Cornerstone Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to meet the required timelines for encoding and transmission of Minimum Data Set (MDS-evaluation of cognition, care needs and functional abilities) assessments for two of five sampled residents (Resident 44 and Resident 68) when the Minimum Data Set Nurse (MDSN) did not complete or transmit discharge MDS assessment for Resident 44 and Resident 68. This deficient practice resulted in the potential of resident's needs upon discharge going unmet. Findings: During a review of Resident 44's admission Record, (AR-a document with personal identifiable and medical information), dated 5/1/25, the AR indicated, Resident 44 was admitted to the facility on [DATE] with diagnoses which included asthma (difficulty breathing) hypertension (high blood pressure) and pain. During a review of Resident 68's admission Record, dated 5/1/25, the AR indicated Resident 68 was admitted to the facility on [DATE] with diagnoses which included muscle weakness, chronic obstructive…

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 Minimum Data Set Assessment (MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for one of five sampled residents (Resident 57) when Resident 57's pressure ulcer (localized injury to the skin and underlying tissue caused by prolonged pressure) was inaccurately coded on the MDS assessment. This failure had the potential to result in Resident 57's care needs not being met and the potential for pressure ulcer to worsen Findings: During a concurrent observation and interview on 4/27/25 at 12:26 p.m. with Resident 57 in his room, Resident 57 was sitting up in bed eating lunch. Resident 57 observed with low air loss mattress (mattress designed to prevent and treat pressure ulcers) and denied any complaints or pain. During a review of Resident 57's admission Record, (AR- a document with personal identifiable and medical information), dated 4/30/25, the AR…

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 accepted professional standards of quality of care for one of three sampled residents (Resident 147) when Licensed Vocational Nurse (LVN) 5 signed Resident 147's electronic Treatment Administration Record (eTAR-digital version of treatment administered to a resident) indicating Resident 147 was wearing compression stockings on 4/29/25. This failure had the potential for Resident 147 to not receive prescribed care which could result in more serious health conditions. Findings: During a concurrent observation and interview on 4/29/25 at 1:10p.m. in B wing hallway outside of Resident 147's room, Resident 147 was observed sitting up in wheelchair. Resident 147 was observed wearing non-skid socks and stated he did not remember wearing compression stockings since he was admitted in the facility. During a review of Resident 147's admission Record, (AR-a document with personal identifiable and medical…

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 each resident's drug regimen was free from unnecessary drugs for three of seven sampled residents (Resident 30, Resident 70 and Resident 294) when: 1. Residents 30 and 294 did not receive appropriate monitoring for Vitamin D (a nutrient that the body needs for absorption of calcium). This failure had the potential risk for Resident 30 and Resident 294 to result in toxicity or ineffective dosing from a continued and unmonitored Vitamin D administration. 2. Resident 294 was administered Torsemide (a medication used to help treat fluid retention and swelling) and did not have a diagnosis for fluid retention or swelling, and was administered Sevelamer Carbonate (a medication used to control high blood phosphate levels). Resident 294's record review indicated an active order for Sevelamer Hydrochloride (a medication used to control high blood phosphate levels) for hypocalcemia (low calcium blood levels) and did not have a diagnosis for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide food in accordance to resident preferences for one of six sampled resident (Resident 295) when Resident 295's preference to receive beverages other than milk was not followed. This failure caused resident 295 to be upset regarding the meal he had been provided and had the potential to cause Resident 295 to not receive the full nutritional benefit of his meal. Findings: During a review of Resident 295's, admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 5/1/25, the AR indicated Resident 295 was admitted to the facility on [DATE] with the following diagnoses: diabetes mellitus (A disease which results in too much sugar in the blood) and kidney failure (when the kidneys have been damaged over time resulting in decreased function). During a review of Resident 295's Minimum Data Set (MDS- resident assessment tool which indicates…

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 comfortable and homelike environment for two of 16 sampled residents (Residents 15 and 78), when: 1.The wall in Resident 78's bedroom had deep scratches, exposing white chalky building material, and missing paint. This failure resulted in Resident 78 feeling unimportant, and not listened to. 2.The wall in Resident 15's bathroom had an approximate one inch (unit of measure), by one inch hole in the wall. This failure had the potential to affect Resident 15's mental state as well as creating a portal for pests to enter the bathroom. Findings: 1.During a concurrent observation and interview on 4/27/25 at 10:26 a.m. with Resident 78 in her room, the wall in her room near her bed had several areas of deep scratches with missing paint and areas of exposed white chalky building material. Resident 78 stated, . if I had more money the nursing home would have fixed the wall . I cannot afford to get a better room . During a review of Resident 78's, Record of Admission (RA), dated 5/1/25, the RA indicated…

