Sunset Park Healthcare

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen by failing to: 1. Ensure leftover tuna was stored in the refrigerator 2. Ensure staff personal bottle of water was not stored in the residents kitchen refrigerator 3. Ensure multiple food items with expiration dates were disposed 4. Ensure multiple food items were labeled with expiration dates or used by dates 5. Ensure debris did not collect on paper towel dispenser 6. Handwashing/eye washing station sink was clean 7. Six cutting knives were clean 8.Ensure eight of 17 resident trays were not cracked and chipped. These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses and other toxins) medically compromised residents who received food from the kitchen. Findings: During the initial tour observation and concurrent…

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 followed guidelines on wearing Personal Protective Equipment (PPE- equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses, PPE may include respirators, gloves, overalls, boots, disposable gowns, and goggles) when providing care to three of five sampled residents (Resident 11, Resident 37, Resident 43) who were on enhanced barrier precautions (utilized to prevent the spread of multi-drug resistant organisms) room. This deficient practice placed residents, staff, and visitors at risk for acquiring and transmitting infections and diseases. Findings: A. During a review of Resident 11's admission Record, the record indicated Resident 11 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including hemiplegia (severe or complete loss of strength leading to paralysis on one side of the body) and hemiparesis (weakness or the inability to move on one…

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: 1. Repair leaking pipe under the kitchen sink. 2. Maintain maintenance repair logs and schedules. These failures had the potential to cause mold (a soft, green or gray growth that develops on old food or on objects that have been left for too long in warm, wet air) to grow that can cause the residents to become ill. Findings: During the initial tour observation of the kitchen and concurrent interview on 5/23/25 at 5:33 p.m., with Dietary [NAME] 1, there was a leaking pipe under a sink and a green bucket was under the sink to catching the water leaking from the pipe. Dietary [NAME] 1 stated the water under the sink has been leaking for about 1 (one) week. Dietary [NAME] 1 stated he notified the maintenance supervisor last week that the pipe under the kitchen was leaking. During an interview on 5/24/24 at 12:49 p.m., the Maintenance Supervisor stated he was notified on 5/23/25 at 5:45 p.m., that there was a leaking pipe under the sink in the kitchen. Maintenance Supervisor stated if there is a leaking pipe 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 observation, interview and record review, the facility failed to: 1. Ensure nine of nine Resident rooms (Rooms 1, 2, 3, 4, 5, 6, 8, 11, and 12) met the 80 square feet (sq. ft. -unit of measure) requirement per resident according to federal regulation by 2. Ensure a bariatric bed (a heavy-duty, typically wider bed designed to accommodate individuals who are significantly overweight) did not impede the free movement of staff and one of three resident (Resident 148). This deficient practice resulted in impeding the free movement of Resident 148 and had the potential to impede the free movement of staff and guests. Findings: a. During a review of the facility Request for Room Size Waiver letter, dated 5/23/2025, submitted by the Director of Nursing (DON), indicated there are 11 rooms that did not meet the 80 sq. ft. requirement per resident according to federal regulation. The letter indicated that the room sizes would not interfere with the daily nursing care or safety of the residents. The letter also…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the resident and/or responsible party (RP) was informed and consented in advance, of the risks and benefits of psychotherapeutic medications (used to treat a variety of mental health conditions by affecting brain chemistry and behavior) for one of three sampled residents (Resident 35) reviewed for psychotropic medications (a medication which are available on prescription to treat a certain type of mental health problems). This deficient practice violated resident/RP's right to make an informed decision regarding the use of psychotropic medications. Findings: During a record review, the admission Record indicated Resident 35 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), unspecified dementia (a progressive state of decline in mental abilities) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss 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 a bariatric bed (a heavy-duty, typically wider bed designed to accommodate individuals who are significantly overweight) did not impede the free movement of staff and one of three resident (Resident 148). This deficient practice resulted in impeding the free movement of Resident 148 and had the potential to impede the free movement of staff and guests. Cross Reference F912 Findings: During a record review Resident 148's admission indicated, Resident 148 was admitted to the facility on [DATE] with diagnoses that included fibromyalgia (a chronic (long-lasting) disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping), muscle weakness, rheumatoid arthritis (a chronic, autoimmune disease that causes inflammation in