Ocean Park Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that two of three sampled residents reviewed for restraints (Residents 3 and 10) were free from physical restraint by: A. Failing to ensure the physician's order for bed siderails was in place and geriatric chair (geri chair - a large, padded, often wheeled chair designed to help seniors or individuals with limited mobility) with lap tray were properly assessed and evaluated for Resident 10. B. Resident 3 was observed with a geri chair parked alongside Resident 3 while she was in bed that restricted the resident's movement. These deficient practices had the potential to result in entrapment and injury with the use of restraints for Residents 3 and 10. Cross Reference F656, F552 Findings: 1. During a record review of the admission Record indicated Resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including encephalopathy (a disease in which the functioning of the brain is affected by…

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' notice of proposed transfer/discharge notification was sent to the Office of the State Long-Term Care Ombudsman (public advocate) on a timely manner for one of three sampled discharged residents reviewed (Resident 39) as indicated in the facility's policy. This deficient practice had the potential to deny Resident 39's protection from being inappropriately discharged . Findings: During a record review of the admission Record, Resident 39 was admitted to the facility 11/18/2024 with diagnoses including epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures), chronic pancreatitis (a long-lasting inflammation of the pancreas, a gland behind the stomach that helps with digestion and regulates blood sugar), and muscle weakness (weakening, shrinking, and loss of muscle). During a record review of the Minimum Data Set (MDS - a resident assessment tool) dated 11/24/2025, indicated Resident 39's cognitive (mental action or process of acquiring knowledge and understanding)…

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 review, the facility failed to ensure the assessment entries were accurate for one of one sampled resident reviewed for resident's assessment (Resident 12) by failing to appropriately assess residents' diagnosis in the Minimum Data Set (MDS - resident assessment tool). This deficient practice had the potential to result in a negative effect on residents' plan of care and delivery of services. Cross Reference F658 Findings: During a record review of the admission Record indicated Resident 12 was originally admitted to the facility 4/1/2021 and readmitted on [DATE] with diagnoses including chronic pulmonary edema (a condition caused by excess fluids in the lungs usually caused by a heart condition), atrial fibrillation (afib- an irregular and very rapid heart rhythm that and can lead blood clots in the heart) 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 activities). 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 interview and record review, the facility failed to ensure that a Pre-admission Screening Resident Review level II (a detailed assessment that determines if someone with a mental illness [like serious mental illness, intellectual disability, or related conditions] needs specialized services and the most appropriate place to receive them) was obtained and maintained in the residents chart for two of three sampled residents (Residents 1 and 25). This deficient practice had the potential to negatively affect the appropriate care and services rendered to Residents. 1 and 25 Findings: During a record review of Resident 1's admission Record indicated the facility admitted Resident 1 on 7/23/2024 and Resident 1 was readmitted to the facility on [DATE] with diagnoses including anxiety (a feeling of worry, fear, or unease, often accompanied by physical symptoms like a rapid heartbeat or shortness of breath), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough),…

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 a comprehensive care plan that met the care/services based on the resident's individual assessed needs for one of 12 sampled residents (Resident 10) by failing to develop a comprehensive (CP) with the use of bilateral bed siderails for Resident 10. This deficient practice had the potential to result negative impact on residents' health and safety, as well as the quality of care and services received. Findings: During a record review of the admission Record indicated Resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and unspecified dementia (a progressive state of decline in mental abilities). During a record review of the Minimum Data…

