Golden Sonora Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure food served was prepared by methods that conserve nutritive value, flavor and appearance for 172 of 172 residents that consumed facility prepared meals. These failures had the potential for decreased meal intake which could result in weight loss, malnutrition, and negatively impact the residents' quality of life. Findings:1. During an observation of the Journey dining room on 8/4/25 at 11:50 a.m. the lunch meal was served. One resident meal out of the 13 meals served had a heating element ( induction chargers ) under the plate to maintain the temperature of the hot items. During an interview on 8/4/25 at 12:38 p.m., Resident 15 stated, Food comes semi warm and there is a lack of edible food.During an interview on 8/4/25 at 12:54 p.m., Resident 28 stated, The food could be hotter. During an interview on 8/4/25 at 12:54 p.m., Resident 34 stated, Food could be hotter.During a review of Resident Council notes, dated 8/5/25 at 10:00…

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 alternate food choices with similar nutritive value to the main meal for 172 residents who received food from the kitchen. These failures had the potential of not meeting estimated nutrient needs and potential weight loss. During an initial kitchen tour on 8/4/25 at 8:11 a.m., the alternate menu was reviewed. The alternate menu included chef's salad, grilled cheese sandwich, cottage cheese and fruit, and hamburgers.During a subsequent interview on 8/4/25 at 8:15 a.m. with the Certified Dietary Manager (CDM), the CDM confirmed that the alternate meal choices were chef's salad, grilled cheese sandwich, cottage cheese and fruit, and hamburgers.During an interview on 8/4/25 at 2:54 p.m. Resident 84 stated that they used to get alternatives like sandwiches but all they get now are snack type items. Resident 84 also stated the new company has decreased the portion sizes.During an interview on 8/4/25 at 2:54 p.m. Resident 1 stated they are not getting alternatives to the main meal anymore.During an 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 store, prepare, and serve food per safety standards when:Cool down log was not followed consistently.Sugar and flour were stored in the same container.Bowls and pans were found stored wetSmall wares (pans, bowls, cutting board, can opener) were not replaced when worn.Shelves were found discolored and worn (under microwave and grill).Fans were found with black residue (dust) Forks stored in a manner causing fingers to touch the eating surface.Resident refrigerator logs were not acted upon when out of range, and had foods improperly labeled and not discarded per policy.These failures had the potential to lead to cross contamination and food borne illness for the 172 residents eating facility prepared meals. 1. During the initial kitchen tour on 8/4/25, at 9:41 a.m., macaroni salad with a preparation date of 8/4/25, was observed in the walk-in refrigerator at 76 degrees F.During an interview on 8/6/25, at 2:45 p.m., with the Certified Dietary Manager (CDM), the CDM stated the macaroni salad was made earlier that…

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 maintain complete and accurate antibiotic monitoring documentation and failed to implement all core elements of the Antibiotic Stewardship Program (ASP, antibiotic use protocols and a system to monitor antibiotic use) for a census of 173 residents when the facility did not have:1. A current infection Surveillance Plan (a written guide that explains how to watch for and track infections), 2. Complete antibiotic tracking data (the information collected by the facility regarding how antibiotics are used and how effective they are against bacteria),3. Documented evidence of antibiotic time-outs (a planned pause usually 48-72 hours after starting antibiotics, to ensure the medication is still appropriate).These failures had the potential to result in incomplete infection tracking, lack of timely antibiotic review, and inappropriate antimicrobial use which may contribute to the development of multidrug resistant organisms (MDRO - germs that have developed the ability to survive antibiotics that were previously used to kill them)…

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 maintain an effective pest control program when multiple flies were seen in the food preparation area. This failure had the potential of contamination of food and food poisoning for the 172 residents eating facility prepared meals. Findings:During the initial kitchen tour on 8/4/25 at 8:21 a.m. a fly was observed in the kitchen.During the initial kitchen tour on 8/4/25 at 8:44 a.m. in the dry storeroom which was separated by a closed door from the kitchen, another fly was observed.During the initial kitchen tour on 8/4/25 at 10:12 a.m. the dumpsters were observed. The door to the dumpster area was noted to be propped open with rock. The dumpsters were approximately 15 to 20 feet from the hallway door.During the lunch plating observation on 8/5/25 at 11:30 a.m., multiple flies were observed in the kitchen. The food for lunch was mostly uncovered and staff were swatting at the flies to keep them off of the meal.During an interview on 8/6/25 at 2:50 p.m., with the Dietary Director (DD), the DD concurred that 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 privacy and dignity were maintained for one of 38 sampled residents (Resident 127) when Resident 127's urinary catheter bag (catheter bag - a bag that collects urine draining from the bladder) did not have a privacy cover (a cover designed to discreetly conceal the visible urine in a urinary catheter bag, improving resident dignity, comfort, and self-worth in public or social settings) over it.This failure had the potential to negatively impact Resident 127s feelings of dignity and self-worth.Findings:During an observation on 8/4/25 at 11:15 AM, in Resident 127's room, a urinary catheter bag was observed hanging under Resident 127's bed and it was not covered with a privacy cover.During a concurrent observation and interview on 8/4/25 at 11:32 AM with Certified Nurse Assistant (CNA) 6 in Resident 127's room, CNA 6 confirmed the catheter bag hanging under Resident 127's bed did not have a privacy cover. CNA 6 stated, Resident 127's catheter bag should have been covered with a privacy cover to preserve…

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

Based on observation, interview, and record review, the facility failed to ensure the storage of bedside self-administered medication was reviewed and approved by a doctor and the care team for one resident (Resident 1) out of 12 sampled residents observed for medication administration when Resident 1's albuterol inhaler (a medication used to treat shortness of breath) was found on her bedside table.This failure had potential to contribute to unsafe and unsecure medication use by Resident 1 and other residents including Resident 1's roommates.During a medication administration observation with Licensed Nurse (LN) 10, at the facility's [NAME] Station hallway, on 8/4/25, at 8:37 a.m., LN 10 was observed giving six medications to Resident 1, which included TRELEGY Ellipta (inhalation drug to treat chronic breathing disease) as a scheduled drug to treat a breathing condition. Further observation of Resident 1's room revealed the presence of an albuterol inhaler (a medication used to treat shortness of breath) at the bedside table.During a concurrent observation and interview with…

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 immediately inform the Responsible Party (RP - an individual chosen by a resident or appointed by a judge to make personal and/or financial decisions for an adult who cannot care for or make decisions for themselves) for one out of thirty-eight sampled residents (Resident 153), when Resident 153 had a change in condition (any change in a resident's physical, mental, or emotional state from their normal baseline, possibly indicating a new illness or injury or worsening of a condition, recognized and treated to prevent serious complications, and to maintain resident health and safety), was sent to the emergency room (ER), and an RP was not notified in a timely manner.This failure resulted in miscommunication between the facility, the RP, and the ER when medical decisions were made for Resident 153 without input from the RP.Findings:During an interview on 8/5/25 at 12:06 PM, with RP 3, RP 3 stated, Resident 153 had an unwitnessed fall on Saturday, 7/19/25…

