Seacrest Post-Acute Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure one of three sampled residents ( Resident 27) maintained adequate nutritional status. The facility failed to:1.Provide one-on-one feeding assistance ( a staff member supports a single resident with eating for the entire meal) as ordered.2.Ensure Boost (nutritional supplement) was administered to Resident 27 as ordered.3.Monitor and respond to Resident 27's declining meal intake.4.Ensure effective communication and follow-through of Registered Dietician nutritional interventions.These deficient practices placed Resident 27 at risk for inadequate nutritional and fluid intake which could lead to malnutrition (a condition resulting from an unbalanced diet), significant weight loss, dehydration (not having enough water in the body), skin impairment, hypoglycemia (low blood sugar), aspiration (the accidental breathing in of food, liquid, saliva, or vomit into the airway and lungs), and subsequently resulted in Resident 27 being admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure medications were not left open and unattended for one of four sampled residents (Resident 63)'s bedside.This deficient practice placed Resident 63 at risk for medication errors, including missed, duplicated, or inappropriate administration.Findings:During a review of Resident 63's admission Record, the admission Record indicated Resident 63 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease (lasting damage to the kidneys), and transient ischemic attack ([TIA]-brief episode of neurologic [relating to the nervous system] dysfunction).During a review of Resident 63's Minimum Data Set (MDS a resident assessment tool) dated 3/11/2026, the MDS indicated Resident 63 required dependent assistance (helper does all of the effort) with toileting, oral hygiene, bathing, and showering.During a concurrent observation and interview on 3/24/2026 at 10:53 a.m. with Resident 63, open medications (nine pills) were…

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 a monthly Medication Regimen Review ([MRR]- a thorough evaluation of a patient's complete medication list to ensure the medication therapy is safe, necessary, and effective) was conducted and maintained by a licensed pharmacist for one of three residents Resident (27). This failure resulted in a lack of professional oversight to identify potential medication irregularities and placed the residents at risk for adverse drug events, excessive sedation, and the continued use of potentially unnecessary medications.Findings: During a review of Resident 27's admission Record, the admission Record indicated Resident 27 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), and diabetes mellitus type 2 (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 27's Minimum Data Set (MDS a resident assessment…

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 one of six sampled residents (Resident 75) was seen by a dentist for her broken, loose missing teeth.This failure had the potential to result in the inability to effectively chew foods, weight loss, lack of energy and loss of muscle mass for Resident 75.Findings:During a review of Resident 75's admission Record (face sheet) dated 3/26/2026, the admission record indicated Resident 75 was admitted to the facility with diagnosis including breast cancer (rapid growth of abnormal cells), atrial fibrillation (irregular heartbeat) and muscle weakness.During a review of Resident 75's History and Physical (H&P) dated 1/30/2026, the H&P indicated, Resident 75 was alert and oriented.During a review of Resident 75's Minimum Data Set (MDS) a standardized assessment and care screening tool) dated 3/6/2026, the MDS indicated Resident 75 had moderate cognitive impairment. The MDS indicated Resident 12 needed substantial/maximal assistance (helper does more than half the work) with activities of daily living ([ADLs]…

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 the accuracy of the medical record for one of three residents (Resident 63). As evidence by documentation indicating medications were administered on 3/24/2026 at 8:08 a.m., while observation revealed medications were left opened/unattended at the bedside and not confirmed as administered.This deficient practice resulted in inaccurate documentation of medication administration and had the potential to affect Resident 63's treatment and care.Findings:During a review of Resident 63's admission Record, the admission Record indicated Resident 63 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease (lasting damage to the kidneys), and transient ischemic attack ([TIA]-brief episode of neurologic [relating to the nervous system] dysfunction).During a review of Resident 63's Minimum Data Set (MDS a resident assessment tool) dated 3/11/2026, the MDS indicated Resident 63 required dependent assistance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection control measures were observed for three of six sampled residents (Residents 6, 12 and 79). The facility failed to:1.Ensure signage for Enhanced Barrier Precautions (EBP- infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug-resistant organisms {microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents}) was in place for Resident 6.2.Ensure the laundry staff cleaned and documented the dryer lint trap screens every two hours.3.Ensure the kitchen staff monitored and documented the refrigerator temperatures.4. Ensure staff member wore personal protective equipment (PPE-gown, gloves) before providing patient care to Resident 12 who was on EBP for stasis ulcers (open sores).5. Ensure Resident 79's care giver removed PPE before exiting Resident 79's room to walk down the hallway after…

