White Blossom Care Center

Based on observation, interview, and record review, the facility failed to safely administer medication for one of thirty sampled residents (Resident 108) when licensed vocational nurse I (LVN I) left three routine medications on Resident 108's overbed table unattended, for self-administration. These failures had the potential for unsafe and improper administration of medications.Findings:During a concurrent observation and interview with Resident 108 on 3/9/2026 at 9:31 a.m., inside Resident 108's room, Resident 108 was positioned flat on bed, awake and had three white tablets in a medication cup on top of his overbed table, unattended. The overbed table was positioned in front of Resident 108. Resident 108 stated he needed to sit up to take his medications.During a concurrent observation and interviews with both LVN I and Resident 108 on 3/9/2026 at 9:33 a.m., inside Resident 108's room, LVN I confirmed the observation and stated that he left the medication because Resident 108 was not ready to take his medications yet. Resident 108 stated he needed one big pill to be cut in half…

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 develop a comprehensive, individualized, resident-centered care plans for two of 30 sampled residents (Residents 105, and 13) when:1.Resident 105's care plan for diagnosis of alcohol dependence with alcohol induced persisting dementia (a form of permanent brain damage caused by long-term, heavy alcohol consumption) since 1/15/2026, with brief interview for mental status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 08 (a score of 00 to 07 indicates severe cognitive impairment, 08-12 moderate impairment, 13-15 patient is cognitively intact) was not developed; and2.Resident 13's care plan for restorative nursing assistant (RNA - a healthcare professional who helps patients regain and maintain their independence and mobility) program for knee splinting (a temporary immobilization of the knee joint using a rigid device [like a brace, splint, or plaster]…

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

Based on interview, and record review, the facility failed to provide services according to professional standards for one of 30 sampled residents (Resident 15) when the speech language pathology (SLP) evaluation and treatment order was not carried out.This failure had the potential to affect Resident 15's care, health, and well-being.Findings:Review of Resident 15's clinical record titled, admission Record, indicated Resident 15 was admitted to the facility with diagnoses including Parkinsonism (a clinical syndrome characterized by a group of movement disorders, primarily featuring tremors, bradykinesia [slowness], muscle rigidity, and postural instability [balance issues]), and chronic pulmonary edema (a long-term condition where fluid slowly and consistently builds up in the lungs' air sac, which causes shortness of breath, fatigue, waking up breathless, and swollen legs).Review of Resident 15's clinical record titled, Order Summary Report, dated 6/30/2025, it indicated the following orders: Mechanical Soft Chopped texture, Thickened Liquid Nectar consistency, Resident on Hospice…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of 30 sampled residents (Residents 40) were free from unnecessary medication when Resident 40 received Lasix (used to treat edema [fluid retention; excess fluid held in body tissues]) for edema not indicating the specific site of edema and there were no monitoring for the nursing staff to monitor the edema. This deficient practice resulted in unmonitored medical condition.Finding:During a review of Resident 40's clinical record indicated Resident 40 was admitted to the facility on [DATE] with diagnosis including extended spectrum beta lactamase (ESBL, are enzymes produced by certain Gram-negative bacteria that make them resistant to many common antibiotics, including penicillins and cephalosporins) resistance and sepsis (is the body's extreme response to an infection. It is a life-threatening medical emergency.), unspecified. A review of Resident 40's physician's orders indicated an order for Lasix 40 milligram (mg, unit of measure), 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper medication storage and maintenance of one out of two medication refrigerators, when1. A thermometer was not present inside the medication refrigerator, and the internal light did not function when the refrigerator door was opened; and,2. Resident 90's medication was not removed from active stock in the medication refrigerator for nine days after the resident expired.These deficient practices had the potential to result in residents receiving medications with reduced potency, as well as medication errors due to failure to remove discontinued medications from active stock. Findings:1.A review of the medication refrigerator temperature log for [DATE] indicated that, on [DATE], the recorded temperature was 39 F (Fahrenheit).During a concurrent observation and interview with the Assistant Director of Nursing (ADON) C in the medication room on [DATE] at 9:18 a.m., it was observed that there was no thermometer inside the medication…

