Fireside Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, facility failed to ensure infection control practices were adhered to in accordance with professional standards of practice when:The facility failed to isolate(to separate individuals with a known or suspected contagious disease from those who are not infected to prevent the spread of illness) Resident 60 after the resident's urine tested positive (presence of) for Extended spectrum beta lactamase (ESBL - bacteria that produce enzymes making them resistant to many common antibiotics, such as penicillin's and cephalosporins, making infections harder to treat).Resident 60 was on the patio with other residents while she was positive for ESBL. These deficient practices placed the residents and staff at increased risk to contract ESBL, and/or hospitalization.Findings: A review of Resident 60's admission Record indicated Resident 60 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses that included encephalopathy (any…

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 for one of three sampled residents (Resident 1), the facility failed to report an allegation of suspected abuse to the correct agencies within the time frame specified by the facility policy.This deficient practice had the potential to leave Resident 1 at risk of further suspected alleged abuse.A review of Resident 1's admission Record indicated the facility admitted this [AGE] year old female on 12/1/2025 with diagnoses including spinal stenosis (narrowing of the spinal cavity), hyponatremia (low sodium in the blood), hydronephrosis with urethral stricture(condition causing urine to back up into the kidneys), venous insufficiency(damaged valves in veins cause blood to back up), adult failure to thrive (syndrome identified by decreased appetite, weight loss, physical inactivity and impaired physical function), chronic lymphocytic leukemia of b cell in remission (cancer of the blood that is not active), chronic kidney disease (irreversible kidney damage) and glaucoma (eye…

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 display and provide a copy of the current Administrators license as per regulation. This failure had the potential for residents, families, and Department of Public Health to be provided the wrong information regarding the current Administrator. Findings: During an unannounced visit tour and observation of the facility on 3/18/2025 at 11:20 a.m., the facility posted the license of a former Administrator and did not the license of the current Administrator. During an interview on 3/19/2025 at 10:57 a.m., Administrator stated he did not have a current copy of his Administrators License because the license was mailed to the wrong address and had no way of printing another copy. Administrator stated he has only been employed with the facility for 1 month. Administrator stated he is aware that his Administrators license is supposed to be posted on the first day of employment. Administrator stated if the current Administrator ' s License is not posted the staff, residents ' family, or Department of Public Health…

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 The facility failed to take the appropriate corrective action to address grievances for two of two sampled residents (Residents 1 and 2) when: 1. Resident 1 complained about a missing cellphone and clothing 2. Resident 2 complained about missing clothing. 3. Facility failed to complete inventory list for Resident 1 upon admission to the facility. 4. The facility failed to investigate reports of missing property for Residents 1 and 2. As a result: 1. Resident 1 was angry about missing clothing and cellphone, and felt disconnected from the outside world 2. Resident 2 was angry about missing clothing. Findings: 1. During a record review, Resident 1's admission Record indicated Resident 1 (Resident 2's roommate) was re-admitted to the facility on [DATE], with the diagnoses of cognitive communication deficit (difficulties in communication arising from impairments in cognitive process like attention, memory, and executive functions), and generalized muscle weakness (lack of physical or muscle strength throughout 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, for one of three sampled residents (Resident 1), facility failed to: 1. Monitored and supervised Resident 1 to prevent elopement (the act of leaving a facility unsupervised and without prior authorization). 2. Ensure the alarm system was functioning on two of five exits doors (Door C- [south side exit door leading to the front of the facility] and Door E [northside door, at the back of the facility leading to the alley]) to alert staff if a resident was eloping and or exiting the facility. 3. Ensure the alarm system was activated/functional on one of five exit doors (Door D- northside back of the facility exit door leading to the side street). 4. Ensure that the alarm system was checked for proper functionality for five of five exit doors. 5. Ensure that Resident 1's care plan was resident specific for possible elopement. These deficient practices resulted in Resident 1 eloping from the facility on 2/27/2025, at 1:40 P.M., placing the resident at increased risk…