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 immediately resolve a grievance and did not respond in writing within five business days to one out of 38 sampled residents (Resident 81), in accordance with facility policy when Resident 81 submitted a grievance form in June 2025, but the facility did not provide a resolution or follow-up until August 2025.This delay in addressing the grievance negatively impacted the psychosocial wellbeing of Resident 81.Findings:A review of Resident 81's Inventory of Resident Personal Items dated 3/9/25 indicated that she brought the following items with her upon admission: 13 pairs of pants, 12 blouses, 7 sweaters, 5 pairs of slippers, and 13 pairs of pajamas among other items.A review of the Grievance/Complaint Resolution Report dated 6/30/25 and signed by the Social Services Director (SSD), showed that Resident 81 reported several missing items, including white slacks, a summer dress and some blouses. The grievance form indicated that an inquiry was made with 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 interview and record review, the facility failed to develop a comprehensive care plan for one of seven sampled residents (Resident 3) who received hospice care services (a specialized care that provides physical comfort and emotional, social and spiritual support for people nearing the end of life), when a hospice care plan was not developed for Resident 3.This failure had the potential to have a negative impact on Resident 3's quality of life, as well as the quality of care and services received.Findings:Review of Resident 3's admission Record indicated, Resident 3 was admitted with multiple diagnoses which included but not limited to chronic obstructive pulmonary disease (COPD - a common lung disease causing restricted airflow and breathing problems), chronic respiratory failure with hypoxia ( a condition where the lungs can't adequately oxygenate the blood, leading to low blood oxygen levels), and chronic kidney disease ( a condition characterized by progressive damage and loss of function in the kidneys).Review of Resident 3's Hospice Care Coordination Note dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to update and revise the comprehensive care plan for one of three sampled residents (Resident 19) who had a pressure ulcer (a skin and tissue injury caused by prolonged pressure, typically on bony areas of the body), when Resident 19's pressure ulcer care plan was not updated to reflect his current treatment plan and pressure ulcer stage (pressure ulcers are categorized into stages based on their severity, ranging from early warning signs to deep tissue damage) after a change on 6/26/25.This failure placed Resident 19 at risk of not receiving adequate wound care, delayed wound healing, potential wound complications, and worsen wound condition.Findings:Review of Resident 19's admission Record, indicated Resident 19 was admitted to the facility with multiple diagnoses which included but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (refer to paralysis or weakness, respectively, on one side of the body…

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 did not ensure the safe storage and handling of hazardous medications (HD - medications that pose potential risks to healthcare workers, patients, or the environment during handling, preparation, administration, or disposal). Additionally, continuous glucose monitoring (CGM) was not used safely according to standards of practice and manufacturer specifications with a census of 172, when:1. Hazardous drugs were stored in active storage areas without warning labels in the facility's medication cart at North-B station, and Finasteride (HD), a drug that blocks hormone production, was administered to one resident (Resident 169) out of 12 residents observed for medication administration without gloves on at South station.2. The facility lacked a policy, staff training, and physician review of medications that could affect or interfere with accurate blood sugar measurement when using a Continuous Glucose Monitoring device on diabetic (blood sugar disease)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide appropriate interventions for one of thirty-eight sampled residents (Resident 14), when Resident 14's hand splint (a device designed to protect and support painful, swollen or weak joints and their surrounding structure) used to address Resident 14's hand contractures (a permanent shortening of muscle, tendon, or scar tissue producing deformity or distortion) were not followed up by Occupational Therapy or facility staff. This deficient practice placed Resident 14 at risk for further decline related to her hand contractures. Findings:Review of Resident 14's admission RECORD, indicated Resident 14 was admitted with diagnoses which included, but were not limited to spinal stenosis (occurs when the space around the spinal cord becomes too narrow and irritates the spinal cord and/or nerves that branch off it causing symptoms of back or neck pain and tingling in your arms or legs), multiple sclerosis (MS, an autoimmune disease that attacks 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 resident's environment remained free of accident hazards for a census of 173 when:1. oxygen signage was not posted outside the door of Resident 36 who was receiving oxygen; and,2. Resident 119, diagnosed with dementia (a decline in mental ability severe enough to interfere with daily life) and a history of exit-seeking behavior, eloped (leaving a healthcare facility or care setting without authorization or discharge, often due to confusion, disorientation, or a lack of safety awareness, putting them at risk of injury or even death) from the facility unsupervised, and was missing for an unknown period of time before being found down the street by family.This failure placed residents at risk of injury due to fire hazards and placed Resident 119 at risk for injury.Findings:1. Review of Resident 36's admission Record indicated Resident 36 was admitted with multiple diagnoses which included but not limited to chronic obstructive pulmonary disease (COPD - a common lung disease causing restricted airflow and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide appropriate health treatment and services to meet the urological (the branch of medicine focused on the urinary tract/system) health needs for two of 38 sampled residents (Resident 70 and Resident 12) when: 1. There was no record of indwelling catheter (urinary catheter, a tube which is inserted into the bladder and left in place to drain urine) care being provided to Resident 70's urinary catheter every shift each day per physician order, and Resident 70's urine output was not documented every shift each day per physician order. 2. Resident 12's urology (specializes in conditions that affect the urinary and reproductive systems in adults and children) consult ordered on 5/17/25 and referral to urologist (medical doctor that specializes in urology) for chronic urinary tract infection (UTI, are an infection in your urinary system. Bacteria cause most UTIs, and symptoms include problems peeing and pain in your side) ordered 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 safe medication administration practices when medication error rate was more than 5% (% or percentage- number or ratio that expressed as a fraction of 100) with resident census of 172. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of three errors out of 57 opportunities which resulted in a facility wide medication error rate of 5.26% in 3 out of 14 residents (Resident 30, Resident 45, and Resident 169) observed for medication administration. The medication errors were as follows: 1. Resident 30 received the wrong formulation of aspirin (medication used to help prevent stroke or heart attack); 2. Resident 45 received the wrong formulation of aspirin; and, 3. Resident 169 received the wrong formulation of metformin (medication to manage high blood sugar levels). These failures may result in unsafe medication use affecting residents' health and well-being.1. During a medication administration…

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 maintain the garbage storage area when 2 out of 6 dumpsters were observed overflowing the sides of the dumpster and the lids could not close. This had the potential of attracting pest potentially leading to food contamination for the 172 residents' eating facility prepared meals. During the initial kitchen tour on 8/4/25 at 10:12 a.m., the dumpster area was observed. Two of the six dumpsters were noted to have garbage exceeding the side walls of the dumpsters, interfering with the closure of the lids. One lid was noted to rest approximately 6 inches above the bin, supported by bags of garbage. The second lid had been left open. The dumpsters were housed in an area approximately 15 to 20 feet from the door to the hallway of the kitchen.During an interview on 8/6/25 at 2:50 p.m., the certified dietary manager stated that it was important for the lids to be closed to limit the pests being attracted to the building. Review of the facility provided policy titled Dispose of Garbage and Refuse (HCSG Policy 030,…

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 maintain complete and accurate medical records for one out of thirty-eight sampled residents (Resident 153), when the facility did not update Resident 153's admission Record (a comprehensive collection of documents and information gathered at the time a resident is admitted or readmitted to a facility) with afterhours and weekend phone numbers for notification to the Responsible Party (RP - an individual chosen by a resident or appointed by a judge to make personal, medical, and/or financial decisions for an adult who cannot care for or make decisions for themselves) when status changes and health updates occurred.This failure resulted in Resident 153's RP 3 and RP 4 not receiving notification when Resident 153 had a change in condition that occurred after regular business hours or on weekends.Findings:During an interview on 8/5/25 at 12:06 PM, with RP 3, RP 3 stated, Resident 153 had an unwitnessed fall on Saturday 7/19/25, and the facility did not…

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

Based on observation, interview, and record review, the facility failed to ensure proper infection prevention practices (a set of measures taken to stop the spread of germs and infections) were implemented and followed for a census of 172 when there were two unlabeled urinals (portable, bottle-shaped containers designed for male patients to urinate into when they cannot reach a toilet) on the nightstand next to Resident 133's bed.This failure had the potential to place residents at risk for developing an infection and the potential to result in transmission of infection in the facility.During an observation on 8/4/25 at 11:40 AM, in Resident 133's room, there were two urinals on the nightstand next to Resident 133's bed and they were not labeled with a name, initials or other identifying information indicating to whom they belonged.During a concurrent observation and interview on 8/4/25 at 3:00 PM with Licensed Nurse (LN) 21 in Resident 133's room, LN 21 confirmed, there were two unlabeled urinals on the nightstand next to Resident 133's bed and that the urinals should be labeled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide adequate supervision to prevent a fall for 1 of 5 sampled residents (Resident 1) when, Resident 1 was left unattended in the bathroom.This failure caused Resident 1 to sustain a fall which resulted in a scalp laceration (cut to the head).Findings:A review of Resident 1's admission RECORD, indicated, she was admitted to the facility on [DATE], with diagnoses which included traumatic subdural hemorrhage (a type of bleeding near the brain that can happen after a head injury) with loss of consciousness (loss of awareness of oneself and one's surroundings) and muscle weakness. A review of Resident 1's pre-admission document titled, Transcriptions-Referral . (hospital information provided to the facility prior to admission to determine if they can meet the needs of the resident) indicated, .admission H&P [history and physical] .6/14/2025 .Chief complaint .possible fall with head strike 4 days ago .transferred from an outside hospital for a higher…

