Creekside Center

Based on observation, interview, and record review, the facility failed to provide adequate care and services to promote healing and prevent pressure injury (a localized injury to the skin and/or underlying tissue because of prolonged pressure) for one of 20 sampled residents (Resident 3), when Resident 3's 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) was not correctly calibrated according to her current weight.This deficient practice had the potential to delay wound healing and place Resident 3 at increased risk for developing pressure injury and/or skin breakdown.Findings: During a review of Resident 3's admission Record, the record indicated Resident 3 was admitted to the facility with multiple diagnoses including morbid obesity (a serious, chronic disease defined as significant excess weight that could increase the risk, or cause of serious illness), and muscle weakness.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 timely medication processing and administration when there was a delay in both processing and administration of a prescribed mental health medication for one of 20 sampled residents (Resident 8). This failure had the potential to negatively impact Resident 8's health and place him at increased risk for a decline in psychological status.Findings: During a review of Resident 8's admission Record, the record indicated Resident 8's diagnosis included depression (mental depression with feeling of sadness), anxiety disorder (persistent or excessive worrying that interferes with daily life), post-traumatic stress disorder (or PTSD a mental condition triggered by experiencing or witnessing a traumatic events with flashbacks and nightmares), and Lewy bodies dementia (a type of memory loss with hallucinations and fluctuating alertness). The record additionally indicated that Resident 8 was a responsible party (being fully accountable for own health care decisions). During a concurrent interview and record review on 3/19/26…

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 identify and report to the Department, an allegation of financial abuse for one of three sampled residents (Resident 1) when Resident 1 reported that his money was missing from his wallet after seeing a staff member holding his wallet.This failure resulted in a delay of the Department's investigation into Resident 1's allegation of theft and had the potential to affect other residents of the facility.Findings:A review of Resident 1's admission RECORD, indicated that he was admitted in the Summer of 2022.A review of Resident 1's MDS [Minimum Data Set, a comprehensive assessment of a resident's functional, medical, psychosocial, and cognitive status], dated 10/31/25, indicated Resident 1 had a Brief Interview for Mental Status Score of 15 (BIMS, a standardized 0-15 point cognitive assessment used primarily upon admission to long-term care facilities to gauge mental acuity, with higher scores indicating better cognition) which indicated Resident 1's cognition (the mental process of knowing and understanding) was intact.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 environment free of accidents or hazards for two of four sampled residents (Resident 3 and Resident 4) when:Resident 3 did not have Wander Gard device (a wearable device that tracks movement and triggers automated security responses when a resident nears a restricted area) placement and functioning checks documented every shift daily per physician order after an elopement (when a resident leaves a healthcare facility against medical advice when doing so poses an imminent threat to the resident's health or safety) episode; andResident 4 did not have a Wander Gard device placed upon admission to the facility despite a recent history of elopement and according to facility policy.These failures put Resident 3 at increased risk of elopement and resulted in Resident 4 eloping (leaving the facility without staff knowledge) on 10/6/25, with the potential to lead to severe harm like falls, a serious injury, and/or deathFindings:1. A review of Resident 3's admission RECORD, indicated that Resident 3 was admitted to the…

