Brookside Care Center

Based on observation, interview, and record review the facility failed to ensure safe infection prevention and control practices with resident census of 88 when:1. Resident 62's oxygen tubing was not properly kept when not in use.2. Enhanced Barrier Precautions (or EBP, an infection control measure designed to prevent the spread of infection) were not implemented for Resident 95. 3. Shared glucometer (a device that measures blood sugar) was not cleaned and sanitized based on standards of practice and manufacturer specifications for Resident 4, Resident 39 and Resident 50.4. Nursing staff handled the pills with bare hands during medication administration for Resident 13 and Resident 93.5. An Air Vent (an opening connected to heating and cooling system and used to manage airflow in the room) in the ceiling of [NAME] medication room was loose with dust/debris and dark particles spilled/pouring on the Automated Dispensing Machine (or ADM, drug dispensing machine). These unsafe practices could result in spread of infection among vulnerable elderly residents in the facility. 1. A review…

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 inform and document an informed consent (a signed document requires healthcare providers to disclose risks, benefits, alternatives to ensure patients make educated decisions about their care or medication use) for use of trazodone (a mind altering medication used for sleep or depression) in 1 out of 5 residents (Resident 50) reviewed for unnecessary drug use.This failure could violate Resident 50's right to be aware of consequences (risks versus benefits) of using a mind-altering drug that could contribute to unwanted adverse effects.Findings:During a review of Resident 50's electronic medical record titled, Medication Administration Record, (MAR, a record nursing staff document drugs given), dated 5/26, the record indicated the following order: .trazodone HCl Oral Tablet 50 MG [or Deseryl; MG is milligram, a unit of measure];Give 0.5 tablet by mouth at bedtime for Depression Insomnia [sleepless].; Dated: 3/9/26 .The MAR record indicated Resident 50 had been refusing the trazodone regularly. Resident 50 had refused to take…

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 resident needs for 1 of 26 sampled residents (Resident 85) when, Resident 85 was not provided with a wheelchair.This failure had the potential for Resident 85 to be at risk for emotional distress, feelings of isolation, and at risk for falls. Findings:Review of Resident 85's admission RECORD, indicated Resident 85 was admitted to the facility with diagnoses that included retention of urine, chronic obstructive pulmonary disease (lung and airway disease that restricts your breathing) and unspecified asthma (when asthma symptoms such as wheezing, coughing, and chest tightness are present but diagnostic records lack details on type or severity of asthma).A review of Resident 85's Minimum Data Set (MDS, an assessment tool) section GG (assessment to measure a resident's functional abilities) dated 4/7/26, indicated that Resident 85 was able to use a manual wheelchair with supervision.A review of Resident 85's MDS section C (to measure a resident's mental status), dated 4/7/26,…

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 26 sampled residents (Resident 68), remained free from abuse (verbal, mental, sexual, or physical abuse) when, Resident 95 hit Resident 68 on his head on 5/4/26.This failure caused Resident 68 to feel sad and fearful for his safety while residing in the facility and had the potential to result in emotional distress and ongoing fear.Findings:A review of Resident 68's admission RECORD indicated Resident 68 was admitted with the diagnosis of depression (persistent feeling of sadness), paraplegia (the loss of movement and feeling in the lower half of the body).During an interview on 5/11/26 at 2:57 PM, Resident 68 stated on 5/4/26 around 10:30 AM, while smoking a cigarette in the courtyard located in the front portion of the facility, himself and another resident (Resident 95), began to disagree on the way Resident 68 spoke to another resident. Resident 68 stated, Resident 95 threatened to physically harm him while expressing his affiliation with a gang and the harm he has done to people in the past while they were…

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 an as needed (PRN) psychotropic medication (any drug that affects brain activities associated with mental processes and behavior) was limited to 14 days for 1 of 26 sampled residents (Resident 12), when Resident's 12's PRN psychotropic medication did not have a stop date.This failure placed Resident 12 at risk of being chemically restrained (the use of any drug for discipline or that makes it more convenient for staff to care for a resident) due to ongoing psychotropic medication use without proper evaluation by the physician. Findings:A review of Resident 12's admission RECORD, indicated Resident 12 was admitted to the facility with diagnoses that included but not limited to depression and unspecified dementia (when a person shows clear signs of memory loss and cognitive decline that affect daily life).A review of Resident 12's Medication Administration Record, dated 4/26, indicated Resident 12 received the PRN Lorazepam (a fast acting drug to calm the brain and central nervous system) at-least daily.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 an allegation of physical abuse was reported in a timely manner, within 2 hours to the department for 2 of 26 sampled residents when Resident 95 hit Resident 68 on 5/4/26 and it was not reported to the required entities until 5/5/26.This failure led to the delayed immediate protection of Resident 68 and delayed abuse investigation process. This failure had the potential to put Resident 68's psychosocial, physical health and safety at risk.Findings:A review of Resident 68's admission RECORD indicated Resident 68 was admitted with the diagnosis of depression (persistent feeling of sadness), paraplegia (the loss of movement and feeling in the lower half of the body).During an interview on 5/11/26 at 2:57 PM, Resident 68 stated on 5/4/26 around 10:30 AM, he was assaulted by another resident while in the courtyard of the facility smoking a cigarette. Resident 68 stated after the altercation multiple staff witnessed the incident. Resident 68 stated after he was assaulted, he waited in his room for a few hours to see if 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 resident assessments accurately reflected a resident's status for 2 out of 26 sampled residents (Resident 49 and Resident 29) when: Resident 49's quarterly Minimum Data Set (MDS - a standardized, federally mandated clinical assessment tool used to evaluate the health, functional capabilities, and care needs of all residents in nursing homes) assessment was not accurate, and The facility did not accurately document Resident 29's diagnosis in the electronic medical record and MDS database.These failures had the potential to negatively affect the care and services provided to Resident 49 and Resident 29, due to the inaccurate assessment of their strengths, needs, diagnosis, and health status and the of risk of not treating the residents accordingly based on resident's medical needs. Findings: 1. A review of Resident 49's admission RECORD, indicated Resident 49 was admitted with the diagnosis of macular degeneration (a disease that damages central vision), occlusion and stenosis of vertebral artery (reduced blood flow…

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 adequate care and services to promote healing and for the prevention of a pressure injury (a localized injury to the skin and/or underlying tissue because of prolonged pressure) for 4 of 8 sampled residents (Resident 105, 111, 64, and 4), when:Low-air loss mattress (LAL mattress, a mattress designed to prevent and treat pressure wounds that uses a continuous, gentle flow of air through a surface of tiny holes to reduce pressure helping to prevent and treat skin breakdown and pressure wounds) pump was not correctly adjusted according to the weight of Resident 105, Resident 64, and Resident 4. This deficient practice had the potential to delay wound healing and placed Resident 105, Resident 111, Resident 64, and Resident 4 at increased risk for developing pressure injury and/or skin breakdown. 1.A review of Resident 105's admission RECORD indicated Resident 105 was admitted to the facility with diagnosis that included nontraumatic intracranial hemorrhage (spontaneous brain bleed), dysphagia (difficulty…

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 intake and output was recorded in the electronic health record (EHR) for one of 26 sampled residents (Resident 2) with an indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine). This failure had the potential to lead to late detection of fluid status abnormalities which could adversely affect Resident 2's health status.Findings:A review of Resident 2's, admission Record indicated Patient 2 was admitted to the facility with diagnoses that included urinary tract infection (UTI), presence of urogenital implants (medical devices surgically placed in the urinary or reproductive tracts to restore function, relieve blockages, or treat incontinence), and anxiety disorder.During a concurrent interview and record review on 5/12/26, at 11:19 a.m., with the Director of Nursing (DON), Resident 2's, Order Summary dated 5/12/26, and Resident 12's, Medication Administration Record dated April 2026, was reviewed. The DON verified Resident 12 had a physician order to monitor urine…

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 provided was consistent with professional standards of practice for 1 of 16 sampled residents receiving respiratory treatment (Resident 29), when Resident 29's oxygen tubing was not dated and labeled to indicate when it was last changed.This failure had the potential to result in a negative impact on Resident 29's health and safety including risks for ineffective oxygen therapy, and respiratory distress.Findings:A review of Resident 29's admission RECORD, indicated Resident 29 was admitted to the facility with the diagnosis of chronic obstructive pulmonary disease (long-term lung diseases that cause breathing to become difficult), shortness of breath, and acute bronchiolitis (swelling of the tubes in the lungs).During a concurrent observation and interview on 5/10/26, at 11:09 AM, with Licensed Nurse (LN) 3, in Resident 29's room, LN 3 confirmed Resident 29's oxygen tubing that was connected to her concentrator (a machine that produces oxygen), was not dated. LN 3 stated the facility'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 ensure the Emergency IV Kit (or IV-Ekit, a sealed container storing emergency intravenous [into the vein, or IV] medication and supplies) in the [NAME] station medication room was replaced in timely manner and communicated to the provider pharmacy after it was opened and used with census of 88 residents.This failed practice could contribute to unsafe medical care when IV medications were not available in a timely manner.Findings: During a concurrent inspection of the [NAME] station medication room, and interview with Licensed Nurse 1 (LN 1), on 5/10/26, at 10:49 AM, the IV-Ekit was observed sitting on the floor with an opened red tag. The contents of the IV-Ekit were checked and a one liter IV bag of saline (sterile salt solution) was missing in addition to an out of wrap bag of Dextrose 10% solution (high concentration sterile sugar solution;% is percent, a fraction of 100). LN 1 stated once the Ekit was opened based on a doctor's order for medication removal, the pharmacy should have been notified for…

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

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 the census of 88 residents. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of six errors out of 31 opportunities which resulted in a facility wide medication error rate of 19.35 % in five out of 16 residents (Resident 69, Resident 12, Resident 7, Resident 50, Resident 13) during medication administration observation as follows:1. Resident 69 was given a medication labeled as Senna-Plus (a combination of Senna and Docusate; a stool softer plus stimulant laxative) when the doctor's order was for Senna (stimulant laxative) only.2. Resident 69 medication called potassium ER tablet (an extended-release form of supplement) was crushed when the product labeling indicated not to crush the medication.3. Resident 12 was given a 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.