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 podiatry services (service provided by a podiatrist; a health professional trained to diagnose and treat diseases and other disorders of the feet) for one of three sampled residents (Resident 1) as ordered by the physician. This deficient practice had the potential to affect Resident 1 ' s foot health with a possibility to contribute to pain and podiatric complications. Findings: Review of Resident 1 ' s clinical record titled admission RECORD, indicated Resident 1 was admitted to the facility with diagnosis which included, dementia (loss of cognitive functioning, remembering, and reasoning to such an extent that it interferes with a person ' s daily life and activities), glaucoma (a group of eye conditions that damages the optic nerve leading to vision loss), hyperlipidemia (a condition in which there are high levels of fat particles (lipids) in the blood), and depression. Review of Resident 1 ' s skin/wound note, dated 12/31/24, the record indicated wound eval and treatment completed on resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure all necessary baseline care plans were created within forty-eight hours of admission for 1 of 3 sampled residents (Resident 1) when, Resident 1 ' s conditions and risks identified upon admission were not created and implemented as part of Resident 1 ' s baseline care plans. This failure resulted in Resident 1's care plan for communication, dehydration, skin, and incontinence not being created and initiated during any part of Resident 1's stay at the facility as they were not initiated until after Resident 1 was discharged from the facility. Findings: A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility on [DATE] and discharged on 6/3/24, with diagnoses including urinary tract infection (UTI; an infection in any part of the system of organs that makes urine), muscle weakness, need for assistance with personal care, aphasia (a language disorder that affects a person's ability to communicate), dysphagia…

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

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received care in accordance with professional standards of practice when: 1. Resident 1's blood pressure (BP - the measurement of the pressure in your arteries when your heart contracts and pumps blood out) medication amlodipine was administered without consistent monitoring of Resident 1's BP prior to administration of the medication and there were no parameters listed on the order to indicate when to hold the medication; and, 2. Resident 1's BPs were not taken regularly during his stay at the facility and a BP of 272/114 was not acted upon (normal blood pressure is less than 120/80). These failures resulted in Resident 1's BP becoming increasingly elevated with inconsistent BP monitoring once Resident 1 started receiving the BP medication amlodipine. These failures also resulted in a BP of 272/114 not being acted upon by licensed nurses and the medical doctor. Ultimately Resident 1 was transferred to one hospital, then another hospital for a higher level of care, on 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 protect one of four sampled residents' (Resident 1) property from loss. This failure resulted in Resident 1 having lost property and had the potential to cause Resident 1 emotional distress. Findings: During an interview on 1/29/25, at 9:39 AM, with Resident 1's Responsible Party (RP), the RP stated while in the facility on 1/5/25, she noticed Resident 1 wearing an adult brief (worn for a lack of bowel/bladder control). The RP explained Resident 1 was fully continent (ability to control bladder and bowels) and used the restroom on his own. During the visits, the RP assisted Resident 1 with dressing and noticed all his boxer briefs the RP purchased and brought to the facility a few months ago were missing. The RP also stated he was missing a forest green, charcoal gray, light gray, and red crew neck sweatshirts and matching sweatpants, and about 10-12 assorted colored boxer briefs. During a concurrent interview and record review 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 interview, and record review, the facility failed to ensure professional standards of care were met for one out of three sampled residents (Resident 1) when Resident 1's post incident documentation (documentation of assessments and observations after an incident occurs) was incomplete. This failure had the potential for Resident 1 to have unassessed injuries and/or illnesses and unmet psychosocial needs. Findings: A review of Resident 1's admission RECORD, indicated he was admitted to the facility in mid-2023, with diagnoses which included schizophrenia (a mental illness that is characterized by disturbances in thought) and muscle weakness. A review of Resident 1's Progress Notes, dated 9/13/24, at 10:15 PM, indicated, .Resident became very enraged throwing and cussing at the police officers .Resident became more upset and storm (sic) outside to smoke a cigarette .When police and house supervisor went outside found resident on the floor, lying flat on the floor, with laceration [cut or tear in skin] on left eye. Police called ambulance .LVN [licensed vocational nurse] staff…

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

Based on interview, and record review, the facility failed to ensure the right to return to the facility was protected for one of one sampled resident (Resident 1), when: 1. Resident 1 was sent to the hospital and was not allowed to return to the facility on 6/7/24, 2. A facility physician did not document a basis for Resident 1's discharge; and, 3. The facility failed to provide a written Notice of Transfer or Discharge to Resident 1, Resident 1's representative (RP), and the Long-Term Care (LTC) Ombudsman (a patient rights advocate). These failures placed Resident 1 at risk for emotional distress, removed the opportunity for the State LTC Ombudsman to advocate on Resident 1's behalf, and deprived Resident 1 or his RP of information regarding rights to appeal the transfer/discharge. Findings: 1. Review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in 2024 with diagnoses including prostate cancer and secondary malignant neoplasm of brain (cancer cells spreading to the brain from another part of the body). Review of Resident 1's hospital 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 interview and record review, the facility failed to develop and implement a person-centered care plan to address resident-specific care needs for one of three sampled residents (Resident 3) when, there was no care plan with interventions developed to address Resident 3's dysphagia (difficulty swallowing foods or liquids). This failure had the potential to result in staff being unaware of Resident 3's aspiration [accidentally inhaling your food or liquid through your vocal cords into your airway, which increases your risk of developing pneumonia (infection in the lungs)] risk and not knowing interventions to reduce possible physical harm and/or death. Findings: Review of Resident 3's admission record indicated Resident 3 was admitted to the facility with diagnoses of, but not limited to; dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), generalized muscle weakness, and dysphagia (difficulty swallowing foods or liquids). During a concurrent interview and record review 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 one of three sampled residents (Resident 3) received care in accordance with professional standards when, speech therapy placed a sign above Resident 3's bed which indicated no straws and Resident 3 had a straw in her milk for the lunch meal on 7/18/24. This failure had the potential to result in Resident 3 aspirating (aspirate; accidentally inhaling your food or liquid through your vocal cords into your airway, which increases your risk of developing pneumonia (infection in the lungs)) on liquids, which could result in physical harm and/or death. Findings: Review of Resident 3's admission record indicated Resident 3 was admitted to the facility with diagnosis of, but not limited to; dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), generalized muscle weakness, and dysphagia (difficulty swallowing foods or liquids). During a concurrent observation and interview, on 7/18/24, at 2:42 p.m., with 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 interview and record review the facility failed to ensure a process was in place for 42 residents, who had funds in the facility trust account (a legal arrangement through which funds are held by a third party), to request and receive personal funds on the weekends or after hours. This failure had the potential to result in residents not having access to their personal funds for dining, shopping, or other resident centered activities after business hours and on the weekend which could adversely affect their psychosocial well-being. Findings: 1. A review of Resident 28's admission RECORD, indicated she was readmitted to the facility in 2022. During an interview on 6/18/2024, at 7:20 AM, Resident 28 stated the facility held her money and she was not able to access cash on the weekends. During an interview and record review on 6/18/2024, at 4:07 PM, the Business Office Manager Assistant (BOMA) stated residents' funds were deposited directly into the facility trust account and stayed there until the residents requested it. The BOMA further stated if a resident wanted cash, they…

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 being served for the lunch meal on 6/19/24 was accurate for 10 residents when 10 residents with an order for Double Protein instead received double of each food item for a census of 171. This failure had the potential for all 10 residents' nutritional needs not to be met and could lead to nutritional related health complications. Findings: During an observation of the lunch meal service on 6/19/24 in the kitchen, 10 residents whose meal tickets indicated an order for DOUBLE PROTEIN were instead served double portions of each food item plated on the meal tray. During an interview on 6/20/24 at 3:27 p.m., with the District Manager (DM), the DM stated, staff should prepare and serve what was ordered. The DM also stated the Dietary Manager should have been present during tray line to make sure the process was done correctly. A review of a facility provided document titled, TRAYLINE ACCURACY/MENU COMPLIANCE, dated 2010, indicated, .The end results of tray line accuracy .are .residents maintain…