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

Based on interviews and record review, the facility failed to ensure medical records were complete and accurate in accordance with professional standards for one of four sampled residents (Resident 4) when Resident 4's Visual Checks (a document detailing staff observations of Resident 4's activity in timed increments), dated 10/06/25 indicated that Resident 4 was in the facility during the time that he had eloped from the facility.This failure resulted in inaccurate documentation in Resident 4's medical record for twenty minutes, with staff documenting safety observations that they did not perform.Findings:A review of Resident 4's admission RECORD, indicated that Resident 4 was admitted to the facility in 2025 with diagnoses which included dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life).A review of Resident 4's SBAR [Situation, Background, Assessment and Recommendation, a healthcare communication tool] Communication Form and Progress Note, dated 10/6/25 indicated, .the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY These findings represent past non compliance with this regulatory requirement. There was significant evidence the facility corrected the non compliance as of 08/15/25 and there were no other occurrences of the same deficient practice at the time of the survey. The facility was in substantial compliance with this regulatory requirement and there for doesn't not require a plan of correction. Based on observation, interview, and record review, the facility failed to implement a comprehensive water safety management program based on nationally accepted standards to minimize the risk of Legionella Disease (a type of pneumonia (lung infection) caused by the bacteria Legionella pneumophila) and other opportunistic waterborne pathogens (a microorganism (bacteria) that exists in water sources or plumbing (pipes required for the water supply, heating, and sanitation in a building) systems that can cause serious illness in people over [AGE] years of age and have weakened immune systems) for a census of 71 when:a. 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 provide an environment to ensure residents' needs related to nursing services were met for a census of 72 when only one scheduled nurse worked the entire night shift on 5/4/25. This failure had the potential for residents' care services not being met by nursing staff and could affect the health and well-being of all residents in the facility. Findings: During an interview on 5/8/25, at 2:58 p.m., Licensed Nurse (LN) 1 stated that in emergency situations such as a code blue (a medical emergency requiring urgent medical help) a nursing shortage could lead to placing residents' safety and well-being at risk. During a phone interview on 5/8/25, at 3:54 p.m., LN 2 confirmed there was one nurse for the entire night shift on 5/4/25. LN 2 stated that it was not a safe practice to have one nurse for the entire facility if a resident had a medical emergency. LN 2 further stated that this unsafe practice could possibly affect residents' safety. During an interview on 5/9/25, at 6:15 a.m., Certified Nursing Assistant (CNA) 1 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.

Based on interview and record review, the facility failed to ensure adequate treatment and services were provided for one of three sampled residents (Resident 1) when, Resident 1 was not transferred to an acute care hospital (provides short-term treatment for illnesses, injuries, or surgeries that require immediate medical attention) in a timely manner for further evaluation after Resident 1 had an unwitnessed fall with a head injury on 2/17/25 and Resident 1 had a fall again on 2/28/25 with noted pain to Resident 1 ' s left hip. This failure placed Resident 1 at risk for delayed treatment and services that could possibly result in a decline in health and well-being. Findings: On 2/24/25, the Department received a complaint report that Resident 1 was not transferred after a fall on 2/17/25 to the acute care hospital for further evaluation till the following day. On 3/4/25, the Department received an additional complaint report that Resident 1 was not transferred after a fall on 2/28/25 to the acute care hospital for further evaluation until the following day. Review of 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 observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when: 1) Clean food service items were found put away wet (e.g. trays, steam table pans, scoops, and blender); 2) Can opener, food processor, and large saucepan were found dirty and/or rusted; 3) Raw chicken was prepared on a metal rack that had an uncovered container of dessert cups underneath; 4) Three bags in the freezer were open to the environment (sausage patties, biscuits, and mixed vegetables); 5) Staff were unable to demonstrate/explain the testing of sanitation concentration for the dish machine and red buckets/manual dish washing); and, 6) Resident refrigerator contained multiple food items with no name and/or date; and nursing staff were uncertain of how to label food brought in from outside, as well as where to reheat. These failures had the potential to lead to food borne illness for the 62 residents eating facility prepared meals. Findings: 1) During the initial kitchen tour on 12/3/24,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to puree (blend foods to smooth consistency) foods using methods that conserve nutritive value and flavor when excessive fluid was added, necessitating the addition of thickener. This failure had the potential of leading to poor intake, nutrient deficiencies, and weight loss for the 4 out of 62 residents eating facility prepared pureed meals. Findings: During a kitchen visit on 12/4/24 at 10:52 a.m., [NAME] (Ck) 1 was preparing the lunch meal. Ck 1 stated she had four residents on a pureed diet but would prepare five servings to add a buffer. Ck 1 placed five meatloaf servings in the food processor bowl and blended for approximately three seconds. She repeated blending for a few more seconds as the texture wasn't smooth enough. Ck 1 then added an unmeasured amount of broth and blended again for a few seconds, repeating this process several more times. After the fourth time of adding broth, Ck 1 found the meatloaf was runny and added 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 provide alternative meal options of similar protein content to the meal entrée when grilled cheese and peanut butter and jelly (PB&J) sandwiches were provided in place of the entree. This had the potential of leading to decreased protein intake for those choosing these alternatives. Findings: During the initial kitchen tour on 12/3/24 at 8:25 a.m., the alternative menu was observed hanging outside of the kitchen. This menu included Grilled Cheese and other sandwiches. During the lunch meal plating on 12/4/24 starting at 12:15 p.m., sandwiches such as grilled cheese and PB&J were provided on some meal trays due to resident request. These meals included the other side items from the lunch meal, but no additional source of protein. During an interview on 12/5/24 at 1:05 p.m. with the Registered Dietitian (RD), the RD concurred that some residents did receive sandwiches for their entrée without an additional source of protein. Review of facility provided grilled cheese sandwich recipe indicated that it provided…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, the facility failed to ensure one of five sampled residents (Resident 16) was treated with dignity and respect when Certified Nursing Assistant (CNA) 1 stood over Resident 16 while assisting with feeding. This failure had the potential to impact Resident 16's self-esteem and negatively affect dining experience. Findings: Resident 16 was admitted to the facility with diagnoses including Gastro Esophageal Reflux Disease (a condition where the stomach acid back flows towards the throat). Review of Resident 1's Minimum Data Set (MDS-a resident assessment tool) indicated Resident 1 required partial to moderate assistance with feeding. During an observation on 12/4/24 at 12:44 PM, CNA 1 was observed standing on the right side of Resident 16 while feeding Resident 16 lunch. CNA 1 stood throughout the entire meal. During an interview on 12/4/24 at 12:58 PM, CNA1 stated standing was the only choice due to a chair not being available. During a concurrent interview and record review 12/6/24 at 10:05 AM, the Director of Staff Development (DSD)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide services which met professional standards of quality for 2 of 16 sampled residents (Resident 60 and Resident 179) when, 1. The physician was not notified when vital signs were outside of ordered parameters for Resident 60; and, 2. The physician was not notified timely of abnormal lab results for Resident 179. These failures had the potential for unsafe medication use and risk of adverse effects for Resident 60, and the potential for a delay in treatment for Resident 179. Findings: 1. A review of Resident 60's admission Record indicated Resident 60 was admitted to the facility in 2024 with diagnoses including end stage renal disease (failure of the kidneys to function normally), dependance on renal dialysis (a type of treatment that helps your body remove extra fluid and waste products from your blood when your kidneys are unable to), and congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should,…