Based on interview and record review, the facility failed to ensure one of sixteen resident's (Resident 69) were free from medication errors when Resident 69's once-monthly drug called Ibandronate for osteoporosis (also called Boniva, a drug used to treat and prevent osteoporosis, a bone disease that weakens bones by decreasing bone mass and caused bone fracture) was administered more than once a month against manufacturer specification.This failed practice could compromise the safety of Resident 69 with over-exposure to a long-acting drug (drug that stays in the body for a long time) with adverse effects and outcomes. Findings:A review of Resident 69's admission RECORD, indicated Resident 69 was admitted to the facility with multiple diagnosis including breast cancer, was on active chemotherapy treatment (drug used to treat cancer), age related osteoporosis (bone disease that weakens bones by decreasing bone mass), and difficulty walking, among others.Review of Resident 69's medical record titled, Medication Administration Record [MAR], dated 5/1/26 to 5/31/26, the MAR record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure safe medication storage practices in the medication room and medication carts with resident census of 88 when: 1. The refrigerator in the medication room (a room that stores medications given to residents) at [NAME] Long station was heavily frosted where insulin and vaccines were stored. 2. The medication cart (a wheeled cart that stores medications given to residents on daily basis) in [NAME] Long station contained medications not dated upon opening. 3. The medication cart at East station contained medications not labeled with open date upon opening. These failures could result in unsafe medication storage and the risk of residents receiving ineffective or contaminated products. Findings: 1. During a concurrent interview and medication room inspection, accompanied by Licensed Nurse (LN) 9, at the [NAME] Long nursing station, on 5/10/26, at 10:08 a.m., the medication room' refrigerator was heavily frosted where insulin (blood sugar…

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 adequate physical therapy services to 1 of 26 sampled residents (Resident 49) when, Resident 49 who was visually impaired, was provided therapy services with a white cane (a tool used by people who are blind or visually impaired to scan the environment in front of them) instead of being provided an appropriate mobility device of a walking stick (a mobility tool used to help with balance and walking).This failure had the potential for Resident 49 not to attain, maintain, or restore his highest practicable level of physical function and well-being. This failure also presented an increased risk for falls for Resident 49.Findings:Review of Resident 49's admission RECORD, indicated Resident 49 was admitted with the diagnosis of macular degeneration (a disease that damages central vision), occlusion and stenosis of vertebral artery (reduced blood flow to the back of the brain), degenerative disease of nervous system (the nerves in your brain break and die), and unsteadiness on his feet.During a concurrent observation and…

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

Based on interview, and record review, the facility failed to implement an effective immunization program to offer, obtain informed consent and provide education to a resident or resident representative (RP) about the influenza (or flu, is a contagious viral infection of the respiratory system that can range from mild to severe, causing symptoms like fever, cough, sore throat, muscle aches, and fatigue) vaccine and pneumococcal (a serious bacterial infection that can cause respiratory illness) vaccine for three out of five sampled residents when:1. Resident 64, Resident 46, and Resident 96 were not offered the Influenza vaccine during the 2025- 2026 flu season; and,2. Resident 64 was not offered a Pneumonia vaccine.These failures had the potential for the residents and resident's responsible parties to not be fully informed about the risks and benefits, and potential side-effects of the flu and pneumonia vaccine prior to receiving or declining the vaccination. It also increased the risk of impacting Resident 64, Resident 46, and Resident 96's health.Findings: 1a. 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 interview, and record review, the facility failed to provide the COVID-19 vaccine, for one of five sampled residents (Resident 64), when there was no documentation in Resident 64's medical record that the COVID-19 vaccine was offered to the resident and the vaccine history (including previous administered COVID- 19 vaccines) was not obtained for Resident 64.This deficient practice placed Resident 64 at risk to be infected with the COVID-19 virus that could lead to severe illness, hospitalization, and/or death.Findings:A review of Resident 64's admission RECORD, indicated Resident 64 was admitted to the facility early 2026.During a concurrent interview and record review on 5/12/26, at 1:51 PM, with the Infection Preventionist (IP), Resident 64's immunization record was reviewed. The IP stated they offered the COVID-19 vaccine to residents upon admission. The IP further stated that they would offer, obtain consent, provide education to the resident or resident representative (RP) if there was a new COVID-19 vaccine. The IP stated if there was a history of the COVID-19 vaccine…

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 a functioning call light system (system/device used by residents to call staff for assistance) was in place for 1 of 26 sampled residents (Resident 63) when Resident 63's call light was not working.This failure had the potential to result in Resident 63 being unable to call staff for help when needed and the resident's needs not being met. Findings:A review of Resident 63's admission RECORD, indicated Resident 63 was admitted to the facility in March 2026 with diagnoses including cellulitis of right lower limb (a common, potentially serious bacterial skin infection that affects the lower legs, ankles, or feet), unsteadiness on feet (imbalance), acquired absence of right great toe (the loss of the right big toe due to a past surgical amputation, accident, or injury), and shortness of breath. A review of Resident 63's clinical record titled, Care Plan Report, dated 3/12/26, indicated, .Focus: The resident has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] Impaired…

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

Based on interview and record review the facility failed to arrange transportation to and from the office of an ophthalmologist (specialist in the treatment of vision) in the provision of an eye examination for 1 of 11 sampled Residents (Resident 1).This failure led Resident 1 to miss his initial ophthalmologist appointment and the potential for delayed treatment for Resident 1 could have resulted in a decline in health and well-being.Findings: Review of Resident 1's admission RECORD indicated Resident 1 was admitted to the facility with diagnoses including type 2 diabetes mellitus (a chronic metabolic condition characterized by insulin resistance and relative insulin deficiency), unspecified osteoarthritis (a medical term used when a physician diagnoses degenerative joint disease, but the specific location of the joint(s) affected has not been explicitly documented or identified yet), unspecified glaucoma (eye diseases that damage the optic nerve, often due to abnormally high pressure inside the eye), and paraplegia (the partial or complete loss of motor and sensory function in the…

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

Based on observation, interview, and record review, the facility failed to ensure 1 out of 11 sampled residents (Resident 1) received proper foot treatment and care, when Resident 1 was not seen by a podiatrist (a specialist physician and surgeon who diagnoses and treats conditions affecting the foot, ankle, and lower leg) to prevent complications from his long and thickened toenails and nail avulsions (detachment of toenail from the bed) to some of his toenails.This failure had the potential for Resident 1 to sustain skin injury and/or to acquire an infection and not achieve his highest practicable well-being.Findings:Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses including type 2 diabetes mellitus (a chronic metabolic condition characterized by insulin resistance and relative insulin deficiency), and paraplegia (the partial or complete loss of motor and sensory function in the lower half of the body, usually caused by a spinal cord injury).A review of Resident 1's Minimum Data Set (MDS- an assessment tool) Cognitive…

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

Based on observation, interview, and record review, the facility failed provide adequate supervision for one of seven sampled residents (Resident 1) when Resident 1 eloped from the facility through the non functioning alarmed front door and was missing from the facility for approximately 20 minutes and eventually located at a corner gas station. This failure to provide adequate supervision placed Resident 1 at risk for injury and psychosocial distress.Findings:During a review of Resident 1's document titled admission RECORD, dated 4/15/26, the record indicated Resident 1 was admitted to the facility with diagnosis that included dementia (a decline in mental ability-specifically memory, thinking, and reasoning-severe enough to interfere with daily life), weakness, and unsteadiness of feet.During a review of Resident 1's document titled Minimum Data Set, (MDS- a standardized, federally mandated assessment tool used to evaluate a resident's functional, medical, psychosocial, and cognitive status) dated 1/16/26, the MDS revealed that in .Section C - Cognitive Patterns. that a Brief…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based an observation, interview, and record review, the facility failed to ensure a resident's right to a quiet environment was maintained for one of three sampled residents (Resident 1) when Resident 1 could not get rest due to continuous noise from Resident 1's roommate from 2/26/26 through 3/4/26.This failure resulted in Resident 1's having sleepless nights that led to migraines (extreme headaches) and emotional and psychological distress.Findings:During a review of Resident 1's clinical record titled, admission RECORD, dated 3/6/26, the record indicated Resident 1 was admitted on [DATE] with a diagnoses which included respiratory failure, heart failure, anxiety disorder (group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation), and takotsubo syndrome (is a temporary, reversible heart condition often triggered by intense emotional or physical stress, causing sudden chest pain, breathlessness, and mimicking a heart attack).During 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to protect, secure, and maintain personal belongings for one of three sampled residents (Resident 1) when Resident 1's black safe box (that contained valuables and collectibles) was not accounted for when Resident 1's belongings were transferred from another facility three days from admission. This failure resulted in Resident 1's black safe box missing and had caused her emotional distress for losing her valuables and collectibles. Findings:During a review of Resident 1's clinical record titled, admission RECORD, dated 3/6/26, the record indicated Resident 1 was admitted on [DATE] with diagnoses that included respiratory failure, heart failure, and muscle weakness.During a review of Resident 1's clinical record titled, MDS, (Minimum Data Set, an assessment tool) dated 2/19/26, under Section C-Cognitive Patterns, the MDS indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which suggested Resident 1 had moderate…

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

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who was dependent on staff to carry out activities of daily living (ADLs, tasks of everyday life including eating, dressing, grooming, bathing, showering, and using the bathroom) received services to maintain personal hygiene, when Resident 1 was not provided with showers or bed baths as scheduled from 2/1/26 through 2/28/26.This failure had the potential to cause discomfort, skin impairment, infection, and a decline in emotional and psychological well-being.Findings:During a review of Resident 1's clinical record titled, admission RECORD, dated 3/6/26, the record indicated Resident 1 was admitted to the facility with diagnoses which included muscle weakness.During a review of Resident 1's clinical record titled, MDS, (Minimum Data Set, an assessment tool) dated 2/19/26, under Section C-Cognitive Patterns, the MDS indicated, Resident 1 had a BIMS (Brief Interview for Mental Status) score of 12 out of 15 suggesting Resident 1 had moderate cognitive impairment. The MDS under…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to provide needed care and treatment to two out of three sampled residents (Resident 1 and Resident 2) when:1. Resident 1 missed 2 scheduled appointments for a follow up order with the cardiologist within 2 weeks from discharge from the acute hospital and the follow up order was not transcribed into Resident 1's electronic file, and 2. Resident 2's attending physician was not notified of Resident 2's 3 consecutive days of poor intake either meal refusals or 0 to 25% consumed. These failures had the potential for Resident 1 not to receive required care in a timely manner and the potential for delayed treatment for Resident 2 that could lead to weight loss and could possibly result in a decline in health and well-being.Findings: 1. During a review of Resident 1's clinical record titled, admission RECORD, dated 3/6/26, the record indicated Resident 1 was admitted to the facility with diagnoses including respiratory failure, heart failure, and hypertension…