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

Based on interview and record review, the facility failed to ensure their policy that only English is spoken in resident care areas when three out of six sampled residents (Resident 1, Resident 6, and Resident 7) stated they heard staff speak language(s) other than English to each other while in resident care areas. This failure had the potential to negatively impact the rights and dignity of the three affected residents by causing confusion and the residents being uninformed of their total health status, including their medical condition, in a language they can understand. Findings: During an interview on 1/22/25, at 1:55 p.m., with Resident 6, Resident 6 stated staff Will talk in their own native tongue [non-English] right in front of you to each other, when they are in my room. It's confusing to me. I don't know what's going on when I can't understand them. During an interview on 1/22/25, at 2:20 p.m., with Resident 7, Resident 7 stated staff speak non-English languages While in my room some of the time. During an interview on 1/22/25, at 2:55 p.m., with Resident 1, Resident 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.

Based on observation, record review, and interview, the facility failed to ensure the facility was free of accident hazards when: 1. One door at the end of C-Wing hallway (door number one) exiting directly to the exterior of the facility had a working alarm, 2. Sliding door number two that led to an outdoor patio courtyard contained an unlocked gate which opened to the exterior of the facility and did not have a working alarm, and there was no system in place to monitor nine more sliding doors (door number three through 11) that led to the same outdoor patio. These failures had the potential for residents to exit the building via multiple (11) exits without staff knowledge and/or supervision, causing potential harm and injury to those residents. Findings: 1. During a concurrent observation and interview on 1/3/25, at 11:26 a.m., with the Director of Maintenance (DM), the C-Wing exit door was observed. The doorframe had an electronic keypad attached to it. The C-Wing door did not alarm when pushed open, and opened immediately to the outdoors, a small concrete sidewalk, and then 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.

Based on observation, record review, and interview, the facility failed to ensure two electrical outlets were not overloaded when outlet adapters were used to increase the number of items that could be plugged into them, and when an extension cord was noted plugged into a power strip adapter. These failures violated the facility's policy on Electrical Safety and had the potential to compromise the facility's safety by overloading outlets, potentially causing electrical circuit overload and/or fire. Findings: During a concurrent observation and interview on 1/3/25, at 11:37 a.m., with the Director of Maintenance (DM), the reception desk at the front lobby was observed. At the reception desk, a six-outlet adapter (electrical outlet extender) was plugged into a two-outlet receptacle. Three electrical cords were noted plugged into the adapter. The DM stated the six-outlet adapter should be in use. At the rear of the reception area, an orange extension cord was noted plugged into a power strip adapter, providing a nearby Christmas tree with electricity. The DM stated the extension cord…

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 three shower rooms were clean when the D-Wing Shower room was noted to be unclean. This failure had the potential for residents needing a shower to do so in an area not clean and sanitary. Findings: During a concurrent observation and interview on 1/3/25, at 2:30 p.m., with Certified Nursing Assistant (CNA) 1, the D-Wing shower room was observed. CNA 1 stated she had used this room today to shower a resident. The D-Wing shower room was noted to have a trail of dark spots on the shower floor, leading out into the D-Wing hallway, in a dripping pattern two feet long. The D-Wing shower room door had several dark spots on the interior side of the door, dripping down the doorway. During a concurrent observation and interview on 1/3/25, at 2:32 p.m., with the Director of Nursing (DON), the D-Wing shower room was observed. The DON stated, This shower room should be clean. During a review of the facility's undated Policy and Procedure (P&P) titled, Policy and Procedure on Housekeeping and Facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow professional standards of practice for 10 of 16 sampled residents (Residents 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16) when: 1. Licensed Vocational Nurse 2 failed to administer medications and fingerstick blood sugar testing as prescribed before meals for Residents 7, 8, 9, 10, 11, 12, 13, 14 and 15 according to physician orders. This failure placed Residents 7, 8, 9, 10, 11, 12, 13,14, and 15 at risk for decreased absorption of the medication, and placed Residents 9, 10, 11, 12, 13, 14, 15 and 16 at risk for inaccurate fingerstick blood sugar (amount of glucose [simple sugar-body ' s primary source of energy from food] in your blood) results which had the potential to affect the sliding scale (amount of insulin [a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication] administered changes based on a person ' s blood sugar results) insulin dosage. 2. Licensed Vocational…