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 (refers to a set commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use) for two of three sampled residents (Resident 54 and Resident 66).This deficient practice had the potential for Resident 54 and Resident 66 to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use.Findings:1. During a review of Resident 54's admission Record, the admission Record indicated Resident 54 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 54 was admitted with diagnoses including cerebral infarction (stroke, loss of blood flow to a part of the brain) and hypertension (HTN- high blood pressure).During a review of Resident 54's Minimum Data Set (MDS- a resident assessment tool) dated 2/28/2026, the MDS indicated Resident 54'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:1. Ensure adequate room size and space to support the comfort and well being for one of six sampled residents (Resident 59).2. Ensure 6 of 26 residents' rooms (Rooms 21, 22, 23, 25, 26 and 27) met the requirements of 80 square feet for each resident.This failure had the potential to negatively impact Resident 59's quality of life by limiting his ability to move freely and safely within his living space and had the potential to result in inadequate provision of safe nursing care and a lack of privacy for residents.Findings:During a concurrent observation and interview on 3/26/2026 at 8:22 a.m. with Resident 59 at bedside, Resident 59's television (TV) stand was observed to be blocking Resident 59 from being able to maneuver his w/c to the left side of his bed. Resident 59 stated this room is way too small for him. Resident 59 TV stand had to be moved for him to get to the left side of his bed. Resident 59 stated there was nothing he could…

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 when Resident 2 presented a new wandering behavior for one of three sampled residents. This failure resulted in Resident 2's wandering behaviors not being addressed and a physical altercation between Resident 1 and Resident 2. Findings: During a review of Resident 2's admission record, the admission record indicated Resident 2 was initially admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior)- bipolar (sometimes called manic-depressive disorder- mood swings that range from the lows of depression to elevated periods of emotional highs) type, and depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities). During a review of Resident 2's History and Physical (H&P), dated 7/21/2025, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure Resident 1 and Resident 2 were free from abuse when Resident 1 and Resident 2 got into a physical altercation on 8/25/2025. The facility failed to ensure: A. Resident 1 received Trazadone (medication for depression [persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities] and insomnia) for three days (8/23/2025, 8/24/2025, and 8/25/2025).B. Resident 2's episodes of wandering (walking around without a specific goal or purpose) and behaviors of taking items from snack carts were communicated to the provider or addressed in a care plan.3.Implement the facility's policy and procedure titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021 which indicated residents have the right to be free from abuse. These deficient practices resulted in a physical altercation between Resident 1 and Resident 2 on 8/25/2025 at approximately 8:30 p.m. when:1. 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 a psychotropic (any medication capable of affecting the mind, emotions, and behavior) medication was not used unnecessarily for one of three sampled residents (Resident 1) by: 1. Failing to monitor manifested behaviors for which Trazadone (medication used to treat depression or insomnia) was prescribed for three consecutive days2. Failing to monitor adverse effects of Trazadone 3. Failing to obtain an active psychotropic informed consent (a process to ensure a resident or the resident's representative receives and understands information about a treatment or medication including its risks, benefits) for Trazadone administration for one of three sampled residents. This failure had the potential to result in lack of identification of adverse effects and the potential to violate the resident's right to be informed or refuse care.Findings: During a review of Resident 1's admission record, the admission record indicated Resident 1 was initially…