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

Based on observation, interviews, and record reviews, the facility failed to implement measures to prevent the development and/or worsening of pressure ulcers/injuries (PU/PI, areas of damaged skin caused by staying in one position for too long, usually over an area on the body where a bone is close to the skin's surface) when:1. Resident 1's low air loss (LAL) mattress (a mattress designed to prevent and treat pressure ulcers/injuries in patients with limited mobility which uses an air-filled bladders that inflate/deflate to relieve pressure, combined with tiny holes that blow air to keep skin cool, dry, and moisture free) was not plugged to an emergency outlet when the power in her room was off; and,2. Resident 2's clinical record did not indicate a skin care plan (a written document where you can summarize a person's health conditions, specific care needs, and current treatments) was initiated and no interventions (any action a nurse performs to help patients reach expected outcomes) to prevent the worsening of a PU/PI.These failures had the potential for Resident 1 to develop…

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

Based on interview, and record review, the facility failed to ensure a resident was free from misappropriation of property for one of four sampled residents (Resident 1), when two facility staff members had accepted money from Resident 1 to buy food.This failure had placed the resident at risk for financial hardship which could eventually affect the psychosocial well-being of Resident 1.Findings:A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses including sensorineural hearing loss (permanent hearing loss caused by aging, noise or infections), cognitive communication deficit (difficulty with speaking, listening, reading, or writing caused by problems with thinking skills) and focal traumatic brain injury with loss of consciousness (damage to one area of the brain that resulted in a being knocked out or not awake).A review of Resident 1's Progress Notes, dated 11/26/25, indicated, .Resident stated that the facility driver and RNA [Restorative Nurse Assistant] used his own money to buy food.A review of Resident 1's IDT…

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

Based on interview and record review the facility failed to implement effective interventions to keep two residents (Resident 1 and Resident 2), in a sample of eleven, who had a prior altercation in the facility's dining room on 1/1/26, apart to prevent further incidents. As a result, on 1/5/26 Resident 1 and Resident 2 were in the facility's dining room again when they got into a physical altercation and Resident 1 was transferred to the hospital due to his injuries and ultimately a different facility.This deficient practice revealed that care planned interventions to keep Resident 1 and Resident 2 safe were not implemented resulting in injuries to Resident 1 including left wrist and left eye swelling, a hematoma of the left zygoma (swelling, bruising, and potential tenderness to the cheekbone), an abrasion (a scraped skin injury) to the forehead, complaints of pain, and was transferred to the emergency room. Although Resident 1 could not articulate how this made him feel, potentially due to a diagnosis of an unspecified intracranial injury (a brain injury where the exact nature is…

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 Resident 1's rights to return to the facility were honored following a transfer to the emergency room due to a resident-to-resident altercation where Resident 1 was the victim when:1. Resident 1 was inappropriately discharged from the facility following an emergency room visit and admitted to a sister facility (a closely related, often co-owned or affiliated, location-frequently in senior living, healthcare, or industrial sectors-that share ownership, management, or services) on 1/6/26;2. Resident 1's reason for discharge did not meet the requirements which would allow for a facility-initiated discharge to occur; and3. Resident 1 was not provided with a bed hold notice and the facilities bed hold policy was not followed.This failure resulted in Resident 1 not being afforded the right to return to the facility following a transfer to the emergency room. This failure also had the potential to result in transfer trauma (a condition characterized by a range of symptoms that can occur when someone is moved from one…

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

Based on interview and record review, the facility failed to provide a notice of transfer/discharge to Resident 1 and the State Long-Term Care Ombudsman office (acts as an independent advocate for residents, protecting their health, safety, welfare, and rights) when, Resident 1 was transferred to the emergency room due to injuries as a result of a resident-to-resident altercation that occurred on 1/5/26 where Resident 1 was the victim and Resident 1 was then discharge from the facility while Resident 1 remained in the emergency room. Resident 1 was admitted to a sister facility (a closely related, often co-owned or affiliated, location-frequently in senior living, healthcare, or industrial sectors-that share ownership, management, or services) after being discharged from the emergency room on 1/6/26.This failure violated Resident 1's right to be notified timely of a discharge and informed of how to appeal the decision of a facility-initiated discharge. This failure also resulted in the State Long-Term Care Ombudsman being uninformed of the discharge decision and removed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an allegation of employee-to-resident physical abuse was reported by the facility for one of three sampled residents (Resident 1) when on 11/17/25, the facility failed to report Resident 1's allegation of physical abuse by a Licensed Nurse to the state agency.This failure resulted in a delayed abuse investigation and had the potential to affect Resident 1's physical and psychosocial well-being.Findings:During an interview on 12/22/25 at 1 PM, in Resident 1's room, Resident 1 stated that a few weeks ago he had his cat food taken away and his arm twisted by Licensed Nurse (LN) 1 and that it was witnessed by a Certified Nursing Assistant (CNA). Resident 1 explained he called the police on 11/17/25 and made a police report because LN 1 got angry with him, grabbed and twisted his left arm hard enough to tear off a bandage on Resident 1's elbow while LN 1 took away Resident 1's bag of cat food. Resident 1 stated he bought cat food with his own money…

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 an allegation of employee-to-resident physical abuse was thoroughly investigated by the facility in a timely manner when on 11/17/25, the facility did not fully investigate an allegation of abuse to Resident 1. This failure resulted in a delayed facility abuse investigation and had the potential to affect Resident 1's physical and psychosocial well-being.Findings: During an interview on 12/22/25 at 1 PM, in Resident 1's room, Resident 1 stated that a few weeks ago he had his cat food taken away and his arm twisted by Licensed Nurse (LN) 1 and that it was witnessed by a Certified Nursing Assistant (CNA). Resident 1 explained he called the police on 11/17/25 and made a police report because LN 1 got angry with him, grabbed and twisted his left arm hard enough to tear off a bandage on Resident 1's elbow while LN 1 took away Resident 1's bag of cat food. Resident 1 stated he bought the cat food with his own money and liked to leave cat food for the stray cats on the patio outside of his room. Resident 1 further stated…

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 protect one of four sampled residents (Resident 1) from misappropriation (the unauthorized use of funds or other property for purposes other than that for which intended) of property and personal belongings, when Resident 1's cell phone went missing while he was hospitalized .This failure caused Resident 1 emotional distress and had the potential for loss and theft for other residents' property while residing in the facility.Findings:A review of Resident 1's admission RECORD, indicated Resident 1 was originally admitted to the facility in 2022 and was readmitted in June of 2025 with multiple diagnoses which included incomplete paraplegia (limited movement and sensation in the lower extremities).A review of Resident 1's electronic health record (EHR) titled, Social Services Progress Note, dated [DATE], indicated, .Resident 7 day bed hold [allows residents of long-term care facilities to reserve their bed for up to seven days when transferred to a…

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

Based on interview and record review, the facility failed to implement its written abuse policies and procedures when staff did not follow the required steps for responding to and reporting a documented allegation of resident-to-resident abuse after Resident 1 reported that Resident 2 threw objects, including cups and utensils, toward Resident 1.This failure left Resident 1 and Resident 2 without required protective interventions and placed them at risk for psychosocial harm.During a review of Resident 1's clinical record titled, admission RECORD, the record indicated Resident 1 was admitted to the facility with multiple diagnoses which included generalized anxiety disorder (a mental health condition that causes fear, a constant feeling of being overwhelmed and excessive worry about everyday things) and depression (mood disorder that causes a persistent feeling of sadness and loss of interest).Review of Resident 2's clinical record titled, admission RECORD, the record indicated Resident 2 was admitted to the facility with multiple diagnoses which included dementia (the loss of…

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

Based on interview and record review, the facility failed to report an allegation of resident-to-resident abuse incident to the Department within the required timeframe when Resident 1 reported that Resident 2 was throwing objects, including cups and utensils toward Resident 1. This failure left Resident 1 and Resident 2 without required protective interventions and placed them at risk for psychosocial (internal cognitive aspects of a person's life and how they interact with those around them) harm. During a review of Resident 1's clinical record titled, admission RECORD, the record indicated Resident 1 was admitted to the facility with multiple diagnoses which included generalized anxiety disorder (a mental health condition that causes fear, a constant feeling of being overwhelmed and excessive worry about everyday things) and depression (mood disorder that causes a persistent feeling of sadness and loss of interest).Review of Resident 2's clinical record titled, admission RECORD, the record indicated Resident 2 was admitted to the facility with multiple diagnoses which included…