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 meet professional standards of quality of care for one of three sampled residents reviewed for behavior, (Resident 12 ) by failing to ensure failed to ensure the assessment entries were accurate for one of three sampled residents (Resident 12) by failing to appropriately assess residents' diagnosis in the Minimum Data Set (MDS - resident assessment tool). This deficient practice had the potential to result in a negative effect on residents' plan of care and delivery of services. Findings: During a record review of the admission Record indicated Resident 12 was originally admitted to the facility 4/1/2021 and readmitted on [DATE] with diagnoses including chronic pulmonary edema (a condition caused by excess fluids in the lungs usually caused by a heart condition), atrial fibrillation (afib- an irregular and very rapid heart rhythm that and can lead blood clots in the heart) and anxiety disorder (a mental health disorder characterized by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility failed to ensure that the resident was safe during mobility using a geri chair (a large, padded, often wheeled chair designed to help seniors or individuals with limited mobility) for one of two sampled residents (Resident 25). This deficient practice had the potential to cause harm/injury and possible hospitalization for Resident 25. Cross Reference F689 Findings: During a record review of Resident 25's admission Record indicated the facility admitted Resident 25 on 6/29/2023 and Resident 25 was readmitted to the facility on [DATE]with diagnoses including hypertension (HTN-high blood pressure), anxiety (a feeling of worry, fear, or unease, often accompanied by physical symptoms like a rapid heartbeat or shortness of breath), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) During a record review of Resident 25's Minimum Data Set (MDS - a resident assessment tool) dated 4/14/2025,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility failed to ensure that the resident's feet did drag on the floor during mobility using a geri chair (a large, padded, often wheeled chair designed to help seniors or individuals with limited mobility) for one of two sampled residents (Resident 25). This deficient practice had the potential to cause harm/injury and possible hospitalization for Resident 25. Cross Reference F684 Findings: During a record review of Resident 25's admission Record indicated the facility admitted Resident 25 on 6/29/2023 and Resident 25 was readmitted to the facility on [DATE]with diagnoses including hypertension (HTN-high blood pressure), anxiety (a feeling of worry, fear, or unease, often accompanied by physical symptoms like a rapid heartbeat or shortness of breath), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) During a record review of Resident 25's Minimum Data Set (MDS - a resident assessment tool) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed ensure the medical record for two of five sampled residents (Residents 32 and 40) was accurate and compete for: 1. Resident 32's Advance Directive Acknowledgement form was filled out completely, 2. Resident 40's Physician's progress note was accurately dated. This failure resulted in an incomplete and inaccurate forms in the medical record and had the potential to effect the delivery of care. Findings: 1. During a record review of Resident 32's admission Record dated 5/4/25 indicated the resident was 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), anxiety disorder (excessive fear or worry), anemia (a condition where the body does not have enough healthy red blood cells), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sample residents (Resident 1) was free from significant medication errors by failing to transcribe all prescribed medications. The facility failed to transcribe apixaban/Eliquis (an anticoagulant or blood thinner medication used to prevent blood clots to prevent stroke and harmful blood clots in the blood vessels) which was part of Resident 1 ' s General Acute Care Hospital (GACH) physician transfer orders. This deficient practice resulted in Resident 1 missing the mediation doses as prescribed and had the potential to a serious harm to the resident causing blood clots that can lead to life threatening complications. Cross Reference: F842. Findings: A review of Resident 1 ' s GACH History and Physical dated 2/8/2025 indicated, Resident 1 has a history of atrial fibrillation (Afib-an irregular heartbeat that can lead to blood clots and increases the risk of stroke and other heart complications) on Eliquis. A review of Resident 1 ' s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sample residents (Resident 1) medical record was complete and accurate by failing to transcribe the prescribed medication apixaban/Eliquis (an anticoagulant or blood thinner medication used to prevent blood clots to prevent stroke and harmful blood clots in the blood vessels) which was part of Resident 1 ' s General Acute Care Hospital (GACH) physician transfer orders. This deficient practice resulted in Resident 1's medical record to be incomplete and inaccurate. Cross Reference: F760. Findings: A review of Resident 1 ' s GACH History and Physical dated 2/8/2025 indicated, Resident 1 has a history of atrial fibrillation (Afib-an irregular heartbeat that can lead to blood clots and increases the risk of stroke and other heart complications) on Eliquis. A review of Resident 1 ' s GACH physicians medication order dated 2/14/2025 indicated apixaban [Eliquis] 5 milligram (mg, unit of measurement) tablet take 1 tablet by mouth 2 times…