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 update a care plan for a new wandering behavior for one of three sampled residents, when Resident 2 was found with new wandering behaviors. This failure resulted in Resident 2's wandering behaviors not being addressed and a physical altercation between Resident 1 and Resident 2. Findings: During a review of Resident 2's admission record, the admission record indicated Resident 2 was initially admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior)- bipolar (sometimes called manic-depressive disorder- mood swings that range from the lows of depression to elevated periods of emotional highs) type, and depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities). During a review of Resident 2's History and Physical (H&P), dated 7/21/2025, the H&P indicated Resident 2 did not have the capacity to understand 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 to ensure one of two sampled employees, Licensed Vocational Nurse (LVN) 1, was competent in medication administration upon hire. This failure resulted in Resident 1 not receiving trazadone for three days on 8/23/2025, 8/24/2025 and 8/25/2025.Findings: During a review of Resident 1's admission record, the admission record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including urinary tract infection (UTI- an infection in the bladder/urinary tract), Heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and major depressive disorder (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities). The admission record indicated Resident 1's brother was the responsible party (RP-decision maker). During a review of Resident 1'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 interview and record review, facility failed to provide medical records upon request for one of three sampled residents (Resident 1) when Resident 1's responsible party (RP1) requested Resident 1's records on 10/11/2024.During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease ([COPD] a chronic lung disease causing difficulty in breathing), chronic diastolic heart failure ( heart disorder that causes the heart to not pump blood effectively) and ischemic heart disease (condition where the blood vessels that supply the heart muscle become narrowed or blocked). During a review of Resident 1's History and Physical (H&P) dated 4/13/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 8/29/2024, the MDS indicated Resident 1'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 interview and record review, the facility failed to ensure a physician visited one of four sampled residents (Resident 1) at least once every 60 days. This deficient practice had the potential to result in an undetected decline in medical, health or psychosocial condition and can lead to a delay in necessary care, treatment and services. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] with a diagnosis including Type 2 diabetes (disorder characterized by difficulty in blood sugar control and poor wound healing) , dementia (a progressive state of decline in mental abilities), anemia (a condition where the body does not have enough healthy red blood cells), and peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs). During a review of Resident 1's Minimum Data Set (MDS), a resident assessment tool, dated 2/20/2025, the MDS indicated Resident 1's 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 interview, and record review, the facility failed to protect one of three sampled residents (Resident 2) who is legally blind verbally abuse repeatedly by Resident 1. This deficient practice resulted in Resident 2 feel unsafe and uncomfortable. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (disruptive blood flow to the brain), and paranoid personality disorder (a mental condition in which a person has a long-term pattern of distrust and suspicion of others). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 3/11/2025, the MDS indicated Resident 1's cognition (ability to think, understand, learn, and remember) was intact and required moderate assistance with toileting, dressing, and personal hygiene. During a review of Resident 1's care plan initiated 9/26/2024, the care plan focus was physical abuse, with goals including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and preparation practices when: 1.There was no trash receptacle (trash can) next to the handwashing sink area in the kitchen. 2. One Dietary Aide (DA1) working in the dish machine area did not wash hands and change gloves when removing the clean and sanitized dishes from the dish machine. 3. Several food items were stored in the refrigerator with dates exceeding storage periods for the ready to eat food. There were 25 previously prepared vanilla flavored pudding and 25 previously prepare chocolate flavored pudding stored in small single serve plastic cups with date of 2/21/2025 exceeding storage period for pudding were stored in the reach in refrigerator. There were 20 single serve cartons of Nutritional Supplements that were voluntarily recalled by manufacturer for potential contamination with listeria (Listeria infection is a foodborne bacterial illness that can be very serious for pregnant women,…

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: 1. Ensure Resident 54's Humalog [NAME] KwikPen ([generic name - insulin lispro] a medication used to treat high blood sugar) in medication cart was labeled with an 'open date' to ensure medication was not expired prior to medication administration, affecting one of ten reviewed residents. 2. Ensure medications requiring refrigeration were stored in accordance with manufacturer specifications and per facility's policy and procedure (P&P) titled, Storage of Medications, dated 08/2019 at temperature range of 36 degrees Fahrenheit [(°F) is a unit of temperature] to 46°F or 2° Celsius [(°C) is a unit of temperature] to 8°C, affecting two of two facility's medication room refrigerators (Station 1 Medication Room Refrigerator and Station 2 Medication Room Refrigerator). These failures had the potential to result in Residents 54 and other residents receiving medications that had become expired, ineffective, or toxic due to improper storage and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review the facility failed to ensure one of 16 reviewed residents (Resident 29) personal items were returned to Resident 29 after being laundered. This failure resulted in Resident 29's blankets being lost, missing, and received a blanket that did not belong to him. Findings: During a review of Resident 29's, admission Record, the admission Record indicated Resident 29 was admitted to the facility on [DATE] with diagnoses including hypertension (HTN-high blood pressure), bladder cancer (a type of cancer that starts in the cells lining of the bladder), Alzheimer's (a disease characterized by a progressive decline in mental abilities) dementia (a progressive state of decline in mental abilities), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dysphagia (difficulty swallowing), and need for assistance with personal care. During a review of Resident 29'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, facility failed to ensure call light was within reach for one of five reviewed residents (Resident 139). This failure had the potential to put Resident 319's safety at risk and not meet his personal needs. Findings: During a review of Resident 319's admission Record, the admission Record indicated, Resident 319 was admitted to the facility on [DATE] with diagnoses including multiple myeloma (blood cancer), difficulty walking, muscle weakness, dementia (a progressive state of decline in mental abilities). During a review of Resident 319's History & Physical (H&P) dated 11/27/24, the H&P indicated, Resident 319 does not have the capacity to understand and make decision. During a review of Resident 319's Minimum Data Set (MDS- a resident assessment tool) dated 12/3/24, the MDS indicated Resident 319's cognition (ability to think, understand, learn, and remember) is severely impaired. The MDS indicated that Resident 319 needs substantial/maximal assist (helper does…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and/or implement an individualized person-centered plan of care with measurable objectives, timeframe, and interventions to meet the resident's needs for one of four reviewed residents (Resident 38). This failure had the potential to negatively affect the delivery of necessary care and services to Resident 38. Findings: During a review of Resident 38's admission Record, the admission Record indicated, Resident 38 was admitted to the facility on [DATE] with the diagnoses including ovarian cancer (a growth of cells that forms in the ovaries [female organ that produce eggs]), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) hypertension (HTN-high blood pressure). During a review of Resident 38's Minimum Data Set (MDS - a resident assessment tool) dated 2/04/2025, the MDS indicated Resident 38's cognition (ability to think, understand, learn, and remember) was intact.…