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 respiratory care (the diagnosis, treatment, and management of residents with breathing or other cardiopulmonary (heart and lung) disorders) consistent with professional standards of practice for two of two sampled residents (Resident 1 and Resident 2) with a tracheostomy (an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs) when: 1. Registered Nurses (RNs) provided care for Resident 1 and Resident 2 without documented competencies (measurable patterns of knowledge that enabled individuals to perform a skill successfully) for tracheal suctioning (a procedure that cleared mucus (a sticky substance produced by the body) and secretions (liquid substance produced by the body) from the trachea (a tube-like structure that allowed air to travel to and from the lungs) through a tracheostomy tube (a removable tube inserted in tracheostomy)), and tracheostomy care (maintaining a clean…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary kitchen environment when:1. Spoiled grapes were available for resident consumption; and,2. Water from a floor sink (a drain in the floor that dirty water flows into) overflowed into the walk-in refrigerator; and,3. The resident refrigerator/freezer was not clean, contained outdated items, contained staff lunch bags and undated food containers, and was not monitored for temperature. 1. During an interview with Resident 4, on 8/5/25, at 2:22 PM, Resident 4 stated when she had asked for fresh fruit, she had been given a bag of 'rotten grapes'.During a concurrent observation and interview, on 8/6/25, at 11 AM, with the Dietary Manager (DM), in the walk-in refrigerator, three bags of grapes were observed to be in a box dated 7/14/25. The grapes were removed and were soft with blackened patches and white patches on the grapes, in a slimy liquid. The DM confirmed the appearance of the grapes. The DM stated when 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 and interview the facility failed to ensure outside garbage bins were kept covered.This failure could have been a contributing factor in the facility harboring pests (cockroaches, flies, ants) with the potential to negatively impact the health and well-being of residents residing in the facility. Findings:During observations made on 8/6/25 at 10:38 AM, 8/7/25 at 11 AM, and 8/13/25 at 10 AM., the lids of the outside garbage bins were noted to be open. During a concurrent observation and interview on 8/13/25 at 10:11 AM, with the Director of Nursing (DON), the DON confirmed the presence of one cockroach on the wall in the conference room. During a concurrent observation and interview on 8/6/25 at 11:45 AM, with the Dietary Manager (DM), the DM confirmed the outside garbage bin lids were left open. The DM explained the outside garbage bin lids should have been kept closed so pests were not attracted to the kitchen. The DM stated the residents could become ill because pests carry germs (a very small virus or bacteria that can make a person ill).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 ensure that the kitchen oven was in good working order when the right oven door was hanging open and could not be closed.This failure had the potential to delay meal service and have hot foods not maintained at a safe food temperature (Hot food should be kept at 140 degrees Fahrenheit ( F - unit of measurement) or above to avoid rapid bacteria (germs) growth, which could negatively affect the health of 87 residents who received food from the kitchen. During an observation on 8/6/25, at 11:40 AM, in the kitchen, the right-side door of a double oven was hanging open and the right-side door of the oven was not attached to the oven.During a concurrent observation and interview with Dietary Aide/Cook (DA/Cook) 1, on 8/6/25, at 11:45 AM, the DA/Cook 1 stated the right-hand oven door had been broken for three to four months. During an interview on 8/12/25, at 1:59 PM, with the Registered Dietitian (RD), the RD stated a kitchen audit was completed on 5/21/25. The RD stated that the Dietary Manager (DM) and herself…

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 administered within professional standards of practice, to one resident (Resident 4) in a sample of four, when Resident 4's medications were left at her bedside.This failure had the potential for Resident 4 not taking her medications and/or another resident taking Resident 4's medication, negatively impacting the resident's health and well-being.Findings:During a concurrent interview and observation, on 8/6/25, at 12:50 PM, Resident 4 was in her room and two liquid medications were observed to be on her bedside table. Resident 4 explained the medications were her protein and her lactulose.A review of Resident 4's clinical document titled, Medication Administration Record (MAR), dated 8/1/25 through 8/31/25, the document indicated, .Lactulose [promotes bowel movements] . and, .[brand name liquid protein] .During an interview with Licensed Nurse (LN) 1, on 8/6/25, at 1:05 PM, LN 1 confirmed he had left Resident 4's liquid protein and lactulose on her bedside table. LN 1 stated he should…

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

Based on observation and interview, the facility failed to ensure one of four sampled residents (Resident 4) received food that was safe and at an appetizing temperature when Resident 4's lunch meal on 8/7/25 was served cold and Resident 4's cold drink was served warm.This failure had the potential for Resident 4 to not obtain her nutritional requirements due to unpalatable food, negatively affecting Resident 4's health and well-being. Findings:During an interview with Resident 4, on 8/6/25, at 12:50 PM, Resident 4 stated the food was always cold and the drinks were always warm.During a concurrent observation and interview with Dietary Aide/Cook (DA/Cook) 1, on 8/6/25, at 12:56 PM, in Resident 4's room, the DA/Cook 1 took the temperatures of the food items on Resident 4's lunch tray that had been delivered at 12:52 PM. The temperatures were as follows: Taco Casserole 115 degrees Fahrenheit (F - a unit of measure); Mixed Vegetables 102 degrees F; Cranberry Juice 60 degrees F. During an interview with the Registered Dietitian (RD), on 8/12/25, at 1:59PM, the RD stated the above food…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure they had the capability to provide a specific respiratory care need prior to admitting one of three sampled residents (Resident 1) with a tracheostomy (a surgical procedure that creates an opening in the trachea (windpipe) to allow air to enter the lungs) when, the facility was not able provide cool aerosol mist (provides humidity to the airway to prevent airway secretions from drying out because a tracheostomy bypasses the natural humidifying and warming functions of the nose and mouth, potentially leading to dry, thick secretions that can obstruct the airway) to Resident 1 upon admission and readmission to the facility. This failure resulted in Resident 1 being sent to the hospital on 7/1/25 (day of admission to the facility), with Resident 1 returning to the facility on 7/7/25 from the hospital, and Resident 1 being sent back to the hospital on 7/7/25. This failure also had the potential to result in transfer trauma (a 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.

Based on observation, interview, and record review, the facility failed to ensure residents' rights to be treated with dignity were honored for 1 of 3 sampled residents (Resident 1) when Resident 1 was not offered to wear her own clothing.This failure had the potential to negatively impact Resident 1's psychosocial well-being. Findings:During a concurrent observation and interview on 6/24/25, at 10:38 a.m., with Resident 1, Resident 1 was observed sitting in bed and wearing a hospital gown. Resident 1 stated the nursing staff had not offered her to be dressed up while having her own clothing here. Resident 1 further stated she would love to wear her own clothes. Resident 1 stated that always being in a hospital gown made her feel she was not being taken care of. Resident 1 further stated that during the care conference meeting (a meeting where the resident, family, and facility care team discuss the resident's care plan, goals and progress) which Ombudsman (an advocate for long term care residents in a skilled nursing facility) attended, she was in a hospital gown. Resident 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 interview, and record review, the facility failed to document and investigate the grievances for one resident (Resident 1) with a facility census of 98, regarding her care concerns.This failure had the potential for Resident 1's care concerns to not be honored and addressed timely.Findings:A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility in 2025 with diagnoses which included polyneuropathy (a general term for peripheral nervous system disorders that impact nerve function in multiple areas of the body), multiple sclerosis (a disease in which the immune system eats away the protective covering the nerves, resulting nerve damage disrupts communication between the brain and the body), post-trauma TIC stress disorder (there is a connection between trauma, stress, and the development or worsening of tic-like movements as a manifestation of trauma related stress).During a concurrent interview and record review on 6/24/25, at 10:38 a.m., with Resident 1 in her room, Resident 1 stated she filed grievances at the facility and kept personal…

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 treatment and care in accordance with professional standards of practice when:1. There was no follow up for Resident 1's appointment with a neurology specialist (specialty doctor who specialized in diagnosing and treating diseases and disorders of brain, spinal cord, nerves, and muscles); and,2. A care plan was not initiated for Resident 1's diagnosis of polyneuropathy (a general term for peripheral nerves system disorders that impact nerve function in multiple areas of the body. Symptoms can include pain, a pins-and-needles sensation, numbness, and weakness).These failures had the potential to result in a worsening nerve condition and/or other serious medical complications including a delay in care without proper interventions.Findings:1. A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility in 2025 with diagnoses which included polyneuropathy, and multiple sclerosis (MS, a disease in which the immune system eats away 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 ensure medications were available for administration for 1 of the 3 sampled residents (Resident 1), when anxiety medication was not available for Resident 1.This failure had the potential to negatively impact Resident 1's health and well-being.Findings:A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses which included post-traumatic stress disorder (PTSD, a mental health condition that develops after experiencing a traumatic event) and anxiety (a mental health condition characterized by excessive worry, fear, and unease).During a concurrent observation and interview on 6/24/25, at 10:38 a.m., with Resident 1, Resident 1 stated she was okay until she ran out of Xanax (medicine to treat anxiety). Resident 1 further stated she requested anxiety medication and did not receive until it was delivered by the pharmacy on 6/21/25 at 3:30 p.m. Resident 1 stated the unavailability of the anxiety medication made her feel distressed and increased her anxiety level.A…

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

Based on observation, interview, and record review, the facility failed to distribute and serve food in accordance with professional standards for food safety for 1 of the 3 sampled residents (Resident 1) when:1. The lunch tray did not contain a dietary ticket/identifier; and,2. The drink on the tray did not match the tray ticket.These failures had the potential to place Resident 1 health at risk for consuming the wrong diet.Findings:1.Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with multiple diagnoses including but not limited to multiple sclerosis (MS, a disease that causes breakdown of the protective covering of nerves resulting in numbness, weakness, trouble walking, vision change and other symptoms), dysphagia oropharyngeal phase (difficulty swallowing in the oropharyngeal phase, which involves the transfer of food from the mouth to the esophagus. Problems in this phase can lead to coughing, choking, and aspiration).A review of Resident 1's Order Summary Report, dated, 4/10/25, indicated, .Cardiac diet Regular texture, Thin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one out of three residents (Resident 1) who were at risk for wandering/elopement received adequate supervision to prevent an elopement (when a resident leaves the facility without supervision) from occurring, when Resident 1 eloped from the facility for the third time on 5/23/25 (Resident 1 had previously eloped from facility on 5/15/25 and 5/20/25). This failure led to Resident 1's elopement on 05/23/25 resulting in a four-day absence, and subsequent hospitalization. Findings: Review of Resident 1's admission RECORD, indicated, Resident 1 was admitted to the facility with diagnoses of toxic encephalopathy (brain dysfunction), brief psychotic disorder (sudden onset of at least one positive psychotic symptom [loss of touch with reality] for more than a day but less than a month), and psychosis (disconnection from reality). Review of Resident 1's Brief Interview for Mental Status (BIMS, an assessment tool), dated 5/22/25, indicated…