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 (Resident 2) received care and support through informed, deliberative decision making that promote respect for the values, needs, and interests through bioethics committee (crucial advisors, assisting with ethical decision-making in complex situations) by serving as decision makers on behalf of Resident 2 and providing psychoactive medication without consent. This deficient practice violated the residents' right to make an informed decision regarding the use of psychoactive medications. Findings: During a record review, Resident 2 ' s admission record indicated Resident 2 was originally admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included psychosis (severe mental disorder that cause abnormal thinking and perceptions) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (Excessive worry or fear, Feeling tense or on edge,…

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 immediately separate residents after a report allegation of 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) in accordance with the facility's policy and procedures (P&P) titled Abuse, Abuse, Neglect, Exploitation and Misappropriation Prevention Program Revised 4/2021, by failing to protect resident from possible further abuse for a resident-to-resident altercation. This deficient practice had the potential to place Resident 1 at risk for further elder abuse. Findings: During a record review, Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 11/27/023 with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough), generalized muscle weakness (feeling weak in most areas of the body), and metabolic encephalopathy (a brain condition that occurs when there ' s 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 ensure that Certified Nursing Assistants (CNA 6 and CNA 5) carried out activities of daily living (ADL- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) services and implemented interventions in accordance with the resident's assessed needs for one of three sampled residents (Resident 1) per facility's policy and procedure (P&P). This deficient practice resulted in Resident 1's toileting, bathing needs not being met, which could negatively affect the resident's health and wellbeing. Findings: A review of the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), urinary tract infection (UTI- an infection in the bladder/urinary tract), unspecified 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, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one of three sampled residents (Resident 1) by failing to: 1. Ensure Resident 1 who required maximal assistance with repositioning had been turned and repositioned according to the resident's care plan (CP). 2. Ensure Resident 1 who was incontinent of bladder had been kept clean to prevent urinary tract infections (UTI- an infection in the bladder/urinary tract) to the extent possible and prevent skin injury. These deficient practices resulted to failure in the delivery of necessary care and services including repositioning and incontinence care for Resident 1. Findings: A review of the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), urinary tract…

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 permit Resident 1 to return back to Skilled Nursing Facility 1 (SNF 1) from a general acute care hospital (GACH) for one of three sampled residents (Resident 1). As a resulted, GACH transferred Resident 1 to SNF 2 which was not the resident's preference. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to SNF 1 on 6/7/2024, with a diagnosis but not limited to anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), unspecified asthma (chronic lung disease that causes the bronchial airways in the lungs to narrow and swell, making it difficult to breathe). A review of Resident 1's History and Physical dated 6/10/2024, indicate Resident 1 had the capacity to make medical decisions. A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 6/11/2024, indicated Resident 1 had moderately impaired cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise the care plan for vision for one of two sampled residents (Resident 32). This deficient practice resulted in Resident 32's decline in activities of daily living (ADL - activities related to personal care such as bathing or showering, dressing, getting in and out of bed or chair, walking, using the toilet, and eating) and enjoying hobbies including watching television (TV), and socializing with the other residents. Findings: A review of Resident 32's admission Record, indicated, Resident 32 was re-admitted to the facility on [DATE] with diagnoses including, history of falling, major depressive disorder (a common but serious mood disorder that causes a persistent feeling of sadness and loss of interest), and generalized anxiety disorder (a condition of excessive worry about daily issues and situations). A review of Resident 32's Minimum Data Set (MDS - a required standardized assessment and care planning tools), dated 01/07/2024, indicated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 32) received proper treatment and assistive devices to maintain vision abilities. Resident 32 has been missing corrective (prescription) eyeglasses since 03/18/2024. This deficient practice resulted in Resident 32's decline in physical and psychosocial needs, as the resident was not able to enjoy hobbies including reading, watching television (TV), and socializing with the other residents. Findings: A review of Resident 32's admission Record, indicated the resident was re-admitted on [DATE] to the facility with diagnoses including traumatic subarachnoid hemorrhage without loss of consciousness (bleeding in the brain due to head injury), abnormalities of gait (a person's manner of walking) and mobility (ability to move freely and easily), muscle weakness (when muscles are weak causing difficulty performing normal activities that require strength), history of falling, 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.