the joints, leading to pain, stiffness, and swelling), hypertension (high blood pressure) and spondylosis (the degeneration of the spine, particularly the intervertebral discs and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to make prompt efforts to resolve the resident ' s grievance concerning missing/lost personal belongings of property by failing to list belongings inventory upon admission for one of two sampled residents (Resident 37). This deficient practice resulted in Resident 37's missing clothes and personal belongings. Findings: During a review of the admission Record indicated Resident 37 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), aphasia (a disorder that makes it difficult to speak) 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 review of the Minimum Data Set (MDS - a resident assessment tool) dated 3/5/2025, indicated Resident 37's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the residents were free of unnecessary physical restraint, for one of four sampled residents (Resident 38) when: 1. Resident 38's middle bed frame was low with a sagging mattress that restricted Resident 38 from getting out of bed. 2. Resident 38 was observed with a bedside table parked alongside Resident 38 while he was in bed that restricted the resident's movement. This deficient practice resulted in unnecessary restraint and placed the resident at risk of entrapment. Cross Reference F656 Findings: During a review of the admission Record indicated Resident 38 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including 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), muscle weakness (weakening, shrinking, and loss of muscle) and anxiety disorder (a mental health 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 a background checks and screening on applicants for positions with direct access to residents was completed for two of 12 sampled employees reviewed according to facility's Policy and Procedures (P&P) titled, Background Screening Investigation. This deficient practice placed all 41 residents in the facility at risk of violence, theft and other safety issues. Findings: During a record review, Registered Nurse (RN) 2 employee file on 5/25/2025 at 2:14 p.m., indicated that RN 2 was hired on 12/18/2022. RN 2's employee file indicated there were no background checks and screening completed during or after her (RN 2) hired date. During a record review, Licensed Vocational Nurse (LVN) 1 employee file on 5/25/2025 at 2:25 p.m., indicated that LVN 1 was hired on 6/4/2024. LVN 1's employee file indicated there were no background checks and screening completed during or after her (LVN 1) hired date. During a concurrent interview and record review with Director of Staff and Development (DSD) 1 on 5/25/2025 at 3:33 p.m., DSD 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Maintain a safe and functional environment for one of six sampled residents (Resident 38) by ensuring that there are no items that may cause him an injury according to Resident 38's behavior of putting objects on his mouth. 2. Properly evaluate one of six sampled residents (Resident 36)'s elopement (the act of leaving a facility unsupervised and without prior authorization) risk assessment (a numerical score used to determine the likelihood of a person, often a patient in a care setting, leaving a facility without authorization or staff knowledge) These deficient findings had the potential to place the residents at increased risk for injuries and accidents. Cross Reference F656 Findings: A. During a review of the admission Record indicated Resident 38 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (a disease in which the functioning of the brain is affected…

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 labeled an open date (indicates how long a medication is safe to use once the container has been opened) of ipratropium-albuterol (used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness) inhalation solution and Atrovent sulfate (medication used to help with difficulty breathing in people) inhalation solution for two of six sampled residents (Resident 11 and Resident 32). This deficient practice had the potential to compromise the effectiveness of the medications, leading to potential complications related to the management of medications. Findings: 1. During a review of Resident 11's admission Record indicated Resident 11 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and chronic respiratory failure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to: A. Ensure one of five sampled residents, (Resident 38)'s diclofenac cream medication (used to treat pain and other symptoms of arthritis of the joints such as inflammation, swelling, stiffness, and joint pain) was properly stored and secured per the facility's policy and procedures (P&P) titled Medication Labeling and Storage reviewed by the facility on 4/2025. B. Ensure pill cutters assigned one of to two medication Carts (Medication Cart 1 ) was maintained clean and sanitized. These deficient practices had the potential to lead to medication under and/or overdosing which could result in serious injury, harm, and death and had the potential to compromise the safety and effectiveness of medications. These deficient practices also had the potential to spread infection and/or diseases. Findings: 1. During a review of Resident 38's admission Record, the admission record indicated Resident 38 was originally admitted to the facility on [DATE]…