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 post the most recent survey results in a place readily accessible to residents and their representatives when the facility survey binder did contain the survey results for the year 2022. This failure had the potential to violate the rights of residents and their representatives to be informed of previous survey results. Findings: During an observation on 6/6/24 at 8:35 a.m. a binder labeled Survey Binder was located in a holder labeled Survey Findings folder on the wall in between the administrator's office and the nurses station. The binder did not contain recertification survey results for the year 2022, which was the facility's last recertification survey. During a concurrent interview and record review on 6/6/24 at 8:40 a.m. with the Administrator (ADM), the Survey Binder was reviewed. The ADM stated, the binder did not have the results of the previous survey done in 2022. The ADM stated the previous survey results should have been in an easily accessible area like in the nurses station. The ADM 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.

Based on observations, interviews, and record reviews, the facility failed to prepare food in accordance with professional standards for food service safety when the food preparation sink did not have an air gap (a vertical space between the end of a pipe and the top of a nearby sink that prevents the backflow of contaminated water). This failure had the potential for contaminated water to flow back into the sink and result in pathogenic (viruses, bacteria and other types of germs that can cause disease) microorganism (an organism that is so small it can only be viewed under a microscope) growth that could inadvertently (accidentally) be transferred to food and served to 93 residents in the facility, causing foodborne illness. Findings: During a concurrent observation and interview on 6/3/24 at 9:33 a.m. with Registered Dietician (RD) 1 and the Certified Dietary Manager (CDM) in the kitchen, there was no air gap (a physical separation between potentially contaminated water and the source of fresh water) underneath the food preparation sink. RD 1 stated there was not a drain under…

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 a clean and homelike environment was provided for five of 14 sampled residents (Residents 8, 44, 56, 85 and 96) when: 1. The ceiling in Resident 8, 44, and 56's room had a hole with water stains surrounding it and peeling cracked paint. 2. Resident 85's wall mounted light pull string was in dis-repair and Resident 85 was using a plastic bag to control the light. 3. One light bulb on Resident 96's wall mounted light was not working. These failures resulted in an environment that was not homelike for Residents 8, 44, 56, 85 and 96. Findings: 1. During a review of Resident 8's Minimum Data Set (MDS- resident assessment tool which indicated physical and cognitive abilities), dated 5/28/24, the MDS indicated, a Brief Interview for Metal Status (BIMS- an assessment of cognitive function) score of seven (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 8 had severe cognitive impairment. During a review of Resident 44's MDS, dated 5/16/24,…

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 implement a comprehensive care plan for six of 21 sampled residents (Residents 18, 40, 44, 22, 55, and 74) when: 1. Resident 18 did not have a care plan for the use of anticoagulant (medication used to prevent blood clot) medication. This failure placed Resident 18 at a potential risk for bleeding which could lead to serious health condition. 2. Resident 40 did not have a care plan for her non-compliance to use proper footwear when ambulating. This failure placed Resident 40 at a potential risk for accidents like falling which could lead to injury like fracture (bone break). 3. A floor mat was not placed on the floor next to Resident 44's bed as indicated in the care plan. This Failure had the potential to cause Resident 44 to be injured during a fall. 4. There were no care plans developed for Resident 22, 55, and 74's prescribed antibiotics. This failure resulted in the Resident 22, 55, and 74 not having a comprehensive…

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 foot care and make necessary podiatry appointments for three of six sampled residents (Residents 6, 64 and 81) when Residents' 6, 64 and 81 had long and thick toenails. This failure placed Residents 6, 64 and 81 at a potential risk for painful, ingrown toenails and infections which could affect Residents 6, 64 and 81's mobility. Findings: During a concurrent observation and interview on 6/3/24 at 12:40 p.m. in the hallway between the dining room and the nursing station, Resident 6 was observed sitting up in his wheelchair. Resident 61 was wearing slide sandals with open toes with really long toenails, curved downward. Resident 6 stated he did not remember when the foot doctor was in the facility and cut his toenails. Resident 6 stated the toenails did not hurt but it was hard to wear socks because the toenails got caught in the socks. During a review of Resident 6's admission Record, (AR- document containing resident personal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide pharmaceutical services which ensured appropriate administration of medications to meet residents needs and have an adequate system for periodically reconciling controlled drugs (substances that have an accepted medical use and have a potential for abuse and may also lead to physical or psychological dependence), when: 1. The facility's injectable emergency kit (e-kit) did not have insulin medications available for emergency use for residents. 2. Residents 6 and 9's diclofenac (medication used to reduce pain and stiffness) gel 1% (concentration) were administered without the use of dosing stick provided by manufacturer. 3. The Director of Nursing (DON) did not have an adequate system to periodically reconcile controlled drugs and was unable to reconcile Resident 86's control substance log sheet (log sheet used to record dose, date of administration and nurse administering doses). These failures resulted in Residents 6 and 9 being…