Based on interview and record review, the facility failed to ensure one of two training records years (2022) on mandated reporter on abuse, was completed. Facility failed to validate that training documentation on mandated reporter on abuse by facility's staff was completed in 2022. This deficient practice had the potential for staff members not to understand/be educated/be informed on the rights of the resident and the responsibilities of a facility to properly care for its residents regarding mandated reporter. Findings: During an interview with Licensed Vocational Nurse 3 (LVN 3) on 04/08/2024 at 3:31 PM, LVN 3 stated LVN 3 received training on mandated reporter on abuse yearly. LVN 3 named the facility's abuse coordinator as the administrator (Adm). LVN 3 stated if LVN 3 witnesses an alleged abuse, LVN 3 will report the abuse allegation to the administrator no more than two hours from the time the alleged abuse happens. During an interview with Certified Nursing Assistant 3 (CNA 3) on 04/9/2024 at 8:56 PM, CNA 3 stated CNA 3 received training on mandated reporter on abuse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement its' policy titled, Care Plans, Comprehensive Person-Centered by failing to ensure the floor mat was in place for one of three sampled residents (Resident 2) who assessed as a high risk for falls. This deficient practice resulted in Resident 2 having multiple falls in the last three months and episodes of rolling or sliding out of bed, when not monitored closely. Findings: A review of Resident 2 ' s face sheet indicated Resident 2 was originally admitted to the facility on [DATE] with diagnoses that included abnormalities of gate and mobility, (This is when a person is unable to walk in a typical way. This may be due to injuries, underlying conditions, or issues with the legs and feet), generalized muscle weakness, (a lack of physical or muscle strength, throughout the body), dementia, (a condition characterized by progressive or persistent loss of intellectual functioning, especially with loss of memory), depression, (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 observations, interviews, and record revies the facility failed to provide necessary services to maintain good personal hygiene and grooming to 4 out of 7 sampled residents (Resident 1, 3, 6, and 7), by failing to provide scheduled showers. This deficient practice placed Residents 1, 3, 6, and7 at risk for skin infections, skin breakdown, and poor self-perception. Findings: A review of Resident 1's admission Record indicated the resident was re-admitted to the facility on [DATE], with diagnoses not limited to urinary tract infection [A condition in which bacteria invade and grow in the urinary tract (the kidneys, ureters, bladder, and urethra)], dementia (The loss of functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person ' s daily life activities). A review of Resident 1 ' s History and Physical dated 2/2/24, it indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (MDS- 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 that facility failed to obtain an order and initiate a care plan for a pressure sensitive alarm while on bed to alert staff when the resident gets up unassisted for one of one sampled resident (Resident 1). This deficient practice could have resulted in inappropriate care and treatment for Resident 1. Findings: A record review of Resident 1's admission Record, indicated the resident was admitted on [DATE] and readmitted on [DATE] with medical diagnosis including metabolic encephalopathy ( disorder of brain function), fracture of left pubis (A break in one or more of the bones in the pelvis), abnormalities of gait and mobility, muscle weakness, dysphagia (inability to swallow), urinary tract infection (bladder infection), thrombocytopenia (Low platelet level), hypertension (elevated blood pressure), major depressive disorder (Mood disorder characterized by sadness), insomnia (inability to sleep), hyperlipidemia (High cholesterol), dementia (memory loss) history…

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 that facility failed to obtain an order and initiate a care plan for a pressure sensitive alarm (An alarm designed to alert the caregiver when the resident gets out of bed) while on bed to alert staff when the resident gets up unassisted for one of two sampled residents (Resident 1). This deficient practice could have resulted in inappropriate and delayed care and treatment for Resident 1. Findings: A record review of Resident 1's admission Record, indicated the resident was admitted on [DATE] and readmitted on [DATE] with medical diagnosis including metabolic encephalopathy ( disorder of brain function), fracture of left pubis (A break in one or more of the bones in the pelvis), abnormalities of gait and mobility, muscle weakness, dysphagia (inability to swallow), urinary tract infection (bladder infection), thrombocytopenia (Low platelet level), hypertension (elevated blood pressure), major depressive disorder (Mood disorder characterized by sadness), insomnia…