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 document review, the facility failed to offer provide a substitute of similar nutritional value for a menu item (milk), when Resident 133 preferred not to have milk at lunch meals. The failure to provide a substitute item of similar nutritional value had the potential to result in Resident 133 not receiving the nutrients meant to be provided by the planned menu leading to an inadequate nutrient intake.The menu spreadsheet titled Spring Cycle Menus dated 3/11/26, showed 8 ounces of milk on the menu for the Regular diet.During an observation in the resident dining room on 3/11/26 at 12:51 p.m., Resident 133 sat at a table eating her facility provided lunch. For her beverage, Resident 133 had one cup of juice in front of her. Resident 133's tray ticket (a piece of paper displaying information such as the resident's diet order, allergies, and food preferences) which was also on the table in front of her, showed Resident 133 was on a Regular diet, and Beverages: Coffee, 4 oz (ounce) Apple. During an interview with the Registered Dietitian (RD) and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure supervision was provided for one of three residents (Resident 1) when Resident 1 was left in the hallway unattended.This failure resulted to Resident 1 falling from her wheelchair. Resident1 sustained abrasion in the left elbow.Findings:Review of Resident 1's admission Record indicated she was admitted to the facility on [DATE], with diagnoses including hemiplegia (loss of strength in the arm, leg, and sometimes face on one side of the body) and hemiparesis (a relatively mild loss of strength in the arm, leg, and sometimes face on one side of the body), type II diabetes mellitus (high levels of sugar in the blood), muscle wasting (the loss of muscle tissue, strength, and mass) and atrophy (the partial or complete wasting away of a body part or tissue).During an interview with the Occupational Therapist (OT), on 11/25/25 at 1:35 p.m., the OT stated Resident 1 was placed outside the room after therapy. The OT also stated he informed a nurse and 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 reviews, the facility failed to provide the necessary care and services for two of 3 sampled residents (Residents 1 and 2) when: 1.Facility staff did not ensure timely assessment, physician notification, or complete documentation of a change in condition for Resident 1; and 2. Facility staff did not notify the physician or conduct a thorough investigation after Resident 2 fell on 2/27/25. These failures placed Residents 1 and 2 at risk for delayed treatment and potential harm. Findings: 1. A review of Resident 1's medical record indicated Resident 1 was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis following unspecified cerebrovascular disease (partial or complete paralysis on one side of the body after a stroke or brain injury), traumatic hemorrhage of cerebrum (bleeding in the brain caused by trauma), type 2 DM (diabetes mellitus, a chronic condition that affects how the body processes blood sugar), memory deficit following cerebral infarction (memory…

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 services in accordance with professional standards of practice for one of two sampled residents (Resident 1) when license nurses did not accurately complete Resident 1's elopement and wandering risk assessment. This failure had the potential to compromise the facility's ability to provide resident-centered interventions based on assessment data. Findings: Review of Resident 1's medical record indicated she was admitted on [DATE] and re-admitted on [DATE] with diagnoses including cerebral palsy (a congenital disorder of movement, muscle tone, or posture due to abnormal brain development), chromosomal abnormality (a genetic condition that occurs when there are missing, extra, or irregular portions of chromosomal DNA [a molecule that carried genetic instructions for the development and functioning of all living organisms]), other lack of expected normal physiological development in childhood (known as developmental delay, means a child or adult 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.