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 served was palatable and of nutritive value for two of 38 residents (Residents 14 and 25) This deficient practice had the potential for residents to have poor meal intake and could lead to weight loss. Findings: During a lunch test tray with the Dietary Supervisor and two Surveyors on 5/25/2025 at 1:15 p.m., the test tray consisted of pork chop, baked potato, mixed vegetables, dinner roll, and slice of cake, milk, and juice. The pork chop was over cooked, hard around the edges and without flavor. The baked potato was over cooked and hard near the edges, mixed vegetables were not palatable. The dinner roll was hard and over cooked. During an interview on 5/25/25 at 2:10 p.m., Resident 14 stated the facility food was not palatable, the pork chops were too hard to eat. Resident 14 stated she had to request a sandwich as an alternative. Stated the food in the facility is not good and it makes her mad that she has to eat a lot of sandwiches just to get full. During an interview on 5/25/25 at 2:36 p.m.,…

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 facility did not leave a breakfast tray within reach of one out of two Residents (Resident 28) who was at risk for aspiration (food, liquid, or other foreign material enters the airway and lungs instead of the stomach), requiring 100% feeding assistance from facility staff. This deficient practice potential to result in choking, aspiration pneumonia (lung infection resulting from foreign material entering the airways), resulting in serious injury or death. Findings: During a record review Resident 28's admission record, the admission record indicated Resident 28 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included metabolic encephalopathy (a brain dysfunction caused by underlying systemic conditions that disrupt the body's chemical processes), dysphagia (difficulty swallowing), obesity (abnormal or excessive fat accumulation that presents a risk to health), hearing loss right and left ear,…

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 facility failed to ensure 1 out of 2 interviewed Residents (Resident1) was provided a fortified CCHO diet (Consistent carbohydrate diet: meals contain carbohydrate-rich foods in fairly equal amounts which help maintain stable blood sugar levels) regular texture, Regular liquid consistency, double portion protein for breakfast and dinner for weight and nutritional management as per physician's order. This deficient practice had the potential to result in hypoglycemia (low blood sugar) due to lack of food, malnutrition, organ failure, and death. Findings: During a review, Resident 1's admission record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included type 2 diabetes mellitus (a chronic condition where the body either doesn't produce enough insulin [hormone that regulates sugar in the blood], or the cells don't respond to insulin properly), anemia (a condition that develops when your…

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 answer call lights timely for two of two sample residents (Residents 148 and 25) when needing assistance with activities of daily living (ADL) from facility staff. This failure resulted in the residents getting angry. Findings: a. During a record review, Resident 148's admission Record indicated Resident 148, was admitted to the facility on [DATE] with a diagnoses including type 2 diabetes (a condition where the body either doesn't produce enough insulin, or the cells don't respond properly to the insulin that is produced, leading to high blood sugar levels, essential hypertension (a chronic condition of persistently high blood pressure with no identifiable cause), generalized muscle weakness (a widespread loss of muscle strength that isn't limited to a specific muscle or region). During a record review, Resident 148's Minimum Data Set (MDS-a resident assessment tool) dated 5/22/2025, indicated Resident 148's cognitive (mental 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.

