Crystal Creek Post-Acute

Based on observation, interview, and record review, the facility failed to ensure one of 35 sampled residents' (Resident 3) PRN (as needed) order for Ativan (a medication used reduce anxiousness) did not exceed 14 days without a documented clinical rationale for extending the medication timeframe order.This failure placed Resident 3 at increased risk for adverse outcomes, including over-sedation, falls, and the potential use of a chemical restraint (a medication used to control a person's behavior or restrict their freedom of movement for reasons other than a standard treatment).Findings:Findings:During a review of Resident 3's admission RECORD, the record indicated Resident 3's diagnosis included anxiety (feeling of fear, nervousness or restlessness).A review of Resident 3's Order Listing Report, dated 12/1/25, indicated, .Ativan Oral Tablet 0.5 MG [milligram - unit of measurement] (Lorazepam) Give 1 tablet by mouth every 6 hours as needed for Anxiety m/b [manifested by] severe restlessness for 30 days aeb [as evidenced by] constant moving aimlessly.During a concurrent 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one resident (Resident 71), in a sample of 35 residents, had person-centered care plans (a personalized document outlining an individual's health, support, and personal needs, detailing what care is required, how it will be given (tasks, timing, by whom), and the goals, preferences, and choices of the person receiving it, ensuring consistent, high-quality, person-centered support) when care plans for Resident 71's diagnoses of diabetes and anxiety were not developed and implemented.This failure had the potential for health care needs to go unrecognized, negatively affecting Resident 71's health, well-being, and psychosocial health and well-being. Findings:A review of Resident 71's clinical record titled, admission RECORD, (contains clinical and demographic data) indicated Resident 71 was admitted on [DATE] to the facility with diagnoses which included diabetes (problems regulating blood sugar) and anxiety disorder (a mental health condition where…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 timely and proper pain relief for two of 35 sampled residents (Resident 72 and Resident 78), when:1.Resident 72 complained of sore gums and discomfort, and the ordered Magic Mouthwash [medicated liquid mouthwash mixture used to relieve pain from mouth and throat sores] and dental evaluation were not carried out and/or administered to Resident 72; and, 2. Resident 78 did not receive comfort measures or pain medication in a timely manner when Resident 78 reported moderate to severe (strong) pain. These failures resulted in Resident 72 and Resident 78 experiencing continued pain, which affected Resident 72's and Resident 78's comfort and emotional well-being (the resident's ability to feel calm, secure, and free from worry).Findings: 1.Review of Resident 72's admission RECORD, indicated Resident 72 was initially admitted to the facility in the spring of 2025, with diagnoses that included depression (serious mood disorder causing persistent sadness, loss of interest in activities), and anxiety disorder…

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

Based on observation, interview, and record review, the facility failed to ensure that informed consent (explaining the risks, benefits, and choices to the resident or their representative [someone authorized to act on behalf of a resident]) for the use of bed rails (adjustable metal or plastic bars along the sides of a hospital bed) was obtained from the appropriate resident representative for one of 35 sampled residents (Resident 107), when the informed consent was obtained from Resident 107, who lacked decision-making capacity.This failure resulted in Resident 107's representative not being able to make an informed choice regarding the use of bed rails and placed Resident 107 at risk of entrapment (when a resident gets caught, trapped, or entangled in the spaces within or around the bed rails, mattress, or the bed frame) injury, or restraint (something that keeps a resident from free movement).Findings: During a review of Resident 107's admission Record, the record indicated Resident 1 was admitted to the facility with diagnoses that included dementia, (condition that causes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 treatment and services to meet the dental health needs for one of thirty-five sampled residents (Resident 72), when Resident 72's mouth wash and dental consult ordered on 11/25/25 were not carried out timely. This deficient practice had the potential to negatively affect Resident 72's dental health needs and could contribute to unnecessary pain and suffering.Findings:Review of Resident 72's admission RECORD, indicated Resident 72 was initially admitted to the facility in the spring of 2025, with diagnosis including but not limited to acute and chronic respiratory failure (lung disease often requiring long-term oxygen therapy), chronic obstructive pulmonary disease (long-term lung condition that blocks airflow and can make it hard to breath), dependence on supplemental oxygen, depression (serious mood disorder causing persistent sadness, loss of interest in activities), and anxiety disorder (mental health condition marked by intense, persistent and excessive worry).Review of Resident 72'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 that staff utilized appropriate Personal Protective Equipment (PPE, special gear worn to protect themselves and others from germs) upon entering an isolation room for one of three sampled residents (Resident 37) when Licensed Nurse (LN) 3 was observed inside a contact isolation room (a room where a sick person is kept separate and staff use additional protective equipment, such as gloves and gowns, to prevent the spread of germs) checking Resident 37's pulse without wearing gloves or a gown.This failure increased the risk of spreading germs to staff, other residents and visitors in the facility.Findings:Review of Resident 37's admission RECORD, indicated that Resident 37 was admitted to the facility with the following diagnoses including, but not limited to, Acute Respiratory Failure with Hypoxia (lungs cannot get enough oxygen into the blood to meet the body's needs), and Pneumonia (lung infection that makes it hard to breathe).During a concurrent observation and interview with Resident 37 on 12/16/25…

