Courtyard Care Center

Based on observation, interview, and record review, the facility failed to dispose of garbage and recyclables properly by not completely covering two of two trash dumpsters (a large trash container designed to be emptied into a truck).This deficient practice had a potential to attract flies, insects, and other animals to the dumpster area placing 56 of 59 facility residents at risk for cross-contamination (a transfer of harmful bacteria from one place to another) and had the potential to cause nausea, vomiting and diarrhea. findings:During a concurrent observation and interview on 12/9/2025 at 9:45a.m. with the Dietary Supervisor (DS) of the garbage area located outside the facility near the kitchen, the DS stated two of two dumpsters were not completely closed and covered. The DS stated the trash had not been picked up from Monday 12/8/2025 was still there. The DS stated the trash lids should be closed and indicated if the trash lid is no closed, bugs can come in and bags can break creating an unsanitary environment. During a review of Food Code 2017, indicated, 5-501.113 Covering…

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

Based on interview and record review the facility failed to provide documented COVID-19 (contagious disease) 2025 to 2026 vaccination (medications used to prevent diseases usually given by injection or by mouth) status, evidence of provision of education on benefits and potential side effects for all employees, including physicians. This failure had the potential to result in staff and residents contracting COVID-19 which could cause serious illness, hospitalization, and death. Findings: During a concurrent interview and record review on 12/10/2025 at 8:10 a.m., with the Infection Prevention Nurse (IPN), the facility's Covid Staff Vaccination Status, undated, was reviewed. The IPN stated there was no documented evidence for all staff of education on benefits and side effects was provided and the offering of 2025 to 2026 Covid-19 booster vaccine. The IPN stated the roster did not include physicians and it should include everyone that has direct access to the residents. During an interview on 12/12/2025 at 7:55 a.m. with the Director of Nursing (DON), the DON stated all staff need 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, the facility failed to inform the physician when a dialysis treatment was missed for one of two sampled residents (Resident 39). This failure had the potential to result in a delay of treatment, fluid overload and possible deterioration of the resident.Findings: During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was admitted to the facility on [DATE] with diagnoses including sepsis (a life-threatening blood infection), osteomyelitis (inflammation of bone or bone marrow, usually due to infection), end stage renal disease (ESRD-irreversible kidney failure), and 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). During a review of Resident 39's History and Physical (H&P), dated 11/19/2025, the H&P indicated Resident 39 had the capacity to understand and make decisions. During a review of Resident 39's Minimum Data Set (MDS - 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 three sampled residents (Resident 63) received the Notice of Medicare Non-Coverage (NOMNC- a written notice that informs the resident of their last date of covered services and their right to appeal the decision) at least 48 hours prior to the last covered date. This failure had the potential for the resident to not receive the skilled treatment they may need and violate the residents' right to appeal the decision.Findings: During a review of Resident 63's admission Record, the admission Record indicated Resident 63 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including wedge compression fracture (when the front part of the bones of the spine body creating a wedge shape) of lumbar vertebra (lower back bones) and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing).During a review of Resident 63's History and Physical (H&P), dated 9/23/2025, the H&P…

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 resident's (Resident 3) Minimum data Set ([MDS] resident assessment tool), dated 11/28/2025, was coded accurately. This deficient practice resulted in an inaccurate assessment of Resident3's current health status and Resident 3's MDS erroneously indicated that Resident 3 received insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) because Resident 3 did not receive any insulin.Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnosis including Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 3's Minimum Data Set ([MDS] resident assessment tool), dated 11/28/2025, the MDS indicated Resident 3 had severe cognitive impairment. The MDS indicated Resident 3 received insulin injections…