Based on interview, record review, and facility document and policy review, the facility failed to ensure a Level I Preadmission Screening and Resident Review (PASRR) was updated to reflect a newly diagnosed serious mental disorder for 1 (Resident #11) of 6 residents reviewed for PASRR requirements. Findings included: A facility policy titled admission Criteria, updated on 10/24/2024, specified, c. The facility designated staff will complete a new PASRR for residents with new diagnosis of mental illness and/or significant change of condition and refer them to the appropriate state-designated authority for Level II PASRR evaluation. An admission Record indicated the facility admitted Resident #11 on 10/04/2007. According to the admission Record, the resident had a medical history that included diagnoses of major depressive disorder and mood disorder, both with an onset date of 01/14/2019. Per the admission Record, Resident #11 also had a diagnosis of psychotic disorder, with an onset date of 06/21/2023. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) 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 record review, interview, and facility policy review, the facility failed to ensure Preadmission Screening and Resident Review (PASRR) Level I screenings accurately reflected the presence of diagnosed serious mental disorders and failed to ensure new PASRR Level I screenings were submitted on the 31st day of admission to the skilled nursing facility following an exempted hospital discharge for 2 (Resident #127 and Resident #25) of 6 residents reviewed for PASRR requirements. Findings included: A facility policy titled admission Criteria, updated on 10/24/2024, specified, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) [another acronym for PASRR] process. a. The discharging hospital conducts a Level I PASARR screen for all potential Skilled Nursing Facility (SNF) admissions, regardless of payer source, to determine if the individual meets 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 infection control practices were implemented when: 1. Eight plastic containers of [brand name] bleach (provide effective infection control for hard surfaces to help stop pathogen transmission) lids were not closed and were exposed in the hallways; 2. Two certified nursing assistants A and B (CNA A and CNA B) were wearing gloves in the hallway walking room to room and did not perform hand hygiene in between task; 3. One box of clean gloves and one bottle of hand sanitizer were on top of a clean movable cart and were approximately 1/2 inch from a treatment cart with attached trash bin with an open lid. 4. Three laundry hampers with three linens on top were stored outside by the facility patio; 5. A bin was over flowing with housekeeping towels outside the laundry area hallway; 6. Two empty drinking water bottles, clean rolled plastic bags, one opened gloves and hand sanitizer were all stored together in a housekeeping cart that 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 interview and record review, the facility failed to ensure one of three residents (Resident 2) were free from unnecessary psychotropic medications (medication capable of affecting the mind, emotions, and behavior) when Resident 2 received quetiapine fumarate (Seroquel, an antipsychotic medication used to treat certain mental/mood conditions) without adequate indication and monitoring a specific target behavior for its use. This failure could result in lack of adequate monitoring and had the potential for residents to receive unnecessary medications. Findings: Resident 2 was admitted to the facility on [DATE] with diagnoses including dementia (loss of thinking, remembering, and reasoning skills) in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; type 2 diabetes mellitus (high levels of sugar in the blood) ; essential hypertension (high blood pressure that does not have a known cause). 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 infection prevention practices were followed for one of four residents (Resident 1) when the door of the Covid-19 isolation room was open. This failure had the potential to result in transmission and spread of Covid-19 infection. Findings: During an observation, on 8/21/24 at 3:20 p.m., the door of a Covid-19 isolation room AA was open. Review of Resident 1's clinical record indicated she was admitted on [DATE] with a diagnosis including acute pulmonary edema (fluid builds up in the lungs making it difficult to breathe), acute and chronic respiratory failure with hypoxia (a condition where not enough oxygen in the body) A condition in which the lungs have a hard time loading the blood with oxygen or removing carbon dioxide. Lungs cannot release enough oxygen into the blood). Resident 1 was covid positive on 8/21/24. During an interview on 8/21/24 at 3:27 p.m., with Licensed Vocational Nurse (LVN) A, she confirmed Resident 1 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.

Based observation, interview, and record review the facility failed to implement infection control practices for three of four emergency crash carts when: 1. Emergency crash carts (crash cart is a set of trays/drawers/shelves on wheels used for transportation and dispensing of emergency medication/equipment at site of medical/surgical emergency for life support protocols to potentially save someone's life) B, and C contained oropharyngeal airway (OPA, also known as an oral airway is a medical device that helps maintain or keep a patient's airway open) kit that was not stored in the original packaging and was not labeled with shelf-life expectancy or no expiration date. 2. Emergency crash cart A contained oropharyngeal airway kit stored in two plastic bags had yellowish substance with no label or expiration date. 3. Emergency crash care B and C had one yankauer (Yankauer suction tips are often used to suction oropharyngeal secretions to prevent aspiration. They can be used in the mouth to remove excess fluid and secretions from people who have difficulty swallowing or spitting) 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 interview and record review, the facility failed to perform a thorough investigation and report for seven of nine residents (Residents 1, 2, 3, 4, 5, 11, and 12). This failure had the potential to compromise the facility's ability to determine the circumstances surrounding the incidents and could have compromised the residents' safety. Findings: During a review of the 5-day investigation summary of an alleged altercation between Residents 2 and 3, the summary did not indicate the outcome for the facility's investigation of whether the facility was able to determine if they thought the altercation did occur, or not. During a review of the 5-day investigation summary of an alleged altercation between Residents 1 and 2, the summary did not indicate the outcome for the facility's investigation of whether the facility was able to determine if they thought the altercation did occur, or not. During a record review and concurrent interview on 5/7/24 at 4:14 p.m., with the Minimum Data Set Nurse (MDSN), she reviewed the Interdisciplinary Team (IDT, a group of healthcare…

