Ocean Pointe Healthcare Center

Based on observation and interview, the facility failed to ensure that a private caregiver did not provide incontinent care direct care to one of one resident (Resident 77) according to the facility's policy and procedures (P&P) tiled Private Duty Sitter, revised 1/2026. This deficient practice had the potential to result in infection, injury and/or hospitalization for Resident 77.Findings: A review of Resident 77's admission Record indicated the facility admitted Resident 77 on 10/23/2024 and readmitted Resident 77 on 5/26/2026 with diagnoses including dementia (progressive state of decline in mental abilities), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and hypertension (HTN - high blood pressure). A review of Resident 77's Minimum Data Set (MDS - resident assessment tool) dated 5/30/2026, indicated Resident 77 is cognitively impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 77 is dependent on staff with activities of 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 interview and record review, the facility failed to ensure that a Registered Nurse (RN) was on duty on the 7am-3pm, 3pm-11pm, and 11pm-7am shifts on 7/20/2026. The facility had 64 residents in house. This failure had the potential for the residents' clinical needs not to be met and delayed assessments and interventions when needed. Findings: During a review of the facility's Licensed Nursing Schedule, dated July 2025, the Licensed Nursing Schedule indicated that there was no RN on duty for 7/20/2025. During a concurrent interview and record review on 6/4/2026 at 11:50 A.M. with the Director of Staff Development (DSD), the facility nursing assignment sheet, dated 7/20/2025 was reviewed. The nursing assignment sheet indicated that on 7/20/2025, there was no RN on-duty for 8 consecutive hours on all three shifts (7am-3pm, 3pm-11pm, and 11pm-7am). The DSD confirmed and stated that there was no RN on duty for 8 consecutive hours on 7/20/2025. The DSD stated that if there is no RN is on duty, the facility cannot perform assessments on the residents and certain medication will not…

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 lids of two of three sampled outside garbage bins were closed. This failure had the potential to attract pests that could create a health and safety risk to the residents, visitors, and staff in the facility.Findings: During a concurrent observation and interview on 6/1/2026 at 1:31 P.M. with the Food Services Director (FSD) in the alley behind the facility, two outside garbage and recycling bin lids were left open. The FSD stated that garbage bins must be covered to prevent pests. During a review of The U.S. Food and Drug Administration's Food Code, dated 2022, the regulation indicated, Receptacles and waste handling units for refuse, recyclables, and returnables used with materials containing food residue and used outside the food establishment shall be designed and constructed to have tight-fitting lids, doors, or covers.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure staff completed documentation on dental ancillary (supportive medical) services for one of one sampled resident (Resident 63) according to facility's job description titled, Social Service Designee, dated 2003, and the facility's policy and procedures (P&P) titled, Dental Services, dated 1/2026. This failure had the potential to not meet the physical and psychosocial needs of Resident 63. Findings: During a review of Resident 63's admission record, dated 3/31/2026, the admission record indicated Resident 63 was admitted to the facility on [DATE] with diagnoses but not limited to fracture of the left mandible (lower jawbone), dementia (a state of decline in mental abilities), hypertension (high blood pressure), and dysphagia (difficulty swallowing). During a review of Resident 63's Minimum Data Set (MDS- a resident assessment tool), dated 4/4/2026, the MDS indicated Resident 63 was cognitively (mental ability to make decisions of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the complete implementation of infection control practices in the facility, when Licensed Vocational Nurse (LVN) 2 did not clean and disinfect (use of chemical agents to destroy germs) shared resident care equipment before and after use for two of 20 sampled residents (Resident 35 and Resident 30).This failure had the potential for resident harm, as not cleaning and disinfecting shared resident care equipment before and after use can spread pathogens (disease causing germs) between residents throughout the facility, leading to transmission of infection to multiple residents in the facilityFindings: During a review of Resident 35's admission Record (Face sheet, which includes a resident's identification, medical, and demographic information), dated 6/4/2026, the admission Record indicated, the facility initially admitted Resident 35 on 6/10/2024, and then readmitted on [DATE], with medical diagnoses that included metabolic…