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 for one of three sampled residents, Resident 2. The facility failed to waste an Ativan (medication used to treat anxiety) 0.5 mg(milligrams) per facility-controlled narcotic (a medication tightly controlled by the government because it may be abused or cause addiction) protocol. This deficient practice resulted in an inaccurate Ativan 0.5mg count for Resident 2. Findings: During record review, Resident 2's admission Record indicated the facility admitted Resident 2 on 1/15/2025 with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), epilepsy (a condition that causes sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), displaced left femur fracture (broken thigh bone), dysphagia (difficulty swallowing), dementia (a progressive state of decline 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, for one of three sampled residents (Resident 2), the facility failed to: 1. Follow up and ensure that a physician ordered oxycodone-APAP (controlled medication used to manage moderate to severe pain). 2. Administer Oxycodone-APAP to Resident 2 for 18 of 54 days, The facility was aware Resident 2 had verbalized and was experiencing eight out of 10 (8/10 - numerical pain assessment tool where 0 is no pain and 10 being the worst pain) pain level in both shoulders, neck, and the back. As a result, Resident 2 experienced pain, frustration, and was unable to attend/participate in activities. Findings: During a review of the admission record for Resident 2 indicated Resident 2 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including cervical disc disorder at cervical 6 (C6-neck bone) to C7 level with radiculopathy (also known as pinched nerve is a condition that results in radiating pain, weakness and/or numbness caused by compression…

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 that a pre-admission screening Resident Review level I(PASRR -an evaluation to determine if an induvial has a serious mental illness, intellectual disability, developmental disability, or related condition) was obtained and maintained in the residents chart for one of five sampled residents (Resident 61). This deficient practice had the potential to negatively affect the appropriated care and services rendered to the resident. Findings: During a review of Resident 61's admission Record indicated the facility admitted Resident 61 on 10/10/2024 with diagnoses including Bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) During a review of Resident 61's Minimum Data Set (MDS - a resident assessment tool)…

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 apply neck brace at all times to Resident 122 according to the physician's order. Resident 122 was admitted to the facility with displaced fracture of second cervical vertebra (a broken bone in the neck), This failure had the potential to cause further injury and pain to Resident 122. Findings: During a review of Resident 122's admission Record indicated Resident 122 was admitted to the facility on [DATE] with a diagnosis of, but not limited to displaced fracture of second cervical vertebra, and abnormalities of gait and mobility (the inability to walk normal). During an observation on 11/29/24 at 9:35 am, with Physical Therapist (PT, a person qualified to treat disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery) and RN 3, Resident 122 lying in bed without neck brace in place. A neck brace was noted next to Resident 122 and not on the resident's neck. During…