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 staff supervised and did not leave a resident unattended in the restroom and develop a plan of care for one of three sampled residents (Resident 1). Resident 1 was a high risk for fall, needed a walker (Walking frame- is a device that gives support to maintain balance or stability while walking) for mobility. Resident 1 had cognitive impairment (When a person starts to have problems with their memory or thinking). As a result, Resident 1 experienced unwitnessed fall on 12/30/2023. Resident 1 experienced a change in condition (COC- A sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. Without intervention, the deviation could lead to clinically significant complications up to and including death) and was transferred to General Acute Care Hospital (GACH) on 12/31/2023. Resident 1 was admitted in Intensive Care Unit (ICU - A medical unit for 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 interview, and record review, the facility failed to meet professional standards of quality for one of five sample residents (Resident 1) by failing to monitor and document Resident 1 ' s blood pressure while administering nifedipine (medication to treat high blood pressure and chest pain) to Resident 1 according to physician ' s order. These deficient practices had the potential to result in unintended complications related to the management of blood pressure such as hypotension (abnormally low blood pressure) and can lead to falls and injury. Findings: A review of admission Record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including hypertensive heart disease (a long-term condition that develops over many years in people who have high blood pressure), unspecified dementia (loss of cognitive functioning-thinking, remembering, and reasoning), and chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure). A review of the Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow its policies on Administering Medications, Documentation of Medication Administration, and Resident Rights to one of three sampled residents (Resident 4) by failing to: 1. Ensure Resident 4 was informed and educated on what medications she was taking. 2. Ensure proper medication administration documentation was performed for Resident 4. These deficient practices violated Resident 4 ' s right to know about her care and treatment and had the potential for Resident 4 to miss her medication. Findings: A review of Resident 4's admission Record (Face Sheet) indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included dementia (chronic mental ability decline characterized by impaired ability to remember, think, or make decisions that interferes with doing everyday activities), chronic systolic heart failure (a condition in which the heart can't pump enough blood to meet the body's needs), hypertension (high…

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 revise a care plan on risk for falls after a fall for one of three sampled residents (Resident 1). This deficient practice had the potential to negatively affect the provision of care and services for Resident 1. Findings: A review of the admission Record (Face Sheet) indicated the facility admitted Resident 1 on 3/22/2023 with diagnoses that included dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (feeling of fear, dread, and uneasiness) and hypertension (high blood pressure). A review of the Minimum Data Set (MDS, an assessment and care screening tool), dated 6/28/2023, indicated Resident 1 had impaired cognition. The MDS indicated Resident 1 required supervision in bed mobility, transfer, walking in the room, walking in the corridor, eating and personal hygiene; and required limited assistance (staff…

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 any Ombudsman (OMB- an appointed official to investigate and attempt to resolve conflicts/concerns raised by individuals against businesses, financial institutions, or other public entities) information inside facility premises. This deficient practice may have prevented residents and resident ' s family access to the OMB. Findings: During a concurrent observation and interview on 8/3/2023 at 10:18 AM with Facility Administrator (FA), there was no posting of the OMB contact information in the nursing station, activity room, facility lobby and/or hallways. FA confirmed the findings and stated, they (Maintenance Department) started painting (the facility) last week. During an interview on 8/3/2023 at 12:00 PM with Registered Nurse Supervisor (RNS), RNS stated the OMB poster, which included the OMB contact telephone number, should be posted in the facility at all times. RNS stated the facility had started repainting the walls of the facility two weeks ago and was not put back up until today (8/3/2023). If…