Based on observation, interview and record review, Facility failed to provide a sanitary, and comfortable environment for residents, staff, and the public by failing to ensure waste equipment was not overflowing with waste in the waste disposal area. This deficient practice had the potential to result in the rapid growth and infestation of disease-causing organisms such as bacteria, insects, vermin, respiratory diseases, infections and air pollution. Findings: During a facility tour on 5/25/2025 at 11:03am, facility waste equipment was observed to be overflowing and disposed waste was spilling over to the ground of the waste dumping area. During an observation on 5/25/2025 at 11:35am, Maintenance (MTD) was observed standing on top of the overflowing trash bin attempting to press down the garbage into the trash can. During an interview on 5/25/2025 at 6:51PM, MTD stated trash waste was not supposed to overflow out of the trash cans and the trash lids had to be kept shut to prevent exposure of waste in the trash bins. MTD stated overflowing waste could attract and expose residents,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its policy and procedures titled Requesting, Refusing and/or Discontinuing Care and Treatment, reviewed March 2025, for one of three sampled residents (Resident 1). By failing to notify Resident 1 ' s physician of the resident ' s refusal to take prescribed tuberculosis (TB, a contagious disease caused by the bacteria Mycobacterium tuberculosis, which typically affects the lungs) medications: 1. Isoniazid (used to treat TB and/or prevent its return) 300 milligrams (mg, metric unit of measure) refused on 4/9/25, 4/12/25, 4/13/25, 4/25/25, and 5/2/25. 2. Pyridoxine 50 mg (treats vitamin B6 deficiency) refused on 4/9/25, 4/12/25, 4/13/25, 4/25/25, and 5/2/25. 3. Rifampin (antimicrobial medication used to kill TB bacteria in the body) 300 mg refused on 4/20/25, 4/25/25, and 5/2/25. This deficient practice had the potential to result in Resident 1 becoming reinfected with active TB, a delay in care and treatment, or cause a decline on overall medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to follow their own Policy and Procedure (P&P) by failing to ensure one of three sampled residents (Resident 1), physician had educated Resident 1 or her Responsible Party (RP) about the risks and benefits of taking mirtazapine (an antidepressant used to treat major depressive disorder). This deficient practice had the potential to result in Resident 1 in receiving a medication that she (Resident 1) was not well informed about. Findings: During a review of the admission record for Resident 1 indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypertension (HTN-high blood pressure) , and dysphagia (difficulty swallowing). During a review of the facility document titled INFORMED CONSENT- INFORMED CONSENT FOR USE OF PSYCHOTROPIC MEDICATION, for Resident 1 indicated, mirtazapine 7.5 milligram (mg,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their policy regarding reporting of a resident-to-resident altercation and to submit a conclusion report of investigation within five days or in accordance with state or federal law for two of five sampled residents (Resident 1 and Resident 2). This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated which can also lead to a delay in prevention of further abuse for Resident 1 and Resident 2. Cross Reference F610. Findings: A. During a review of the Resident 1 ' s admission Record, it indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), schizophrenia (a mental illness that is characterized by disturbances in thought) and peripheral…