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 clean the Bilevel positive airway pressure (Bipap- is a breathing device that helps people breathe when they have trouble on their own) machine for one of six residents, Resident 8. This deficient practice had the potential to cause respirartory infection to Resident 8. Cross Reference F726 Findings: During a review of Resident 8's admission Record indicated Resident 8 was admitted to the facility on [DATE] with a diagnoses of, but not limited to Generalized muscle weakness (feeling significantly weaker than usual in most of your body muscles, making it harder to move your arms, legs, or other parts of your body, often due to a medical condition that affects your overall muscle strength), Morbid Obesity (a severe and dangerous level of obesity that's characterized by a body mass index of 40 or higher), Chronic Respiratory Failure (COPD, when the lungs can't effectively exchange oxygen and carbon dioxide). During a review of Resident 8'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: 1. Ensure staff were competent in operating and cleaning a Bilevel positive airway pressure (Bipap- is a breathing device that helps people breathe when they have trouble on their own). 3. Ensure five of five staff (registered nurse supervisor 4 (RNS 4), licensed vocational nurse 3 (LVN 3), certified nursing assistant 4 (CNA 4), CNA 5, and rehabilitative nursing assistant 1 (RNA 1) providing care and services to residents had the current required Cardiopulmonary Resuscitation (CPR: a credential that qualifies the holder to perform a life-saving procedure on someone who cannot breathe on their own due to a near-drowning incident, suffocation, or a cardiac event) certification by the American Heart Association (AHA - trains healthcare professionals to meet national performance standards) and or required annual competencies. These failures had the potential to cause physical harm to residents when RNS 4, LVN 3, CNA 4, CNA 5, and RNA 1 were not certified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a functional bed and a comfortable mattress for one of four sampled residents (Resident 8). The facility failed to ensure the resident's mattress was not worn out and the bed was not operating properly. This failure resulted in Resident 8 feeling very angry. Findings: During a review of Resident 8's admission Record indicated Resident 8 was admitted to the facility on [DATE] with a diagnoses of, but not limited to generalized muscle weakness (feeling significantly weaker than usual in most of your body muscles, making it harder to move your arms, legs, or other parts of your body, often due to a medical condition that affects your overall muscle strength), Morbid Obesity (a severe and dangerous level of obesity that's characterized by a body mass index of 40 or higher), Chronic Respiratory Failure (COPD- when the lungs can't effectively exchange oxygen and carbon dioxide over a long period or time leading to a constant During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 27) Preadmission Screening and Resident Review (PASRR - a screening evaluation used to determine whether placement in a long term care facility is appropriate for the resident) Level II (a person-centered evaluation that helps determine placement and specialized services) assessment was completed as required by PASRR Level I (a tool that helps identify possible serious mental illness and/or intellectual/development disability) assessment. This deficient practice of failing to complete PASRR Level II assessment for Resident 27 put Resident 27 at risk for not receiving the necessary care and specialized services tailored to Resident 27's needs. Findings: During a review of Resident 27's face sheet (admission Record- a document containing demographic and diagnostic information) indicated Resident 27 was admitted to the facility on [DATE] and was re-admitted on [DATE] with the following 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 and, interview, facility failed to ensure two of 15 sampled Residents (Resident 17 and Resident 46) were in a hazard and clutter free environment by failing to ensure the residents room entrance was accessible to staff and the residents. This deficient practice had the potential to place Residents 17 and 46 at risk from unnecessary accidents, hazards, and delay in necessary emergency care and/or treatment that could result in poor outcomes, unnecessary hospitalization and/or death. Findings: During a review of Resident 17's admission record indicated Resident 17 was originally admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included sepsis (the body's extreme reaction to an infection), morbid obesity (a weight that exceeds an individual's desirable weight by more than 100 pounds) diabetes type 2 (blood glucose, or blood sugar, levels are too high.) and cellulitis (bacterial infection that affects the skin and deep tissues,) of the right lower limb. 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.

Based on observation, interview, and record review, the facility failed to ensure one of ten sampled residents (Resident 41) who was incontinent of bowel and bladder received appropriate treatment and services to prevent urinary tract infection (UTI - an infection that can occur in any area of the urinary tract, including the ureters, bladder, kidneys, or urethra) by failing to assess and monitor Resident 41's urinary catheter for signs of infections. This deficient practice had the potential for delayed UTI treatment and reoccurrence of UTIs. Findings: During a review of Resident 41's admission Record indicated the facility admitted Resident 41 on 8/14/2024 and readmitted Resident 41 on 11/1/2024 with diagnoses including obstructive and reflux uropathy (blocked urine flow), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough), and generalized muscle weakness (feeling weak in most areas of the body requiring extra effort to move the muscles) During a review of Resident 41'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.