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 in accordance with professional standards of practice for one of five reviewed residents (Resident 22) investigated for use of unnecessary psychotropic (any medication capable of affecting the mind, emotions, and behavior) drug, by failing to ensure a medical diagnosis or indication was documented to support administration of Seroquel (generic name - quetiapine, a medication used to treat schizophrenia [a mental illness that is characterized by disturbances in thought]. This failure had the potential to place Resident 22 at risk for significant adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have) from the use of unnecessary psychotropic drug, which could result to impairment or decline in the resident's mental, physical condition, functional, and psychosocial status. Findings: During a review of Resident 22's admission Record, the admission Record indicated Resident 22 was admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure denture care was done for one of 16 reviewed residents (Resident 29). This failure resulted in Resident 29's dentures not being cleaned and stored properly in a denture container. Findings: During a review of Resident 29's, admission Record, the admission Record indicated Resident 29 was admitted to the facility on [DATE] with diagnoses including hypertension (HTN-high blood pressure), bladder cancer (a type of cancer that starts in the cells lining of the bladder), Alzheimer's (a disease characterized by a progressive decline in mental abilities) dementia (a progressive state of decline in mental abilities), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dysphagia (difficulty swallowing), and need for assistance with personal care. During a review of Resident 29's Care Plan, titled Oral/Dental Care, dated 3/8/2023, the Care Plan indicated goal of adequate oral/dental…

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 reviewed residents (Residents 20 and 319) intravenous catheter (IV - a flexible tube that is inserted into vein to deliver fluids or medications) was maintained in accordance with professional standard of practice. The facility failed to: a.Ensure Resident 20's IV catheter was removed in a timely manner after Resident 20's IV therapy was completed. b.Ensure Resident 318/'s IV site was changed Rotated when Resident 318's IV site was not changed for 14 days. This failure had the potential to cause an infection at the insertion site. Findings: During a review of Resident 20's admission Record, the admission Record indicated, Resident 20 was admitted on [DATE] and readmitted on [DATE] with the diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), takotsubo syndrome (causes chest pain, shortness of breath, symptoms mimic a heart attack), sepsis (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 ensure the Licensed Vocational Nurse (LVN) 4 was trained and had knowledge of conducting a blood pressure (BP) check for one of ten reviewed residents (Resident 368) prior to determining whether hydralazine (a medication used to treat hypertension [high blood pressure]) should be administered per parameters ordered by physician. This failure had the potential for medication errors, hypertension, hypotension (low blood pressure) and hospitalization for Resident 368. Findings: During a review of Resident 368's admission Record, dated 2/27/2025, the admission Record indicated, Resident 368 was admitted to the facility on [DATE] with diagnoses including but not limited to, essential (primary) hypertension, end stage renal disease (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 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 administer medications in accordance with physician order and manufacturer specifications for two of ten reviewed residents (Residents 37 and 367) by failing to: a. Ensure Resident 37's Aspirin (a medication used to prevent heart attack [flow of blood and oxygen is blocked] and stroke [loss of blood flow to a part of the brain]) chewable tablet was administered as chewable during medication administration. b. Clarify order with physician and administer Resident 367's Vitamin D3 (also referred as cholecalciferol - a vitamin used to treat low level of vitamin D) within 60 minutes of its prescribed time as per facility's policy and procedure (P&P) titled, Medication Administration - General Guidelines, dated 11/2021. These failures of not administering medications to Residents 37 and 367 in accordance with physician orders or professional standards of practice had the potential to result in vitamin deficiency, stroke (damage to the brain…

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 and consultant pharmacist (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) failed to identify irregularities during medication regimen review ( MRR a comprehensive evaluation of a patient's current medication list to identify potential drug interactions, adverse effects, and other medication-related issues) related to administration of Seroquel (generic name - quetiapine, a medication used to treat schizophrenia [a mental illness that is characterized by disturbances in thought] without a medical diagnosis or indication, affecting one of five reviewed residents for unnecessary medications (Resident 22). This failure of failing to identify and report irregularities resulted in Resident 22 receiving quetiapine unnecessarily without an indication possibly resulting in medication side effects (a secondary, typically undesirable effect of a drug or medical treatment) and leading to a decrease in…