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 safekeep and maintain Resident 1 ' s personal belongings by not updating Resident 1 ' s Inventory List as indicated in the facility ' s policies and procedures (P&P). This deficient practice had resulted in missing packages for one of three residents (Resident 1). Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), rheumatoid arthritis (a disorder affecting joints of they body including hands and feet), and hypothyroidism (or underactive thyroid, happens when your thyroid gland doesn't make enough thyroid hormones to meet your body's needs). A review of Resident 1 ' s Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 6/9/2023, indicated Resident 1 was moderately cognitive impaired (the mental action or process 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 report no later than 24 hours the allegation of abuse to the facility administrator, and to other officials (including to the State Survey Agency adult protective services where state law provides for jurisdiction in long-term care facilities), failed to report the results of the investigations within five (5) working days, and failed to provide proof that appropriate corrective action was taken by the facility regarding the alleged abuse for one of three sampled residents (Residents 1). This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect residents from abuse. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), rheumatoid arthritis (a disorder affecting joints of they body including…

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

Based on interview and record review, the facility failed to keep employee records in the facility. This deficient practice prevented the State, during an unannounced visit to the facility, an audit to employee files while onsite and delayed the complaint investigation. Findings: During an interview on 8/3/2023 at 2:16 PM with Director of Staff Development Nurse (DSD) and Facility Administrator (FA), DSD stated she does not have Social Services Director (SSD), Director of Nursing (DON), and any other department head employee files. FA stated the facility does not have the SSD or DON employee files in the facility and corporate has both employee files. FA stated the facility was unable to provide the State the actual original copy of SSD and DON ' s employee files for audit and had caused a delay in the complaint investigation. FA stated both employee files should have remained in the facility. During a review of the facility ' s policy and procedure (P&P) titled Employee Personnel Policies, dated 1/2008, indicated information relative to our employee personnel policies may be…

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 interviews and record review, the facility failed to: 1. Annually review facility policies and procedures (P&P) for 13 of 13 sampled P&P. 2. Have a readily available copy of the facility's P&P in the nursing station for staff access. This deficient practice may place residents at risk of harm if staff does not have access to P&P and does not follow facility guidelines. Findings: During a concurrent observation and interview on 8/3/2023 at 10:46 AM with Licensed Vocational Nurse (LVN 1) and Facility Administrator (FA), in the Nursing Station, no policy and procedures were found in the Nursing Station. FA stated it is not mandated to keep a copy of P&P in nursing stations and the P&P binder is located in the FA and Director of Nursing ' s (DON) office. FA stated the DON is not in the facility. LVN 1 stated if she needs to find a policy, she will call the DON for guidance. During a concurrent interview and record review on 8/3/2023 at 1:27 PM with Medical Records (MR), the facility ' s P&P titled, Facility Policies and Procedures- Annual Review, revision date of 10/2018 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medical records were updated to indicate that advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) information was provided and discussed residents and/or responsible parties for four of19 sampled residents (Residents 1, 33, 84 and 235). These deficient practices violated the rights of Residents 1, 33, 84, and 235 and/or their representatives to be fully informed of the option to formulate advance directives and had the potential for conflict with the Residents 1, 33, 84 and 235 health care wishes. Findings: 1. A review of Resident 1's admission Record indicated the facility re-admitted Resident 1 on 1/20/2022, with diagnoses limited to acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood), malnutrition (lack of sufficient nutrients in the body), muscle weakness,…