Based on observation, interview, and record review the facility failed to ensure one of ten sampled residents (Resident 220) received the appropriate treatment and services needed to maintain and prevent gastrostomy tube (a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube) complications. By failing to label the resident's tube feeding syringe with an open date. This deficient practice had the potential to cause a spread of infection. Findings: During a review of Resident 220's admission Record indicated the facility admitted Resident 220 on 11/27/2024 with diagnoses including Diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), cerebral infarction (stroke, loss of blood flow to a part of the brain), and pulmonary embolism (PE -a life threatening blockage in a lung artery that occurs when a blood clot travels from a vein to the lungs). Durng a review of Resident 220's Minimum Data Set (MDS - a resident assessment tool) dated 11/30/2024, indicated 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 maintain infection control measures necessary to prevent the spread of infections by failing to ensure: 1) Residents' shower room were always maintained in safe and hygienic conditions; the facility utilized the resident shower room to store a heavy-duty large garbage can designated for dirty diaper only. 2) The for patients use only restroom located between rooms [ROOM NUMBERS] was not used by staff or visitors to prevent cross contamination. 3) The sink in the restroom located between rooms [ROOM NUMBERS] was not used to rinse urinals after emptying the contents in the toilet. 4) Rooms 15, 17, 22, 23 and 32 with residents who were under enhanced barrier precaution measures (EHB-precaution used for residents who are at higher risk of acquiring or spreading Multi drug resistant organisms [MDROs] and/or who are known to be infected or colonized with an MDRO, or who have wounds or indwelling medical devices) were provided with restrooms…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews, the facility failed to ensure Restorative Nurse Assistant 1 (RNA - assists the resident in performing tasks that restore or maintain physical function) had been properly certified and trained in the RNA training program prior to providing care to residents. This deficient practice had the potential to harm residents when RNA 1 performed inadequate techniques in therapeutic rehabilitation. Findings: During a concurrent record review and interview on [DATE] at 2:39 PM with the director of staff development (DSD), the DSD stated RNA 1's Certified Nursing Assistant (CNA - provides basic care and support to patients under the supervision of a licensed nurse) certification could not be found in RNA 1's employee file. During a concurrent record review and interview on [DATE] at 2:39 PM with DSD, DSD stated RNA 1's Cardiopulmonary Resuscitation (CPR - a credential that qualifies the holder to perform a life-saving procedure on someone who cannot breathe on their own due to 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 follow the physician's orders were carried out by failing to provide one of three sampled residents (Resident 1) with a hospice (A program that provides care for people who are near the end of their life and have stopped treatment. Hospice offers physical, emotional, social, and spiritual support for patients and their families) agency during/upon discharge as ordered. This deficient practice resulted in Resident 1 receiving incomplete discharge information which caused confusion. Findings: During a review of the admission record indicated Resident 1 was i admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities), and hypertension (HTN-high blood pressure). During a review of the Minimum Data Set (MDS – a resident assessment tool) dated 12/8/2023, indicated Resident 1 had severe…

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. Return medications after discharged from the facility for four of eight sampled residents Residents 3, 5, 6, 7 and 8), and 2. Destroy medications per policy for four of eight sampled residents Residents 3, 5, 6, 7 and 8). This deficient practice led to multiple medications left behind in the medication storage room accessible to all staff with access to the room. Findings: 1.A review Resident 3 ' s admission Record indicated the facility admitted this [AGE] year old male on 7/23/2024 with diagnoses including, Hemiplegia and Hemiparesis on left side following cerebral infarction (weakness on left arm and leg after having a stroke), dislocation of left shoulder, history of falling, polyneuropathy (damage to nerves causing pain), Hypertension (HTN-high blood pressure), and Major depressive disorder (a mental health disorders characterized by persistent low mood and loss of interest in activities). A review of Resident 3 ' s physician…

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. Secure a discharged residents ' -controlled substances (medications that are high risk for addiction and dependence and can cause respiratory distress and death when taken in high doses) as per facility protocol for one of eight sampled residents (Resident 4). 2. Store discontinued controlled substances per facility policy. These deficient practices resulted in these controlled substances easily accessible to all staff with access to the medication storage room and potential for drug diversion. Findings: 1. A review of Resident 4 ' s admission Record indicated the facility originally admitted this [AGE] year old male on 1/25/2024 and most recently on 9/18/2024 with diagnoses including Diffuse Large B cell Lymphoma (cancer of the white blood cells), secondary malignant neoplasm of bone (cancer in the bones), malignant neoplasm of prostate (cancer in the prostate), sciatica left side (pain that travels down the sciatica nerve in the leg)…