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 record review and interview, the facility failed to implement its abuse policy and procedure by failing to investigate a resident-to-resident altercation between two of five sampled residents (Resident 1 and Resident 2). This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect residents from abuse. Cross Reference F609. Findings: A. During a review of the Resident 1 ' s admission Record, it indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), schizophrenia (a mental illness that is characterized by disturbances in thought) and peripheral vascular disease (PVD - a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). During a review of the Minimum Data Set (MDS – resident assessment tool) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, for one out of four residents (Resident 3), the facility failed to ensure the enteral feeding (liquid nutrition -a medical procedure that delivers nutrients, medications, and or fluids directly into the gastrointestinal [GI] tract) bottle/container was: 1. Labeled time when the feeding was hung up. 2. The enteral feeding was disposed/discarded after 48 hours as per facility's policy and procedures and the manufacturer's guidelines to prevent the growth of microorganisms that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food), as well as toxins. These deficient practices had the potential to result in pathogen (germ) exposure to Resident 3 and placed the resident at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one out of four residents received the correct therapeutic dose (of oxygen (a colorless, odorless gas that is essential for life and the proper functioning of the body) as ordered by the physician This deficient practice placed Resident 4 at risk of oxygen poisoning (lung damage that happens from breathing in too much extra (supplemental) oxygen.) and had the potential to negatively impact the Resident 4 ' s health and well-being. Findings: During a review of Resident 4's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included, encephalopathy (a change in your brain function due to injury or disease), dysphagia (difficulty swallowing), depression (a depressed mood or loss of pleasure or interest in activities for long periods of time) and chronic obstructive pulmonary disease (COPD- lung disease marked by permanent damage to tissues in the lungs) During a review of Resident 4s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to observe its infection control policy for one out of three sampled residents (Resident 1) by failing to ensure the licensed nurse did not administer Resident 1 a pill/medication that had fallen onto the floor. This deficient practice resulted in the contamination of Residents 1's medication and had the potential to cause gastrointestinal illnesses and possibly hospitalization. Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with medical diagnoses that included diabetes (a disease in which your body does not produce enough insulin needed to control sugar levels in the blood), hypertension (HTN -elevated blood pressure), and generalized muscle weakness (lack of physical or muscle strength). 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 intact…

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

Based on interview and record review the facility failed to protect one of four sampled residents (Resident 1) and from verbal abuse (the use of oral, written, or gestured communication, or sounds, to residents; including harassing, mocking, yelling, cussing, or threatening) by failing to ensure Licensed Vocational Nurse 2 (LVN2) did not engage in a verbal altercation with Resident 1 and cuss at Resident 1. As a result, Resident 1 was exposed to verbal abuse from LVN2, placing the Resident 1 at risk for psychosocial harm, mental anguish (suffering) and emotional distress. Findings: A review of Resident 1's admission record indicated the facility admitted Resident 1 on 5/16/2024, with diagnoses that included encephalopathy (a disorder of the brain caused by disease, injury, drugs, or chemicals), psychosis (a mental disorder in which a person loses the ability to recognize reality or relate to others), depression and anxiety disorder. A review of Resident 1's Minimum Data Set (MDS- standardized data collection tool used to assess cognitive brain's ability to think, read, learn,…

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 staff failed to inform one of four sampled residents (Resident 1) and Resident 1's representative/family/responsible party that Resident 1 would be discharged from Skilled Nursing Facility 1 (SNF1) to SNF2 before 5/16/2024. This deficient practice resulted in SNF1 transferring Resident 1 to SNF2 on 5/16/2024. Resident 1 became aggressive towards staff and difficult to manage at SNF2. Findings: A review of Resident 1's admission record indicated the facility admitted Resident 1 on 5/16/2024, with diagnoses that included encephalopathy (a disorder of the brain caused by disease, injury, drugs, or chemicals), psychosis (a mental disorder in which a person loses the ability to recognize reality or relate to others), depression and anxiety disorder. A review of Resident 1's Minimum Data Set (MDS- standardized data collection tool used to assess cognitive brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions] and functional status, and care needs) dated 5/16/2024, indicated the…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and food handling practices in the kitchen by failing to ensure one of three staff (Cook 1) wore a hairnet and gloves while working in the kitchen area while preparing food. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of bacteria from one object to another) that could lead to foodborne illness in all 41 medically compromised facility residents who received food from the kitchen. Findings: During an initial brief tour observation of the kitchen on 5/25/2024 at 7:21 a.m., [NAME] 1 was observed not wearing a hairnet while working in the kitchen and handling food which was to be served directly to residents. [NAME] 1 was also observed not wearing gloves while handling food to be served directly to residents. During an interview on 5/25/2024 at 7:24 a.m. with [NAME] 1, [NAME] 1 stated she should have worn a hairnet and gloves while working in the kitchen area and handling food to be served to 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 meet professional standards of quality for one of three sampled residents (Resident 1) by: 1. Failing to ensure an accurate post-fall assessment was performed. 2. Failing to perform an assessment and interdisciplinary team meeting after Resident 1 was found on the floor. This deficient practice had the potential to result in miscommunication among staff about Resident 1 ' s fall risk. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included schizophrenia (a serious mental disorder in which people interpret reality abnormally), muscle weakness and abnormalities of gait and mobility. A review of Resident 1 ' s History and Physical, dated 9/21/2023, indicated Resident 1 did not have the capacity to understand and make decisions. A review of the Minimum Data Set (MDS - a standardized assessment tool), dated 9/25/2023, 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 interviews and record review the facility failed to ensure physician ' s order for Ativan (psychotropic medication [any medication capable of affecting the mind, emotions, and behavior] to treat anxiety) to be administered as necessary (PRN), did not exceed 14 days for one of three sampled residents (Resident 1) in accordance with the facility's policy and procedures titled Antipsychotic Medication Use dated 12/2016. As a result, Resident 1 received PRN Ativan for 22 days for the month of 9/2023, with the potential to result in the use of unnecessary psychotropic medication, undesired side effects and adverse consequences including a decline in quality of life and functional capacity for Resident 1. Findings: A review of Resident 1 ' s admission records (facesheet) indicated, Resident 1 was initially admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD- ongoing inflammatory lung disease that causes obstructed airflow from the lungs), type 2 diabetes…