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 all medications used in the facility were properly labeled and discarded after the expiration date or discontinued date when: 1. In the C wing IV (intravenous- into the vein) medication cart, three 0.9% Normal Saline (mixture of salt and water used to replenish fluid and electrolytes) 100 ml (milliliter- unit of measure) bags in opened manufacturer overwrap packaging were observed without a use by date labeling. 2. In the D wing medication cart, Resident 76's discontinued nystatin cream (medication used to treat fungal infection) 15 GM (gram- unit of measurement) was observed not separated from medications that were in use for facility residents. 3. In the A wing medication cart, Residents 34 and 72's discontinued ondansetron (medication used for nausea) 4 mg (milligram- unit of measurement) medication cards, Resident 80's hydrocodone/acetaminophen (medication for pain) 5-325 mg (milligram- unit of measurement) and lorazepam 0.5 mg medication cards, and Resident 91's discontinued oxycodone/acetaminophen…

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 establish and maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent infections for 5 of 14 sampled residents (Residents 77, 78, 79, 59, and 95) when: 1. Residents 77, 78 and 79's toilet including toilet seat commode in room [ROOM NUMBER] was soiled and splattered with feces (stool). This failure had the potential to result in cross contamination (bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and transmission of infection between residents. 2. Two bags of dirty linens were found on the floor in a resident room. This failure had the potential to result in cross contamination which could lead to more serious health condition. 3. Licensed Vocational Nurses (LVN) 4 and 5 did not properly disinfect resident shared glucometer (device used to measure blood sugar) for Residents 59 and 95 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 observation, interview, and record review, the facility failed to ensure residents were treated with dignity and respect for one of two sampled residents (Resident 52) when Resident 52's urinary catheter (flexible tube inserted into bladder to drain urine) bag was not covered and was visible to residents and visitors to see. This failure had the potential to violate Resident 52's privacy and dignity. Findings: During a concurrent observation and interview on 6/3/24 at 9:50 a.m. in Resident 52's room, Resident 52 was sitting up in his wheelchair at bedside with a urinary catheter bag hanging underneath the wheelchair uncovered. The urine bag was visible when entering the room and the bag was filled with yellow urine. Resident 54 stated he needed the urinary catheter because he was not able to void (urinate) but could not remember how long he had the urinary catheter. Resident 54 stated he did not know staff had been hanging the catheter bag without a cover for everyone to see. 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 facility failed to ensure the Minimum Data Set assessment (MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status of one of five sampled residents (Resident 64) when Resident 64's anxiety (feeling of fear, dread, and uneasiness) diagnosis was not accurately coded on the MDS assessment. This failure had the potential to result in Resident 64's care needs not met. Findings: During a review of Resident 64's admission Record (document with resident demographic and medical diagnosis information), dated 6/6/24, indicated Resident 64 was admitted in the facility on 10/9/23 with diagnoses which included unspecified psychosis (mental health problem that causes people to perceive or interpret things differently from those around them) and dementia (loss of cognitive functioning-thinking, remembering, and reasoning). During a review of Resident 64's, Physician Order, undated, the Physician Order, indicated, .…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure accurate documentation of a mental health diagnosis for 1 of 28 sampled residents (Resident 75) based on standards of practice when Resident 75's medical record was marked with schizoaffective disorder (a mental health disorder marked by a major mood episode and a break down between thought, emotion, and behavior) as a diagnosis for use of quetiapine (brand name used- an antipsychotic [mind altering] medication used to treat mental disease) and aripiprazole (brand name used, antipsychotic) with no prior history of such diagnosis. This failure resulted in Resident 75 being inappropriately administered aripiprazole and quetiapine, which resulted in adverse events including weight gain. Findings: During an observation on 6/5/24 4:36 p.m., in Resident 75's room, Resident 75 was observed lying on right side in his bed watching television. When asked how he was doing, Resident 75 responded, by pointing to his ears and stating he couldn't…