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, the facility failed to ensure that the resident's call button (a button or remote on a cord that a patient in a hospital or nursing home presses to get help) was within reach for three of seven residents (Residents 8, 47, and 58) when residents 47's according to the facility's policy and procedure (P&P) tiled Call Lights: Accessibility and Timely Response, with revision date 10/2025. This deficient practice had the potential to result in delayed care, falls, accidents and/or hospitalization for Residents 8, 47, and 58. Findings: 1. During a review of Resident 8's admission Record, the record indicated that Resident 8 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (a type of irregular heart beat), Alzheimer's disease (a brain disease that affects memory, thinking skills, and the ability to carry out simple daily tasks), and care following a surgery on the digestive system. During a review of Resident 8's Minimum Data Set (MDS, an assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record reviews, the facility failed to ensure one of four sample resident (Resident 1) was provided with immediate interventions such as monitoring and assessment to assure the safety of the resident after Resident 1 reported an allegation of physical altercation between another resident (Resident 2) according to facility's policy and procedure (P&P) titled, Alleged or Suspected Abuse and Crime Reporting and Charting and Documentation.This deficient practice placed residents being subject to neglect, verbal, mental and physical abuse.Findings:During a review of Resident 1's admission Record, it indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), difficulty in walking, Type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and depression (a mood 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 observation, interview, and record review, the facility failed to ensure resident's call light (a device used to notify the nurse that the resident needs assistance) were answered promptly for two of three sampled residents (Resident 2 and Resident 3). This deficient practice had the potential to result in the residents not being able to summon staff for assistance for care and services as needed, which could lead to accidents such as falls with injuries. During a review of the admission Record, the record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including history of falling, muscle weakness (weakening, shrinking, and loss of muscle), fibromyalgia (a condition that causes pain all over the body, sleep problems, fatigue, and often emotional and mental distress) and difficulty in walking. During a review of the Minimum Data Set (MDS - resident assessment tool) dated 12/9/2025, indicated Resident 2's cognitive (mental action or process of acquiring knowledge and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that staff follow infection prevention when Treatment Nurse 1 (TXN 1) and Certified Nurse Assistant (CNA) 3 did not wear personal protective equipment (PPE- protective items or garments worn which includes the use of gloves, gown, mask, face shield, when anticipating coming in contact with blood, body fluids or other communicable toxins or agents) when providing suprapubic catheter change for one of four sampled residents (Resident 1) who was on Enhanced Barrier Precaution (an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs - bacteria that are resistant to more than one antibiotic and can cause serious infections in nursing facilities).This deficient practice has a potential for Resident 1 risk for acquiring and transmitting infection to other residents, staff and visitors in the facility.Findings:During a review of Resident 1's admission Record , the admission record 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 interview and record review, the facility failed to notify a physician after a significant change (COC- a sudden clinically important decline from a patient's baseline in physical, cognitive, behavioral, or functional abilities) in the mental or physical condition of a resident who had abnormal laboratory (lab) results for one of the three sampled residents (Resident 1)This deficient practice could have resulted in in the worsening of Resident 1's symptoms such as pain and sepsis (a life-threatening blood infection).During a review of the admission record for Resident 1indicated Resident 1was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (a condition where the brain does not function properly due to an underlying metabolic disturbance), hypertension (HTN-high blood pressure), and dementia (a progressive state of decline in mental abilities). During a review of history and physical (H&P- is a thorough assessment a doctor does to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, facility failed to meet professional standards of quality by failing to ensure that one of four sampled residents (Resident 1)'s medications were administered in accordance with the physician's orders, including any required time frame according to facility's policy and procedure (P&P), titled, Administering MedicationsThis deficient practice increased the risk for accidents and jeopardized resident's health and safety by failing to administer necessary medications in accordance with the physician order.Findings:During a review of the admission Record, Resident 1 was admitted to the facility on [DATE] with diagnosis including unspecified convulsions (sudden, involuntary muscle spasms that can affect the whole body or a part of it), sepsis (a life-threatening blood infection) and congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).During a review of the Minimum Data Set (MDS - resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident received appropriate treatment and services to prevent urinary tract infection (UTI- an infection in the bladder/urinary tract) for one of three sampled residents (Resident 1) by failing to notify the physician when Resident 1 complained of pain and staff observed sediments in Resident 1's indwelling urinary catheter (foley catheter - a hollow tube inserted into the bladder to drain or collect urine).This deficient practice had the potential to result in urinary tract infections and urinary complications for Resident 1.Findings:During a review of the admission Record, Resident 1 was admitted to the facility on [DATE] with diagnosis including UTI, sepsis (a life-threatening blood infection) and congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).During a review of the Minimum Data Set (MDS - resident assessment tool) dated 9/10/2025 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 interview and record review, the facility failed to follow their policy and procedures for resident rights by failing to inform the resident's Responsible Party (RP, person who agrees to handle the resident's affairs)/Power of Attorney (POA, a legal document where a person (the principal) appoints an agent to make decisions for them when they are unable to do so themselves) about a change in the resident's medication dosage for one of three sampled residents (Resident 1). This deficient practice had the potential to negatively affect the resident's health and care.During a review of Resident 1's admission Record, dated 11/14/25 indicated, the resident was admitted to the facility on [DATE] with diagnoses including; muscle weakness, dysphagia (difficulty swallowing), dementia (a progressive state of decline in mental abilities), hyperlipidemia (HLD - a condition characterized by elevated levels of lipids (fats) in the bloodstream), and hypothyroidism (a condition where the thyroid gland doesn't produce…