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 care plan for anti-depressant Medication to treat depression [a mood disorder that causes persistent feeling of sadness and loss of interest], anti-anxiety (medication to treat/reduce anxiety [intense, persistent worry and fear], and sedative [medication to aid with sleep] medications for two of two sampled residents (Residents 24 and 33) These deficient practices had the potential for Residents 24 and 33 to not receive/benefit from necessary care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings: 1. A review of Resident 24's admission Record indicated the facility re-admitted Resident 24 on 11/15/2021, with diagnoses not limited to metabolic encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), COVID-19 (Coronavirus- a deadly respiratory disease…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based an interview and record review, the facility failed to ensure that a Registered Nurse (RN) was designated to work onsite in Facility 1 for at least eight consecutive hours a day, 7 days a week, and was not shared between two sister facilities for 41 of 41 in house residents. This deficient practice had the potential for the facility to not manage, oversee nursing services and, deliver high-quality and effective health care services to achieve positive clinical outcomes, and resident/family satisfaction for 41 residents. Findings: A review of Facility 1's Daily Census dated 1/23/2022, indicated Facility 1 had 41 residents in house. A review of Facility 1's nursing hours posted on 1/24/2022, 1/25/2022, 1/26/2022 and 1/27/2022 indicated the facility had an RN working 8 hours on the 7-3 shift. During an interview with the Director of Staff Development (DSD) on 1/26/2022 at 3:24 p.m., the DSD stated that an RN always worked 8 hours a day in Facility 1, however, the RN was shared with Facility 2 which was next…

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 portion sizes as indicated on the menu for residents on mechanical soft and pureed diet as indicated on the menu. This deficient practice had the potential for inadequate and or over adaequate protein and caloric intake for residents on mechanical soft and pureed diet. Findings: A review of the facility's document titled Cooks Spreadsheet Winter Menus dated 12/29/21, 01/26/22, and 02/23/22, indicated food portioning as follows: a) regular portion for oatmeal would be 3/4 cup or 6 ounces (oz-unit of measurement) b) regular portion for mechanical soft breakfast meat should be served with a # (number) 24 scoop providing a 1/6 cup (graded cup) c) regular portion for pureed breakfast meat should be served with a #24 scoop providing a 1/6 cup. During a concurrent observation and interview with Dietary Supervisor (DS),on 01/26/22, at 6:52 a.m., [NAME] 1 did not use a spoodle (a cross between a spoon and a ladle) with a dark blue handle serving 8 oz to serve oatmeal for residents. The DS stated that [NAME] 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, interview, and record review, the facility failed to ensure food was served at appetizing temperatures and as recommended per facility's policy and procedures. This deficient practice had the potential to result in decreased food intake for residents who eat at the facility. Findings: During dining room observation and concurrent interview with Dietary Supervisor (DS) on 01/26/22, at 7:52 a.m., the following test foods temperatures were recorded as follows: a) Regular French toast: 77.5°F (Fahrenhiet-unit to measure temperature). b) Regular sausage: 85°F. c) Hot oatmeal: 116.9°F. d) Juice: 48.2°F. A review of the facility's policy and procedure titled Meal Service, dated 2020, indicated recommended temperature at delivery to resident are as follows: a) Waffles/Pancakes, French Toast: greater than or equal to 120°F b) Hot Entrée: greater than or equal to 120°F c) Soup or Hot Cereal: greater than or equal to 140°F d) Milk/Cold Beverage: less than or equal to 45°F A review of the facility's policy and procedures titled Meal Service dated 2020, indicated Cold 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 observation and interview the facility failed to ensure Certified Nurse Assistants 2 and 4 ( CNAs 2 and 4) performed hand hygiene before and after direct contact with Resident 185, and before and after distributing residents' meal. These deficient practices had the potential to spread infection and food borne illness from staff to among residents. Findings: A review of Resident 185 admission Record indicated the facility admitted Resident 185 on 12/08/2021 with diagnoses that included chronic kidney disease (long standing kidney disease that can result in kidney failure), Urinary Tract Infection (UTI-an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney), and Benign Prostatic Hyperplasia (enlarged prostate gland that can cause difficulty to pass urine). During an observation on 01/04/2022, at 10:44 a.m., CNA 4 provided patient care to Resident 185 and exited the room without performing hand hygiene. During a concurrent interview with CNA 4 on 01/04/2022 at 10:46 a.m., CNA 4 stated that she should perform hand hygiene 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 Certified Nurse Assistant 1 (CNA 1) did not stand when feeding two of two sampled residents (Residents 1 and 31). This deficient practice violated the right to be treated with dignity and respect, enhance the quality of life and individuality, and had the potential to compromise the safety of Residents 1 and 31. Findings: 1. A review of Resident 1's admission Record indicated the facility re-admitted Resident 1 on 1/20/2022, with diagnoses that included, and not limited to acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood), malnutrition (lack of sufficient nutrients in the body), muscle weakness, dysphagia (difficulty swallowing food or liquid), and diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]) A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 12/6/2021, 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 observation, interview, and record review, for one of one sampled resident (Resident 22), the facility failed to: Ensure bilateral (one each side) full side rails were not pulled up while Resident 22 was in bed Obtain physician's order to use bilateral full bed side rails for Resident 22 Conduct Interdisciplinary Team (IDT-A team of primary care providers, specialist, and professionals who plan, coordinate, and deliver a person's health care) assessment for Resident 22. These deficient practices resulted in physical restraint (any manual method, physical or mechanical device, equipment, or material, that is attached or adjacent to the resident's body; and cannot be removed easily by the resident) and had the potential to result in entrapment (state of being caught in), injury, and or death for Resident 22. Findings: A review of Resident 22's admission Record indicated the facility re-admitted Resident 22 on 1/10/2022, with diagnoses not limited to COVID-19 (Coronavirus- a deadly respiratory disease transmitted from person to person), chronic obstructive pulmonary disease…