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 comprehensively assess the root cause of behavioral symptoms, develop and implement measurable goals and interventions to address the individualized care plan for 1 of 28 sampled resident (Resident 75), who was diagnosed with dementia (progressive decline in memory that affects the ability to perform everyday activities and interferes with daily functioning). This failure resulted in Resident 75 not receiving the appropriate treatment and services needed to meet his dementia care needs and achieve his highest level of functioning. Findings: During an observation on 6/5/24 4:36 p.m., in Resident 75's room, Resident 75 was observed lying on right side in his bed watching television. When asked how he was doing, Resident 75 responded, by pointing to his ears and stating he couldn't hear too good in a loud voice. During a review of Resident 75's Hospital Medical Records (HMR) dated, 11/19/22, the HMR indicated, History of Present Illness .…

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 each resident's drug regimen was free from unnecessary drugs for one of seven sampled residents (Resident 56) when Resident 56 did not have the appropriate monitoring for the use of levetiracetam (medication used to treat seizure disorders). This failure had the potential for Resident 56's levetiracetam level to be elevated and for Resident 56 to be administered levetiracetam unnecessarily. Findings: During a review of Resident 56's admission Record (AR), dated 2/7/22, the AR indicated Resident 56 was an [AGE] year old female who was admitted on [DATE] to the facility. During an observation on 6/5/24 at 4:30 p.m., in Resident 56's room, Resident 56 was observed lying in bed with eyes closed. Resident 56 did not respond to her name when verbally called out twice. During a concurrent observation and interview on 6/6/24 at 8:59 a.m. Resident 56 was observed lying in her bed. Certified Nursing Assistant (CNA) 9 was present in room and translated…

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 an effective pest control program for one of three sampled residents (Resident 85), when two cockroaches were found in the Resident 85's bathroom. This failure resulted in an ineffective pest control program with cockroaches found in Resident 85's bathroom. Findings: During a concurrent observation and interview on 6/3/24 at 3:34 p.m. with the Director of Nursing (DON), in Resident 85's bathroom, two, small brown, insects were observed. The DON stated, the insects were cockroaches. During an interview on 6/3/24 at 3:34 p.m. with the Administrator (ADM), in Resident 85's bathroom, the ADM stated, the pest control vendor that came to the facility was (Pest Control Company Name). During an interview on 6/3/24 at 3:34 p.m. with Resident 85, Resident 85 stated, he had seen cockroaches in the bathroom before. Resident 85 stated, I've stomped on them while I was on the [NAME]. During an interview on 6/4/24 at 9:17 a.m. with Housekeeper…

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 rights to formulate an advance directive (legal document that allow one to spell out the decisions about end-of-life care ahead of time) was supported for seven of 19 sampled residents (Residents 6, 13, 44, 54, 61 and 183) when there were no POLST (Physician Orders for Life-Sustaining Treatment) form in the residents' clinical records. This failures placed Residents 6, 13, 44, 54, 61 and 183 at a potential risk for not having their wishes for end of life care upheld. Findings: During a review of Resident 183's clinical record, the admission Record (AR - a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated [DATE], the AR indicated, . admission Date [DATE] . Resident 183 did not have an advanced directive on file. During a review of Resident 44's clinical record, the AR, dated [DATE], the AR indicated, . admission Date [DATE] . Resident 44 did not have an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan for 12 of 24 sampled residents (Residents 185, 183, 184, 182, 5, 44, 54, 58, 29, 4, 20, 60) when: 1. There were no care plans for recreational activities for Residents 185, 183, 184, 182, 5, 44, 54, 58, 29. This failure resulted in Residents 185, 183, 184, 182, 5, 44, 54, 58, 29 not meeting their activity preferences and psychosocial needs. 2. There were no care plans for diagnoses of Anxiety (a mental health illness characterized by a sudden feeling of panic and fear, restlessness, and uneasiness) and Depressions (a persistent feeling of sadness and loss of interest); no non-pharmacological interventions care plan; and no measurable goals or timeline for schizophrenia (chronic and severe mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others) care plan for Resident 4. 3. There was no care plan for Olanzapine (antipsychotic…