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 72543(b) Based on observation, interview and record review, the facility failed to maintain medical records for one out of three residents (Resident 1) in accordance with accepted professional standards and practices by ensuring accurate documentation. This failure resulted in the facility's failure to reflect Resident 1's condition and care services provided across all disciplines when Resident 1 had a Change of Condition (COC- a sudden clinically important decline from a patient's baseline in physical, cognitive, behavioral, or functional abilities) as transferred to General Acute Care Hospital (GACH) on 8/3/2025.During a review of the admission record for Resident 3 indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including left and right rim of pubis (bone located in the front part of the pelvis [bony structure inside your hips, buttocks and pubic region]) fractures (break in bone), cerebral infarction (ischemic stroke - is the death of 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.

Based on interview and record review the facility failed to: 1) Ensure staffing information on the Direct Hours Patient Day (DHPPD - a list of staff hours of direct daily care) form was completed and posted in a prominent place readily accessible to residents and visitors daily. 2) Ensure daily staffing (DHPPD) form was completed and available to the public for review upon request. 3) Maintain/Retain records of the posted daily nurse staffing (DHPPD) data for a minimum of 18 months. These deficient practices misinformed all 63 residents, families, and visitors about the facility's daily nurse staffing data. Findings: During a concurrent interview and record review on 03/20/2025 at 2:40 PM with the Director Staff Development (DSD), the DSD stated DSD was responsible in filling out the DHPPD. The DSD stated the DHPPD forms for 10/11/2024, 10/12/2024, and 3/9/2025 forms were missing. The DSD stated facility should post the DHPPD form every morning and keep the records for 18 months. The DSD also stated DHPPD form should be reviewed and signed by DON or Designee and the records should…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and preparation practices when the facility failed to: 1. Ensure all opened food items stored in one out of three reach-in refrigerators were labeled with the name of the food item, open date, and expiration date. 2. Have a room thermometer in the dry storage area. These deficient practices placed all sixty three facility residents at risk for foodborne illness which could lead to serious infections and death. Findings: During a concurrent observation and interview on 3/18/2025 at 7:50 AM with the Dietary Supervisor (DS), the facility's Reach-In Refrigerator #3 had 3 halved avocados wrapped in saran wrap. The opened avocados were not labeled with an opened date, expiration date or name of the food item. The DS stated opened avocados should be kept more than two days. The DS further stated the avocados were not labeled and are required to be once opened. The DS also stated we date opened items so that we know when it was opened and when to discard them in order to prevent…