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 five reviewed residents (Resident 22), for unnecessary medication care area, was free from the use of unnecessary psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) by failing to ensure there was a medical diagnosis and/or indication to support the administration of Seroquel (generic name - quetiapine, a medication used to treat schizophrenia [a mental illness that is characterized by disturbances in thought]. This failure had the potential to place Resident 22 at risk for significant adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have) from the use of unnecessary psychotropic drug, which could result to impairment or decline in the resident's mental, physical condition, functional, and psychosocial status. Findings: During a review of Resident 22's admission Record, the admission Record indicated Resident 22 was admitted to the facility on [DATE] with diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5 percent (%) during medication pass for three of ten reviewed residents (Residents 54, 37 and 367) by failing to: a. Ensure Resident 54's Humalog [NAME] KwikPen ([generic name - insulin lispro] a medication used to treat high blood sugar) in medication cart was labeled with an 'open date' to ensure medication was not expired prior to medication administration. b. Ensure Resident 37's Aspirin (a medication used to prevent heart attack [flow of blood and oxygen is blocked] and stroke [loss of blood flow to a part of the brain]) chewable tablet was administered as a chewable during medication administration. c. Clarify order with physician and administer Resident 367's Vitamin D3 (also referred as cholecalciferol - a vitamin used to treat low level of vitamin D) within 60 minutes of its prescribed time as per facility's policy and procedure (P&P) titled, Medication Administration - General…

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 kitchen staff were routinely trained and evaluated for competency related to their duties when: 1.Dietary Aide (DA 1) did not know the proper sanitizer test strip to use for the dish machine sanitizer and the concentration strength of the chlorine sanitizer used in the dish machine (chlorine sanitizer a product that is used to reduce or eliminate pathogenic agents on surfaces). This failure had the potential to result in unsafe and unsanitary food production that could place 60 out of 62 residents in the facility who received food at risk for food borne illness (illness cause by food contaminated with bacteria, viruses, parasites, or toxins ) Findings: During an observation on 2/25/2025 at 10:15 a.m., in the dishwashing area, DA1 was requested to check the dish machine sanitizer concentration (chlorine sanitizer). DA1 attempted to pick up the QUAT sanitizer test strips (QUAT another type of sanitizer) to test the sanitizer concentration in the dish machine. [NAME] 2 stopped DA1 and asked to look 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to observe infection control measures by not ensuring staff perform hand hygiene for one of one reviewed resident (Resident 33). This failure had the potential to result in cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another) and place the residents at risk for the spread of infection. Findings: During a review of Resident 33's admission Record dated 2/28/25 the admission Record indicated, Resident 33 was admitted on [DATE] with the diagnoses including osteomyelitis (bone infection) left ankle and foot, type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), partial traumatic amputation (surgically cutting off limb) of left foot. During a review of Resident 33's Minimum Data Set (MDS - a resident assessment tool) dated 2/11/25, the MDS indicated Resident 33's cognition (ability to think, understand, learn, 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 to ensure a Surveillance Data Collection form was completed for one of 16 reviewed residents (Resident 39) who received Keflex (antibiotic used to treat infections caused by bacteria) 500 milligrams (mg-unit of measurement) by mouth twice a day from 1/23/2025 to 1/30/2025 to treat a urinary tract infection (UTI- an infection in the bladder/urinary tract). This failure had the potential to put Resident 39 at risk for antibiotic resistance (when bacteria change to resist antibiotics used to effectively treat them) and inappropriate use of antibiotic. Findings: During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including urinary tract infections, diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), bronchitis (inflammation of the bronchial tubes, the airways that carry air…

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 interview and record review, the facility failed to ensure that staff were being in serviced (staff education) for dementia (a progressive state of decline in mental abilities) care. This failure had the potential to jeopardize the safety of residents when staff are not adequately trained. Findings: During an interview on 2/27/2025 at 12:21 p.m., with Certified Nurse Assistant (CNA) 1, CNA 1 stated that she had not received dementia training. CNA 1 stated that she does provide care for residents with dementia in the facility. CNA 1 stated staff should receive dementia training because residents with dementia require special care. CNA 1 stated residents with dementia need to be approached and communicated differently. CNA 1 stated residents with dementia could become agitated easily if they are not approach appropriately. CNA 1 stated that residents with dementia could become combative and injure the other residents and staff if not approached appropriately. During an interview on 2/27/2025 at 12:33 p.m., with CNA 2 stated that she provides care for residents with dementia. CNA…

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 that one of one resident (Resident 1) has been noncompliant with taking Risperidone (medication is used to treat certain mental/mood disorders) 0.25 milligrams every 8 hours as ordered. This deficient practice had the potential to result in the delay of care for Resident 1 who may need alternative treatment measures prescribed by the physician due to noncompliance of taking the Risperidone. Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis including malignant neoplasm (abnormal growth of tissue or cancerous tumor) of the right breast, schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and bipolar disorder (a mental illness 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 interview and record review the facility failed to develop care plan for one of one resident ' s (Resident 1) noncompliance with care. This deficient practice had the potential to result in the delay of care for Resident 1 who may need alternative interventions and measures. Findings: During a review of Resident 1 ' s admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis including malignant neoplasm (abnormal growth of tissue or cancerous tumor) of the right breast, schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care…