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

Based on observation, interview, and record review, the facility failed to maintain infection prevention and control practices for a census of 67 residents when: 1. Urinals (a urine collection container) were not labeled and stored in a sanitary manner; 2. Two resident wash basins were stored on the floor in the bathroom, one was not labeled, and contained a soiled cloth; and, 3. Intramuscular Muscular Injection (an injection deep in the muscles) reconstitution (adding liquid to dry medication) was not properly handled; These failures increased the risk of infectious diseases for residents in the facility. Findings: 1.During a concurrent observation and interview with Certified Nursing Assistant (CNA) 1, on 12/3/24, at 9:32 AM, there were two urinals in a resident bathroom. One was not labeled with a name or room number and was upside down top of the toilet above the flushing handle. The other was placed on the assistive handrail next to the toilet. CNA 1 stated the urinal should be labeled and stated the location of both containers placed the residents at risk of an infection 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 ensure adequate treatment and services were provided for one of five sampled residents (Resident 1) when, a. Resident 1 needed to be suctioned (secretions from the mouth and throat are removed with a device for individuals who are not able to swallow or clear their own secretions) and the suction machine was not present at his bedside; and, b. Resident 1's change in condition was not assessed and reported to the physician in a timely manner. These failures placed Resident 1 at risk for aspirating (when liquid or solids are inhaled and may cause breathing difficulty and pneumonia), and his condition to be unrecognized and untreated. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in October 2021 with diagnoses included End Stage Renal Disease (irreversible kidney failure), Dysphagia (trouble swallowing) following a stroke, and Hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). A review of Resident 1 ' s Physician Orders 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 one of three sampled residents' (Resident 1) needs were accommodated promptly, when Resident 1's call light was not within her reach. This failure had the potential of Resident 1's needs not being met and to cause psychosocial and/or physical harm for Resident 1 when Resident 1 was unable to contact staff for assistance if needed. Findings: Review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in early 2024 with multiple diagnoses including unsteadiness, and muscle weakness. Review of Resident 1's admission assessment titled, Nursing Documentation Evaluation dated 2/3/24, indicated, .Fall Risk indicators Identified .ABLE TO MAKE NEEDS KNOWN .1 PERSON ASSIST WITH ADLS [Activities of Daily Living] .CALL LIGHT WITHIN REACH, INSTRUCTED TO CALL FOR ASSISTANCE . Review of Resident 1's Change in Condition Evaluation record dated 2/4/24, indicated, .Pt. [Patient] noted on floor next to bed with back resting on side of bed. Pt. stated took brief off due to had an incontinent…