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 the industrial washing machine used to wash the facility linen and residents including clothing was not leaking. This deficient practices had the potential to result in a significant delay in providing clean and sanitary linen for 63 of 63 medically compromised residents who depend on staff to provide a homelike environment. In addition to allowing easy access and exit to and from the dining hall for residents that chose to eat in the dining hall. Findings: During observation of the laundry room on 3/20/25 at 9:36 AM, there was a red bucket with towels placed under the bucket on the floor. The bucket was used to catch water leaking from the washing machine creating a medium to large size puddle next to and around the immediate area of the laundry machine. During an interview on 3/20/25 at 9:38 AM, Laundry Supervisor (LS) stated LS was not sure how long the laundry machine has been leaking for and that LS needed to check with Maintenance Supervisor (MS) regarding same. LS stated MS takes care of all…

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: 1. The floor in laundry room walkway did not have holes and was not cracked. 2. The door leading to the resident dining hall was operational and functional. These deficient practices had the potential for injury to residents, staff, and guests, and interfere with the residents, staff, guests to safely enter or exit through the door. Findings: 1. During observation of the laundry room on 3/20/25 at 9:36 AM, the floor in front of the industrial laundry machine was cracked and had medium to large size holes in the concrete floor just in front of the washing machine. During an interview on 3/20/25 at 9:38 AM Laundry Supervisor (LS) stated the Maintenance Supervisor (MS) takes care of all repairs. The LS stated he was not aware of how long the floor have been in disrepair either because, the MS handles all the repairs in the facility. During an interview on 3/20/25 at 10:16 AM, MS stated MS was considering replacing the floor by pouring concrete on the floor instead of the ceramic tiles that currently…

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 a resident's written notice of transfer was provided to the resident's responsible party as soon as practicable for one (1) out of the three residents (Resident 13). This deficient practice had the potential to result in the resident's responsible party being unaware on the resident's status and whereabouts, on how to contact the State Long Term Care Ombudsman (public advocate), and on how to appeal the transfer if necessary. Findings: During a record review, Resident 13's admission Record indicated that the facility originally admitted Resident 13 on 12/27/2014, and readmitted the resident on 11/28/2024, with diagnoses including ESRD (End Stage Renal Disease-irreversible kidney failure), dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) and dementia (a progressive state of decline in mental abilities). During a record review, Resident 13's Minimum Data Set (MDS- a resident assessment tool) dated 12/3/2024,…

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 two residents (Resident 30) had bilateral floor mats per the physician order and the resident's high risk for falls and injury care planned interventions. This deficient practice placed Residents 30 at risk for injury. Findings: During a record review, Resident 30's admission Record indicated the facility admitted Resident 30 on 11/5/2024 with diagnoses including dementia (a progressive state of decline in mental abilities), muscle weakness (a lack of strength in the muscles), abnormalities of gait and mobility (when the pattern in which you walk and move is not normal) and atrial fibrillation (AFib - an irregular heartbeat that can lead to blood clots and increases the risk of stroke and other heart complications) . During a record review, Resident 30's Minimum Data Set (MDS - a resident assessment tool) dated 2/8/2025, indicated Resident 30 had moderate impaired cognition (ability to think, understand, and reason). The MDS further indicated Resident 30 required supervision to moderate…

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 label enteral hydration for one of sixteen sampled residents (Resident 162). These deficient practices had the potential to cause complications associated with enteral (delivery of nutrients or medications through the gastrointestinal tract, via a tube.) feeding, including infection and/or possible hospitalization. Findings: During a record review, Resident 162's admission Record indicated the facility admitted Resident 162 on 3/17/2025 with diagnoses including moderate protein-calorie malnutrition (deficiency of both protein and energy [calories] in the diet, leading to a weight loss of 75% (percent) to 85% of expected weight for length or height), gastrostomy status (a surgical opening, or stoma, directly into the stomach), adult failure to thrive (decline in older adults, characterized by weight loss, poor nutrition, decreased appetite, and inactivity, often accompanied by dehydration, depression, impaired immune function, and low cholesterol), methicillin resistant staphylococcus aureus infection (MRSA- a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure one of one sampled resident (Resident 1) was properly supervised and monitored for safety after the facility was notified of Resident 1's Family Member 2's (FM 2) had a case order with the Adult Protective Services (APS - a social services program focused on helping elderly adults and adults with disabilities live with dignity and respect by investigating allegations of abuse, neglect, self-neglect and exploitation). This deficient practice placed Resident 1 at risk of abuse and neglect. Cross reference to F656 Findings: A review of the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including ESRD (End Stage Renal Disease-irreversible kidney failure), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong…