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

Based on observation, interview, and record review, the facility failed to provide a safe and hazard free environment when one of two resident lift devices (a resident lift device used by caregivers to safely transfer residents) wheels were not locked. This failure placed a resident census of 93 and staff at risk for injury. Findings: During a concurrent observation and record review on 3/6/25 at 3:10 PM with Certified Nursing Assistant (CNA) 1, CNA 1 confirmed the resident lift device located on the east wing wheels were not locked and secured in place. CNA 1 stated the resident lift device wheels should have been locked when not in use and it was a fall risk to staff and residents. During an interview on 3/6/25 at 3:25 PM with Licensed Nurse (LN) 1, LN 1 stated resident lift devices should be locked if left unsupervised in the hallway. LN 1 further stated any resident could move the resident lift device and the unlocked resident lift device could increase the risk of falls to residents. During an interview on 3/6/25 at 3:50 PM with the Administrator (ADM), the ADM stated it 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 interview, and record review, the facility failed to provide a copy of written Notice of Transfer/ Discharge to the appropriate parties for one of one sampled resident (Resident 1), when the Long Term Care (LTC) Ombudsman (a patient rights advocate) was not notified in writing of Resident 1's transfer to the acute care hospital on 1/9/25. This failure resulted in the State LTC Ombudsman not being informed of Resident 1's transfer and removed the opportunity for the State LTC Ombudsman to advocate on Resident 1's behalf. Finding: Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility in 2018 with diagnoses which included paraplegia (a condition where there is a loss or impairment of motor and sensory function in the lower half of the body, typically affecting both legs). During a concurrent interview and record review on 2/4/25, at 3:23 p.m., with the Director of Nursing (DON), Resident 1's NOTICE OF TRANSFER/ DISCHARGE, dated 1/9/25 was reviewed. The DON stated Resident 1 was sent to the hospital from the facility on 1/9/25 for concern of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to re-admit one of one sampled resident (Resident 1), when Resident 1 was transferred to an acute care hospital on 1/9/25 and was ready to return to the facility on 1/13/25. This failure resulted in a violation of Resident 1's right to return to the facility and had the potential to cause psychosocial harm due to not being able to return to the facility. Findings: Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility in 2018 with diagnoses which included paraplegia (a condition where there is a loss or impairment of motor and sensory function in the lower half of body, typically affecting both legs). During a phone interview on 2/4/25, at 9:33 a.m., with the Hospital Case Manager (HCM), the HCM stated Resident 1 was admitted to the hospital on [DATE] and was ready to be discharged on 1/13/25. The HCM further stated the hospital was calling the facility everyday since 1/13/25 for bed availability, but 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.

2. During a review of Resident 48's clinical record titled, admission RECORD, indicated Resident 48's diagnosis included hearing loss. During a concurrent observation and interview on 1/28/25, at 8:39 AM, with LN 8, Resident 48 was in her room and there was a whiteboard (writing board) on her nightstand approximately three feet from her bed and not within reaching distance. There was no whiteboard marker in the room. LN 8 stated Resident 48 was deaf (unable to hear) and mute (unable to speak); however, Resident 48 pointed at objects and wrote on her whiteboard in order to make her needs known. LN 8 stated he thought Resident 48 had a marker at her bedside and left the room and retrieved a whiteboard marker. Resident 48 wrote a sentence on the white board, but the handwriting was not discernable. During a concurrent observation and interview on 1/30/25, at 12:11 p.m., with the Certified Nursing Assistant (CNA) 10, Resident 48 was in her wheelchair, in the dining room, and was ready to eat lunch. CNA 10 stated Resident 48 did not have her whiteboard with her in the dining room and…

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

Based on observation, interview, and record review, the facility failed to provide an ongoing activity program that was resident centered for 2 of 27 sampled residents (Resident 23 and Resident 54) when: 1. Person-centered activities were not provided for Resident 23 while on contact precautions (set of steps to prevent the spread of illnesses that can be transmitted by direct or indirect contact) isolation; and, 2. Person-centered activities were not provided for Resident 54 who preferred to remain in his room. These failures had the potential to negatively impact Resident 23's and Resident 54's physical, mental, and psychosocial well-being. Findings: 1. Review of Resident 23's admission RECORD, indicated Resident 23 was admitted to the facility in the beginning of 2025 with diagnoses which included osteomyelitis (bone infection), MRSA (Methicillin Resistant Staphylococcus Aureus) infection, and a pressure ulcer to right heel. During a review of Resident 23's Skin Care Plan, dated 1/10/25, the care plan indicated, .Resident will be compliant with contact/isolation (help 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 residents were free from accidents and hazards when: 1. One of two sampled residents (Resident 43) who were at risk for elopement (leave the facility or a safe area without the facility's knowledge and supervision), did not have an effective plan of care was in place to protect Resident 43 from elopement, 2. The facility did not ensure the lint traps were clean in 2 out of 2 dryers; and, 3. The facility did not ensure 1 of 27 sampled residents (Resident 45)'s sliding door was operational. These failures could have resulted in injury such as falls, burns, or inability to exit a room. Findings: 1. During a review of Resident 43's clinical record titled, admission RECORD, indicated Resident 43's diagnosis included schizoaffective disorder (a mental condition that includes seeing and hearing things that are not real). A review of Resident 43's clinical record titled, IDT - Interdisciplinary Post Event Note, dated 12/11/24, on 12/10/24, at 5:41 p.m., by the Assistant Director of Nursing (ADON), indicated…

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

Based on observation, interview, and record review, the facility failed to ensure direct care staffing information was posted as required for a census of 92. This failure prevented the residents and visitors from viewing the hours and number of direct care staff providing care to the residents of the facility daily. Findings: During a concurrent interview and record review on 1/30/25, at 4:35 PM, with the Director of Staff Development (DSD), while reviewing a document titled, The PPD (Per Patient Day) Spreadsheet, The DSD stated, the spreadsheet was in his binder and the binder was used to calculate the PPD daily. The DSD further stated the PPD Spreadsheet was also used when admissions and discharges were expected. During a concurrent observation, interview, and record review, on 1/31/25 at 10:50 AM, with the Director of Nursing (DON), the DON stated when determining the daily schedule for staff they used the PPD that was current at the time and included consideration of the acuity of the residents. The DON stated when needed they would adjust the PPD. When asked where the PPD 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 food was stored, prepared, and distributed in accordance with professional standards for food service safety for 85 out of a census of 92 residents who ate facility prepared meals when: 1. Several containers of spices had lids left open, 2. Expired food item was not removed from the dry storage area, 3. Kitchen staff did not wear gloves while preparing ready to eat food, 4. Kitchen staff did not perform hand hygiene when moving from dirty to clean surfaces, 5. Appropriate measuring utensil was not used during food distribution; and, 6. Chopping boards were not color-coded to indicate different food items for a specific color. These failures placed residents at risk for foodborne illnesses. Findings: 1. During the initial kitchen tour on 1/28/25, at 8:27 a.m., with the Certified Dietary Manager (CDM), there were several containers of used spices had their lids left open. These spices were located in an open shelf above the preparation food counter. The CDM confirmed the lids of the spice containers were…

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

Based on observation, interview, and record review, the facility failed to ensure safe and effective infection prevention practices with a resident census of 92 when: 1. The facility's policy on Enhanced Barriers Precaution (or EBT, an infection control measures used to prevent the spread of disease and required the caregivers wear gowns and gloves during high-contact care activities) and use of protective gown (Protective gear worn to reduce exposure of germs to resident and prevents the spread) was not followed in one out of six residents (Resident 76) observed for medication administration during a high contact ( involves significant physical contact) resident care activity when the Feeding Tube (or FT, also known as enteral nutrition, where a tube was inserted into the stomach to provide nourishment, fluids or medications to a patients unable to take by mouth) was accessed to administer medication and nutrition, 2 a. Resident 66's bed mattress had large areas of exposed, stained foam, 2 b. Resident 87's bathroom was dirty, 3. Resident 3 was placed on contact/isolation…

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 2 of 27 sampled residents (Resident 66 and Resident 87) were provided a home-like environment when: 1. Resident 66's bed mattress had tears in the plastic barrier and the bed sloped to the left side; and, 2. Resident 87's bathroom had stool and urine on the toilet seat, toilet paper on the bathroom floor, and a non-operational soap dispenser in the bathroom. These failures led to an uncomfortable sleeping environment for Resident 66 and Resident 87's bathroom was not clean enough to utilize. Findings: 1. During a review of Resident 66's clinical record titled, admission RECORD, indicated Resident 66's diagnosis included pain in his left knee. During a concurrent observation and interview on 1/28/25, at 9:35 a.m., with Resident 66, Resident 66 stated he had been at the facility for approximately two and half months. Resident 66 stated he would like a new bed because it felt like there was a sinkhole in the middle of the bed and at night, he was afraid he would fall out of bed. Resident 66's bed 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 report an allegation of stolen property when Resident 40 reported his suspicion that 2 facility staff members had stolen his money. These failures resulted in a delay of the state survey agency investigating the allegations of abuse, which had the potential to put residents' psychosocial and physical health and safety at risk. Findings: Review of Resident 40's electronic medical record titled, admission RECORD, indicated, Resident 40 was admitted into the facility with a diagnoses including but not limited to depression (affects how you feel, think and behave and can lead to a variety of emotional and physical problems) and anxiety (excessive fear or worry about a specific situation). Review of Resident 40's facility document titled, Property Loss Report, dated 8/9/24, indicated, Resident 40 reported to the facility staff that two CNAs (Certified Nurse Assistants) took his $2400 cash kept in his zip-lock bag on 8/9/24. The report also indicated that the facility decided not to reimburse the missing cash as…

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

Based on observation, interview, and record review, the facility failed to ensure 1 of 27 sampled residents' (Resident 48) assessment was completed accurately to identify her hearing and speech disability. This failure could have resulted in Resident 48 not receiving the needed services and communication aids to effectively make her needs known and could have resulted in a decrease in quality of life. Findings: During a review of Resident 48's clinical record titled, admission RECORD, indicated Resident 48's diagnosis included hearing loss. During a concurrent observation and interview on 1/28/25, at 8:39 AM, with Licensed Nurse (LN) 8, Resident 48 was in her room and there was a whiteboard (writing board) on her nightstand approximately three feet (unit of measurement) from her bed and not within reaching distance. There was no whiteboard marker in the room. LN 8 stated Resident 8 was deaf (unable to hear) and mute (unable to speak); however, Resident 48 pointed and wrote her needs on the whiteboard. During a concurrent observation and interview on 1/30/25, at 12:11 p.m., 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.