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

Based on interview and record review, the facility failed to protect one of three sampled residents (Resident 1) from verbal abuse when Certified Nursing Assistant (CNA) 1 told Resident 1, I could kill you. This failure resulted in verbal abuse and potential psychological harm for Resident 1. Findings: Review of a facility reported incident received on 1/28/24, indicated, .RESIDENTS . [Resident 1] .Alleged Perpetrator . [CNA 1] . Date of Alleged Event: 01/26/2024 .Resident reported to nurse that on Friday, CNA made statement, I could kill you and nobody would know. Review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in early 2024 with multiple diagnoses including anxiety disorder, heart failure, difficulty in walking, and muscle weakness. Review of Resident 1's Minimum Data Set (MDS, a standardized assessment tool that measures health status in nursing home residents) dated 1/18/24, indicated Resident 1 had intact cognition (The assessment uses a points system that ranges from 0 to 15 points, 0 to 7 points suggests severe cognitive impairment. 8…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff failed to report an abuse allegation for one of three residents (Resident 1), when Certified Nursing Assistant (CNA) 2 witnessed CNA 1 telling Resident 1 that she could kill him on 1/26/24 . This failure resulted in delayed immediate protection of Resident 1 and a delayed investigation of the alleged abuse and placed other residents in the facility at risk of abuse. Findings: Review of a facility reported incident received on 1/28/24 at 5:31 p.m., indicated, .RESIDENTS . [Resident 1] .Alleged Perpetrator . [CNA 1] . Date of Alleged Event: 01/26/2024 .Resident reported to nurse that on Friday, CNA made statement, I could kill you and nobody would know. Review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in early 2024 with multiple diagnoses including anxiety disorder, heart failure, difficulty in walking, and muscle weakness. Review of Resident 1's Minimum Data Set (MDS, a standardized assessment tool that measures health status in nursing home residents) dated 1/18/24, indicated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one resident (Resident 2) of three sampled residents was free from abuse when Resident 1 hit Resident 2 with Resident 1 ' s fist causing ecchymosis (a bruise, with skin discoloration from damaged, leaking blood vessels underneath the skin) in Resident 2 ' s left eye. This failure resulted in Resident 2 not free from abuse by Resident 1. Findings: A review of an admission RECORD indicated Resident 1 was admitted to the facility in late 2018 with multiple diagnoses which included paranoid schizophrenia (a mental disorder which makes a person feels distrustful and suspicious of other people and acts accordingly), psychosis (seeing or hearing things that other people cannot see or hear). A review of a Minimum Data Set (MDS, an assessment tool), dated 8/18/23, indicated Resident 1 had very mild memory problems. A review of Resident 1 ' s care plan (CP) dated 6/17/21, 2/1/21, and 1/8/24 respectively, indicated, Resident has a tendency to…

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

Based on observations, record reviews, interviews, and facility policy review, the facility failed to update comprehensive care plans to include bed rail recommendations for 2 (Resident #26 and Resident #31) of 3 sampled residents reviewed for bed rail usage. Findings included: A review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, with a revision date of March 2022, revealed, The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 1. A review of Resident #26's admission Record revealed the facility admitted the resident on 04/22/2021 with diagnoses that included aphasia (a comprehension and communication disorder) following a cerebral infarction (stroke), chronic kidney disease, dementia, and schizophrenia. A review of Resident #26's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/05/2023, revealed Resident #26 had 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.

Based on observations, record reviews, interviews, and facility policy review, the facility failed to obtain consents and physician's orders for the use of bed rails for 2 (Resident #26 and Resident #31) of 3 sampled residents reviewed for bed rail usage. Findings included: A review of the facility policy titled, Bed Safety and Bed Rails, revised in August 2022, revealed, The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. Per the policy Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consent: a. The assessed medical needs that will be addressed with the use of bed rails; b. The resident's risks from the use of bed rails and how these will be mitigated; c.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, record review, and facility policy review, the facility failed to obtain a timely urine specimen for urinalysis for 1 (Resident #54) of 2 sampled residents reviewed for hospitalization. Findings included: Review of a facility policy titled, Lab and Diagnostic Test Results - Clinical Protocol, revised in November 2018, indicated, 1. The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. Review of Resident #54's admission Record revealed the facility admitted the resident on 08/31/2023, with diagnoses that included unspecified cirrhosis of the liver and left clavicle fracture. Review of Resident #54's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/03/2023, revealed Resident #54 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required substantial/maximal assistance with toileting hygiene and was always continent of bowel and bladder function. Review of Resident…