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 quality care in accordance with professional standards of practice when the facility failed to ensure one of one resident ' s (Resident 5) lower extremities edema (fluid retention in the body) was assessed after it was identified on 6/21/2024. This deficient practice had the potential to result in unidentified complications with worsening edema and result in poor resident health outcomes. Findings: During a record review of Resident 5 ' s admission Record, the admission record indicated Resident 5 was admitted to the facility on [DATE] with diagnosis including type 2 diabetes (long-term condition in which the body has trouble controlling blood sugar and using it for energy), contusion (bruise) of lower back, hypertension (condition in which the force of the blood against the artery walls is too high), difficulty walking, muscle weakness, and atherosclerosis (buildup of fats, cholesterol and other substances in and on the artery walls) of aorta…

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 one resident ' s (Resident 5) echocardiogram (imaging test that checks the structure and function of the heart) was completed as ordered on 6/22/2024. This deficient practice resulted in a delay of care that had the potential to result in a continued undiagnosed heart problem for Resident 1. Findings: During a review of Resident 5 ' s admission Record, the admission record indicated Resident 5 was admitted to the facility on [DATE] with diagnosis including type 2 diabetes (long-term condition in which the body has trouble controlling blood sugar and using it for energy), hypertension (condition in which the force of the blood against the artery walls is too high), difficulty walking, and atherosclerosis (buildup of fats, cholesterol and other substances in and on the artery walls) of aorta (main blood vessel of the body). During a review of Resident 5 ' s Minimum Data Set ([MDS] a standardized assessment and care screening 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 interview and record review, the facility failed to ensure documentation was completed and correct when the hand sink in the bathroom for one of three sampled residents (Resident 1) fell off the wall causing Resident 1 to fall to the floor, breaking her hip and causing her to sustain a bump to her left eye and the left side of the back of her head. This deficient practice resulted in confusion regarding the timeline of events related to Resident 1's fall, and the inability to determine what Resident 1's actual assessment was after her fall including the subsequent discovery of Resident 1's injuries. This deficient practice had the potential for a delay in evaluation and treatment and non-continuity of care. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including cerebral infarction [stroke] occurs when blood flow is disrupted to the brain) affecting Resident 1's left side, dementia…

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 timely and accurate resident medical records for five of 15 sampled residents (Resident 47, 3,15,19 and 38) when: a. Resident 47's January and February 2024 Restorative Nursing Aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) Documentation Survey Report (record of nursing assistant tasks) was not accurately documented indicating Resident 47 received RNA for ambulation (walking) and ambulated when Resident 47 did not receive RNA treatment for ambulation and/or did not walk. b. Resident 47's quarterly (every three months) Joint Mobility Assessment ([JMA] assessment of joints to monitor joint range of motion {ROM, full movement potential of a joint}) dated 1/10/24 was completed on 2/14/24 (about one month later). c. Resident 3's quarterly Joint Mobility assessment dated [DATE] was completed on 11/7/23 (about one month later) and quarterly Joint Mobility assessment dated [DATE] 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 two of 15 sampled residents (Resident 41and Resident 256) baseline care plans were developed and implemented. a. The facility failed to address Speech Therapy in the Care Plan for Resident 41 who was receiving Speech Therapy daily three times a week for four weeks due to dysphagia (difficulty swallowing). b. The facility failed to address mood and behavior concerns in the Care Plan for Resident 256 who was diagnosed with anxiety (intense, excessive, and persistent worry and fear about everyday situations) and depression (mental state of low mood and aversion (a strong dislike) to activity) and taking medications for anxiety. These failures had the potential to result in a delay of Resident 41 and Resident 256 not receiving the necessary care and services. Findings: a. During a review of Resident 41's admission Record (Face Sheet), the Face Sheet indicated, Resident 41 was admitted to the facility on [DATE] with diagnoses of but not limited to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure two of 15 sampled residents (Resident 41 and Resident 256) Comprehensive Care Plan was developed to address speech therapy, mood, and behavior concerns. a. the facility failed to address speech therapy in the Care Plan for Resident 41 who was receiving Speech Therapy daily three times a week for four weeks due to dysphagia (difficulty swallowing). b. the facility failed to address mood and behavior concerns in the Care Plan for Resident 256 who was diagnosed with anxiety and depression and taking medications for anxiety. These failures had the potential to result in a delay of Resident 41 and Resident 256 not receiving the necessary care and services. Findings: a. During a review of Resident 41's admission Record (Face Sheet), the Face Sheet indicated, Resident 41 was admitted to the facility on [DATE] with diagnoses of but not limited to gastro-esophageal reflux disease, muscle weakness, dementia, and chronic constipation. 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 interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship for two of two sampled residents (Resident 46 and 47) by failing to: a.Resident 46 was prescribed antibiotic drug without meeting the criteria, before being screen for urinary tract infection ([UTI]an infection in any part of the urinary system). b.Resident 47 was prescribed antibiotic drug without meeting the criteria, before being screen for upper respiratory tract infection. These failures had the potential for resident to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use. Findings: a. During a record review of Resident 46's admission Order (Face Sheet) indicated Resident 46 was admitted on [DATE] with diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), type 2 diabetes mellitus (high blood sugar), severe chronic kidney…