Based on observation, interview, and record review, the facility failed to ensure safe cleaning and sanitization of shared glucometer (a device used to measure blood sugar) in-between resident care on one out of six residents (Resident 30) observed for medication administration based on the facility's policy and manufacturer specifications. This failure had potential to spread infection among residents and compromise resident's well-being. Findings: During a medication administration observation with Licensed Nurse 9 (LN 9), at East Short hallway, on 1/28/25, at 9:28 AM, LN 9 with gloved hand took the glucometer and supplies inside a basket, into the Resident 30's room to measure the blood sugar. LN 9 then poked Resident 30's right middle finger with lancet (small, sharp needles used to obtain a small amount of blood from the finger for blood sugar testing) to get the blood and soaked the test strip (a plastic strip contains chemicals to help with blood sugar measurement) with blood to measure the blood sugar. LN 9 used one Sani-Cloth-Bleach wipe (brand name for a wipe 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.

Based on observation, interview, and record review, the facility failed to provide quality care for 1 of 27 residents (Resident 56) when Resident 56's physician orders for cardiology (medical specialty that focuses on the heart), urology (medical specialty that focuses on urinary tract or organs that produce urine), psychiatry consults, and neurology (medical specialty that focuses on conditions of the brain, spine and nerves) referral were not addressed. These failures could contribute to health concerns not being addressed and could lead to adverse events for Resident 56. Findings: Review of Resident 56's electronic medical record titled admission RECORD, indicated, Resident 56 was admitted to the facility during February of 2022, with a diagnosis including but not limited to paraplegia (inability to voluntarily move the lower parts of the body), spina bifida (birth defect that occurs when the spinal cord and spine do not develop normally), post-traumatic stress disorder (PTSD, a mental health condition that is caused by an extremely stressful or terrifying event), anxiety…

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 seven residents (Resident 76) was provided with appropriate care and services with enteral feeding (also referred to as G-Tube feeding-gastrostomy tube feeding, the delivery of food and nutrients through a feeding tube directly into the stomach or part of the intestines) when: 1. The enteral feeding formula container did not have a stop time and a re-start time labeled on the bottle; and, 2. The water flush bag was not labeled with Resident 76's name, room number, date, time started and stopped, the administration rate, and initials of the nurse. These failures had the potential for Resident 76 to not receive adequate enteral nutrition and proper hydration and to not receive the correct water flush bag. Findings: During a review of Resident 76's admission RECORD, indicated resident was admitted to the facility in the middle of 2024 with diagnoses which included dysphagia (inability to swallow). The Minimum Data Set (MDS, an assessment tool) dated 12/19/24, indicated Resident 76 was receiving…

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

Based on observation, interview, and record review, the facility failed to ensure safe and timely medication acquisition, handling, use, and disposition (destruction of unused medications) with a resident census of 92 when: 1. Non-controlled prescription medication (medications prescribed by a doctor and not an opioid) destruction logs were either not signed or not co-signed by licensed nurses in the destruction medication binder in one of two nurse's stations (East nurse station); and, 2. Resident 45's and Resident 83's prescribed medications were not available and not refilled (process of obtaining additional medication) in a timely manner leading to missed doses. These failed practices led to the residents not receiving prescribed medications as a result of unavailability and delay in the refill process, and potential for medication diversion. Findings: 1. During a concurrent interview with Licensed Nurse (LN) 2 and record review of a binder of the facility's documents titled MEDICATION DISPOSITION SHEET on 01/28/25, at 4:50 PM, the medication destruction logs were missing either…

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.

3. Review of Resident 56's electronic medical record titled, admission RECORD, indicated, Resident 56 was admitted to the facility during February of 2022, with a diagnoses including but not limited to post-traumatic stress disorder (PTSD, when a person's past experience cause emotional problems on their daily life), anxiety disorder (excessive fear or worry about a specific situation), major depressive disorder (affects how you feel, think and behave and can lead to a variety of emotional and physical problems), and insomnia (inability to sleep) among others. During a concurrent observation and interview with Resident 56, in his room, on 1/28/25, at 11:33 a.m., Resident 56 stated he requested psychiatric (mental health provider) help and needed to see a mental health female doctor in person and he did not approve of the telehealth mental health services through video calls he had received. Review of Resident 56's electronic medical record, titled Medication Administration Record (or MAR, where nurses document what and when ordered medications were administered), dated 5/2024,…

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

Based on observation, interview, and record review, the facility failed to ensure safe medication administration practices when the medication error rate was more than 5% (% or percentage- number or ratio that expressed as a fraction of 100) with a resident census of 92. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of five errors out of 35 opportunities which resulted in a facility wide medication error rate of 14.29% in 3 out of 6 residents (Resident 17, Resident 5, and Resident 76) were observed for medication administration. These failures may result in unsafe medications use affecting residents' health and well-being. Findings: 1a. During a medication administration observation, accompanied by Licensed Nurse 1 (LN 1), on 1/28/25, at 8:40 AM, in the [NAME] Long hallway, LN 1 administered a total of 10 medications to Resident 17. The medications included an inhaler called Breo Ellipta (an inhaled medication containing two medications in one; used to treat breathing…

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 accurate medical records for 2 of 27 sampled residents in accordance with accepted professional standards and practices when Protected Health Information (PHI - any information that can be used to identify a person and is related to their health including any information about a person's physical or mental health, treatment, and payment for healthcare) of another resident was found in Resident 40's and Resident 43's Electronic Medical Record. These failures had the potential to violate the safeguarding of residents' health information, privacy, and confidentiality. Findings: 1a. During a record review of Resident 40's electronic medical record, the document under the heading History and Physical (H&P) contained another resident's H&P information. During a concurrent interview with the Assistant Director of Nursing (ADON) and a record review of Resident 40's electronic medical record on 1/30/25, at 5:04 PM, the ADON confirmed the H&P in Resident 40's chart belonged to a different resident who had been discharged .…

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 2) personal funds were protected when the facility filled out documentation to receive Resident 2's Social Security without Resident 2's knowledge and consent. This failure had the risk of financial insecurity and psychosocial harm to Resident 2. Findings: A review of Resident 2's admission RECORD, indicated Resident 2 was admitted to the facility with diagnoses which included depression (mood disorder with a persistent feeling of sadness) and multiple sclerosis (condition with symptoms including weakness, numbness, loss of coordination, visual disturbances, and problems with speech and bladder control). Further review of the record indicated Resident 2 was his own responsible party. During an interview on 10/9/24, at 11:08 AM, with the Ombudsman (OMB- long term care advocate for resident rights), the OMB stated the facility filled out an application to Social Security to have a payee (someone who receives the money) assigned to Resident 2 without informing Resident 2. 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 safeguard and take reasonable care of one discharged resident's (Resident 1) personal property when Resident 1's personal property was given to Family Member (FM) 1 without Resident 1's knowledge, and without requiring FM 1 to sign for the property on Resident 1's inventory sheet (a list used to track what personal items come in and out of the facility). This failure resulted in Resident 1 in not receiving his personal property and the risk for negatively impacting Resident 1's psychosocial well-being. Findings: A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses which included depression (mood disorder with prolonged episodes of sadness). A review of Resident 1's Progress Notes, dated 9/1/24, indicated, .Resident left AMA [Against Medical Advice] . During an interview on 10/10/24, at 12:29 PM, with Resident 1, Resident 1 stated he had not received his personal property from the facility. Resident 1 further stated the facility informed him they would send him his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain a homelike environment when seven Resident rooms were dirty and unkept. These failures had the potential to negatively impact the residents' feelings of self-worth and self-esteem. Findings: During a tour of the facility on 10/11/24, between 10:26 AM and 10:45 AM, the following was observed: -room [ROOM NUMBER] had stains on the floor, the curtain was not hanging correctly with five hooks off the track, and there were tears on the inner lining. The privacy curtain dividing bed A from bed B was dirty with five dime size brown, grey spots and a grey, brown stain going up the seam for the length of the curtain. -room [ROOM NUMBER] had dirty floors with multiple black, grey areas. The curtain's six hooks were hanging off the rails with the lining torn, and the privacy curtain was dirty with multiple black stains and three moderate sized grey stains. -room [ROOM NUMBER] had dirty floors with a small number of black stains and debris. The curtains had…