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 five employees (Licensed Vocational nurse-LVN 3) had an active basic life support certification ([BLS] essential emergency care for cardiac/breathing arrest) . This failure had the potential to result in providing ineffective cardiopulmonary resuscitation (CPR-emergency life-saving procedure that is performed when the heart stops beating) to a resident who is in cardiac arrest.Findings: During a concurrent interview and record review on [DATE] at 2:54 p.m. with the Director of Staff Development (DSD), LVN 3's employee file was reviewed. The DSD stated LVN 3 does not have an active BLS certification on file. During an interview on [DATE] at 11:29 a.m. with the Director of Nursing (DON), the DON stated all nursing staff including Certified Nurse Assistants (CNA)s, LVNs, and Registered Nurses (RNs) are required to have active, not expired, BLS certifications to ensure their skills are up to date with current standards. The DON stated, if…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 39) received dialysis as ordered. This failure had the potential to result in a possible deterioration, fluid overload or even death.Findings: During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was admitted to the facility on [DATE] with diagnoses including sepsis (a life-threatening blood infection), osteomyelitis (inflammation of bone or bone marrow, usually due to infection), end stage renal disease (ESRD-irreversible kidney failure), and 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). During a review of Resident 39's History and Physical (H&P), dated 11/19/2025, the H&P indicated Resident 39 had the capacity to understand and make decisions. During a review of Resident 39's Minimum Data Set (MDS - a resident assessment tool), dated 11/20/2025, the MDS…

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 two of five employees (Certified Nurse Assistant [CNA] 2 and Restorative Nurse Assistant (RNA) 1) received a performance evaluation annually. This failure had the potential to result in employees not being at current skill level of care which could result in poor health outcomes.Findings: During a concurrent interview and record review on 12/11/2025 at 2:58 p.m. with the Director of Staff Development (DSD), CNA 2 and RNA 1's employee files were reviewed. The DSD stated CNA 2 and RNA 1 did not receive performance evaluations in the last twelve months. The DSD stated performance evaluations should be completed every year and filed in their employee file. The DSD stated if the staff do not receive performance evaluations annually, there is a risk the employee will underperform. During an interview on 12/12/2025 at 11:30 a.m. with the Director of Nursing (DON), the DON stated performance evaluations should be completed once a year or every twelve months. The DON stated if performance evaluations are not completed…

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 the antibiotic stewardship program (effort to measure and improve how antibiotics are prescribed by clinicians) for one of three sampled residents (Resident 39).This deficient practice had the potential to increase antibiotic resistance and provide antibiotics without justification. Findings: During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was admitted to the facility on [DATE] with diagnoses including sepsis (a life-threatening blood infection), osteomyelitis (inflammation of bone or bone marrow, usually due to infection), end stage renal disease (ESRD-irreversible kidney failure), and 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). During a review of Resident 39's History and Physical (H&P) dated 11/19/2025, the H&P indicated Resident 39 had the capacity to understand and make decisions.…

