages of a terminal illness) services had coordinated care between the facility and the hospice agency. Resident 10 did not receive all services as indicated on Hospice's Initial Order and Plan of Care (IOPC). This deficient practice had the potential for the Resident 10 to not receive the appropriate care and/or services from the facility and the hospice agency. Finding: A review of Resident 10's admission Record indicated the resident was admitted on [DATE] with diagnoses that included sepsis (infection of the blood) of unspecified organism and hyperlipidemia (a condition in which there are high levels of fat particles (lipids) in the blood). A review of Resident 10's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 10/25/23, 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 ensure a functioning communication system for seven (7) of 22 sampled residents (Residents 34, 38, 192, 19, 22,71, and 26) as indicated on the facility policy: 1. Resident 34's bedside call light was found on top of the resident's bedside table. Resident 34's bathroom call light did not have a pull string. 2. Resident 38's bedside call light was found on top of the resident's bedside table and was not functional/defective. 3. Resident 192's call light was found under the bed frame. 4. Resident 19's call light was functioning and within the resident's reach (arm's length) 5. Resident 22's call light was functioning and within the resident's reach 6. Resident 71's call light was functioning and within the resident's reach 7. Resident 26's call light was on the floor as observed. IPN stated the call light should be within Resident 26's reach to ensure resident is able to call the staff when assistance is needed. These deficient practices 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 observation, interview, and record review, the facility failed to maintain a safe and comfortable environment for seven (7) of nine (9) sampled occupied rooms. Rooms A, B, C, D, E, F and G's temperature were below 71 degrees Fahrenheit (unit of measurement). This deficient practice has the potential risk of hypothermia (dangerously low body temperature, below 95 degrees Fahrenheit caused by prolonged exposures to very cold temperatures) to the residents in Rooms A, B, C, D, E, F and G and could potentially affect other residents in the facility. Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility 4/4/14 with a diagnosis that included aphasia (a language disorder caused by damage to in specific area of the brain that controls language expression and comprehension), and intellectual disabilities (a condition that limits intelligence and disrupts abilities necessary for living independently). A review of Resident 1's History and Physical (H&P), dated…

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 implement written policies and procedures that prohibit loss and misappropriation of property for one of three sampled residents (Resident 1) by not documenting in the inventory list (Resident Belonging List) of the resident's blanket brought in by Family 1 on 10/10/23. This deficient practice had the potential to result in a loss of Resident 1's and other residents' personal belongings. Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility 4/4/14 with a diagnosis that included aphasia (a language disorder caused by damage to in specific area of the brain that controls language expression and comprehension), and intellectual disabilities (a condition that limits intelligence and disrupts abilities necessary for living independently). A review of records titled, Residents Clothing and Possessions Update, dated 6/26/20 indicated, Resident 1 had a blanket listed on the resident's belongings list. A review of Resident 1's History and Physical (H&P), dated 4/12/23, 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 interview and record review, the facility failed to notify the physician (MD) as indicated on the facility policy and procedure, when one of three sampled residents (Resident 1) had a behavioral change in condition (COC). This deficient practice had the potential to delay necessary care and treatment which could result in the deterioration of Resident 1's overall health condition. Findings: A record review of the admission Record indicated Resident 1 was admitted on [DATE] with diagnoses that included stimulant abuse (use of stimulants despite harm to the user), lack of coordination, and paraplegia (the inability to voluntarily move the lower parts of the body). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 6/5/23, indicated Resident 1 had an intact cognition (thought process and ability to reason or make decisions). Resident 1 required limited assistance (resident highly involved in activity, staff provide guided maneuvering of limbs or other…

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 in accordance with the facility's policies and procedures for one of five Residents (Resident 1) due to Resident 1 verbalizing feeling of being disrespected due to an allegation of physical abuse (any intentional act causing injury, trauma, bodily harm or other physical suffering to another person or animal by way of bodily contact). This deficient practice had the potential to cause a decline in Resident 1's individuality, self-esteem, and self-worth. Findings: A review of Resident 1's Face Sheet (admission information) indicated resident was admitted to the facility on [DATE] with diagnosis of displaced intertrochanteric fracture of left femur (broken hip) subsequent encounter for closed fracture with routine healing (used for encounters after the resident has received active treatment of the injury and is receiving routine care for the injury during the healing or recovery phase), repeated falls,…

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 assess the functional status of one of three sampled residents (Resident 1 ) in accordance with the facility ' s Minimum Data Set (MDS, a standardized assessment and care-screening tool) policy. This deficient practice resulted to Resident 1 not having a care plan for locomotion, which had the potential for the resident not to receive specific interventions to prevent injuries. Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] and re- admitted on [DATE]. Resident 1 ' s with diagnoses which included cerebral infarction (refers to damage to tissues in the brain due to a loss of oxygen to the area), hemiplegia (paralysis [refers to temporary or permanent loss of voluntary muscle movement in a body part or region] of one side of the body) and hemiparesis (weakness on one side of the body) affecting the right dominant side, aphasia (a language disorder caused by damage in a specific…

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 develop and implement a comprehensive person-centered Activities of Daily Living (ADLs, are activities related to personal care including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) care plan for one of three sampled residents (Resident 1). This deficient practice had the potential for Resident 1 to not receive specific interventions to prevent decline in Resident 1 ' s functional ability and also result in injury and harm. Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] and re- admitted on [DATE]. Resident 1 ' s diagnoses included cerebral infarction (refers to damage to tissues in the brain due to a loss of oxygen to the area), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) affecting the right dominant side, aphasia (a language disorder caused by damage in a specific area…

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.