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

Based on interview and record review, the facility failed to report an allegation of alleged abuse to the Department (the states licensing and certification agency whom conducts inspections of health care facilities) for one resident (Resident 1), in a sample of four residents when, Resident 1 reported to Family Member (FM) 1 that she had been hit on the head by an unknown person, FM 1 reported the allegation made by Resident 1 to facility staff on 7/30/25, and the allegation was not reported to the Department by the facility.This failure had the potential to result in continued abuse of Resident 1, with the potential to negatively affect Resident 1's physical and psychosocial well-being.Findings:A review of Resident 1's clinical document titled, admission RECORD, (contains clinical and demographic data) indicated Resident 1 was admitted to the facility with diagnoses which included hemiplegia (paralysis or weakness on one side of the body) of her right dominant side.During an interview with Family Member (FM) 1 on 9/18/25 at 1:42 p.m., FM 1 stated Resident 1 had complained to her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 alleged abuse to the Department (the states licensing and certification agency whom conducts inspections of health care facilities) for one resident (Resident 1), in a sample of four residents when, Resident 1 reported to Family Member (FM) 1 that she had been hit on the head by a staff person while care was being provided to Resident 1, FM 1 reported the allegation made by Resident 1 to facility staff on 7/30/25, and the allegation was not reported to the Department by the facility.This failure had the potential to result in continued abuse of Resident 1, with the potential to negatively affect Resident 1's physical and psychosocial well-being.Findings:A review of Resident 1's clinical document titled, admission RECORD, (contains clinical and demographic data) indicated Resident 1 was admitted to the facility with diagnoses which included hemiplegia (paralysis or weakness on one side of the body) of her right dominant side.A review of Resident 1's clinical document titled, GRIEVANCE / COMPLAINT…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Infection Preventionist (IP) was consistently employed by the facility from January 1, 2021 through December 31, 2022. This failure had the potential to increase the spread of illnesses within the facility and communicable illnesses not to be appropriately tracked and assigned the appropriate precautions; negatively impacting the health and safety of all residents residing in the facility.During an interview on 8/6/25, at 2:15 PM, with Payroll/Human Resources (Payroll/HR), Payroll/HR was unable to provide information on the IPs working in the facility between 1/1/21 and 12/31/22 as the facility no longer had the files. Payroll/HR explained the facility had shipped the employee files to the previous corporation (that owned/ managed the facility) the prior week.During an interview on 8/7/25, at 10:15 AM, with the Administrator (ADM), the ADM stated he had the names of IP 1 and IP 2 and was able to provide their names. The ADM was not able to provide details from the employee files for IP 1 and IP 2 as the ADM 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) to the responsible party (RP, a person has the authority to make decisions for another person) for one of three sampled residents (Resident 1), when Resident 1's change in behavior was not reported to Resident 1's RP. This failure resulted in Resident 1's family being uninformed that Resident 1 had gotten into an altercation with another resident. Findings: Review of Resident 1's clinical record titled, admission RECORD (a document that contained Resident 1's demographic information), indicated Resident 1 was admitted to the facility with diagnosis that included, but not limited to depression. Review of Resident 1's clinical record titled, eINTERACT Change in Condition Evaluation, dated 4/12/25, by the Licensed Nurse (LN 1), indicated Resident 1 had been physically aggressive towards another resident. The eINTERACT Change in Condition Evaluation further indicated, Son [of Resident 1] . made aware. During an…