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 safe and orderly discharge from the facility to home for one of four sampled residents (Resident 1) by failing to: 1. Properly discharge Resident 1's without completing a pre-dialysis and post-dialysis assessment after resident's dialysis treatment on 12/30/2024. 2. Complete a discharge plan summary upon Resident 1's discharge to home on [DATE]. 3. Complete an Interdisciplinary Team (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need) meeting for Resident 1's discharge planning according to facility's policy and procedure (P&P). These deficient practices had the potential to result in incomplete or ineffective discharge planning and can lead to lack of necessary care for Resident 1 after discharge. Findings: A review of the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including ESRD…

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 four sampled residents (Resident 1) by failing to ensure that a comprehensive (CP) was developed after the facility was notified that Resident 1's Family Member 2 (FM 2) have a case order with the Adult Protective Services (APS - a social services program focused on helping elderly adults and adults with disabilities live with dignity and respect by investigating allegations of abuse, neglect, self-neglect and exploitation). 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. Cross Reference F600. Findings: A review of the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including ESRD (End Stage Renal Disease-irreversible kidney failure), chronic…

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 reasonable accommodation of resident needs and preferences for one of four sampled residents (Resident 3) by failing to ensure Resident 3 felt safe and comfortable inside Resident 3's room. Resident 3's roommate (Resident 2) was constantly screaming and cursing. This deficient practice had the potential to negatively impact the psychosocial well-being of Resident 3 and had the potential to delay necessary care for Resident 3. Findings: A review of Resident 2's admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnosis that included sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), anxiety, depression (a mood disorder that causes persistent feeling of sadness and loss of interest) and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic…

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 a grievance involving one of two sampled residents (Resident 1) was completed per the facility policy by failing to: 1. Ensure a prompt effort to resolve Resident 1's family members (R1FM) grievance when R1FM expressed issues against Resident 1's roommate (Resident 2). 2. Ensure facility staff report all alleged violations (neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property). These deficient practices violated R1FM's right to have grievance addressed and had a potential to delay any necessary care and services for Resident 1. Findings: A review of Resident 1's admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses that included lack of coordination, diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]) and dementia (a chronic or persistent disorder of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its policy and procedure for ensuring the reporting of a reasonable suspicion of an abuse in accordance with state and federal law involving one of one sampled resident (Resident 1). This resulted in a delay of an onsite inspection by the State Agency (SA) to ensure the safety of the residents and had the potential to result in unidentified abuse in the facility as well as failure to protect residents from any possible abuse. Cross Reference F610. Findings: A review of Resident 1's admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including lack of coordination, diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]) and dementia (a chronic or persistent disorder of the mental processes caused by brain disease). A review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and care screening 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 interview and record review, the facility failed to implement its abuse policies and procedures to ensure an investigation was completed for any reasonable suspicion of an abuse in accordance with state and federal law for one of one sampled resident (Resident 1). This resulted in a delay of an onsite inspection by the State Agency (SA) to ensure the safety of the residents and had the potential to result in unidentified abuse in the facility as well as failure to protect residents from any possible abuse. Cross Reference F609. Findings: A review of Resident 1's admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including lack of coordination, diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]) and dementia (a chronic or persistent disorder of the mental processes caused by brain disease). A review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and…