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 proper food handling practices for 171 residents who received food from the kitchen when: 1. Multiple food items were found not labeled with a use by date (the last date recommended for the use of the product while at peak quality) in the refrigerator, freezer, and the dry storage area (foods that do not require to be kept cold), and were available for resident consumption (to eat/drink); 2. Expired (outdated) food products were not removed from the kitchen, and were available for resident consumption; 3. A fan above the double coffee maker in the kitchen had dust and lint; 4. Plastic cups in the kitchen were stacked wet after washing; 5. Three opened boxes of plastic silverware were opened and uncovered in the dry storage area; 6. The [NAME] Unit nursing station's nourishment (food) refrigerator contained unlabeled food items; and, 7. The East Unit nursing station refrigerator contained hair, spilled liquid, and stains. These failures had the potential to cause an outbreak of food borne illnesses…

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 maintain its infection control program when: 1a. The facility did not ensure enhanced barrier precautions (targeted gown and glove use during high contact care activities for those with indwelling devices and/or certain infections) were observed when completing a dressing change for Resident 126; 1b. The facility did not ensure the dressing changes were dated, timed, and initialed for Resident 126; 2. A clean linen cart, containing clean linen items, was transported with the cover flap open; and, 3. Hand hygiene was not performed during wound care for Resident 2. These failures had the potential to spread infections to residents residing in the facility, negatively impacting their health and well-being. Findings: 1a. A review of the facility's document titled, admission Record (a document that contained the resident's demographic information), indicated Resident 126's diagnoses included cancer of the right ureter (tube that transports urine from the kidneys to the urinary bladder), complications with 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 privacy and dignity were maintained for one of seven resident's (Resident 2) with a urine collection bag (urinary catheter-a tube that is inserted into the bladder and drains into a collection bag) in a census of 170, when Resident 2's urine collection bag did not have a privacy cover over it. This failure had the potential to negatively impact Resident 2's feelings of dignity and self-worth. Findings: A review of Resident 2's admission Record, indicated Resident 2 was admitted to the facility with diagnoses which included the need for assistance with personal care. A review of Resident 2's Care Plan, initiated on 2/22/24, indicated, .[Resident 2] has a [brand name] catheter .The resident will be/remain free from catheter-related trauma through review date . During an observation on 6/18/24, at 12:37 PM, in Resident 2's room, Resident 2's urinary collection bag was noted to be not covered with a privacy bag. During a subsequent observation on 6/19/24, at 3:19 PM, in Resident 2's room, Resident 2's…

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

Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs for 2 of 39 sampled residents (Resident 103 and 169) when: 1. Resident 103's call light (a device used to call for assistance) was not within reach; and, 2. Resident 169's call light was not within reach. This failure had the potential to result in Resident 103 and 169 being unable to ask for needed assistance. Findings: 1. A review of Resident 103's admission Record, indicated Resident 103 was admitted to the facility with multiple diagnoses which included muscle weakness and difficulty in walking. During an observation on 6/18/24, at 8:01 a.m., in Resident 103's room, Resident 103 was observed sitting at the edge of his bed with no call light visible. Resident 103 was seen trying to use the television remote control to call for help. During a concurrent observation and interview on 6/18/24, at 8:07 a.m., with Certified Nursing Assistant (CNA) 1 in Resident 103's room, CNA 1 confirmed Resident 103's call light was on the floor and out of reach. CNA 1 stated when…

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 1 of 39 sampled residents (Resident 150) right to self-determination was respected when Resident 1 requested to get a shower instead of a bed bath and staff did not honor his wishes. This failure had the potential to negatively impact Resident 150's psychosocial well-being. Findings: A review of Resident 150's admission RECORD, indicated that Resident 150 was admitted with diagnoses which included abnormalities of gait (walking) and mobility and the need for assistance with personal care. During an interview on 6/20/24, at 12:47 p.m., with Resident 150, Resident 150 stated he was not given his shower last week on his shower days. Resident 150 stated that he was told by a Certified Nursing Assistant (CNA) that they did not have time to give Resident 150 a shower. During a concurrent interview and record review on 6/20/24, at 7:09 a.m., with the Director of Nursing (DON), Resident 150's clinical records were reviewed. Resident 150's Minimum Data Set (MDS, an assessment and care screening tool) dated 4/26/24,…

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 coordinate assessments with the Preadmission Screening and Resident Review (PASRR, a federal requirement to screen all potential nursing home residents for mental illness and intellectual disability, to help ensure that individuals are not inappropriately placed in a nursing home, and to ensure they receive any specialized services that are required) program for 1 of 39 sampled residents (Resident 26) when Resident 26's PASRR level I screening assessment did not include her mental illness diagnosis of schizophrenia (a serious mental illness that affects how a person thinks, feels and behaves). These failures had the potential for Resident 26 to not receive the necessary services to meet her mental and psychosocial (link between social factors and individual thought and behavior) needs. Findings: A review of Resident 26's admission RECORD, indicated, she was readmitted to the facility in 2023. A review of Resident 26's - Minimum Data Set (MDS, a resident assessment and screening tool) Section I-Active Diagnoses, dated…

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

Based on observation, interview, and record review, the facility failed to ensure an environment free of accidents or hazards for one resident (Resident 80) in a census of 170 with access to smoking paraphernalia when Resident 80 went to the sidewalk in front of the facility to smoke unsupervised. This failure had the potential to place Resident 80 at risk for accidental burns and injuries. Findings: A review of Resident 80's admission Record, indicated, Resident 80 was admitted to the facility in mid-2023 with diagnoses which include chronic obstructive pulmonary disease (COPD, a long-term lung disease that causes shortness of breath and cough), pulmonary embolism (occurs when a blood clot gets stuck in an artery in the lung blocking blood flow to the lung), and diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). During an observation and interview with Resident 80 outside the facility near the front entrance on 06/18/24 at 2:20 p.m., Resident 80 was observed walking outside of the facility toward the street with a walker. Resident 80 was…

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

Based on observation, interview, and record review, the facility failed to ensure one of thirty nine sampled residents (Resident 189) was provided services consistent with professional standards of practice when Resident 189's Peripherally Inserted Central Catheter (PICC line; a thin, soft long tube that is inserted into a vein in the arm with the tip of the catheter positioned in a large vein that carries blood to the heart in order to provide medications) dressing was not changed per physician orders. This failure had the potential to result in a PICC line malfunction and/or infection for Resident 189. Findings: A review of Resident 189's admission RECORD, indicated he was admitted to the facility in mid-2024 with diagnoses which included bacteremia (an infection of the blood). During a concurrent observation and interview on 6/17/2027, at 3:52 PM, Licensed Nurse (LN) 4 confirmed Resident 189's PICC line dressing was dated 6/8/2024. LN 4 stated the PICC line dressing should be changed every week on the night shift. During an interview on 6/17/2024, at 5:41 PM, LN 3 confirmed…

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 respiratory care was provided in accordance with professional standards of practice for one of 39 sampled residents (Resident 52) when Resident 52's oxygen tubing was not changed per physician order. This failure had the potential to result in a negative impact on the Resident 52s' health and safety. Findings: A review of Resident 52's admission Record indicated Resident 52 was admitted to the facility with diagnoses which included respiratory failure (a condition in which a person's blood doesn't have enough oxygen). During an observation on 6/17/24, at 2:56 p.m., Resident 52 was observed in her room with the oxygen concentrator (a machine that uses room air to deliver pure oxygen) on and running at a flow rate of 3 liters per minute (LPM, unit of measurement for oxygen delivery) via nasal cannula (a small flexible tube that contains two open prongs intended to sit just inside the nostrils). When asked, Resident 52 stated she had been using oxygen since her last stay at the hospital. During a…

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

Based on interview and record review, the facility failed to ensure one of thirty nine sampled residents (Resident 71) received services consistent with professional standards of practice when Resident 71's pre and post dialysis (treatment of kidney failure that rids the blood of unwanted toxins, waste products, and excess fluids by filtering the blood) documentation (documentation that communicates the residents weight, blood pressure, temperature and heart rate,vital signs), dialysis catheter site (flexible tube placed in the blood vessel inserted in the chest consisting of two tubes one to take blood to the dialysis machine and one to return blood to the body) assessment, medication changes, changes in condition, and other pertinent clinical information, between the facility and dialysis center) was incomplete for 5 out of 6 days of treatment. This failure resulted in a lack of communication between the dialysis center and the facility and had the potential to result in adverse health consequences for Resident 71. Findings: A review of Resident 71's admission RECORD, indicated,…