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

Based on interview, and record review the facility failed to ensure the Medical Director had filed an application with the State Licensing and Certification department ' s Centralized Applications Branch (CAB). This failure resulted in the Medical Director (MD) not being listed in the Electronic Licensing Management System (ELMS) and had the potential to affect resident care and medical oversight in the facility. Findings: A review of ELMS on 9/5/2024, indicated the facility did not have a listed MD. During an interview on 9/5/24 at 6:24 pm with the Administrative Assistant (AA), AA stated facility had a MD. During an interview on 9/5/24 at 6:45 pm Licensed Vocational Nurse (LVN) 1, LVN 1 stated the facility had a MD but didn ' t know the name of the MD. During an interview on 9/5/24 at 6:55 pm, the Interim Director of Nursing (IDON) stated the facility had a MD and was able to verbalize the name of the MD. During an interview on 9/12/24 at 2:00 pm with the facility Administrator (ADM), Administrator confirmed the MD ' s name and stated he was getting the application ready to submit…

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 Notice of Proposed Transfer and Discharge was provided to the resident as soon as practicable. The facility also failed to provide documentation to show that the State Long Term Care Ombudsman (public advocate) was notified of the transfer and discharge from the facility for one out of the three sampled residents (Resident 1). This deficient practice denied the residents additional protections from being inappropriately discharged and caused Resident 1 to have feelings of confusion and become upset. Findings: A review of Resident 1 ' s admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis (loss of the ability to move in one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting left non-dominant side, post-traumatic stress disorder (a disorder that develops in some people who have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and/or implement an individualized person-centered plan of care with measurable objectives, timeframe, and interventions to meet the residents' needs for one of three sampled residents (Resident 1) by failing to: Develop an individualized/person-centered care plan with goals and interventions upon readmission for discharge plan to ensure a smooth and safe transition from the facility to the post-discharge setting. This failure resulted in Resident feeling confused and anxious. Cross reference F623. Findings: A review of Resident 1 ' s admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis (loss of the ability to move in one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting left non-dominant side, post-traumatic stress disorder (a disorder that develops in some people who…

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 physician documentation to support a facility-initiated discharge for one of two sampled residents, Resident 1. This deficient practice placed the resident at risk for an unsafe discharge. Findings: A review of Resident 1's admission Record indicated the facility originally admitted this [AGE] year-old male on 9/5/2013 with diagnoses including cerebral infarction (an area of death in the brain tissue due to a blockage in a vessel in the brain), hemiplegia and hemiparesis (weakness and or paralysis on one side of the body) following unspecified cerebrovascular disease, difficulty walking, Tobacco Use, Major Depressive Disorder and Anemia (low red blood cells). A review of Resident 1's History and Physical (H&P- a formal assessment by the health care provider that involves a patient interview, physical exam, and documentation of findings) dated 11/22/2023 indicated Resident 1 has capacity to understand and make decisions. 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 protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1) who has severe cognitive impairment with no capacity to make decisions in accordance with facility's abuse policy and procedures. By failing to: 1. Implement the facility's policy and procedures (P&P) Abuse Prevention and Prohibition Program to protect residents from abuse by screening and training caregivers (a person who tends to the needs or concerns of a person with short- or long-term limitations due to illness, injury, or disability) two of two caregivers (CG1 and CG2). 2. Implement the facility's P&P Caregiver Policy that all caregivers for resident will undergo an orientation with the Director of Staff Development (DSD) which includes education on abuse, facility policy and procedures, and safety in the facility for two of two caregivers (CG1 and CG2). 3. Ensure…

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 investigate and report allegations physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for one out of three sampled residents (Resident 1) to the Department of Public Health, Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement in accordance with the facility's policy and procedures (P&P) titled Abuse Prevention and Prohibition Program dated 10/24/2022, by failing to report the unusual occurrence of a resident-to-caregiver altercation to the State Survey Agency (SSA) within 2 hours after the allegation occurred on 7/23/2024. This deficient practice had the potential to place Resident 1 at risk for elder abuse and delay onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated. Cross Reference F600 Findings: 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 interview and record review the facility failed to report alleged abuse to the abuse coordinator and state agency for one of three residents sampled residents (Resident 1). This deficient practice placed other residents at risk for potential alleged abuse. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the [AGE] year-old male on 7/23/2024 with diagnoses including Hemiplegia affecting the left side (weakness of paralysis of the entire left side of the body), dislocation of left shoulder joint, history of falls, essential hypertension (high blood pressure) and polyneuropathy (many nerves in different parts of the body have pain). A review of Resident 1 ' s Minimum Data Set (MDS-a standardized assessment and care planning tool) dated 8/7/2024, indicated Resident 1 ' s cognition (mental ability to make decisions for daily living) was mildly impaired. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) with toileting,…