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 notify the resident's physician (MD 1) for one of 15 sampled residents (Resident 47) for a change in condition (COC) for significant decline in physical functioning and inability to ambulate (walk) with Restorative Nursing Aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) over a 4-week period by failing to: a. Assess, address and report to MD Resident 47's inability to ambulate during RNA treatment and decline in physical function from walking 85 feet with moderate assistance (about 25-50 percent [%] physical assistance) with a platform walker (PFW, a type of walking assistive device with forearm supports to provide extra support during walking) to ambulating zero feet from week of 1/18/24 to 2/12/24. b. Implement the facility's policy and procedures (P&P) titled, Change in a Resident's Condition or Status, for facility staff to notify the resident's attending physician when there was a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of 15 sampled residents (Resident 41) Minimum Data Set (MDS - a comprehensive assessment and screening tool) was documented accurately to reflect Resident 41's current health condition of dysphagia (difficulty swallowing) and Speech Therapy (assesses and treats speech and language problems including swallowing disorders) daily three times a week for four weeks due to dysphagia. This failure had the potential to result in a delay of Resident 41 not receiving the necessary care and services. Findings: During a review of Resident 41's admission Record Face Sheet, the Face Sheet indicated, Resident 41 was admitted to the facility on [DATE] with diagnoses of but not limited to gastro-esophageal reflux disease (when stomach content repeatedly and regular flows up into the tube connecting the mouth and stomach (esophagus) resulting in symptoms or complications like dysphagia), muscle weakness, dementia (a general term for loss of memory, language,…

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 15 sampled residents (Resident 45) assessment entries on the Minimum Data Set (MDS- an assessment and care screening tool) related to the section in the MDS called Active Diagnoses was accurately documented to reflect Resident 45's diagnosis of schizophrenia (a mental disorder characterized by recurring episodes of psychosis that are corelated to a misconception of reality). This failure had the potential to result in a negative effect of Resident 45's plan of care and delivery of necessary care and services. Findings: During a review of Resident 45's Face Sheet, the Face Sheet indicated, Resident 45 was admitted to the facility on [DATE] with diagnoses of but not limited to schizophrenia, dementia(a general term for loss of memory, language, problem-solving and thinking abilities that are severe enough to interfere with daily life), depression (mental state of low mood and aversion (a strong dislike) to activity), and anxiety (intense,…

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 reviewed and revised care plans to reflect the changes in the Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) services for one of 15 sampled residents (Resident 15). This deficient practice had the potential to inaccurate provision of services for Resident 15. Findings: During a review of Resident 15's admission Record indicated Resident 15 admitted to the facility on [DATE] with diagnoses including but not limited to, contracture (loss of motion of a joint) right knee, contracture left knee, and type 2 diabetes mellitus (condition in which the body does not metabolize (process) blood sugar correctly). During a review of Resident 15's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 12/3/23 indicated Resident 15 had severe cognitive (ability to learn, remember, understand, and make decision) impairment and required…

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 place the nasal cannula (a device that gives you additional oxygen (supplemental oxygen or oxygen therapy) through the nose to deliver oxygen for one of one sampled resident (Resident 10). This failure had the potential for Resident 10 to not receive necessary respiratory care and services needed. Findings: During a review of Resident 10's admission Order, the admission Order indicated Resident 10 was initially admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses including type 2 diabetes mellitus (high blood sugar), essential hypertension (high blood pressure), functional quadriplegia (a form of paralysis that affects all four limbs, plus the torso), acute and chronic respiratory failure with hypoxia (happens when you don't have enough oxygen in your blood). During a review of Resident 10's Minimum Data Sheet (MDS- a comprehensive assessment and care screening tool) dated 2/03/24 indicated Resident 10 had no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a documented justification for the continuation of an as needed (PRN) psychotropic medication (Ativan - an anti-anxiety medication) and clonazepam (anti-anxiety medication) beyond 14 days for one 1 out of the 15 sampled residents (Resident 45). This failure had the potential to result in Resident 45 receiving unnecessary medications and can lead to adverse side effects. Findings: During a review of Resident 45's admission Record Face Sheet, the Face Sheet indicated, Resident 45 was admitted to the facility on [DATE] with diagnoses of but not limited to anxiety (intense, excessive and persistent worry and fear about everyday situations schizophrenia(a mental disorder characterized by recurring episodes of psychosis that are corelated to a misconception of reality), dementia (a general term for loss of memory, language, problem-solving and thinking abilities that are severe enough to interfere with daily life), depression(mental state of low mood…