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 two of two residents (Resident 1 and 3) neurological checks (Neuro check -series of tests performed by healthcare providers to evaluate the function of the brain) were completed as indicated in the policy. This deficient practice had the potential to result in the delay of care and services which could result in poor health outcomes. Findings: A. During a review of Resident 1's admission record, the admission Record indicated the facility admitted Resident 1 originally on 3/14/2025 with a diagnosis including acute respiratory failure (a condition where you don't have enough oxygen in the tissues in your body or when you have too much carbon dioxide in your blood), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set (MDS), a resident 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 review the facility failed to ensure one of three resident's (Resident 1) nurse progress notes for [DATE] were accurate. This deficient practice resulted in an inaccurate depiction of services and care rendered. Findings: During a review of Resident 1's admission record, the admission Record indicated the facility admitted Resident 1 on [DATE] with a diagnosis including acute respiratory failure (a condition where you don't have enough oxygen in the tissues in your body or when you have too much carbon dioxide in your blood), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated [DATE], the MDS indicated Resident 1 had severely impaired cognition. During a review of Resident 1's Order Entry, dated [DATE] at 3:53 p.m., the order indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify two of three sampled resident ' s (Resident ' s 1 and 2) primary care doctors (MD ' s 1 and 2) when Resident ' s 1 and 2 refused to wear their Bilevel positive airway pressure ([BiPAP] a machine that delivers air to help a person breathe) mask (a special mask that that fits over the nose and mouth which is connected to the BiPAP machine) as ordered. This deficient practice had the potential for Residents ' 1 and 2 to have difficulty breathing, low blood oxygen levels and poor sleep quality. Findings: a. During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with the diagnoses including obstructive sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops). During a review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool) dated 1/10/2025, the MDS indicated Resident 1 ' s cognition was intact and was dependent 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure Resident 1, who was unable to carry out activities of daily living received care services to maintain good personal hygiene for one of three sampled residents (Resident 1) who was left with wet diaper for more than five hours. This failure resulted in Resident 1 feeling frustrated and embarrassed, due to lack of or delay in receiving sufficient services to maintain personal care and incontinent care and had the potential to lead to skin breakdown for Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1was admitted to the facility on [DATE] with diagnoses including, bipolar (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs)chronic obstructive pulmonary disease (COPD-is a chronic lung disease that causes breathing difficulties.), bilateral hip osteoarthritis (wear down the cartilage in 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: 1. Ensure Resident 1 ' s Norco as needed (controlled medications used to treat severe pain) was refilled on time. 2. Ensure licensed nurse documents in resident health records when physician was called for authorizing the refill of pain medications. 3. Ensure discontinued medication was removed out of medication cart. These deficient practices have the potential to result in an insufficient number of medications on hand in the event Resident 1 needed pain medication to treat severe pain. This deficient practice had the potential to result in a delay of necessary care and treatment and can lead to adverse health outcome for Resident 1. Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1was admitted to the facility on [DATE] with diagnoses including, bipolar (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement infection control practices when Certified Nursing Assistant 2 (CNA) did not perform hand hygiene for one of three sample residents (Resident 1). This failure had the potential to result in cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another) and place the residents at risk for the spread of infection. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1was admitted to the facility on [DATE] with diagnoses including, bipolar (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs)chronic obstructive pulmonary disease (COPD-is a chronic lung disease that causes breathing difficulties.), bilateral hip osteoarthritis (wear down the cartilage in the hip joint). During a review of Resident 1's Minimum Data Set (MDS- a resident 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 review, the facility failed to ensure a resident, who was assessed to have a cognitive (the mental process of thinking, learning, remembering, being aware of surroundings and using judgement) impairment and the inability to make medical decisions, was not allowed to leave from the facility against medical advice ([AMA] when a patient chooses to leave a hospital before the doctor recommends discharge) and they failed to ensure discharge planning was conducted for one of three sampled residents (Resident 1) when the facility was made aware that Resident 1's significant other had intentions of taking Resident 1 from the facility AMA. The facility failed to: 1. Ensure a plan for Resident 1's safe discharge was developed when the facility was made aware of Resident 1's significant other's desire to leave the facility, five days before Resident 1's significant other took Resident 1 from the facility without the facility's knowledge or permission. 2. Ensure Resident 1 was not taken from…

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 a resident, who was assessed to have a cognitive (the mental process of thinking, learning, remembering, being aware of surroundings and using judgement) impairment and the inability to make medical decisions, was not taken out of the facility by a person who was listed in his clinical record as his contact and who had no contact information such as an address or telephone number listed. These deficient practices resulted in Resident 1, who was incontinent (involuntary voiding of urine and stool), non-ambulatory (inability to walk) with medical conditions/diagnoses that required medication, and whose cognition was severely impaired, being removed from the facility by an unauthorized person without the facility's knowledge or permission. Resident 1's whereabouts were unknown to the facility for two days before he was found residing in a homeless encampment approximately two miles from the facility. Resident 1 was found lying on the floor 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.