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

Based on interview and record review, the facility failed to ensure accurate dispensing and administering of narcotic drugs (regulated and highly addictive pain medication) for one of 39 sampled residents (Resident 545). This failure resulted in Resident 545 not being administered pain medication for the management of pancreatic (pancreas, an organ in the body that makes juices that help break down food into substances the body can use) cancer and lung cancer. Findings: Review of Resident 545's clinical record titled, admission Record (a document that contained the resident's demographic information), indicated Resident 545's diagnoses included pancreatic and lung cancer. During a concurrent observation, interview, and record review on 6/20/24, at 10:06 AM, with the Licensed Nurse (LN) 10, the locked narcotic drawer for Medication Cart B on the North station and the Antibiotic or Controlled Drug Record document (a record of when a narcotic was administered from the medication cart) was reviewed. Inside Medication Cart B was Resident 545's medication card (a sealed medicine card that…

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 proper use of psychotropic drugs (affecting brain activity) for 1 of 39 sampled residents (Resident 155) when: The physician did not document a rationale for extending PRN (as needed) medication beyond 14 days for Resident 155. This failure could have resulted in the use of unnecessary medications and placed the residents at risk for injury. Findings: A review of Resident 155's medical record titled, Order Audit Report, dated 4/1/24, by the PHYS (Physician), indicated, Resident 155 was ordered to receive Lorazepam (psychotropic/anti-anxiety medication) 0.5 milligrams (mg - unit of measurement) every 12 hours as needed for agitation for a duration of 6 months. During an interview on 6/19/24, at 10:23 a.m., with the Medical Director (MD), the MD stated the ordering physician should have documented the rationale for continuing Resident 155's Lorazepam PRN order past the two-week time period. During an interview on 6/19/24, at 10:30 a.m., with the Administrator (ADM), the ADM stated she was unable to find any…

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

Based on observation, interview, and record review, the facility failed to ensure medications were labeled and stored appropriately when: 1. Medication bottles had spillage on them, and there was a sticky substance on the bottom of the medication storage drawers in the medication carts; and, 2. An insulin pen (a device used to inject insulin, a medication to control blood sugar) for Resident 92, was available for use past its expiration date. These failures had the potential to cause illness in residents receiving medications from bottles of medications with spillage on them and Resident 92 was at risk of receiving insulin that had lost is efficacy (potency). Findings: 1a. During a concurrent interview and inspection of the facility's [NAME] Hall Medication Cart B, on 6/20/24, at 9:30 AM, accompanied by licensed nurse (LN) 15, the medication cart's third drawer, on the right-hand side, contained bottles of liquid medications with spillage on the outside for the following medications and supplements; Liquid Protein, Milk of Magnesia, and Valproic Acid. LN 15 confirmed the bottles…

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 Minimum Data Set (MDS, a resident assessment and screening tool) Assessment was completed on admission, within 21 days of the assessment reference date (ARD) for one of three sampled residents (Resident 3) when Resident 3 was admitted to the facility on [DATE] and the MDS assessment was incomplete on 5/17/24. This failure had the potential to delay the development of individualized care plans based on Resident 3's needs, strengths, and goals. Findings: A review of Resident 3's admission RECORD, indicated she was admitted to the facility on [DATE] with diagnoses which included, cerebral palsy (a group of conditions that affect movement and posture), depression (mood disorder that causes a persistent feeling of sadness), and chronic kidney disease (progressive loss of kidney function that impairs the ability to filter blood normally). A Review of Resident 3's electronic health record under the tab MDS , indicated, in red letters, .ARD: 3/3/24 75…

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 professional standards of quality care were met for 5 of 6 sampled residents, (Resident 1, Resident 2, Resident 4, Resident 5, and Resident 6) when their scheduled morning medications were not administered in a timely manner. This failure had the potential to negatively affect the therapeutic benefits of the medications prescribed to Resident 1, Resident 2, Resident 4, Resident 5, and Resident 6. Findings: During an observation on 4/11/24, between 9:45 -9:56 AM, licensed nurse (LN) 8 was observed, with her medication cart, at the rooms for Resident 4, Resident 5, and Resident 6. During an interview on 4/11/24, at 11:33 AM, LN 6 stated medications scheduled for 8 AM should be administered between 7 AM and 9 AM. LN 6 further stated medication administration needed to be spread out to accommodate a resident receiving the same medication two or three times per day. LN 6 stated it was the facility ' s policy to administer medications within a 2-hour time frame. During a random record review of medication…

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, observation, and record review, the facility failed to provide an environment free from the risk of infection for a census of 183 residents when, 1. The facility did not provide or ensure working hand sanitizer dispensers throughout the facility when eight of fifteen hand sanitizer dispensers on the South Wing and six of twenty-two hand sanitizer dispensers on the East Wing were found to not be functioning; and 2. Staff did not perform hand hygiene (washing your hands) prior to entering and exiting residents ' room and before and after performing resident care. These failures resulted in a potential for the spread of infection to residents, visitors, and staff of the facility. Findings: During a concurrent observation and interview on 3/27/24, at 10:26 a.m., with Certified Nurse Assistant (CNA) 1 on the South Wing, CNA 1 was observed to use the hand sanitizer dispenser on the wall outside of room A13 and rubbed her hands together, after which she walked across the length of a hall. CNA 1…

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

Based on observation, interview, and record review, the facility failed to notify one of three sampled residents (Resident 1) responsible party (RP, one person has the authority to make decisions for another person) of the results of a hearing examination performed on 11/7/23, Resident 1's need for hearing aids after the hearing examination, and when hearing aids were recommended and issued to Resident 1. This failure prevented Resident 1's RP from being involved in Resident 1's care and removed the opportunity for the RP to make decisions for Resident 1 regarding a medical examination (hearing test) and a medical device (hearing aids). Findings: A review of Resident 1's physicians order dated 2/20/24, indicated, .Resident [1] is uncapable of participating in own plan of care .uncapable of understanding and exercising rights . A review of Resident 1's Advanced Medical Directive and Power of Attorney for Healthcare [a document naming a representative to make decisions for someone without the ability to make decisions on their own], dated 4/20/20, indicated, .My agents authority…

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 their care plan interventions and/or develop care plans for 2 of 4 sampled Residents (Resident 2 and Resident 3) when: 1. Resident 2 and Resident 3 ' s fall risk care plan interventions of call lights in reach were not followed and, 2. Resident 2 did not have care plans developed for the psychotropic medications she received for striking out, yelling, social isolation and attention seeking behaviors. These failures had the potential for Resident 2 and Resident 3 to sustain further falls and Resident 2 ' s behavioral care needs and goals to not be addressed and reassessed. Findings: 1a. A review of Resident 2 ' s admission RECORD, indicated, Resident 2 was admitted to the facility in June of 2023 with diagnoses which included left femur fracture (a break in a thigh bone), left artificial hip joint and difficulty in walking, generalized anxiety disorder (a disorder characterized by excessive, uncontrollable, and often irrational worry) and mild cognitive impairment (slight decline in mental abilities). 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 interview and record review the facility failed to ensure that one of four sampled residents (Resident 2) was free from unnecessary psychotropic drugs (drugs that effect brain activities associated with mental processes and behaviors) when Resident 2 was prescribed: 1. Lorazepam (antianxiety medication) as needed (PRN) twice a day for greater than 14 days with inconsistent documentation of behaviors to justify its use, and 2. Sertraline (Antidepressant medication) without an appropriate diagnosis and no documentation to justify its use. These failures placed Resident 2 at risk of unsafe medication use and adverse medication side effects. Findings: A review of Resident 2 ' s admission RECORD, indicated, Resident 2 was admitted to the facility in June of 2023 with diagnoses which included generalized anxiety disorder (a disorder characterized by excessive, uncontrollable, and often irrational worry) and mild cognitive impairment (slight decline in mental abilities). 1. A review of Resident 2 ' s Medication Administration Record ' s (MARs) dated November 2023 and December…