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 baseline care plan that reflected the assessment and immediate needs including interventionst that addressed fall risk for one of four sampled residents (Resident 3). This deficient practice had the potential for Resident 3 to not receive appropriate care and treatments specific to his needs including interventions to prevent falling. Findings: A review of the admission Record (Face Sheet) indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that include schizophrenia (a serious mental disorder in which people interpret reality abnormally), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), muscle weakness, and abnormalities in gait and mobility. A review of the fall risk assessment, dated 8/28/2023, indicated Resident 3 was a high risk for fall secondary to his intermittent confusion, history of 1-2 falls in the past…

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 four of four sample residents (Resident 9, Resident 18, Resident 131 and Resident 134) were fed in a dignified manner. This deficient practice had the potential to affect the residents' self-esteem and self-worth. Findings: During an observation on 01/24/22 at 12:48 PM, certified nursing assistant (CNA) 2 was observed feeding Resident 131, while standing over the resident. During an observation on 01/24/22 at 12:50 PM restorative nursing assistant (RNA) 1 was observed feeding Resident 18, while standing over the resident. During an observation on 01/24/22 at 12:55 PM RNA 2 was observed feeding Resident 9, while standing over the resident. During an observation on 01/25/22 at 12:34 PM CNA 3 was observed feeding Resident 134, while standing over the resident. During an observation with concurrent interview with CNA 2 on 01/25/22 at 12:45 PM, CNA 2 was observed seated and feeding Resident 131 and RNA 2 was observed seated feeding Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the call light (a device used by a resident to signal for assistance from the facility's staff) was within reach for four out of four residents (Residents 7, 330, 331, and 326). This deficient practice had the potential for delay in responding to the necessary care and services by facility staff , increasing residents' risk for skin breakdown, skin irritation, and falls. Findings: A review of Resident 7's admission Record indicated the resident was admitted to the facility on [DATE]. Resident 7's diagnoses included spinal stenosis (narrowing of the spaces within the spine, which can put pressure on the nerves that travel through the spine), hypertension (HTN - elevated blood pressure) and glaucoma (eye condition that may cause blindness). A review of Resident 7's Minimum Data Set (MDS- a comprehensive standardized assessment and care-screening tool), dated 10/21/21, indicated the resident was cognitively (the mental action or…