Based on observations, interviews, and record reviews, the facility failed to store food under sanitary conditions in one of one kitchen, by failing to: A. Ensure opened food items were labeled with date opened. B. Ensure the dry storage area was clean; and C. Ensure the residents refrigerator's freezer temperature was at or below 0 degrees Fahrenheit and the refrigerator temperature was below 40 degrees Fahrenheit. These deficient practices had the potential to result in contamination of food items that placed residents in high risk for food borne illness (any illness resulting from eating contaminated/spoiled foods) that can lead to hospitalization and a decline in health. Findings: During an observation and interview on 10/15/2024 at 8:36 a.m. with [NAME] 1 in the facility kitchen, the following opened and used items were noted to have no open date labeled on the items: Simply thick easy mix in the kitchen counter, horseradish sauce, bread, and hamburger buns in the refrigerator. [NAME] 1 stated the indicated items did not have an open date and should have had it. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure three of three sampled residents (Resident 1, 23, and 25) was assessed for use, received informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered), and had a physician order for Resident 1, 25, and 23's beds against the wall. This deficient practice resulted in a violation of resident rights to be free from restraints (any manual method, physical or mechanical device, equipment, or material that is adjacent to the resident's body, cannot be removed easily by the resident, and restricts the resident's freedom of movement). Findings: During a review of Resident 23's admission Record, the admission Record indicated Resident 23 was originally admitted to the facility on [DATE] with diagnoses including age related cataract (cloudy area in the lens of your eye), vision loss, hearing loss, and unspecified osteoarthritis (degenerative joint…

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 accurately assess and code the Minimum Data Set (MDS, a federally mandated assessment tool) assessment for two of seven sampled residents (Resident 1 and Resident 25) by failing to a. Ensure Section GG 0115 was coded correctly to include functional limitations in range of motion (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) of both of Resident 1's arms. b. Ensure accurate documentation of Resident 25's diagnosis of anxiety disorder (a medical condition described by feeling of fear dread, or uneasiness) in the MDS. This deficient practice had the potential to result in delayed or missed identification of joint range of motion (ROM, full movement potential of a joint) changes, inaccurate care planning, and inadequate provision of services and treatments for Resident 1 and the potential for missed care and treatments for anxiety for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure availability of magnesium oxide (a dietary supplement to treat low magnesium [a mineral important to healthy body function] level), lactulose solution (a medication used to treat constipation and certain conditions of the brain) and gabapentin [a medication used to treat nerve pain and seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness)] in accordance with physician's orders or professional standards of practice affecting three of three sampled residents during medication administration (Residents 5, 28, and 202). 2. Ensure Resident 28's physician order for Aspirin [a medication used to prevent heart attack (flow of blood and oxygen is blocked) and stroke (loss of blood flow to a part of the brain)] was administered as a chewable according to manufacturer formulation specifications and not swallowed, on 10/16/2024. This deficient…