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 professional standards of care were met for one out three sampled residents (Resident 3), who had sustained a fall, when post fall alert charting (documentation of assessments and observations) was not completed for Resident 3. This failure had the potential for Resident 3 to have sustained an injury which was not identified, and could result in a delay of treatment. Findings: A review of Resident 3's admission RECORD, indicated she was admitted to the facility in November of 2023 with diagnoses which included unspecified dementia (condition characterized by memory disorders, personality changes and impaired reasoning), difficulty in walking, muscle weakness, and chronic pain syndrome. A review of Resident 3's progress notes dated 11/21/23 at 3:16 PM, indicated, .Nursing Note .Resident noted to have unwitnessed fall at approximately 1500 [3 PM]. Resident was found by CNA [certified nursing assistant] sitting on the floor. Resident was noted to be sitting in her wheelchair and attempted to stand up and fell onto 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 interview and record review, the facility failed to follow professional standards of care for one of three sampled residents (Resident 1), when Resident 1's laboratory test (a medical procedure performed to detect, diagnose, or monitor disease) result was missing from Resident 1's record, and was not followed up on by the facility. This failure had the potential abnormalities in Resident 1's lab results would be undetected and could result in a delay of treatment for Resident 1. Findings: A review of Resident 1' s admission RECORD, indicated he was admitted to the facility in May of 2023 with diagnoses which included displaced trimalleolar fracture of left lower leg (break in the lower bones that form the ankle), malignant neoplasm (cancer) of lower lobe of left lung, and hyperkalemia (elevated potassium which can have adverse effect on the heart and muscles). A review of Resident 1's Facility Transfer Summary/Physician Admitting, orders dated 5/8/23, indicated, .Repeat CMP [comprehensive metabolic panel, a blood test to assess the body's fluid balance, levels of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1) received adequate care and treatment, when the facility: 1. Failed to promptly inform Resident 1's physician of her abnormal laboratory test results indicating that the resident had a urinary tract infection (UTI, an infection involving any part of the urinary system, including urethra, bladder, and kidney) start treatment; and, 2. The facility failed to assess Resident 1 and identify the cause of the resident's cognitive decline, lethargy, and decreased food and fluids intake after her delayed treatment for her UTI. These failures resulted in a delay in promptly identifying, assessing, and treating Resident 1's urinary tract infection until 12 days after results were obtained. The facility did not identify and did not intervene when Resident 1 had a decline in mental and physical condition, resulting in the resident's transfer to a general acute care hospital (GACH) with diagnoses of dehydration,…

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 drug record forms were in order and an account of all controlled drugs (drugs whose use and distribution are tightly controlled because of their abuse potential) was maintained and periodically reconciled when 64 tablets of various narcotics (prescribed by doctors to treat persistent or severe pain) were found to be missing out of the emergency drug kit (E-Kit) by the Pharmacy. This failure allowed for possible diversion (the illegal distribution or abuse of prescription drugs) of controlled drugs. Findings: A review of a facility document, untitled, dated 9/5/23, indicated, Regarding CII (Controlled Drugs) Narcotic Emergency Kit [E-Kit] at Station East, numbered 2068, Date Out: 8/11/23, Date In 9/4/23 .Below are discrepancies that are not logged/not accounted for . HYDROMORPHONE (Dilaudid) [pain medication] 2 MG [milligram, a unit of measure] tab [tablet] QTY [quantity] 8 tabs .DISCREPANCY .Took 8 METHADONE [pain medication] 5 MG tab .QTY 8 . DISCREPANCY .Took 8 HYDROCODONE-APAP (Norco) [pain medication] 5-325 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.

Based on observation, interview, and facility policy review, the facility failed to follow proper sanitation and food handling practices for 157 residents, in a census of 158, receiving food from the kitchen when: 1. Storage bins containing clean utensils had dust and debris on the bottom; 2. Food items were available for use past the expiration date; 3. The nourishment refrigerator in the kitchen did not have a June temperature log; 4. Overhead lights above steam table were dusty, cracked, and with debris; 5. Unit nourishment refrigerators contained food items past their expiration date; and, 6. Unit refrigerators contained food debris and stains. These failures had the potential to cause an outbreak of foodborne illnesses (eating or drinking something that is contaminated with germs or chemicals that can make people sick). Findings: 1. During a concurrent observation and interview on 6/19/23, at 8:35 AM, in the kitchen, with the Dietary Manager (DM), cooking utensils were stored in bins containing debris at the bottom and the bins were not clean. The DM confirmed the bins were not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a person centered care plan for 3 of 39 sampled residents (Resident 19, Resident 109 and Resident 66) when: 1. Range of motion (ROM) care plans were not developed for Resident 19 and Resident 109; and, 2. An anticoagulant (medication to prevent blood clots) care plan was not developed for Resident 66. These failures had the potential to result in adverse effects to the health and well- being of Resident 19, Resident 109 and Resident 66. Findings: 1a. Review of Resident 19's admission Record indicated Resident 19 was admitted to the facility early 2021 with multiple medical diagnoses that included hemiplegia (paralysis of one side of the body). Review of the Minimum Data Set (MDS - an assessment tool used to guide care) dated 5/10/23, Section C indicated Resident 19 had BIMS Score of 15, which indicated Resident 19 had no memory loss. MDS section G indicated Resident 19 needed extensive assistance in performing Activities of Daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure three of 39 sampled residents (Resident 38, Resident 5, and Resident 19) were assisted with nail care as part of their Activities of Daily Living (ADLs- normal daily functions required to meet basic needs) when: 1. Resident 38 had long, jagged fingernails with sharp edges, and with blackish substance underneath the fingernails; 2. Resident 5 had fingernails that were long and with blackish substance underneath the fingernails; and, 3. Staff did not trim Resident 19's fingernails. These failures resulted in Resident 38 sustaining scratches on the right forearm, Resident 5 to be at risk for worsening skin condition of lower back and buttocks due to scratching, and had the potential for Resident 19 to sustain injury and/or for the residents to acquire an infection. Findings: 1. A review of Resident 38's clinical record indicated Resident 38 was admitted in 2022 and had diagnoses that included diabetes mellitus (a chronic condition…

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 in accordance with professional standards of practice for one of thirty-nine sampled residents (Resident 116) when, Resident 116's wound care dressings were not consistently changed as ordered. This failure had the potential to result in infection and delayed wound healing for Resident 116. Findings: Review of Resident 116's admission RECORD, indicated Resident 116 was admitted to the facility with diagnoses which included infection of the right ankle and foot, gout (a form of arthritis characterized by severe pain, redness, and tenderness in joints that occurs when too much uric acid crystallizes and deposits in the joints), and infection of the skin and subcutaneous (the layer of tissue located directly under the skin) tissue. During a concurrent observation and interview on 6/20/23, at 8:10 AM, Resident 116 stated sometimes the staff did not change his dressings. Resident 116 stated he would ask for the dressing to be…

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

2. a. During an observation on 6/19/23, at 8:35 a.m., Resident 104's oxygen flow rate was at 5 liters per minute (LPM). During an interview on 6/19/23, at 8:40 a.m., with LN 7, she stated the oxygen flow rate for Resident 104 should be at 4 LPM. During a review of Resident 104's oxygen order, dated 6/19/23, indicated, Oxygen 2-4 liters per nasal canula. b. During an observation on 6/19/23, at 8:53 a.m., Resident 549's oxygen flow rate was at 5 liters per minute (LPM). During an interview on 6/19/23, at 8:53 a.m., with LN 8, she stated the oxygen flow rate for Resident 549 should be at 4 LPM. During a review of Resident 549's oxygen order, dated 6/19/23, indicated, Oxygen 4 L [liters] nasal canula or mask .Document .liters per minute. Based on observation, interview, and record review, the facility failed to ensure respiratory care was provided in accordance with professional standards of practice for four residents (Resident 35, Resident 104, Resident 443, and Resident 549) in a sample of 27 residents receiving oxygen in the facility when: 1. Resident 35's oxygen concentrator filter…