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

Based on observation, interview, and record review, the facility failed to ensure the safety of storing, preparing, distributing, and serving food in accordance with professional standards and its policies for food service when: 1) Multiple food items in the kitchen did not bear a label indicating a use-by date in accordance with the policy. 2) Multiple food items were expired or did not have an open date. These deficiencies had the potential to result in food-borne illness in medically vulnerable residents who consumed the food prepared by the facility kitchen. Findings: During an observation and a concurrent interview with Dietary Supervisor (DS), on 3/12/2024 at 8:30 AM, the following were observed: 1. A container of dill weed had an expiration date of 2/25/24. 2. A container containing beans did not have a use by label. 3. A bag of green lentils did not have a used by label. 4. A gallon of milk did not have an open date or expiration date. 5. A container containing prunes did not indicate a use by date. 6. A container containing peaches did not have any labels indicating use 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 interview and record review, the facility failed to initiate a change of condition (COC) for one of six sampled residents (Resident 13), who was readmitted from a general acute care hospital (GACH) with significant weight loss. As a result, a physician was not notified of Resident 13's weight loss, which placed Resident 13 at risk for further weight loss. Findings: A review of Resident 13's admission Record, indicated Resident 13 was initially admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including thrombocytopenia (low platelet level), elevated white blood cell count (measures the number of white cells in the blood), end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), chronic respiratory failure (a condition when the lungs cannot get enough oxygen into the blood), muscle weakness, dysphagia (inability to swallow), type 2 diabetes (body's inability to process blood sugar), depression (loss of pleasure or interest…

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 a safe homelike environment for eight ambulatory residents. This deficient practice had the potential to result in residents falling in the hallway due to uneven surfaces in the facility hallways and resident rooms. The area of the floor was slightly raised potentially leading to a tripping hazard for the residents in the facility. Cross Reference F919 Findings: During an observation on 11/6/2023 at 8 AM., the hallway floor in front of Resident rooms 9, 10, 11, 14, 15, and 16, and in Nurses' Station 2, had bulged up area. During an interview on 3/13/2024 at 12:06 PM., Maintenance Supervisor (MS) stated that MS had spoken to the Administrator concerning the bulges floor outside rooms Resident rooms 9, 10, 11, 14, 15, and 16. MS stated the Administrator (ADM) was aware the floor had uneven surface with air bubbles, causing the floor to bulge. MS stated MS attempted to take out the bubble by cutting the tiles and allowing the air to escape; however, that did not work, and the floor remained uneven with small to medium…

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 a comprehensive care plan for one of five residents (Resident 49), who was placed on a psychotropic medication (medication that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior). This deficient practice had a potential for Resident 49 to not receive appropriate care and treatment related to the specific use of psychotropic medication. Findings: A review of Resident 49's admission Record, indicated Resident 49 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including type 2 diabetes (elevated blood sugar), lack of coordination, hyperlipidemia (elevated cholesterol), anxiety disorder (a mental health disorder characterized by feelings of worry), hemiplegia (paralysis of one side of the body), hypertension (elevated blood pressure), retention of urine (inability to urinate), transient ischemic attack (a short period of symptoms similar to a stroke), cerebral…

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 the physicians order for oxygen supplementation for one of six sampled residents (Resident 119). This deficient practice had the potential to result in inappropriate treatment of oxygen delivery, placing Resident 118 at risk to experience shortness of breath and/or hypoxia (a state in which oxygen is not available in sufficient amounts at the tissue level to maintain adequate homeostasis) Findings: A review of Resident 118's admission Record, indicated Resident 118 was initially admitted on [DATE], and readmitted on [DATE] with diagnoses including bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), anxiety disorder (persistent worry), depression (a mood disorder characterized by feelings sadness), anemia (low blood red blood cells), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), chronic respiratory…