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 revise and implement a person-centered comprehensive care plan for three of 10 sampled residents (Resident 14, 20, 45) when activity care plans were not updated to reflect the residents current goals and preferences. This failure had the potential for residents activity needs to go unmet. Findings: During an observation on 2/7/22, at 11:30 a.m., Resident 20 was observed laying in bed with eyes open. Resident 20 was unable to answer questions. During a review of Resident 20's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive [pertaining to reasoning, memory, and judgement] and physical functioning level) assessment dated 12/4/21, indicated, Resident 20's Brief Interview for Mental Status (BIMS-screening tool used in the nursing home to assess cognition) assessment score was four out of 15, (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 20 had severe cognitive deficit. During an interview on 2/8/22,…

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.

Based on interview and record review, the facility failed to provide services which met professional standards of practice for three of 11 sampled residents (Residents 14, 29 and 52) when: 1. Resident 14's (hydrocodone/acetaminophen brand name [medication used to treat pain]) was administered on 12/3/21 for a pain level of 10/10 ( 1-3 mild pain, 4-6 moderate pain, 7-9 severe pain, 10 excruciating pain on a scale of zero to 10) and acetaminophen (medication used to treat pain) was administered on 1/15/22 for a pain level of 10/10 and Licensed Nurses (LN) did not call the MD (medical doctor) to advise per MD's orders and LN's did not reassess pain within an hour after administering pain medication. 2. Resident 29's (hydrocodone/acetaminophen brand name) was administered on 2/1/22, 1/28/22, and 1/30/22 for a pain level of 10/10 and LN did not call the MD to advise per MD's orders and LN's did not reassess pain within an hour after administering pain medication. These failure placed Resident 14 and Resident 28 at a potential risk of their pain not being relieved. 3. Resident 52's pain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to implement its pharmaceutical policies and procedures for two of two controlled substance records reviewed (for Residents 44 and 20) when nursing staff did not ensure accurate controlled substance (medications which can be easily abused and under strict government control) accountability. This failure had the potential for diversion (used illegally) of controlled substance medications. Findings: During a concurrent observation and interview on 2/7/22, at 4:14 p.m., with the Infection Preventionist (IP), inside the medication room, the narcotic binder was reviewed and observed to have CII medication (drugs that require additional care or regulations due to the potential of being intentionally or unintentionally abused) filed together with other control and non-controlled medications. IP stated, the control and non-controlled medication manifest (delivery details) were filed together in a binder. IP stated he did not know where the staff kept 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 irregularities in the drug regimen review and resident chart review were addressed for five of six sampled residents (Residents 4, 20, 21, 52 and 60) when: 1. There were no physician-documented resident clinical justification rationale for not conducting the required Gradual Dose Reduction (GDR- 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) recommendation from the Consultant Pharmacist (CP) for Resident 21 and 52. 2. There was no baseline Abnormal Involuntary Movement Scale (AIMS- a side effect of antipsychotic medication) for Residents 4, 20, 21, 52 and 60 when antipsychotic medications were started. 3. Resident 52 did not have a documented monitoring for A1c (blood sugar measurement). These failures resulted in Residents 4, 20, 21, 52 and 60 being administered psychotropic (drug that affects brain activities associated with mental processes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the facility medication error rate did not exceed five percent or greater when observation of 28 opportunities during the medication pass resulted in six errors. The calculated medication error rate was 19.23 percent. These failures resulted in: 1. Placing Resident 22 at risk for weight gain and increased blood pressure as a result of not taking Furosemide (used to treat in removing extra fluid in the body caused by conditions such as heart failure) and at risk for elevated magnesium blood levels as a result of not taking Magnesium Oxide (used to treat low blood levels of magnesium) at least two hours apart from other medicines. 2. Placing Resident 57 at risk for elevated blood sugar levels as a result of taking an expired Insulin Lispro (used to control high blood sugar) and at risk for elevated potassium blood level and stomach upset as a result of crushing Potassium Chloride Extended Release (used to treat low blood levels 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 safely store, and label drugs and supplies in accordance with acceptable standards of practice when: 1. There were 28 expired intravenous (IV, given through a vein) medications were not removed from the medication room and were available for administration. This failure placed residents at a potential risk of being given expired IV medications which could compromise the health of residents. 2. One of two medication carts stored two expired medications (Docusate Sodium and Nystatin Powder) and were available for administration, and one medication (Nystatin Powder) was stored in the medication cart with no patient identifier. This failure placed residents at a potential risk of being given expired and unlabeled medications. 3. Resident 188's Budesonide-Formoterol (medication for shortness of breath) inhaler was opened and available for use without an open date label, dispose by date label and patient identifier. This failure placed Resident…