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 discharge plan that included visits by an operating hospice (medical care for people with an anticipated life expectancy of 6 months or less, when cure isn't an option, and the focus shifts to symptom management and quality of life) agency (HA1) for one of one sampled resident (Resident 1). The facility also failed to provide information about HA1 to Resident 1's family member. This deficient practice resulted in Resident 1 not receiving physical comfort and emotional, social, and spiritual support when nearing the end of life. Findings. A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis including malignant neoplasm of left female breast (a disease in which malignant (cancer) cells form in the tissues of the breast), type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]) and major depressive disorder (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 the Influenza (Flu-common viral infection that can be deadly, especially in high-risk groups) vaccine was offered to one of six sampled residents (Resident 3). This deficient practice placed Resident 3 at a higher risk of possibly acquiring and transmitting influenza infection to other residents in the facility. Findings: A review of Resident 3 ' s admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), end stage renal disease (ESRD-a medical condition in which a person ' s kidney [organ in the body that lifters waste and excess fluid from the blood] function stop functioning on a permanent basis), and hemiplegia and hemiparesis (loss of the ability to move in one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of 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 failed to ensure that COVID-19 (a viral infection, highly contagious, that easily transmits from person to person, causing respiratory problems and may cause death) vaccination was offered/ re-offered and/or administered per facility ' s policy for one of six sampled residents (Resident 2). This deficient practice resulted COVID-19 infection to Resident 2 and placing other resident and staff at risk for COVID-19 infection. Findings: A. A review of Resident 2 ' s admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses including aftercare following joint replacement surgery (a procedure in which a surgeon removes a damaged joint and replaces it with a new, artificial part), hereditary and idiopathic neuropathy (a condition in which a person's peripheral nerves are damaged), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one ' s daily…

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 expiration dates on food packages, and remove expired food stored on the shelves in the kitchen. These deficient practices had the potential to cause food-borne illnesses. Findings: During an observation on 11/6/2023 at 8:19 a.m., during an observation of the kitchen there were 14 packages of cake mix, jello, corn bread mix, vanilla pudding, chocolate pudding noted without manufactured expiration date on the package stored on the shelves. it was observed that 1 package of hamburger buns with the expiration date of 10/31/2023. On 11/6/2023 at 8:30 a.m., during an interview, the Dietary Aide (DA) confirmed and stated there was no expiration date on the food packages stored on the shelf. The DA further stated this was the way the packages always come. The DA further stated the Dietary Supervisor (DS) was the person that orders the food for the kitchen. The DA further state if the residents ate expired food they could get sick. On 11/6/2023 at 8:45 a.m., during an interview, [NAME] 1 confirmed there was…

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

Based on observation, interview, and record review, the facility failed to follow its policies and procedure (P&P) for food storage in resident's refrigerator to ensure the refrigerator temperature log was completed daily and food brought from outside was properly labeled and dated. Those deficient practices had the potential to cause food borne illnesses among the residents who consumed spoiled and expired food brought from outside of the facility. Findings: During an observation on 11/6/2023 at 12:15 p.m., of food stored in the refrigerator for residents located in the residents' dining room with director of staff development (DSD), 16 food items were observed without labels and /or dates on food containers and four (4) items were observed without expiration dates on food containers. The refrigerator temperature log was incomplete for the month of October 2023. During an interview on 11/6/2023 at 12:30 p.m., the DSD stated the facility policy states food brought into the facility from family members must be labeled properly with the resident's name, room number, date and the food…