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 three of three resident (Residents 8, 9, and 10) were kept free from constipation when physicians orders were not followed for interventions according to the facility's policy and professional standards. This failure caused each resident to become unnecessarily constipated. Findings: Review of Resident 8's clinical record indicated she was admitted with diagnoses which included hemiplegia and hemiparesis (hemiplegia refers to complete paralysis, while hemiparesis refers to partial weakness) following cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), constipation, and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 8's bowel movements (BMs) documentation in the medical record, it indicated that Resident 8 did not have a BM from 5/9/24 - 5/12/24. During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the Social Service Director (SSD) failed to inform the responsible party (RP, person designated to make decisions on behalf of a resident) of one of two sampled residents (Resident 1) regarding Resident 1's appointment with a psychologist. This failure had the potential to affect the ability of the RP to participate in Resident 1's treatment. Findings: Review of Resident 1's clinical record indicated she was admitted on [DATE] and had diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction (weakness or complete paralysis on one side of the body due to a stroke), Aphasia (loss of ability to understand or express speech), dementia (mental disorder caused by brain disease or injury), Parkinsonism (brain conditions that cause slowed movements, stiffness and tremors), Major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), Bipolar Disorder (mental illness that causes unusual shifts in a person ' s mood, energy,…

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

Based on observation, interview, and record review, the facility failed to provide a safe and comfortable environment for one of three Residents (Resident 1) when space heater was used in the rehabilitation room. This failure had the potential to compromise residents' safety, health and well-being. Findings: During an interview on 4/19/24 at 8:25 a.m., with Resident 1, she stated that when she was in the rehabilitation room, the therapy staff could not turn up the space heater and Resident 1 was not allowed to have space heater and heating pad while the Rehabilitation (Rehab) staff currently use a space heater. Resident 1 further stated that the staff in the rehabilitation room was using space heater for six months because the heating unit was not functioning, and the rehabilitation room was cold if there was no space heater. During an initial tour of the facility with the Administrator (ADM) on 4/19/24 at 12:27 p.m., in the rehabilitation room, a space heater was plugged in. A red indicator light was on and the space heater was located under a desk During a concurrent observation…