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: a.Label canned foods, vegetables spring rolls, ice creams, eggs, juices, meat products, and vegetables with no dates received. b.Ensure Freeze 1 was in good working condition. c.Ensure Dietary Aid 1 (DA1) change gloves and wash his hands in between touching dirty surfaces in the kitchen and Dietary Supervisor (DS) wears a glove while carrying an open lid ice cream. These failures had the potential to not identify when food was received, and when it would expire, which could affect resident's health when serve to the residents in the facility and had the potential to cause food-borne illnesses. Findings: a.During a facility kitchen tour observation on 2/13/2024 at 8:49 a.m., observed inside the kitchen freezer some broccoli, corn, carrots, brussels sprouts, vegetables spring rolls, eggs, milk, thick and easy, grape juice, tortillas, cranberry blend, tea bags, tomato catsup, Splenda, pizza sauce, mini marshmallows, multiple 6 pounds canned…

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 laundry aide (LA) perform hand hygiene (hand washing using soap and water, and cleaning hands with waterless or alcohol-based hand sanitizers) after removing dirty gloves and proceeded to handling clean linens. This failure had the potential to cause contamination of clean linens and place residents of the facility at risk for infection. Findings: During an observation on 2/15/2024 at 2:38 p.m. in the facility's laundry room, the LA loaded dirty linens into the washing machine, removed his gloves and gown, put on clean gloves and gown, and went to unload clean laundry without performing hand hygiene. During an interview on 2/15/2024 at 2:50 p.m., the LA stated hand hygiene should have been performed in between handling dirty to clean laundry and when removing dirty gown and gloves. LA stated failure to perform hand hygiene may result in infections among the facility residents. During a record review of the facility's policy and procedure ( P&P) revised 12/2007, titled Handwashing/Hand Hygiene,…

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 three sampled residents were assisted with their ADLS ([activities of daily living] activities related to personal care) when a. Resident 2 ' s urinal (a receptable used by men to urinate) was not emptied and it was left at the resident's bedside; and b. Resident 3 call light was not answered in a timely manner. These deficient practices resulted in Resident 2 feeling uncomfortable and undignified as he had to endure the smell of an old urine in his room; and it placed Resident 3 at higher risk for moisture associated skin dermatitis (skin damage that occurs when the skin is repeatedly exposed to various bodily wastes and fluids, also known as MASD). Findings: a. During a review of Resident 2 ' s admission Record (face sheet), the face sheet indicated Resident was admitted to the facility on [DATE] with a diagnosis that included liver (organ that removes toxins from the body ' s blood supply and performs hundreds of 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 interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) were provided incontinence (loss of control of bladder and bowel control)care to prevent the development of skin breakdown. These deficient practices placed Resident 3 at high risk for moisture associated skin dermatitis (skin damage that occurs when the skin is repeatedly exposed to various bodily wastes and fluids, also known as MASD). Findings: During a review of Resident 3 ' s face sheet, the face sheet indicated Resident 3 was admitted to the facility on [DATE] with a diagnosis that included diabetes mellitus (a condition where the blood sugar level was elevated), neuropathy (a condition of nerve damage leading to pain, weakness and feelings of numbness/tingling in one or more parts of the body), hypertension (a condition when the blood pressure[force it takes for heart to pump blood in the body] was abnormally high), muscle weakness and abnormalities in gait and mobility. 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.

Based on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident 3) was assisted to ambulate (walk) during the Restorative Nursing Assistant (RNA) Therapy Program five times a week, as ordered by the physician. This deficient practice has resulted to Resident 3 to feel worried about her health progress and recovery and had the potential to negatively affect her joint function and integrity. Findings: During a review of Resident 3 ' s admission Record (face sheet), the face sheet indicated Resident 3 was admitted at the facility on 4/28/2022 with a diagnosis that included diabetes mellitus (a condition where the blood sugar level is elevated), neuropathy (a condition of nerve damage leading to pain, weakness and feelings of numbness/tingling in one or more parts of the body), hypertension (a condition when the blood pressure is abnormally high), muscle weakness and abnormalities in gait and mobility. During a review of Resident 3 ' s Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 8/5/2023, 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.