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 have a dedicated director of nursing (DON) and registered nurse (RN) supervisor whose hours were not shared with a second facility. This failure had the potential to affect resident care, clinical outcomes, and assessment. Findings: A review of the facility's Registered Nurse - Supervisor job description with release date of May 2017 indicated, The Supervisor is an RN who is responsible for the overall supervision of nursing care in the facility during their shift. Responsible for the provision of direct, age specific, resident care to those assigned to his/her care for each established shift. A review of the facility's Director of Nursing job description with release date of May 2017 indicated, The Director of Nursing has 24-hour accountability and is responsible for the delivery of high-quality and cost-effective health care while achieving positive clinical outcomes, and patient/family and employee satisfaction. During a concurrent interview and record review of the facility's staff schedules for January of 2022,…

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 record review, the facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition services when Dietary Aide 1 failed to describe how to manually wash dishes correctly. This failure had the potential to result in unsafe and unsanitary food preparation and production, and a potential for food-borne illness affecting all residents who received foods from the kitchen. Findings: During a concurrent observation and interview on 01/24/2022, at 9:39 AM, with Dietary Aide 1 (DA 1), he stated he is one of the dishwashers, and he would wash, sanitize, then rinse dishes at the three-compartment sink for manual dishwashing. For the required sanitizing contact time (contact time is how long a disinfectant needs to stay wet on a surface in order to be effective) during manual dishwashing, the DA 1 stated that the sanitizing process would need about 10 to 20 seconds. A review of the facility's policy and procedures titled, 3 Compartment Procedure for Manual Dish Washing, dated…

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

Based on observation, interview and record review, the facility failed to: 1) follow portion size as written on the menu for residents on mechanical soft and regular diet. Residents on mechanical soft and regular diet received inaccurate portion. 2) follow instructions as written on the tray card for residents on NAS (no added salt) diet. With two trays marked NAS on the tray card, each had a salt packet. These deficient practices had the potential for residents to receive wrong protein and caloric intake when not following the menu, which could result in undernutrition or overnutrition and further compromise their medical status. Findings: 1) A review of the facility's document titled, Cooks Spreadsheet Winter Menus, dated 12/27/21, 01/24/22, and 02/21/22, indicated food portioning as follows: a) regular portion for regular black beans should be served with a #12 scoop providing a 1/3 cup; b) regular portion for mechanical soft beef enchilada was not indicated; c) regular portion for pureed beef enchilada should be served with a #8 scoop providing a 1/2 cup. During an interview on…

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

Based on observation, interview, and record review, the facility failed to ensure that food was served at appetizing temperatures and as recommended per its policy. This deficient practice had the potential to result in decreased food intake and affect the nutrition needs for the residents who ate at the facility. Findings: During a concurrent observation and interview on 01/24/22, at 12:49 PM, with Dietary Supervisor (DS), in the conference room, the DS confirmed and acknowledged multiple food items served on the test tray did not meet the recommended temperature indicated on the facility's policy as follows: a) Regular black bean: 117°F. b) Rice: 110°F. c) Custard: 54.7°F. d) Milk: 49.5°F. A review of the facility's policy and procedures titled, Meal Service, dated 2020, indicated recommended temperature at delivery to resident as follows: a) Hot Entrée: greater than or equal to 120°F; b) Fruit or Cold Dessert: less than or equal to 50°F; c) 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…

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 an effective infection control program was maintained, as evidenced by: 1) Certified Nursing Assistant (CNA 1) did not perform hand hygiene when indicated. 2) Housekeeping staff (HKS 1) did not properly take off personal protective equipment (PPE - personal protective equipment, including isolation gown, gloves, face mask, face shield, and goggles) before exiting Resident 331's red zone room (an area/room of the facility where COVID-19 positive residents are placed during quarantine to control the spread of infection). These deficient practices had the potential for cross-contamination, resulting in spreading infections to the residents and staff in the facility. Findings: 1) During an observation on 01/24/22 at 12:30 PM, CNA 1 delivered a lunch tray to Resident 333 and did not perform hand hygiene before or after getting Resident 333's lunch tray from the tray cart and entering or exiting Resident 333's room. During an observation…