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

Based on interview and record review, the facility failed to ensure the facility's infection control program included a water management to monitor and test the water for disease causing pathogens (organisms that cause disease). This failure had a potential to place residents at risk for water-related healthcare-associated infections resulting from the growth and transmission of organisms. Findings: During an interview on 11/7/23 at 2:18 a.m., with Maintenance Supervisor (MS), the MS stated he was not aware of any water management program in the facility. The MS stated he tested the water's temperature and kept a log of his activity, but he did not know about any water testing program regarding infection control. During an interview on 11/8/23 at 9:40 a.m. with infection preventionist (IP), the IP stated that she was not aware of any water management program for infection control and about to speak to the administrator about the program. During an interview on 11/8/23 at 12:26 a.m., with the Administrator (ADM), the ADM stated a water management company will be testing the water 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.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 77) received written notice of room change prior to changing the resident's room. This deficient practice violated Resident 77 and Resident 77's Responsible Party's rights to receive written notice of the room change, including the reason for the change, before the resident's room in the facility was changed. Findings: A review of Resident 77's admission Record dated 9/14/2023 indicated the facility admitted Resident 77 on 9/14/2023 with diagnoses including Encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition), heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), hypokalemia (a blood level that is below normal in potassium, an important body chemical), and hypertension (a condition in which the force of the blood against the artery walls is too high). A review of Resident 77's Minimum Data Set (MDS - a standardized assessment care screening tool) dated 9/21/2023, indicated Resident 77'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.

Based on observation, interview, and record review, one of two sampled residents (Resident 283) complained of uncomfortable noise levels within the facility. The deficient practice of loud noises had the potential to cause Resident 283 distress. Findings: A review of Resident 283's admission Record dated 11/1/2023 indicated the facility admitted Resident 283 on 11/1/2023 with diagnoses including fibromyalgia (a chronic (condition that last 1 year or more and require ongoing medical attention or limit activities of daily living or both, disorder characterized by widespread pain), diabetes mellitus (a chronic, metabolic disease characterized by elevated levels of blood sugar), anemia ( low red blood cells), hyperlipidemia (an abnormally high concentration of fats or lipids [any of a class of organic compounds that are fatty acids], in the blood). A review of Resident 283's Risk Assessment (a systematic process of evaluated a resident's physical and mental capabilities), dated 11/1/2023 indicated Resident 283's cognition (the mental ability to make decisions of daily living) 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 initiate and implement comprehensive care plans for two of six sampled residents (Residents 71 and 183), by failing to develop and implement care plans for: 1. Resident 71 for hospice (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally [serious illness leading to death] ill) care. 2. Resident 183 for smoking and pain management. These deficient practices had the potential to result in inconsistent implementation of care that may have resulted in injury or delay in the delivery of services for Residents 71 and 183. Findings: 1. A review of Resident 71's admission record dated 8/14/2023, indicated Resident 71 was admitted to the facility on [DATE] with diagnoses that include malignant melanoma (a disease in which malignant [spread] cells form in melanocytes [cells that color the skin]) of skin, malignant neoplasm (growth of new and abnormal growth of cells) of brain, epilepsy (disorder 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.

Based on interview and record review the facility failed to update comprehensive care plan for Duloxetine (medication used to treat depression) 20mg (one thousandth of a gram) daily for one of two sampled resident (Resident 39). This deficient practice had the potential to cause inconsistent treatment in relation to this medication for Resident 39. Findings: A review of Resident 39's admission Record indicated the facility originally admitted Resident 39 on 10/12/2021 and most recently on 10/14/2022 with diagnoses including Diabetes Mellitus (a chronic, metabolic disease characterized by elevated levels of blood sugar), hyperlipidemia (high blood pressure), Post Traumatic Stress Disorder (PTSD - disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) and major depressive disorder (mental condition characterized by persistently depressed mood and long term loss of pleasure or interest in life). A review of Resident 39's Minimum Date Set (MDS - a standardized assessment care screening tool) dated 10/17/2023, indicated Resident 39'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.