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 appropriate treatment and care, based upon current standards of practice and the resident's care plan for the prevention of a urinary tract infection (UTI-an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney) to the fullest extent possible for Resident 185 This deficient practice had the potential to result in UTI for Resident 185 Findings: A review of Resident 185's admission Record indicated the facility admitted Resident 185 on 12/08/21 with diagnoses not limited to Type 2 Diabetes Mellitus (a chronic [long term] condition that affects the way the body processes blood sugar), Anemia (a low amount of red blood cells in the blood), Schizoaffective Disorder (a mental health condition including schizophrenia and mood disorder symptoms), Chronic Kidney Disease [disease of the kidneys leading to kidney failure], UTI, and Benign Prostatic Hyperplasia [prostate gland enlargement that can cause difficulty passing urine] A review of Resident 185's Minimum…

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

Based on observation, interview and record review, the facility failed to ensure Licensed Vocational Nurse 1 (LVN 1) immediately and accurately documented Ativan (sedative medication that can relieve anxiety) medication on the Controlled Medication Count sheet (CMCS-accountability record log record for medications considered to have strong potential for abuse) after administration to one sampled resident. This deficient practice increases the risks medication diversion (transfer of a medication from legal to an illegal use) and delayed Ativan refill for the resident. Findings: During a concurrent observation of the medication cart and interview with LVN 1 on 1/24/2022 at 10:53 a.m., Ativan bubble pack (packaging in which the medications are organized and sealed between a cardboard backing and clear plastic cover) and Ativan documented on the CMCS count were not the same. LVN 1 stated and verified that there were 26 tablets in the bubble pack while 27 count was reflected on the CMCS. LVN 1 further stated that she forgot to document and sign the CMCS after she administered Ativan 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.

Based on observation, interview and record review, the facility failed to ensure that: 1. Unopened insulin (medication to treat high blood sugar) vials and pens were refrigerated. 2. Opened fluphenazine (anti-psychotic medication) vial, ketoconazole (anti-fungal medication) 2% cream, nystatin-triamcinolone (anti-fungal and yeast medication) cream and Lotrisone (anti-fungal medication) cream was labeled with date. 3. Ointments and creams were placed separated with the oral medications in the medication cart. 4. Temperature logs for medication and specimen fridge were monitored and recorded twice daily per facility policy. These deficient practices had the potential to compromise the safety and effectiveness of medications, resulting in possible medication errors. Findings: During an observation with the Licensed Vocational Nurse 1 (LVN 1) in Nursing unit 1 on 1/24/2022 at 10:48 a.m., the following were identified: 1a. Unopened Insulin lispro (medication to treat diabetes [high blood sugar]), Humulin R (medication to treat diabetes) and Admelog (medication to treat diabetes) vials…

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.