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 administer pain medication in accordance with physician's orders and care plans for one out of eight sampled residents (Residents 58). As a result, Resident 58 suffered burning pain level 9 out of 10 (9/10 - numerical pain assessment tool where zero is no pain and 10 is severe pain) to the left leg for two hours. Cross reference to F919 Findings: A review of Resident 58's admission Record dated 3/13/2024, indicated the facility initially admitted Resident 58 on 10/18/2022 with diagnoses that included toxic encephalopathy, (a brain dysfunction caused by toxic (poisonous substances) exposure), muscle weakness (a lack of physical or muscle strength, throughout the body, essential hypertension (high blood pressure), and hemiplegia, (paralysis (is when you are not able to move some or all your body) that affects only one side of your body) affecting the left side of the body. A review of Resident 58's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 1/17/2024, indicated Resident 58 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, interviews, and records review, the facility failed to: 1) Ensure staffing information was posted in a prominent place readily accessible to residents and visitors. 2) Make nurse staffing information readily available in a readable format to residents and visitors at any given time. 3) Make daily staffing available to the public for review upon request. 4) Maintain the posted daily nurse staffing data for a minimum of 18 months. Findings: During an observation on 3/12/2024 at 12:50 PM, the nurse staffing data information was not posted anywhere in the facility visible to residents and visitors. During an observation on 3/13/2024 at 9:50 AM, the nurse staffing data information was not posted anywhere in the facility visible to residents and visitors. During an interview with Director of Nursing (DON) on 3/15/2024 at 4:22 PM, DON was asked why the required daily nurse staffing data was not posted at the Nurse's Station 1 where it would be visible to residents and visitors. DON stated the facility posted Census and Direct Care Service Hours Per Patient Day (DHPPD…

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 up and communicate with a physician the consultant pharmacist's recommendation to perform blood tests for two of three sampled residents (Residents 49 and 51) in accordance with facility's policy titled Medication Regime Reviews. This deficient practice had the potential to result in missed opportunity to correct identified irregularities regarding prescribed medications for Residents 49 and 51. Findings: A review of Resident 49's admission Record, indicated Resident 49 was admitted on [DATE] with diagnoses including type 2 diabetes (elevated blood sugar), lack of coordination, hyperlipidemia (elevated cholesterol), anxiety disorder (a mental health disorder characterized by feelings of worry), hemiplegia (paralysis of one side of the body), hypertension (elevated blood pressure), retention of urine (inability to urinate), transient ischemic attack ( a short period of symptoms similar to a stroke), cerebral infarction (occurs as a result of…

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

Based on interview and record review, the facility failed to implement a safe water management program to prevent water borne diseases including legionnaire's disease (a serious type of pneumonia, can occur in persons who inhale water droplets contaminated with the bacterium Legionella). This deficient practice had the potential to spread water borne illnesses including legionnaire's disease in the facility. Findings: During an interview on 11/7/23 at 2:18 AM with Maintenance Supervisor (MS). MS stated MS was not aware of any water management program. However, MS stated MS had tested the water temperatures and kept a log of his activity. The MS stated MS did not know about any water testing program. During an interview on 3/14/2024 at 9:20 AM, Infection Preventionist (IP) stated, currently maintenance increases water temperature to kill bacteria such as legionella. MS stated all the shower heads are changed every three months and IP tests the water twice a month. MS stated MS checks/tests daily water temperatures daily and completes water testing monthly. IP stated water tests are…

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 Pneumonia (PNA-infection of one or both lungs) vaccines was offered and/or re-offered to one of six sampled residents (Resident 29) per facility policy titled Pneumococcal Vaccination. This deficient practice had the potential to place Resident 29 at risk of acquiring and transmitting pneumonia infection. Findings: A review of Resident 29's admission Record, indicated Resident 29 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including elevated white blood cell count (a white blood cell count measures the number of white cells in the blood), retention of urine, difficulty walking, muscle weakness, bipolar disorder (a disorder associated with episodes of mood swings), neuroleptic induced parkinsonism (drug induced parkinsonism), mild cognitive impairment (problems with a person's ability to think), tremors (a condition that affects the nervous system), hyperlipidemia (elevated cholesterol), hypertension (elevated blood…

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 19 out of 29 resident rooms (Rooms 1, 2, 3, 4, 5, 6, 7 ,8, 9, 10, 11, 12, 15, 16, 17, 18, 19, 20, and 21) met the square footage requirement of 80 square feet per resident in multiple resident rooms. This deficient practice had the potential to result in inadequate useable living space for the residents and working space for the health care givers. Findings: During an observation on 3/15/2024, at 5:28 p.m., all rooms listed on the facility's room waiver letter were observed that enough space was provided for the care of the residents, and that the privacy curtains were provided privacy for each resident, and that the rooms had direct access to the corridors. The facility submitted a written request for a continued waiver. On 7/17/2024, the Department (State Survey Agency) reviewed updated room waiver letter, dated 7/17/2024, submitted by the administrator, indicating resident rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 15, 16, 17, 18, 19, 20, and 21 did not meet the minimum requirement of 80 sq.…