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 staff followed their fall policy for one of three sampled residents (Resident 1). Resident 1 fell six times within a month and the interdisciplinary team (IDT, members of the health care team who meet to discuss and plan residents' care) did not meet after every fall, comprehensive post fall assessments were not always conducted and post fall care plans were not consistently updated with preventative measures. This failure placed the resident at risk for further falls and injury. Findings: During an observation on 12/9/23 at 1:40 p.m., Resident 1 was seated on his bed and was yelling, water, water that could be heard from the hallway for about 10 minutes. During an interview on 12/9/23 at 1:45 p.m., registered nurse (RN) A stated Resident 1 had right sided weakness, did not walk, and was not able to say what he wants but made his needs known by answering yes or no to questions. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 12/11/23, indicated the resident had problems with memory and had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their room change policy for one of three sampled residents (Resident 1) when there was no documentation that the responsible party (RP, person designated to make decisions on behalf of the resident) was notified of multiple room changes. There was also no documentation that the facility monitored Resident 1 after these room changes occurred. These failures had the potential to compromise Resident 1's rights and psychosocial well-being. Findings: Review of Resident 1's medical record indicated he was admitted on [DATE] and had the diagnosis of dementia (a mental disorder caused by brain disease or injury). The medical record indicated Resident 1 had a RP. Further review of Resident 1's medical record indicated he had room changes on 2/22/23, 2/24/23, 3/11/23, 3/14/23, 3/26/23, 4/26/23, 5/11/23, and 9/20/23. There was no documentation in Resident 1's electronic or paper medical record that indicated the RP was notified of these room changes.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an advance directive (AD, a written instruction, such as a living will or durable power of attorney for health care when the individual is incapacitated) or Physician Orders for Life-Sustaining Treatment (POLST, document that specifies the medical treatments the resident wants to receive during serious illness) was completed for 5 of 29 sampled residents (Residents 44, 91, 122, 493, 496 and 512). These failures could lead to the delivery of unnecessary or inappropriate medical services, which are against the resident's goals and wishes. Findings: 1. Review of Resident 122's clinical record indicated he was admitted to the facility on [DATE]. Review of Resident 122's undated POLST form indicated the AD section of the POLST was blank. The POLST form did not indicate if there was an advance directive in place or it was not available. Review of Resident 493's clinical record indicated she was admitted to the facility on [DATE]. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure seven of 29 sampled residents (Residents 1, 13, 19, 23, 35, 37 and 442) had a Baseline care plan within 48 hours of resident's' admission when residents' Baseline care plan were incomplete. These failures had the potential for the facility staff not to meet the residents' immediate care needs and safety against adverse events that most likely to occur right after admission. Findings: 1. Resident 13's clinical record indicated she was admitted on [DATE] and had the diagnoses of dementia (a group of condition with impairment of brain function) without behavioral disturbance, history of falling, pneumonia (a lung infection) and anemia (a condition in which the blood does not have enough healthy red blood cells). Review of Resident 13's Baseline care plan dated 11/25/21, indicated 'in progress' and missing information on the following sections: resident and/or resident representative (RR) participating in baseline care plan meeting, describe…

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 controlled medications (those with high potential for abuse and addiction) were fully accounted; and medications were available to administer or given according to the physician's order/manufacturer's specifications, when: 1. Three out of four nurses failed to document on the controlled substance accountability sheet (aka Count Sheet, an inventory sheet that keeps record of the usage of controlled medications) in a timely manner after they removed the medications from the medication carts; 2. Norco (a potent narcotic for pain) 10/325 milligrams (mg, unit of measurement) for Resident 90 was given too soon before it was due and not according to the physician's order; 3. Random controlled medication use audit for six of six residents (Residents 11, 21, 57, 89, 107, and 503) did not reconcile. The medications were signed out of the Count Sheets but not documented on the Medication Administration Record (MAR) to indicate they were given…

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 three out of 29 sampled residents (Residents 1, 37, and 55) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors) when: 1. Resident 37 received Abilify (an antipsychotic medication) when there was no clinical indication; 2. Resident 55 received Seroquel (an antipsychotic medication) without adequate indication for its use or documented evidence of target symptoms resulting harm or severe distress to the resident; and 3. Resident 1 received as-needed (PRN) lorazepam (an anti-anxiety medication) since 4/2021 without specified duration for use, and did not receive gradual dose reduction (GDR, a tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) for Depakote (a mood stabilizer), trazodone (an anti-depressant), and Ambien (a hypnotic medication for sleep). 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 proper medication storage and labeling of medications when: 1. Temperature monitoring was not consistently documented twice daily on the temperature log sheets, in November 2021 and January 2022, for two of three medication refrigerators (REF #1 and REF#2); 2. An prescription eye medication and five insulin pens did not have the pharmacy labels; 3. Three inhalers were not dated after being opened in Medication Cart #1A; 4. An insulin vial and an oral inhaler were identified in the active stock, being used beyond the discard (expiration) date; and 5. An insulin dispensed and labeled for Resident 52 was being used for Resident 71. The deficient practices had a potential for residents to receive medications with unsafe and reduced potency from being used past their discard date; medication errors due to medications not being labeled; and inadequately monitored medications, which could lead to unsafe and ineffective medications for the…