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

Based on interview and record review, the facility failed to ensure residents rights to participate in resident groups was supported when Resident Council Meetings (meeting with residents designed to give the opportunity to voice any concerns or grievances about the facility) were not held once a month for two out of four months (December 2021 and January 2022). This failure had the potential for residents to not have an opportunity to voice their concerns and grievances to the facility that could lead to residents needs not being met. Findings: During an interview on 2/8/22, at 10:03 a.m., at a Resident Council Meeting with Residents (Residents 14, 32, 43, 67, 74), Resident 14 stated, a Resident Council Meeting had not been done during the month of December 2021. Resident 14 stated, there was no staff member that made rounds to residents' rooms to ask about concerns or grievances. During a review of the facility's Resident Council Meeting Minutes for the months of October to December 2021 and January 2022, there were no meeting minutes for December 2021 and January 2022. During an…

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

Based on observation, interview and record review, the facility failed to provide the necessary care and services based on the resident's needs and choices for activities of daily living (ADLs) for one of three sampled residents (Resident 45) when the facility did not assist Resident 45 to get out of bed daily. This failure placed Resident 45 at risk for her abilities in ADL to diminish. Findings: During a review of Resident 45's Face sheet, (FS- a document containing resident profile information), undated, the FS indicated, Resident 45 was admitted to the facility with diagnoses which included morbid (severe) obesity and muscle weakness. During a review of Resident 45's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical functional level) assessment, dated 11/26/21, the MDS indicated, Resident 45's Brief Interview for Mental Status (BIMS) assessment score of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 15 was cognitively intact. Functional status…

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 dialysis (treatment for people whose kidneys are failing) assessment was completed for one of five sampled resident (Resident 185), when the facility did not perform a post dialysis assessment (contains vital signs and assessment of access site of dialysis catheter [used for connecting to a machine that filters blood during treatment]) on 2/4/22. This failure placed Resident 185 at a potential risk of dialysis complications (low blood pressure, fluid overload, blood clots, muscle cramps, access site infection, itchy skin) to go unnoticed which could lead to harm or death. Findings: During a review of Resident 185's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 2/9/22, the AR indicated, . admission Date 2/2/22 . Diagnosis Information . End Stage Renal Disease (ESRD - medical condition in which a person's kidneys stop functioning on a permanent basis and needing long-term dialysis) . 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 facility failed to ensure residents were free from unnecessary medications in their treatment plan for one of 10 sampled residents (Resident 22) when Resident 22 had no appropriate indication and monitoring for the use of magnesium oxide (medication supplement to maintain adequate magnesium in the body). This failure placed Resident 22's at risk of being administered magnesium oxide unnecessarily which could potentially lead to elevated blood magnesium level. Findings: During a review of Resident 22's admission Record (AR), dated 2/7/22, the AR indicated Resident 22 was a [AGE] year old female who was admitted from an acute care hospital on 4/9/18 to the facility with diagnoses which included deficiency of other vitamins. During a concurrent interview and record review on 2/7/222, at 2:27 p.m., with LVN 2, Resident 22's Physician Order (PO), dated 5/25/21 was reviewed. The PO indicated, Magnesium Oxide Tablet 400 MG [milligrams - unit of measure] Give 1 tablet by mouth…

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 an effective infection control program when: 1. Resident 34 was not restricted to staying within the yellow zone (an area designated for suspected COVID-19 [Corona Virus- a contagious serious respiratory infection transmitted from person to person] positive residents). Resident 34 was observed seated at the facility main entrance next to Resident 36 in a green zone (residents without exposure, confirmed negative or recovered COVID 19). These failures had the potential to place residents at increased risk for transmission of COVID-19. Findings: 1. During a concurrent observation and interview on 2/11/22, at 11:38 a.m., with Receptionist (REC), at the facility's main entrance, Resident 34 and 36 were seated next to each other at the front entrance. REC stated, Resident 34 and 36 were seated next to each other and were not maintaining a 6 foot distance. REC stated, she educated Resident 34 to maintain 6 feet distance. During a…

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