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: a) One of two sampled resident's (Resident 33's) PRN (given as needed or requested) Lorazepam (medication used to treat anxiety - feeling of fear dread, or uneasiness) had a specified duration in the order, had nonpharmacological interventions prior to the use of Lorazepam, behavior monitoring, and informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered). b) One of two sampled resident's (Resident 18) Mirtazapine (medication used to treat depression - a mood disorder that causes a persistent feeling of sadness and loss of interest) had an informed consent when dose was increased, and the behavior monitoring was changed. This deficient practice had the potential to result in use of unnecessary psychotropic drugs for Residents 33, and the potential for Resident 18 to use medication without knowing the risks and benefits of the medication. which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5 % (percent) during medication pass for three of three sampled residents (Residents 5, Resident 28, and Resident 202) observed during medication administration by failing to: a. Ensure availability and administration of Resident 5's magnesium oxide (a dietary supplement to treat low magnesium level) in accordance with physician orders. b. Ensure availability and administration of Resident 28's lactulose solution (a medication used to treat constipation and certain conditions of the brain) in accordance with physician orders. c. Ensure Resident 28's physician order for aspirin [a medication used to prevent heart attack (flow of blood and oxygen is blocked) and stroke (loss of blood flow to a part of the brain)] was administered as a chewable tablet according to manufacturer formulation specifications instead of being swallowed, on 10/16/2024. d. Ensure availability and administration 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. One of one resident (Resident 25) had physician orders and documentation for Enhanced Barrier Precautions (EBP - infection control practice requires the use of gown and gloves only for high-contact resident care) implemented. b. Certified Nurse Assistant (CNA)1 donned (put on) an isolation (a type of personal protective equipment (PPE) that protects the wearer from the transfer of infections and contamination) gown while feeding and giving care to one of one resident (Resident 25) c. A Clean and sanitary environment for medications' storage in one of two inspected medication carts (Station 2 Medication Cart). These deficient practices had the potential to result in the spread of infections in the facility, contamination of medications and cause undue harm to the residents' health and well-being. Findings: a and b. During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was admitted 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 reviews the facility failed to ensure one of three sampled residents (Resident 23) received feeding assistance at the same time Resident 17 was eating lunch. This deficient practice resulted in an undignified dining experience which does not promote enhancement of quality of life. Findings: During a review of Resident 23's admission Record, the admission Record indicated Resident 23 was originally admitted to the facility on [DATE] with diagnoses including age related cataract (cloudy area in the lens of your eye), vision loss, hearing loss, and unspecified osteoarthritis (degenerative joint disease that occurs when the cartilage and tissues in a joint break down over time). During a review of Resident 23's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/6/2024, the MDS indicated Resident 23's cognition was severely impaired. The MDS indicated Resident 23 was dependent (helper does all the effort) on staff when eating. During a record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the call light device was within reach for one of six sampled residents (Resident 1). This deficient practice had the potential to prevent Resident 1 from receiving necessary care and services. Findings: During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including cataracts (medical condition in which the lens of the eye becomes cloudy causing impaired vision), rheumatoid arthritis (chronic autoimmune inflammatory disease that affects the joints), and contracture (loss of motion of a joint associated with stiffness and joint deformity) of the upper arm. During a review of Resident 1's Minimum Data Set (MDS, a federally mandated assessment tool) dated 7/8/2024, the MDS indicated Resident 1 had severely impaired vision, difficulty hearing, and severely impaired cognition (ability to think, understand, learn, and remember). The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of three sampled resident's (Resident 19) Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder (MD) are placed in facilities that can provide the appropriate care) screening reflected Resident 19 had a MD that qualified Resident 19 for a Level II PASARR (a comprehensive evaluation conducted by the appropriate state-designated authority that determines whether an individual has MD, determines the appropriate setting for the individual, and recommends what, if any, specialized services and/or rehabilitative services the individual needs). This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 19. Findings: During a review of Resident 19's admission Record, the admission Record indicated Resident 19 was originally admitted to the facility on [DATE] with diagnoses including major…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan addressing Resident 25's activities and Resident 1's visual impairments. These deficient practices had the potential to result in the delay of care and services for Resident 1 and 25 who may need specialized interventions. Findings: a. During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was originally admitted to the facility on [DATE] with diagnoses including Major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), generalized muscle weakness, and Resident 25 had a gastrotomy tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 25's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 8/29/2024, the MDS indicated Resident 25's cognition (ability…