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

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when: 1. Kitchen refrigerator's wire rack had yellowish to orange color; 2. Spatula was chipped; 3. Seven pans were stacked and not air dried; 4. Knife sharpener had tape; 5. Measuring scoop had brownish color 6. Microwave's plastic film was peeling off and had accumulation of orange particles; 7. Can opener gear had orange to brownish color; 8. Station X's ice machine bin had whitish to brownish buildup and Station XYZ ice machine had whitish and greenish discoloration; 9. Two cutting boards had deep cuts; 10. Food in the residents refrigerator was not labeled; and 11. Refrigerator temperature for residents' food were not monitored consistently. These failures had the potential to cause foodborne illness (illness resulting from contaminated food) for 142 of 148 residents who received food from the kitchen. Findings: 1. During an initial kitchen tour on 2/7/22 at 1:06 p.m., with the dietary supervisor (DS), the kitchen refrigerator's six…

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

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Laboratory staff (LS) was not properly screened before entering the facility; 2. Mortuary Staff (MS) was not wearing N95 (a high filtering mask) and did not gown up; 3. Certified nursing assistant R (CNA R) was not wearing N95; 4. Infection Preventionist (IP) was not wearing N95 properly; 5. Licensed vocational nurse C (LVN C) did not perform hand hygiene and change gloves after touching potentially contaminated surfaces during the medication administration for Resident 71. These failures could result in the spread of infection and cross-contamination that could affect the 148 residents that reside in the facility. Findings: 1. During an observation in the front lobby on 2/8/22 at 7:33 a.m., the LS was in front of the surveyor and signed the respiratory screening questionnaire for COVID-19 (Coronavirus disease 2019; a highly contagious respiratory disease) form for visitors. The ward clerk (WC) was in the receptionist desk and the WC did not check…

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 29 sampled residents (Residents 89 and 243) who kept medications at bedside had a physician order, care plan and an assessment as capable of self-administering medication. These failures had the potential to result in unsafe medication administration and could have allowed other residents to access unlocked medications. Findings: 1. During a concurrent observation and interview on 02/08/22 at 9:36 a.m. with Resident 89, an artificial tears eye drop was on Resident 89's overbed table, written on the front of the box with a permanent marker was, exp 2/23 (expiration 2/23). Resident 89 stated the nurse gave her the artificial tears because she wears contact lenses. During a concurrent interview and record review on 02/08/22 at 10:01 a.m., licensed vocational nurse L (LVN L) reviewed Resident 89's physician order and medication administration record (MAR), she did not find any order for artificial tears. She stated there should…

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 needs were accommodated for three residents (35, 55, and 72) when the call light devices were not within reach. This failure had the potential for a delayed response and not meeting the resident needs. Findings: 1. Resident 55's clinical record indicated she was admitted on [DATE], was on hospice and had diagnoses of muscle weakness, osteoarthritis (a chronic joint disease), dementia (a group of condition with impairment of brain function) with behavioral disturbance, hypertension (high blood pressure), anxiety disorder (a mental health condition) and difficulty in walking. During an observation of Resident 55 on 2/07/22 at 1:47 p.m., Resident 55 was lying in bed and the call light was over the head board not within reach. During an observation and interview with certified nurse assistant H (CNA H) on 2/07/22 at 1:47 p.m., CNA H confirmed Resident 55's call light was over the head board and was not within reach. CNA H stated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately assess the preadmission screening and resident review report (PASRR, an evaluation data requirement to determine whether a resident with mental illness (MI) requires specialized services such as referral to a mental health authority) for three of 29 sampled residents (Residents 91, 496, and 507). This failure had the potential to put the residents at risk for not receiving appropriate care and services. Findings: 1. Review of Resident 91's clinical record indicated he was re-admitted to the facility on [DATE] with diagnoses including encounter for palliative care (specialized care for people with serious illness promoting quality of life) anxiety (feelings of worry and fears). During a concurrent interview and record review with the minimum data set coordinator (MDSC) on 2/9/22 at 2:36 p.m., the MDSC reviewed Resident 91's clinical record and stated PASSR was not updated when Resident 91 was admitted to hospice. During a concurrent interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide care and services in accordance with professional standards of practice for two of 29 sampled residents (Residents 37 and 43 ) and 2 non-sampled residents (Residents 55 and 125) when: 1. For Resident 125 intravenous solution and intravenous tubing were not dated; 2. For Resident 43, bruise was not monitored; 3. For Resident 37, oxygen was administered without a physician's order; 4. For Resident 55, oxygen was not administered as ordered. These failures had the potential to compromise the residents' health and well-being. Findings: 1. During an observation on 2/7/22 at 1:50 p.m., Resident 125 had an IV (intravenous) solution bag hanging on a pole next to her bed. The solution label read: Sodium Chloride 0.45%. Administer 75ml (ml- unit of measure) per hour. The solution was dripping into a tubing that was connected to Resident 125's right arm intravenously peripherally inserted central catheter (PICC, a thin, soft, long catheter…