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

Based on interviews, record review, and facility document and policy review, the facility failed to provide a pneumococcal vaccination for 1 (Resident #37) of 5 sampled residents reviewed for immunizations. Findings included: Review of a facility policy titled, Pneumococcal Vaccine, revised in October 2019, revealed, All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. The policy specified, Pneumococcal vaccines will be administered to residents (unless medically contraindicated, already given, or refused) per our facility's physician-approved pneumococcal vaccination protocol. Review of Resident #37's admission Record revealed the facility most recently admitted the resident on 05/12/2022, with diagnoses that included unspecified dementia. Review of Resident #37's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/09/2023, revealed Resident #37 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. Review of a Pneumococcal 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 interviews, record reviews, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidance titled Interim Clinical Considerations for Use of COVID-19 Vaccines in the United States, the facility failed to provide a COVID-19 vaccination for 2 (Resident #37 and Resident #16) of 5 sampled residents reviewed for immunizations. Findings included: Review of a facility policy titled, Coronavirus Disease (COVID-19)- Vaccination of Residents, revised in June 2022, revealed, Each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident has already been immunized. The policy specified, 15. Booster vaccine doses are provided in accordance with current CDC guidance and 19. If a resident requests vaccination, but missed earlier opportunities for any reason, the vaccine will be offered to that resident as soon as possible. Efforts to help the resident obtain vaccination are documented. Review of CDC guidance titled, Interim Clinical Considerations for Use of COVID-19 Vaccines in the United States,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, clinical record review, and facility documents review, the facility failed to ensure Resident 1 was treated with dignity and respect when Certified Nursing Assistant (CNA 1) stated, You know how to pee on the toilet. You need to pee on the toilet. I don't know why you are peeing in your diaper. You're going to have a pissy bed. This failure had the potential for Resident 1 to feel emotional distress. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses that included cirrhosis of liver (liver damage from a variety of causes leading to scarring and liver failure), difficulty in walking and muscle weakness. Review of Resident 1's Nursing Documentation Evaluation, dated 11/22/23, indicated Resident 1 was alert and orientated to time, place, and person. The evaluation documented Resident 1 had clear speech, no behavioral issues and was Spanish speaking only. During a review of Facility Reported Event, dated 11/15/23, indicated Licensed Nurse (LN) 1 reported, that offensive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adequate infection prevention and control measures were practiced for a census of 71, when, 1. Staff donned (put on) an N95 (type of mask that offers the highest level of respiratory protection) on top of a surgical facemask (does not filter or block very small particles in the air that may be transmitted by coughs, sneezes, or certain medical procedures), 2. Staff did not don a faceshield/goggles before entering a COVID room (in which COVID positive residents reside for isolation), and 3. Staff did not change an N95 between the care of a resident in a COVID room and non-COVID room. These failures had the potential to spread COVID-19 infection among residents and staff which could cause serious illness and/or even death. Findings: During an observation on 10/10/23, at 10:52 a.m., the Director of Nursing (DON) stated a COVID positive resident was on isolation precautions (separated from others and measures taken to prevent the spread…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adequate care and services to promote healing and prevent pressure ulcers (a localized injury to the skin and/or underlying tissue because of pressure) for one of three sampled residents (Resident 2), when an air mattress was not provided to Resident 2 as ordered. This failure had the potential to worsen the pressure ulcer and to develop new pressure ulcers for Resident 2. Findings: Review of an admission Record indicated Resident 2 was admitted to the facility in September 2023 with multiple diagnoses including protein-calorie malnutrition (not consuming enough calories), malignant neoplasm of liver (liver cancer), muscle weakness, and difficulty in walking. Review of the Minimum Data Set (MDS: a standardized assessment tool that measures health status in nursing home residents), dated 9/20/23, indicated Resident 2 had moderately impaired cognition, had a pressure ulcer and was at risk of developing new pressure ulcers. 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.