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

Based on interview and record review the facility failed to ensure one of 39 sampled residents (Resident 53) was free of significant medication errors, when Resident 53 did not receive insulin (medication to regulate blood sugars) as ordered by the physician. This failure had the potential for Resident 53's blood sugars to remain above 200 which could adversely affect her health and well-being. Findings: A review of Resident 53's admission RECORD, indicated Resident 53 was admitted to the facility in Spring of 2023 with diagnoses which included, Type 2 diabetes mellitus (disease that occurs when blood sugar is too high) with diabetic neuropathy (nerve damage associated with diabetes). A review of Resident 53' s clinical document titled Order Summary Report indicated, Insulin Glargine Solution [long-acting medication to regulate blood sugar] 100 UNIT/ML [milliliter, unit of measure] Inject 5 unit subcutaneously [under the skin] one time a day for diabetes .Order Date 6/3/2023 .Start Date 6/4/23. A review of Resident 53's medication administration record (MAR), dated June 2023,…

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 at an appetizing temperature when: 1. 2 of 39 sampled residents' (Resident 110 and Resident 81) meals were delivered late and cold; 2. The facility failed to ensure standardized recipes were followed for puree (smooth texture) food preparation for 1 of 15 residents (Resident 450) who received pureed food; and, 3. The facility failed to provide 1 of 39 sampled residents (Resident 133) with a salt substitute. These failures had the potential for decreased meal intake which could result in weight loss, and decreased nutritive value and negatively impact the residents' quality of life. Findings: 1. During an interview on 6/19/23, at 12 PM, Resident 110 stated, We're the last ones to get our meals. Lucky to get lunch 2-230 [PM] and dinner 6:45-7 [PM]. During an interview on 6/19/23, at 12:23 PM, Resident 81 stated the food did not have any flavor, and sometimes the food was served cold. Resident 81 stated he had lost a lot of weight prior to admission to the facility and needed…

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 maintain complete and accurate medical records for two of thirty-nine sampled residents (Resident 108 and Resident 440) when; 1. Resident 440's meal intake documentation was incomplete; and 2. Resident 108's ADL (activities of daily living) documentation was incomplete. This failure had the potential to not provide sufficient information that reflected the condition, care and services provided for Resident 440 and Resident 108. 1. During a concurrent interview and record review on 6/22/23, at 2:50 PM, Resident 440's Task: Amount Eaten, for the month of 6/2023 was reviewed with the Assistant Director of Nursing (ADON). The ADON stated CNA's (certified nurse assistant's) were required to document the meal intake for every meal, three times a day. The ADON stated the intake information could influence nourishments provided to the resident and was information used by all disciplines to make clinical decisions related to things such as weight loss/gain and changes in condition. The ADON confirmed the following missing…

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 maintain infection prevention and control practices for a census of 158 when; 1. Staff did not wear gown and gloves while providing care for a resident on contact precautions (used to prevent the spread of infectious germs); 2. Two out of two clean linen delivery carts were found with a thick layer of dust on the inside corners; and, 3. Resident 83's indwelling urinary catheter (a tube inserted into the bladder to drain or collect urine) bag was placed on the floor. These failures had the potential to spread germs and cause infection among residents, staff, and visitors. Findings: 1. Review of Resident 451's admission RECORD, indicated Resident 451 was admitted to the facility with a diagnosis of clostridium difficile (C. diff; inflammation of the intestines caused by a bacterium that can be transmitted from person to person). During a concurrent observation and interview on 6/20/23, at 10:35 a.m., three staff persons were in Resident 451's room. There was a contact precautions sign at the door that…

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 protect two out of 39 sampled residents' (Resident 33 and Resident 51) right to be treated with respect and dignity when Resident 33 and Resident 51's meals were not served at the same time with other residents in the east dining room during the 6/20/23 lunch meal. This failure resulted in Resident 33 and Resident 51 experiencing emotional distress and irritation. Findings: A review of Resident 33's clinical record indicated Resident 33 was admitted with diagnoses that included dementia (memory loss that interferes with daily functions) and need for assistance with personal care. A review of Resident 33's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 4/6/23, indicated Resident 33 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 11 out of 15 which indicated Resident 33 had moderately impaired cognition. A review of Resident 33's MDS Functional Status, dated 4/6/23, indicated Resident 33 required set-up help with eating. A review of…

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

Based on observation, interview, and record review, the facility failed to ensure the call light (device used to communicate a need for assistance) was in reach for 2 of 39 sampled residents (Resident 3 and Resident 87), when Resident 3 and Resident 87's call lights were attached to the bottom of the bed rail out of reach. This failure had the potential for Resident 3 and Resident 87 to suffer adverse consequences and potential harm due to the inability to call for assistance. Findings: During a concurrent observation and interview on 6/19/23, at 8:47 AM, Resident 3 attempted to access his call light while lying in bed. The call light was attached to the bottom of the bed rail a few inches from the floor. Certified nurse assistant (CNA) 1 stated Resident 3's call light was out of reach. CNA 1 further stated without access to the call light, Resident 3, is at risk of a fall and unable to make his needs known. It is a safety concern. CNA 1 stated Resident 87 was at risk since his call light was also out of reach. During an interview on 6/19/23, at 12:26 PM, LN 1 stated, if 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.

Based on interview and record review, the facility failed to provide three of three sampled residents (Resident 11, Resident 19, Resident 99), whose funds were managed by the facility, with quarterly financial statements. This failure resulted in Resident 11, Resident 19, Resident 99 lacking information regarding the status of their funds. Findings: During an interview on 6/21/23 at 11:12 p.m., with Resident 11, Resident 11 stated, he never received quarterly financial statements. During an interview on 6/21/23 at 11:53 p.m. with Resident 19, Resident 19 stated she did not receive quarterly financial statements. During an interview on 6/21/23 at 12:02 p.m. with Resident 99, Resident 99 stated, no one gave her quarterly financial statement until today. Resident 99 further stated someone from business office came today and asked her to sign it was received. During an interview on 6/21/23 at 12:10 p.m. with Business Office Manager (BOM), the BOM confirmed, she did not provide quarterly financial statements to residents. During an interview with Administrator (ADM) on 6/21/23 at 12:22…

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

Based on observation and interview, the facility failed to provide a clean, comfortable, homelike environment for 2 of 39 sampled residents (Resident 2 and Resident 66) when: 1. The wall beside Resident 2's bed had deep gouges and peeling paint in an area measuring 20 inches in length by 11 inches in width; and, 2. Resident 66's bedside table had a torn foam border surrounding the table edges with exposed glue. These failures resulted in Resident 2 and Resident 66 not being provided a homelike environment, with the potential to negatively impact their psychosocial well-being. Findings: 1. During a concurrent observation and interview on 6/20/23, at 3:11 PM, in Resident 2's room, the Administrator (ADM) observed the wall beside Resident 2's bed and stated the wall, .is really banged up, it is not a homelike environment . 2. During a concurrent observation and interview on 6/19/23, at 1 PM, in Resident 66's room, Licensed Nurse (LN) 1 observed the bedside table with its torn foam border and exposed glue with crumbs attached. LN 1 stated, .It does not look good .could potentially be an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop all of the identified components of a baseline care plan within 48 hours of admission, to address resident-specific care needs for one of thirty-nine sampled residents (Resident 444) when, Resident 444's oxygen use care plan was not created upon admission. This failure had the potential to result in unmet oxygen use needs for Resident 444. Findings: Review of Resident 444's admission RECORD indicated Resident 444 was admitted to the facility on [DATE] with a diagnosis of respiratory failure. During a concurrent interview and record review on 6/21/23, at 3:24 PM, Resident 444's medical record was reviewed with the Assistant Director of Nursing (ADON). The ADON confirmed Resident 444's oxygen care plan was not created until 6/1/23. The ADON confirmed Resident 444's .Admission/readmission Evaluation ., dated 5/19/23, indicated, .Devices and treatment .[check box checked] O2 [Oxygen] at 6-10 L/min [liters per minute] by Nasal Canula/Mask .Chronic .…