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, facility failed to implement dish washing cleaning and sanitizing procedures while cleaning cups, plates, lids, and utensils for 64 of 64 Residents. These deficient practices had the potential to result in food-borne illnesses (food poisoning) of the residents with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and could lead to other serious medical complications and hospitalization. Findings: On 11/28/2023 during an unannounced visit was made to the facility to investigate a complaint regarding an allegation of poor dietary sanitation. On 11/28/2023 at 9:50am during an observation and concurrent interview, Dietary Aide (DA) was observed stacking drinking cups, and plate lids with breakfast food residue on to disk racks and placing them into the dishwasher and sanitizer without first rinsing off the food particles off the cups and plates lids. DA collected the washed and sanitized cups and plate lids, some of which still contained food residue and placed them on to a clean shelf to air dry.…

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 necessary respiratory care services for two of six sampled residents (Resident 3 and Resident 4) by failing to ensure the nasal cannula (NC -a connector attached to oxygen) tubing was changed per policy. This deficient practice had the potential for the residents to develop respiratory infection. Findings: 1. A review of admission Record indicated Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including pneumonia (lung infection that inflames air sacs with fluid or pus), dysphagia (difficulty swallowing food or liquid) and difficulty in walking. A review of Resident 3's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 7/31/2023, indicated Resident 3 ' s cognition level (action or process of acquiring knowledge and understanding) for daily decision-making was intact and required supervision to limited assistance from staff for activities 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 act upon the licensed pharmacist's recommendation to change the prescribed form of fluphenazine HCL (an antipsychotic medication used to treat schizophrenia and psychotic symptoms such as hallucinations, delusions, and hostility, HCL[Hydrochloride]: short acting) to fluphenazine Deconate (long acting) for one of two sampled residents (Resident 1). This deficient practice resulted in Resident 1 missing two doses of the medication placing the resident at risk for a decline in mental condition, functional condition, or psychosocial status. Findings: A review of the admission record indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis that included schizophrenia (a disorder that affects a person ' s ability to think, feel and behave clearly), depression (a mental disorder causing a depresses mood), and agoraphobia (fear of places and situations that might cause panic). A review of Resident 1's Minimum Data Set (MDS- a standardized…

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 documentation was accuracy for one of three sampled residents (Resident 1), when Resident 1's Treatment Administration Records (TARs) and Medication Administration Records (MARs) indicated that care and treatment was provided while Resident 1 was not at the facility. This deficient practice resulted in inaccurate information entered into Resident 1's medical record. Findings: A review of Resident 1's admission's record (Facesheet) indicated the facility initially admitted Resident 1 on 6/21/2023 and readmitted the resident on 7/15/2023 with diagnoses including hyperosmolality and hypernatremia (a condition in which the blood has a high concentration of salt (sodium), glucose, and other substances. This draws the water out of the body's other organs, including the brain), dysphagia (difficulty or discomfort in swallowing, as a symptom of disease), and muscle weakness (decreased strength of the muscles, affecting both distal and proximal musculature). A review of Resident 1's Minimum Data Set (MDS- a standardized…

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 its ' visitation policy was in compliance with the federal regulation to not limit resident visitation hours. This deficient practice had the potential to violate the residents rights of being able to receive visitors at the facility and could affect the residents ' mental health and psychosocial wellbeing. Findings: During on observation on 8/4/23 at 12:25 pm, a sign posted on facility ' s lobby door indicating Please note facility visitation hours below: Monday through Sunday: 10:00 am – 8:00 pm . Visitation appointment must be at least 24 hours in advance .No walk-ins allowed. During a concurrent interview and record review, on 8/4/23 at 1:15 pm with the Administrator (ADM), the facility ' s policy and procedures (P&P) titled, Visitation (undated) was reviewed. The P&P indicated, Current visitation hours are from 10:00 am to 8:00 pm with a 1-hour limit for in-room visits. The ADM verified the policy and stated the facility is not limiting visitation. During a review of the Department of 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.