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 privacy of one of ten sampled residents (Resident 8) during wound care. This failure resulted in Resident 8 being exposed during wound care to anyone walking by his room, denying Resident 8's right to privacy and dignity. Findings: A review of Resident 8's admission RECORD, indicated Resident 8 was admitted to the facility with diagnoses which included pressure ulcers (wounds to the skin and muscle of varying depths) and a suprapubic catheter (a flexible tube that drains urine from the bladder through a small incision in the lower abdomen). During a wound care observation with licensed nurse (LN) 1, on 10/11/24, at 10:48 AM, LN 1 did not draw the privacy curtain around Resident 8's bed and LN 1 did not close the door to Resident 8's room at any time during wound care. During an interview with LN 1, on 10/11/24, at 11:32 AM, LN 1 acknowledged she did not draw the privacy curtain while performing wound care for Resident 8. LN 1 explained providing privacy to Resident 8 was important because a lot 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 maintain its infection prevention control program when infection control practices, including Enhanced Barrier Precautions (EBP-a set of measures used to prevent the spread of infection) were not maintained during wound care for one of ten sampled residents (Resident 8). This failure had the potential for cross-contamination (the transfer of harmful bacteria, parasites, or viruses from one person, object, or place to another) to Resident 8 and to residents residing in the facility, negatively impacting their health and well-being. Findings: A review of Resident 8's admission RECORD, indicated Resident 8 was admitted to the facility with diagnoses which included pressure ulcers (wounds to the skin and muscle of varying depths) and a suprapubic catheter (a flexible tube that drains urine from the bladder through a small incision in the lower abdomen). During a wound care observation with licensed nurse (LN) 1, on 10/11/24, at 10:48 AM, LN 1 gathered supplies for Resident 8's wound care, a gauze roll, normal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Resident 2 ' s rights were protected when, a. Resident 2 left the facility in the morning of 9/1/24, and upon his return in the afternoon, he was not allowed to enter the facility; b. The facility told Resident 2 he left AMA (choosing to leave against medical advice), but did not provide Resident 2 an explanation, a copy of the AMA form, or notify Adult Protective Services (APS, provides emergency intervention for vulnerable dependent adults and seniors) per their policy; and, c. Resident 2 was hospitalized on [DATE], and the hospital attempted to transfer him back to the facility on 9/2/24, but the facility refused to allow him to return. This failure resulted in Resident 2 waiting in the hospital for two days for placement in another facility out of the area and had the potential for Resident 2 to experience emotional distress due to leaving a familiar area. Findings: A review of Resident 2 ' s admission Record indicated Resident 2 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 interview, and record review, the facility failed to report a change of condition (COC- a change in the resident's normal physical, mental, or behavioral state) for one of two sampled residents (Resident 1) to the physician when Resident 1 had a weight loss of 6 lbs. (pound- a unit for measuring weight) on 8/6/24. This failure had the potential for a delay in staff intervention and care and to cause a decline in function in Resident 1. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in 2020 with diagnoses which included palliative care (specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness). During an interview on 9/3/24, at 5:28 p.m., Licensed Nurse (LN) 1 stated the physician would be notified if a resident experienced weight loss because it would be a change of condition. During a concurrent interview and record review on 9/3/24, at 6:08 p.m., with the Assistant Director of Nursing (ADON), Resident 1's electronic health record (EHR) was reviewed. The ADON 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 activities of daily living (ADL- essential self-care tasks related to personal care such as dressing, eating, bathing, grooming, and toileting) were provided to maintain good hygiene for one of two sampled residents (Resident 1) when: 1) Resident 1's shirt was dirty with multiple stains; and, 2) Resident 1's hair was tangled and not brushed. This failure resulted in Resident 1 not being well groomed, and had the potential to cause psychosocial distress. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in 2020. A review of Resident 1's Minimum Data Set (MDS- an assessment tool) dated 6/7/24, under Section GG, indicated Resident 1 required substantial/ maximal assistance from staff for her upper body dressing and personal hygiene. A review of Resident 1's Care Plan revised on 2/26/22, indicated, [Resident 1] has an ADL self-care performance deficit. The resident will maintain current level of function. DRESSING: The resident REQUIRES extensive…

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

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) received respiratory care according to professional standards when Resident 1's oxygen order was not followed. This failure placed Resident 1 at risk for respiratory distress and inadequate medical treatment. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in 2020 with diagnoses which included heart failure. During a concurrent interview and record review on 9/3/24, at 5:38 p.m., with Licensed Nurse (LN) 1, Resident 1's electronic health record (EHR) was reviewed. LN 1 confirmed Resident 1 had a physician order for receiving continuous oxygen with a flow rate of 2 liters per minute (LPM- a unit of measurement for oxygen delivery). During a concurrent observation and interview on 9/3/24, at 5:40 p.m., with LN 1 in Resident 1's room, Resident 1 was observed lying in bed. LN 1 confirmed Resident 1 was using oxygen, and the oxygen concentrator (a machine that provides supplemental oxygen) was on and running at 3…

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 meet food storage and food service practices that met professional standards for food service safety when: 1) Kitchen staff did not consistently use a beard guard while in the kitchen, 2) Food not consistently labeled appropriately, 3) Expired foods were not discarded, 4) Refrigerated and frozen food was not consistently covered, 5) Ice build-up was found around the freezer door and fans, 6) Grime and debris was found on kitchen equipment, 7) Kitchen had multiple walls with large areas of chipped paint showing dry wall, rusted equipment, and corroded metal surfaces, 8) Dishwasher gauge was not consistently showing wash temperature; and, 9) Resident refrigerator with food items was not consistently labeled. These had the potential for leading to food borne illness for 89 out of 91 residents eating facility prepared foods. Findings: 1) During the initial kitchen tour on 1/9/24, at 8:32 a.m., the Dietary Manager (DM) entered the kitchen. The DM was wearing a surgical mask below his nose and mustache. 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 observation, interview, and record review, the facility failed to ensure 6 of 23 sampled residents (Resident 143, Resident 9, Resident 89, Resident 67, Resident 81, Resident 65) and one unsampled resident (Resident 61) had their call lights within reach per facility policy. This failure had the potential to allow for unmet needs of the residents. Findings: During a concurrent observation and interview on 1/9/24, at 8:45 a.m., in Resident 143's room, the call light for Resident 143 was observed on the floor. Resident 87 stated the call light for his roommate Resident 143 had never worked. Resident 87 stated there should be a manual bell for Resident 143. During a concurrent observation and interview on 1/9/24, at 9 a.m., with the Infection Preventionist (IP) in Resident 143's room, the IP confirmed there was no manual call light located for Resident 143. The IP stated Resident 143 should have a manual call bell since the electronic call light near his bed was not working. During a concurrent observation and interview on 1/9/24, at 9:36 a.m., with Certified Nursing Assistant…

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 develop and implement a resident specific care plan (provides direction on the type of nursing care the resident may need based on their health, medication, mental, and or psychosocial needs) for 4 of 23 sampled residents (Resident 9, Resident 63, Resident 67, and Resident 89) when: 1. Resident 63 had no smoking care plan, 2. Resident 9 and Resident 89 had no communication care plan; and, 3. Resident 67's communication care plan intervention of a communication board was not implemented. These failures placed the residents at risk to not have appropriate, consistent, and individualized care to meet their needs and provide for their safety. Findings: 1. A review of Resident 63's admission RECORD, indicated Resident 63 was admitted to the facility in 2022. During an interview on 1/10/24, at 8:59 AM, with Resident 63, Resident 63 stated he was a smoker. During an observation on 1/10/24, at 11 AM, Resident 63 was observed sitting in a wheelchair in the facility's patio designated smoking area, wearing an apron,…

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 3 of 23 sampled residents (Resident 63, Resident 294, and Resident 22) were assisted with their Activities of Daily Living (ADLs- normal daily functions required to meet basic needs) when: 1.) Resident 63 and Resident 294 had long fingernails with dirty substances underneath the fingernails; and, 2.) Resident 294 did not receive showers since admission, and Resident 22 did not receive showers for 2 weeks. These failures had the potential to result in Resident 63, Resident 294, and Resident 22's poor personal hygiene, low self-esteem, psychosocial decline, and risk for infection. Findings: 1a. During a concurrent observation and interview on 1/10/24, at 8:59 a.m., with Resident 63, Resident 63's fingernails were observed to be untrimmed, unclean, long, and had dirty substances underneath the fingernails. Resident 63 stated he wanted to cut his fingernails. Resident 63 further stated it had been one week since telling multiple staff members that he wanted a nail cutter to cut his fingernails, but no one…

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

Based on observation, interview, and record review, the facility failed to ensure an environment was free of hazards for a census of 91 when the Maintenance Director (MD) did not use a dial stem thermometer (a metal pointer on a circular scale to indicate temperature measurements) to measure and check the temperature of the hot water in residents' rooms. This failure had the potential to affect all residents' safety and to cause skin burns. Findings: During an interview on 1/11/24, at 4:24 p.m., with the MD, the MD stated he checked the temperature in the resident's bathroom sink whenever he got the chance to do it. The MD further stated he did it maybe once a week to maybe not even once a week. During a concurrent observation and interview on 1/11/24, at 5:30 p.m., with the MD in a resident's bathroom, the MD turned on the hot water sink faucet and placed his hand under the running hot water to check the hot water temperature. The MD stated he would let the hot water run for 30 seconds before he placed his hands under the running hot water. The MD stated he was unsure if the water…

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 promote dignity and respect for 1 of 23 sampled residents (Resident 295) when Resident 295's indwelling urinary catheter (a tube inserted into the bladder to drain or collect urine) bag was not covered with a privacy bag. This failure had the potential to cause Resident 295 to feel demeaned and disrespected. Findings: A review of Resident 295's admission Record indicated Resident 295 was admitted to the facility in 2021. During an observation on 1/9/24, at 12:14 p.m., in Resident 295's room, Resident 295 was observed lying in his bed with a visitor seated at his bedside. Resident 295's indwelling urinary catheter bag was observed to be full and not covered with a privacy bag. During a concurrent observation and interview on 1/9/24, at 12:18 p.m., with Certified Nursing Assistant (CNA) 1 in Resident 295's room, CNA 1 confirmed Resident 295's indwelling urinary catheter bag was not covered with a privacy bag and stated it should be covered. During a concurrent observation and interview on 1/9/24 at 12:21 p.m.,…

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

Based on observation, interview, and record review, the facility failed to provide a homelike environment for 1 of 23 sampled residents (Resident 55) when Resident 55's room light did not work. This failure violated Resident 55's right to a homelike environment and had potential to negatively impact Resident 55's psychosocial well-being. Findings: During a concurrent observation and interview on 1/9/24, at 9:46 a.m., with Resident 55 in Resident 55's room, Resident 55's room light was noted to be not working. Resident 55 stated her room light had not been working for several months and the facility staff were aware. Resident 55 further stated she was upset that she had to buy her own table lamp to provide lighting in the room. During an interview on 1/9/24, at 9:52 a.m., with Certified Nursing Assistant (CNA) 5, CNA 5 confirmed Resident 55's room light was not working. CNA 5 stated maintenance was aware. CNA 5 further stated missing parts for the room light had been ordered. During an interview on 1/11/24, at 4:17 p.m., with the Maintenance Director (MD), the MD stated he was aware…