Based on observation, interview and record review the facility failed to order a dermatology (the branch of medicine concerned with the diagnosis, treatment, and prevention of diseases of the skin, hair, nails) consult for one of two sampled residents (Resident 48). This deficient practice may have delayed potential treatment for this abnormal growth on Resident 48's left shoulder. Findings: A review of Resident 48's admission Record indicated the facility admitted Resident 48 on 12/11/2021 with diagnoses including quadriplegia (paralysis in both arms and legs), dysphagia (difficulty swallowing), spinal stenosis (narrowing of the cavity that runs down the spine in between each bone and contains the spinal cord), pressure ulcer of the sacrum (bed sore on the lower back) and left hip, bipolar(a disorder associated with episodes of mood swings from depression to high energy excitement), Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities) and gastroesophageal reflux disease (GERD - acid backs into the tube…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow the facility's policy and procedures (P&P) and complete smoking assessment to determine resident smoking-related privileges for one of three sampled residents (Resident 183) upon admission to the facility. This deficient practice had the potential for injury or a smoking related accident for Resident 183. Findings: A review of resident 183's admission record dated 10/30/2023, indicated Resident 183 was admitted to the facility on [DATE] with diagnoses that included spinal stenosis (narrowing of the spinal canal), chronic obstructive pulmonary disease (COPD-chronic inflammatory lung disease that cause obstructed airflow for the lungs), and seizures (a burst of uncontrolled electrical activity between brain cells). A review of Resident 183's history and physical dated 11/2/2023, indicated Resident 183 had the capacity to understand and make decisions. During an interview with Resident 183 on 11/6/2023 at 9 a.m., Resident 183 stated he was recently…

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 medication as per physician's order for two of four sampled residents (Resident 11 and Resident 53). This deficient practice had the potential to place resident at risk for feeling dizzy, upset stomach, or feeling weak for Resident 53 and medication error related to self-medication administration for Resident 11. Findings: 1. A review of Resident 53's admission record, dated 7/22/2022, indicated Resident 53 was admitted to the facility on [DATE] with diagnoses that included cerebral infraction (stroke-injury to the brain due to lack of blood supply) with hemiplegia (unable to move one side of the body) affecting the right dominant side, hypertension (high blood pressure), abnormalities of gait and mobility (difficulty with walking and transferring from one surface to another). A review of Resident 53's physician order summary dated 9/28/2022, indicated to administer Carvedilol (medication used to treat hypertension) oral tablet…

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 perform recommended gradual dose reduction (GDR-a stepwise tapering of a dose to determine if symptoms, conditions or risks can be managed by a lower dose or if the dose or the medication can be discontinued) for the medication Duloxetine (medication used to treat depression) 20mg (one thousandth of a gram) daily for one of two sampled resident (Resident 39). This deficient practice could have caused too high or too low levels of the medication to manage Resident 39's symptoms. Findings: A review of Resident 39's admission Record indicated the facility originally admitted Resident 39 on 10/12/2021 and was readmitted on [DATE] with diagnoses including Diabetes Mellitus (ongoing, metabolic disease characterized by elevated levels of blood sugar), Hyperlipidemia (high blood pressure), Post Traumatic Stress Disorder (PTSD-disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) and Major depressive Disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow its policy and procedure (P&P) to ensure 1 of 2 sampled residents (Resident 71) had an interdisciplinary (IDT-a group of professional and direct care staff that have primary responsibility for the development of a plan for the care and treatment of a patient) prior to entering hospice care program (a program focused on the care, comfort, and quality of life of a person with a serious illness who is approaching the end of life). This deficient practice had the potential for Resident 71's care needs including physical and emotional needs not being met. Findings: A review of Resident 71's admission record dated 8/14/2023, indicated Resident 71 was admitted to the facility on [DATE] with diagnoses that included malignant melanoma (a serious form of skin cancer that begins in cells known as melanocytes [cells produce melanin which is responsible for skin color]), malignant neoplasm (growth of new and abnormal growth of cells) of brain, epilepsy…

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.