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

Based on observation, interview and record review, the facility failed to provide a homelike environment for two out of two residents (Resident 329 and 331), as evidenced by: 1) Resident 329 did not have adequate space for personal belongings 2) Resident 331's room furniture was in poor condition These deficient practices had the potential to negatively impact the comfort level and quality of life of the residents. Findings: 1) A review of Resident 329's Face Sheet (admission record) indicated the facility admitted Resident 329 on 01/12/22, with diagnoses including, but not limited to, muscle weakness (lack of strength in the muscles), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities), and seizures (abnormal brain activity). During an observation on 01/24/22 at 10:28 AM, Resident 329's had personal belongings at his bedside. During a concurrent interview, Resident 329 stated he did not have space to place his personal belongings. Resident 329 further stated his closet had clothes belonging to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of four sample residents (Resident 133) was free from physical restraints. This failure resulted in a violation of the Resident 133's right to be free from restraints. Findings: During an observation on 01/24/22 at 11:31 AM, Resident 133's bed was observed being pushed against the wall. During an observation on 01/24/22 at 12:35 PM, Resident 133's bed was observed staying pushed against the wall. During an interview on 01/25/22 at 02:47 PM with infection preventionist (IPN), the IPN stated resident's bed should not be pushed up against the wall, unless there is an order, and bed up against the wall is care planned as a resident's preference, otherwise it can be considered a restraint. The IPN further stated they do not use restraints at this facility, and in resident's 133 case, the bed up against the wall was the resident's personal preference. A review of Resident 133's admission Record, dated 01/25/22, indicated, Resident 133…

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 care plan was developed for 1) Restraints or personal preference of resident bed against the wall for one of two sample residents (Resident 133). 2) Psychotropic medication (a drug that affects behavior, mood, thoughts, or perception) for two of four sample residents (Resident 12 and Resident 133). This deficient practice had the potential to result in a delay in monitoring the restraints or personal preferences and a delay in recognizing signs and symptoms of side effects associated with psychotropic medication use. Findings: 1). During an observation on 01/24/22 at 11:31 AM, Resident 133's bed was observed being pushed against the wall. During an observation on 01/24/22 at 12:35 PM, Resident 133's bed was observed staying pushed against the wall. During an interview on 01/25/22 at 02:47 PM with infection preventionist (IPN), the IPN stated resident's bed should not be pushed up against the wall, unless there is an order, and bed…

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 low air loss (LAL) mattress (mattress designed for pressure reducing which is used to prevent and treat pressure wounds) was set up correctly for one of two sampled residents (Resident 18). This deficient practice had the potential to contribute to the worsening of pressure wound and/or delay wound healing. Findings: During an observation on 01/24/22 at 10:36 AM, Resident 18's LAL mattress machine/pump setting was set to 5, 210 lb (pound). During an interview with certified nursing assistant (CNA) 2 on 01/24/22 at 11:55 AM, CNA 2 stated she did not touch the air mattress pump settings, nor did she know what the appropriate setting for the resident should be. During a concurrent observation and interview with licensed vocational nurse (LVN) 1 on 01/24/22 at 12:30 PM, LVN 1 stated she did not know the exact setting for the air mattress pump, but she knew there must have been an order for it. After checking physician orders in a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 8) received the accurate flow rate of oxygen according to physician's order. This deficient practice had the potential to result in complications associated with oxygen therapy. Findings: A review of Resident 8's admission Record indicated the resident was admitted to the facility on [DATE]. Resident 8's diagnoses included chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe), emphysema (lung condition that causes shortness of breath) and heart failure (a condition in which the heart does not pump blood as well as it should). A review of Resident 8's Minimum Data Set (MDS- a comprehensive standardized assessment and care-screening tool), dated 01/07/22, indicated that Resident 8 was moderately cognitively (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) impaired…

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.