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 revise a person-centered care plan for one out of two sampled residents (Resident 149), who was receiving artificial nutrition (a form of nutrition that is given as liquids, including liquid foods, through a tube inserted into a vein, under the skin, or into the stomach) through a gastrostomy tube (G-tube, feeding tube placed in the stomach). This deficient practice had the potential for Resident 149 to receive the wrong feeding formula. Findings: During a review of Resident 149's admission Record, the admission Record indicated Resident 149 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of dysphagia (trouble swallowing), cerebral palsy (a group of neurological disorders that affect a person's ability to move, balance, and maintain posture), and unspecified abnormal physiological (how the body works) development in childhood (developmental delays). During a review of Resident 149's care plan for alteration 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 provide treatment and services to prevent and/or limit a decline in range of motion (ROM, full movement potential of a joint) to one of six sampled residents (Resident 1) who was identified as having ROM limitations in both legs and a decline in ROM of both hips. This deficient practice resulted in a decline in ROM of Resident 1's both hips and had the potential to cause Resident 1 to have a further decline in ROM leading to contracture (loss of motion of a joint associated with stiffness and joint deformity) development, decreased mobility (ability to move) and a decline in activities of daily living (ADLs, basic activities such as eating, dressing, and hygiene). Findings: a. During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including cataracts (medical condition in which the lens of the eye becomes cloudy causing impaired vision),…

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 removal of an expired Folic Acid (a medication used to treat low level of folic acid or Vitamin B-9) and a discontinued Inbrija [(generic name - Levodopa inhalation powder) - a medication used to treat Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements)] affecting one resident (Resident 25) from one of one inspected medication room (Medication Room). 2. Ensure Brimonidine tartrate ophthalmic solution [(a medication in form of eye drops used to treat high intraocular pressure (a term used to describe fluid pressure inside the eye)] was stored in accordance with manufacturer requirements affecting one resident (Resident 29) in one of one inspected medication room (Medication Room). 3. Ensure Insulin Glargine prefilled pen [a type of insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via…

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 a plan of care was developed for one of four sampled residents (Resident 1) who was diagnosed with osteopenia (a condition that occurs when the body doesn ' t make new bone as quickly as it reabsorbs old bone, causing weakened) and a fracture (a break in the bone) to her left femur (thigh bone), via an x-ray, after she was observed with swelling to her left thigh with indications of pain. This deficient practice resulted in the non-existence of goals and interventions to care for a resident with osteopenia and had the potential for Resident 1 to sustain additional injuries and/or fractures. Findings: During a review of Resident 1 ' s admission Record (Face sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including epilepsy (a brain condition that causes repeated seizures [uncontrolled movement]), diabetes mellitus ([DM] a disorder in which the amount of sugar in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure records were provided within 48 hours following a request by the resident's Responsible Party (RP) for one out of two sampled residents (Resident 1). This deficient practice resulted in the inability of Resident 1 and/or Resident 1's RP to access requested records and violated Resident 1's rights to have access to their records. Findings: During a review of Resident 1's admission Records (Face Sheet), the Face Sheet indicated, Resident 1 was admitted to the facility on [DATE] and Resident 1's family member was listed as Resident 1's RP. During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care planning tool), dated 7/10/2023, the MDS indicated, Resident 1's cognitive skills for daily decision-making were severely impaired. During a concurrent interview and record review on 10/20/2023, at 1:51 p.m., with the Medical Records Director (MRD), Resident 1's Medical Record Request was reviewed. The Medical Record…

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

Based on observation, interview and record review, the facility failed to: a.Ensure chocolate cream squares in the freezer maintained a temperature of 41 Fahrenheit ([F] unit of measurement) or below. b.Ensure the dishwashing machine was running at the proper temperature. c.Ensure the [NAME] performed hand hygiene after removal of gloves during food preparation. These deficient practices had the potential to place residents at risk for food borne illness (any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites). Findings: a.During the initial observation of the kitchen on 9/29/2023 at 8:10 a.m. with the [NAME] (CK1), a tray of chocolate cream squares was on the freezer with a temperature of 43 Fahrenheit ([F] unit of measurement). CK 1 stated the chocolate cream squares will be served during dinner. During a concurrent observation and interview on 9/29/2023, at 12:00 p.m. with Dietary Service Supervisor (DSS), chocolate cream squares remained on the freezer with a temperature of 44 F. DSS stated the chocolate cream squares would be thrown out…