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 the twenty-three sampled residents (Resident 57) received care which met professional standards when Resident 57 received her morning medications without staff identifying and explaining what those medications were for. This failure had the potential for Resident 57 of not knowing what medications she took and its indication for use. Findings: During a review of Resident 57's admission RECORD, indicated Resident 57 was admitted to the facility in 2022 with diagnoses which included depression (a mood disorder with constant feelings of sadness), diabetes (high blood sugar), anemia (lack of red blood cells in the body), and osteoporosis (bones become weak and brittle). During an interview on 1/9/24, at 9:52 a.m., with Resident 57, Resident 57 stated she did not know what medications the nurses were giving her. Resident 57 further stated the nurses did not explain what the medications were for. During a concurrent observation and interview on 1/11/24, at 8:56 a.m., with Licensed Nurse (LN) 4 at 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 provide appropriate services necessary to ensure 3 of 23 sampled residents' (Resident 9, Resident 89, and Resident 67) communication abilities including language did not diminish when there was no interpretation services available in the facility for non-English speaking residents. This failure allowed for a lack of communication between the residents and staff which could lead to unmet needs of the residents. Findings: During a concurrent observation and interview on 1/9/24, at 9:40 a.m., with Certified Nursing Assistant (CNA) 2 in Resident 9's room, Resident 9 was observed speaking in a non-English language. When CNA 2 who was providing care for the resident, was asked what language the resident spoke, CNA 2 stated he did not know. During a concurrent observation and interview on 1/9/24, at 10:20 a.m., with Licensed Nurse (LN) 1 in Resident 89's room, Resident 89 was observed speaking in a non-English language. When LN 1 who was providing care for the resident, was asked if she understood the resident, she…

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 meet the interests and support the physical, mental, and psychosocial needs for one of twenty-three sampled residents (Resident 37) when in-room activities were not provided for Resident 37 who preferred to remain in her room. This failure had the potential to affect the psychosocial needs and wellbeing of Resident 37. Findings: During a review of Resident 37's admission RECORD, indicated Resident 37 was admitted to the facility in 2023 with diagnoses which included chronic pain syndrome and depression (mood disorder with constant feelings of sadness). During a concurrent observation and interview on 1/9/24, at 10:54 a.m., with Resident 37 in the resident's room, Resident 37 was noted to be in bed. Resident 37 stated she had not attended activities in the activity room, and no one did room visits to do activities with her. Resident 37 further stated she preferred to do activities in her room, and she would like someone to talk to her. During an observation on 1/9/24, at 1:20 p.m., Resident 37 was in bed in…

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

Based on observation, interview, and record review, the facility failed to ensure residents received the proper assistive device to maintain vision function for 1 of 23 sampled residents (Resident 59) when Resident 59 did not receive an ophthalmologist (a physician specializing in medical and surgical diagnosis and treatment of eye disorders) referral consultation to obtain a pair of eye glasses. This failure resulted in a delay of services for Resident 59 and placed Resident 59 at risk for impaired psychosocial well-being. Findings: A review of Resident 59's admission Record indicated, Resident 59 was admitted to the facility in late 2021 with diagnoses including Diabetes Mellitus (or DM- a chronic condition that affects the way the body processes blood sugar). A review of Resident 59's Minimum Data Set (MDS- a resident assessment tool) dated 4/26/22, indicated, a brief interview for mental status (BIMS) score of 15. A BIMS score of 13-15 indicated intact memory. During an interview on 1/9/24, at 11 a.m., with Resident 59, Resident 59 stated his vision was impaired and his…

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 residents received proper foot care when 1 of 23 sampled residents (Resident 59) did not receive podiatry (the medical care and treatment of the human foot) services. This failure had the potential to affect Resident 59's foot health contributing to injury and/or infection. Findings: A review of Resident 59's admission Record indicated, Resident 59 was admitted to the facility in late 2021 with diagnoses including Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar). A review of Resident 59's Minimum Data Set (MDS- a resident assessment tool) dated 4/26/22, indicated, a brief interview for mental status (BIMS) score of 15. A BIMS score of 13-15 indicated intact memory. During a concurrent observation and interview on 1/9/24, at 11 a.m., with Resident 59, Resident 59's toenails were observed to be long and thick with calluses (buildup of hard, thick areas of skin usually seen on feet) on both feet. Resident 59's right big toe was noted to be dirty and had black…

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 storage practices for one out of two medication rooms (a locked room for storage of prescription, non-prescription and controlled medications) and two out of four medication carts (mobile cart that stored resident's medication and supplies) with a census of 97 when expired (outdated) medications were stored in medication carts, and hazardous (drugs that pose short-or long-term harm upon exposure to human via skin or inhalation) medications were not safely stored and labeled as hazardous. These unsafe medication storage practices could contribute to medication error and unsafe medication use. Findings: 1a. During a concurrent interview and inspection of the facility's [NAME] station medication cart on 1/11/24, at 9:14 a.m., with LN 3, the following were acknowledged by LN 3: i. One opened bottle of Pancrelipase Creon (drug used to help improve food digestion) had no open date labeled on the box or bottle. LN 3 confirmed there was no open date on the box. LN 3 stated the opened bottle of…

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

Based on interview, and record review, the facility failed to ensure pneumococcal vaccination (infection caused by a bacteria immunization status) was obtained, offered, and/or facility provided vaccination education for one of five sampled residents (Resident 65) when Resident 65 had no record of a pneumococcal vaccination on file. This failure increased the risk of Resident 65 to acquire, transmit, or experience complications from pneumococcal disease. Findings: Review of Resident 65's admission Record indicated Resident 65 was admitted to the facility in 2022. Review of Resident 65's clinical records indicated no documentation that pneumococcal vaccination was obtained, offered, and/or Resident 6 was educated about the vaccination. During a concurrent interview and record review on 1/11/24, at 11:16 a.m., with the Minimum Data Set Coordinator (MDSC), Resident 65's electronic and paper clinical records were reviewed. The MDSC confirmed Resident 65 had no documentation of pneumococcal vaccination in the electronic and/or paper clinical records. The MDSC stated the charge nurse or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a clean and comfortable environment for a census of 90 residents living in the facility, when: 1. Resident 1 had a bed without a mattress stored in her room, 18 inches from her bed; 2. room [ROOM NUMBER] had gouges on the wall and black colored substance on the floor and the wall, and extended a quarter of the way up the wall; 3. Resident 4's room had a non-functioning toilet in the bathroom that was filled with feces and had a strong odor; 4. room [ROOM NUMBER] had an overbed table that was dirty with white debris and other miscellaneous debris; 5. The east long shower had dirty floors, black substances in the corners and along where the walls met, and a pink substance which extended up approximately 4 inches from floors; and, 6. The facility carpets were stained. These failures resulted in an environment that was not clean, comfortable, and homelike for residents residing in the facility, potentially negatively impacting…

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 garbage and refuse was disposed of properly when three large garbage bins were left open, and two garbage bags were broken open on the ground with garbage and refuse in the surrounding area, for a census of 90 residents. These failures had the potential to attract rodents and pests to the garbage bins and facility. Findings: During a concurrent observation and interview with the Certified Dietary Manager (CDM), on 12/1/23, at 8:10 AM, three large trash bins were opened, two trash bags were broken open with debris, used personal care items, and empty food containers were on ground behind one of three open trash bins. The CDM confirmed the three large trash bins were open and confirmed the debris on the ground. The CDM explained the bins should be closed and there should not be trash bags and debris on the ground. The CDM further explained it was important to keep the bins closed and the area clean, so rodents and pests were not attracted to the area. During an observation on 1/3/24, at 11:08 AM, three…

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 12 sampled residents (Resident 4) received vision services in a timely manner when Resident 4's referral to an ophthalmologist (a doctor who specializes in vision care) was not made. This failure resulted in Resident 4 not receiving services to address her sight loss and resulted in Resident 4 feeling anxious about her vision. Findings: A review of Resident 4's admission Record indicated Resident 4 was admitted to the facility with diagnoses which included high blood pressure and depression. During an interview with Resident 4, in Resident 4's room, on 12/1/23, at 9:45 AM, Resident 4 stated she lost sight in her left eye in September. Resident 4 further stated she saw an optometrist about 5 weeks prior. A review of Resident 4's clinical document titled, [Name of Optometry Group], dated 9/28/23, indicated, .Optic atrophy (damage to the optic nerve, which carries impulses from the eye to the brain) .RECOMMENDATIONS: Ophthalmology referral . During an interview with the Social Services Director (SSD), on 12/5/23,…

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 oxygen therapy consistent with professional standards of practice when: Resident 2 did not receive oxygen per physician orders. This failure resulted in Resident 2's oxygen requirements not being met and had the potential to negatively affect his health and well-being. Findings: A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility with diagnoses which included heart failure and chronic respiratory failure with hypoxia (not enough oxygen in the blood). During a concurrent observation and interview with Resident 2, on 12/1/23, at 9:15 AM, Resident 2 was sitting on the side of his bed leaning over and was not wearing a delivery device, such as a nasal cannula, for oxygen. Resident 2 stated the staff had not been able to get him oxygen. Resident 2 stated he was discharged from a local acute care hospital the night before at about 10 PM, and stated he had COPD (chronic obstructive pulmonary disease - problems with oxygenation). During an interview with licensed nurse…

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 1 of 12 sampled residents (Resident 4) a room equipped with a bathroom, or quick access to bathroom facilities, when Resident 4 ' s toilet was out of order for 10 days. This failure increased the risk of urinary tract infection or constipation for Resident 4. During a concurrent observation and interview with Resident 4, in Resident 4's room, on 12/1/23, at 9:45 AM, Resident 4's bathroom was noted to have a handwritten sign on the door which indicated, This Bathroom is Out of Order Pls [please] Do not open. Resident 4 stated she placed the sign on the door herself. When the door was opened there was a strong smell of feces in the bathroom. When the toilet lid was opened the smell became overpowering. The toilet was filled with feces. Resident 4 stated she had been using staff bathrooms which were quite a distance away from her room and she has had to train herself to only use the restroom once a day. A review of the facility document titled, Work Order #674, dated 11/21/23, indicated, .Room/Area…

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 a safe and functional environment for 1 of 12 sampled residents (Resident 12) when Resident 12's television was taped to small entertainment center for stability. This failure had the potential to result in injury to residents, staff, and visitors entering Resident 12's room. Findings: During an observation in Resident 12's room, on 12/1/23, at 8:35 AM, Resident's 12 ' s television was taped to a small bookcase with two-inch-wide brown tape. During an interview with the with the Administrator (ADM), on 12/7/23, at 10:02 AM, the ADM stated if the stand was not stable, the television could fall. During an interview with certified nursing assistant (CNA) 2, on 12/7/23 at 10:56 AM, CNA 2 stated she was not sure why the television was taped to the bookcase, and stated it was probably too wobbly and they did not want the television to get knocked over. A review of the facility policy titled, Resident Environmental Quality, dated 2023, the policy indicated, .The facility must provide each resident 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.