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

Based on interview and record review, the facility failed to ensure one of thirty-nine sampled residents' (Resident 451) comprehensive care plan interventions met professional standards of practice when, Resident 451's infection care plan interventions did not include the correct Personal Protective Equipment (PPE; protective clothing, goggles, facemask, or other garments used to prevent the spread of germs) for staff to put on prior to providing care to Resident 451. This failure resulted in insufficient interventions to provide appropriate infection control, with the potential for staff to spread infectious germs to others. Findings: Review of Resident 451's admission RECORD, indicated Resident 451 was admitted to the facility with a diagnosis of clostridium difficile (C. diff; inflammation of the intestines caused by a bacterium that can be transmitted from person to person). Review of Resident 451's provider orders indicated, .Order Date 06/11/2023 .Order Summary: Contact plus isolation precautions [staff to wear gown and gloves prior to entering a resident room to prevent 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 one of thirty-nine sampled residents (Resident 108) received activities that met their interests and needs, when Resident 108 did not attend group activities and in room activities were offered infrequently. This failure had the potential to adversely affect the psychosocial needs and well-being of Resident 108. Findings: A review of Resident 108's admission RECORD, indicated he was admitted in 2022 with diagnoses which included displaced intertrochanteric fracture (fracture that occurs 3-4 inches from the hip bone) of left femur (thigh bone) and muscle weakness. During an interview in Resident 108's room on 6/20/23, at 8:50 AM, Resident 108 stated, .I don't do any activities. None have been offered. I would like to do something . During an interview on 6/20/23, at 11:16 AM, the Recreation Director (RecDir) stated, .we see [Resident 108] three times per week . The RecDir was unable to provide documentation to indicate the dates of the visits. During a concurrent observation and interview on 6/20/23, at…

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 preventive care and treatment consistent with professional standards of practice for two of 39 sampled residents (Resident 32 and Resident 7) when: 1. Resident 32's pressure injury (PI, injury to skin and underlying tissue resulting from prolonged pressure) treatment order on the left heel was not followed; and, 2. Resident 7's variable pressure pump system overlay pad (a specialized overlay mattress designed to prevent prolonged/constant pressure on any skin area and is used for prevention and treatment of pressure injuries) was found folded/curled on the bottom of the bed and the pad was only reaching up to Resident 7's waist while in use. These failures had the potential for Resident 32's left heel pressure injury to get worse and develop complications and had the potential for Resident 7 to develop pressure related injuries. Findings: 1. A review of Resident 32's clinical record indicated Resident 32 was admitted in 2019 and had diagnoses that included Parkinson's disease (a brain disorder that…

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

Based on interview and record review, the facility failed to ensure one of thirty-nine sampled residents (Resident 133) received proper treatment and care to maintain good foot health when, Resident 133 was not referred to podiatry (a branch of medicine devoted to the study, diagnosis, and treatment of disorders of the foot and ankle) services when requested. This failure resulted in Resident 133 attempting to maintain his own footcare and had the potential to result in injury and/or infection. Findings: Review of Resident 133's admission RECORD, indicated Resident 133 was admitted to the facility with diagnoses of diabetes (a chronic condition that affects the way the body processes blood sugar) and peripheral vascular disease (a blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block, or spasm). During an interview on 6/20/23, at 10:11 AM, Resident 133 stated he had asked staff to cut his toenails, but no one would touch them. Resident 133 stated he requested to be seen by a podiatrist, but never heard anything back. 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.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained free of accident hazards for one of thirty-nine sampled residents (Resident 444) when, Resident 444's oxygen cylinder (a metal cylinder containing oxygen under pressure) was placed on the floor in Resident 444's room without a cylinder stand. This failure had the potential to cause injury to Resident 444 if the oxygen cylinder fell over. Findings: During a concurrent observation and interview on 6/19/23, at 12:16 PM, in Resident 444's room, the Assistant Director of Nursing (ADON) confirmed there was an oxygen cylinder placed on the floor between Resident 444's bed and nightstand. The ADON stated the oxygen cylinder should have been in a storage container to prevent it from shooting off like a torpedo if it fell over. Review of Resident 444's provider orders indicated, .Order Date 06/01/2023 .Order Summary: Oxygen 6-10 liters per nasal canula [flexible tubing inserted into the nostrils to provide additional oxygen] . Review of a facility policy titled QUALITY OF CARE…

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

Based on observation, interview, and record review, the facility failed to ensure one of one resident (Resident 116) who received parenteral fluids (delivery of fluid or medication through a vein) was provided services consistent with professional standards of practices when: 1. Resident 116's PICC (Peripherally Inserted Central Catheter; a thin, soft, long catheter (tube) that is inserted into a vein in the arm with the tip of the catheter positioned in a large vein that carries blood into the heart in order to provide medications) line hubs (the area of the cap where syringes are attached) were not cleaned with alcohol for the appropriate length of time; 2. There were no PICC line dressing change or cap change (removable caps at the end of the PICC line) orders for Resident 116; and, 3. There was no care plan created in relation to Resident 116's PICC line. These failures had the potential to result in a central line malfunction and/or infection for Resident 116. Findings: 1. During a concurrent observation and interview on 6/21/23, at 10:07 AM, in Resident 116's room, Licensed…

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 pain management was provided for one of thirty-nine sampled residents (Resident 448) when, Resident 448's lidocaine patch (a medicated patch applied to the skin to relieve minor pain) was not applied and a pain care plan was not created. This failure has the potential to result in poorly controlled pain for Resident 448. Findings: During an interview on 6/19/23, at 10:26 AM, Resident 448 stated he was at the facility because he fell off a chair at home and hurt his hip. Resident 448 stated he had shooting pain from his hip to his knee. Resident 448 stated his pain was at a five (out of ten, with ten being the worst pain and zero being no pain) and a tolerable pain level would be a two. Resident 448 stated his pain was worse with movement and limited him from getting out of bed. Resident 448 stated he used lidocaine patches in the past at home with relief and had asked a nurse for them a few days ago. Resident 448 stated that nursing staff had not brought any lidocaine patches in. During an interview on 6/19/23, at…

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 medication administration error rate was less than five percent when two medication errors occurred, out of 31 opportunities, during medication administration for one out of five residents observed (Resident 53). The facility error rate was 6.45 percent. This failure had the potential to negatively impact the health and well-being of Resident 53. Findings: During a concurrent observation and interview on 6/20/23, at 9:42 AM, licensed nurse (LN) 2 administered two different insulin (medication used to regulate blood sugar) injections to Resident 53. During the administration of the injections Resident 53 stated, .my insulin should be given before breakfast . In the hallway outside of Resident 53's room LN 2 stated, she gave Resident 53 short acting and long-acting insulin. LN 2 stated the medications were administered at this time .because this is when I am passing meds . LN 2 further stated, insulin should be given before 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 interview and record review, the facility failed to store medications in accordance with professional standards for one of four medication rooms when the north station medication room temperatures were not monitored as required. This failure had the potential for medications to lose effectiveness. Findings: During a review of facility document titled, Temperature Log, dated June 2023, there were six days (6/5, 6/9, 6/10, 6/15, 6/16, and 6/17) in which temperatures were not recorded. During an interview with Licensed Nurse (LN) 9 on 6/19/23, at 3:20 p.m., LN 9 stated the temperature log for the medication room should be completed every day. During a review of the facility's policy and procedure titled, Storage of Medications, dated 4/2008, indicated, Medication storage conditions are monitored on a routine basis and corrective action taken if problems are identified.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that food preferences were assessed in a timely manner and honored for one of thirty-nine sampled residents (Resident 440) when: 1. Resident 440's food allergies, intolerances, and preferences were not assessed until 8 days after admission; and, 2. Resident 440 was not provided coffee and was served eggs and milk for breakfast on 6/22/23 which was not in accordance with Resident 440's assessed preferences. These failures had the potential to result in unintended weight loss and other medical complications such as constipation for Resident 440. Findings: 1. Review of Resident 440's admission RECORD, indicated Resident 440 was admitted to the facility on [DATE]. During an interview on 6/19/23, at 2:47 PM, Resident 440 stated he had not been seen by the dietary manager or dietician since he had been admitted to the facility. During a concurrent interview and record review on 6/22/23, at 10:42 PM, Resident 440's .Diet - Dietary Profile, 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.