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 care and services were provided in accordance with professional standards of practice for three of 29 sampled residents (Residents 242, 6, and 52) when: 1. Resident 242's intervention to have psych consult was not implemented and her care plan was not person-centered; 2. Resident 6's care plan for non-compliance with fluid restriction was not initiated. 3. Resident 52's care plan for heparin (blood thinner to treat or prevent blood clots) and furosemide (water pill) use were not initiated. These failures had the potential to compromise the resident's health and well-being. Findings: 1. Review of Resident 242's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including hemiplegia (loss of muscle function of one side of the body) and hemiparesis (partial weakness of one side of the body) following a cerebral infarction (stroke, damage to brain tissues due loss of oxygen) affecting 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 interview and record review, the facility failed to provide services to promote healing of pressure ulcers (damage to the skin and underlying tissue as a result of prolonged pressure) for one of 29 sampled residents (Resident 501), when there was no admission skin assessment completed and the licensed nurse did not obtain measurements when facility aquired pressure ulcers were identified on the bilateral heels and mid-back of Resident 501. These failures had the potential to delay treatments and potentially lead to new or worsening pressure ulcers. Failure to obtain measurements had the potential to compromise the facility's ability to determine whether Resident 501's pressure ulcers were increasing or decreasing in size. Findings: Review of Resident 501's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including fracture of the right femur (upper bone of the leg), malignant neoplasm of the bone (cancer), scoliosis (abnormal curvature of the spine), kyphosis (outward…

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 appropriate treatment and services were provided for one of 29 sampled residents (Resident 91) when the restorative nursing assistant (RNA, program that helps residents to gain and improve quality of life by increasing their level of strength and mobility) program was not implemented. The deficient practice had the potential to result in residents' decline in range of motion. Findings: Review of Resident 91's clinical record indicated he was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including muscle weakness and other abnormalities of gait and mobility. Review of Resident 91's physician order dated 1/13/22 indicated an order for RNA program every shift. During a concurrent interview and record review with the minimum data set coordinator (MDSC) on 2/10/222 at 9:30 a.m., the MDSC reviewed Resident 91's physician order and confirmed the above order. During an interview with the MDSC on 2/10/22 at 9:42 a.m., 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 non smoking policy and fall management policy were implemented to prevent accident for three of 29 sampled residents (Residents 90, 128, and 130) when: 1. The interdisciplinary team (IDT, team composed of members from different departments involved in resident's care) failed to do a proper smoking risk assessment, provide adequate monitoring and failed to revised Resident 90's smoking care plan. 2. Resident 128 did not have a post fall assessment, fall care plan was not updated and IDT was not done; and 3. Resident 130's neurological assessment (neuro checks, an assessment of neurological functions and level of consciousness) was incomplete. These failures had the potential to result in serious injury to the residents in the facility. Findings: 1. A review of Resident 90's clinical records indicated he was admitted to the facility with diagnoses including chronic obstructive pulmonary disease, unspecified (COPD, a long lasting lung…

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 receiving dialysis (removal of waste and excess fluid from the body) treatment received care consistent with professional standards for one of 29 sampled residents (Resident 43) when his dialysis communication reports (DCR) were incomplete. This deficient practice had the potential for Resident 43's dialysis care not being properly communicated and could put Resident 43 at risk for complications. Findings: Review of Resident 43's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including end stage renal disease (kidney failure, kidney's no longer functioning in permanent basis). Review of Resident 43's DCRs dated 1/4/22, 1/8/22, 1/11/22, 1/20/22, 1/24/22 indicated, the dialysis unit part of the DCR were blank. During a concurrent interview and record review with the minimum data set coordinator (MDSC) on 2/14/22 at 9:31 a.m., the MDSC reviewed Resident 43's DCRs dated 1/4/22, 1/8/22, 1/11/22, 1/20/22…

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.