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 infection control measures by failing to: a.Handle soiled linens in a safe and sanitary way by leaving a plastic bag with soiled linens on the floor while providing care to a resident (Resident 1). b.Ensure Laundry Aide did not reuse isolation gown (specialized clothing worn by an employee for protection against infectious materials) when sorting soiled linens in the dirty linen room. These deficient practices had the potential to result in cross contamination(physical movement or transfer of harmful bacteria from one person, object, or place to another) and placed residents and staff at risk for infection. Findings: a.During a review of Resident 1's admission Record indicated resident was admitted on [DATE] with diagnoses that included hypertension (high blood pressure) scoliosis( abnormal curvature of the spine) atherosclerotic heart disease(thickening or hardening of blood vessels that carry oxygen and nutrients to the heart)…

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 follows the policies and procedure (P& PP) for the application of medication patches for two out of two sampled residents (Resident 2 and Resident 32), by not putting the Licensed Vocational Nurse(LVN) initial and dating the medication patches. This deficient practice had the potential for Resident 2 and Resident 32 to have the medication patch on for the incorrect time ordered by the physician. Findings: A. During a review of Resident 32's admission record (face sheet), the face sheet indicated Resident 32 was admitted to the facility on [DATE] with diagnosis of muscle weakness and unspecified osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time), unspecified site. During a review of Resident 32's history and physical (H&P) report dated 12/30/2022, the H&P indicated resident 32 had the ability to understand and make decisions. During a review of Resident 32's Order Summary Report…

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 notify the physician regarding insect bites for one of two residents (Resident 34). This deficient practice had the potential to result in lack of necessary care and treatment and place Resident 34 at risk for psychosocial harm. Findings: During a review of Resident 34's admission Record (AR), the AR indicated resident was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis (chronic condition that affects your brain and spinal cord ) osteoarthritis( condition caused by wearing down the cartilage that covers the ends of bones) and morbid obesity(when a person weighs 100 pounds over the recommended weight). During a review of Resident 34's Minimum Data Set([MDS]standardized screening tool) dated 8/3, 2023, the MDS indicated resident had an intact cognition (thought process) and required one-person physical assist with bed mobility, toilet use and personal hygiene. During a concurrent observation and interview…

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

Based on observation, interview and record review the facility failed to follow physician orders and provide a snack-sack (food items) for one of two sampled residents (Resident 205) who was scheduled to receive hemodialysis (HD, the removing of waste, salt and extra water to prevent build up in the body for residents who have loss of kidney function) treatment on Tuesday, Thursday and Saturday. This deficient practice had the potential to cause Resident 205 to experience hunger and exhaustion after hemodialysis treatment. Findings: During a review of Resident 205's admission record (face sheet), the face sheet indicated resident 205 was admitted to the facility 9/26/2023 with diagnosis of unspecified protein-calorie malnutrition and dependence on renal dialysis. During a review of Resident 205's history and physical (H&P) report dated 9/28/2023, the H&P indicated Resident 205 had the capacity to understand and make decisions. During a review of Resident 205's Order Summary Report (OSR), the OSR indicated an order was placed 9/26/2023 for send snack-sack during dialysis days…

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 to assist Resident 11 that was on one to one supervision (1:1 a nurse who is assigned solely to one Resident) during lunch time for one of one sample resident. This deficient practice had the potential to put Resident 11 at risk for choking or aspiration ( have severe difficulty in breathing because of a constricted or obstructed throat or a lack of air). Findings : During a review of Resident 11's admission record (face sheet ) , the face sheet indicated Resident 11 was originally admitted to the facility on [DATE] and re-admitted on 2/3/ 2023 with diagnosis that included a history of Alzheimer's Disease (a progressive disease that destroys memory and other important memory functions ) , Hemiplegia , unspecified affecting the left dominant side ( paralysis), and dysphagia, oropharyngeal phase (swallowing problems occurring in the mouth and/or throat). During a review of Resident's 11 history and physical (H&P) reported 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.