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

Based on observation, interview, and record review, the facility failed to ensure a safe environment and adequate supervision for one of three sampled residents (Resident 1) with a history of falls when Resident 1 fell on 1/6/25, 1/11/25, 1/19/25, and 1/21/25 and no new interventions were added to Resident 1 Fall Care plan after the falls on 1/19/25 and 1/21/25. These failures had the potential for Resident 1 be injured as a result of falling. Findings: A review of Resident 1 ' s admission RECORD indicated Resident 1 was admitted to the facility with diagnoses including anxiety disorder (a feeling of fear, dread, or uneasiness), brain stem stroke syndrome (blood supply to base of brain is cut off, which may cause dizziness, weakness, blurred vision, confusion), bipolar disorder (clear shifts in a person ' s mood, energy, activity level, and concentration), and encounter for palliative (end of life) care. During a concurrent observation and interview on 1/23/25 at 3:47 PM, Licensed Nurse (LN) 1 stated that he was regularly assigned to Resident 1 who was a frequent faller, and this…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and sanitary food storage practices for a total of 127 residents receiving food from the kitchen when: 1. Food items available for use in the dry storage area, were found in an opened and unsealed container and/or past their use by or best by dates; 2. Vegetables available for use in the walk-in refrigerator were wilted, decomposing, and moldy, and containers of sour cream were past their best by dates; 3. Freezer #2 contained ice buildup on all four walls; and, 4. The dishwasher water temperature was not within range. These failures had the potential to expose the 127 residents receiving food from the kitchen to expired, contaminated foods, and placed these residents at risk of food borne illness (an illness/infection caused by consuming contaminated food). Findings: 1. During a concurrent observation and interview on 11/5/24, at 8:21 AM, during the initial kitchen tour the following items were observed: a. an opened,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 41 sampled residents (Resident 21, Resident 94, and Resident 50) needs were accommodated based on their physical limitations when, 1. Resident 21 was unable to easily use a push button call light (a handheld device with a button to call for staff assistance) and was not assessed for the need of an adaptive call light (a device that allows people with limited hand function to call for assistance); 2. Resident 94 was unable to easily use a push button call light, was not assessed for the need of an adaptive call light, and Resident 94's fall mat (a soft pad used to reduce risk of injury in case of a fall) was not in place near the bed; and, 3. Resident 50's wheelchair was lost, and the facility provided him with a wheelchair which was too large, uncomfortable, and did not fit through his door. These failures placed Resident 21 and Resident 94 at risk for falls, injury, and psychosocial distress when both residents were unable to easily call for assistance from staff, and placed Resident 50 at risk…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 smoking practices, for eight sampled residents out of nineteen residents who smoked (Resident 22, Resident 38, Resident 49, Resident 53, Resident 61, Resident 112, Resident 118, and Resident 120) when: 1. Resident 38 was observed to have cigarettes and a lighter unsecured in his room, and Resident 38 was assessed and determined not to be an independent smoker; 2. Resident 49 stated she kept her cigarettes and lighter in her room unsecured, and she was observed in her room to be receiving continuous oxygen via nasal canula (NC, tubing that delivers oxygen into your nose), and was assessed and determined to not be an independent smoker; and, 3. Resident 53, Resident 120, Resident 118, Resident 112, Resident 22, and Resident 61 had their cigarettes and/or e-cigarette (a battery powered device that simulates tobacco smoking), and lighter on their person, unsecured in their room. These failures exposed the residents, staff, and visitors to be risks of burns, fire, and or explosion while 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 prepare and serve foods in a consistent and appetizing manner when, 1. Resident 40 and Resident 120 were served food that was cold, and the test trays sampled on 11/7/24 were bland in flavor and not of an appetizing temperature; and 2. Recipes were not followed for 15 of 15 residents receiving pureed diets (food that have been ground to a soft, smooth consistency, like pudding) on 11/7/24. These failures had the potential to result in decreased meal intake for the 127 residents receiving meals in the facility, which could lead to weight loss and malnutrition. Findings: 1. A review of Resident 40's admission RECORD, indicated he was admitted to the facility in the fall of 2024. A review of Resident 120's admission RECORD, indicated he was admitted to the facility in the spring of 2023. During an interview on 11/5/24, at 12:28 PM, Resident 40 stated the food was always served cold. During an interview on 11/6/24, at 8:29 AM, Resident 120 stated the food was always cold. 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 ensure coordination of care with hospice services (provides symptom management at the end of life) for three of fifteen residents (Resident 139, Resident 121, and Resident 25) receiving hospice services in the facility, when the facility failed to ensure Hospice Provider's Visit Notes were received and reviewed by the facility staff. These failures had the potential for Resident 139, Resident 121, and Resident 25, care needs to go unrecognized, negatively impacting their health and well-being. Findings: a. A review of Resident 139's admission Record, indicated Resident 139 was admitted to the facility in Fall 2024, with diagnoses which included depression, anxiety disorder, and repeated falls. During a review of Hospice 1's binder (contains information to coordinate care with the facility, such as hospice nursing notes and hospice physician orders), the section for Resident 139 indicated there were no hospice visit notes available in the binder from 9/7/24 to 9/20/24 (13 days), and from 9/20/24 to 10/30/24 (40 days).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain its Infection Prevention and Control Program for a census of 137, when: 1. Isolation precautions (measures taken to prevent spread of infection) were not implemented timely for Resident 68; and, 2. The facility did not ensure glucometers were cleaned and sanitized. These failures had the potential for cross contamination, negatively impacting the health and well-being of residents residing in the facility. Findings: 1a. A review of Resident 68's admission Record indicated Resident 68 was admitted to the facility in 2020 with diagnoses which included diabetes mellitus (a chronic condition that affects the way the body processes blood sugar) and end stage renal disease (failure of the kidneys to function normally). A review of Resident 68's Physician Order Summary, dated 10/9/24, indicated, . Loperamide Hydrochloride (medication given for diarrhea) 2 milligrams (mg, unit of measure) give two tablets by mouth one time only for after…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not ensure one of 41 sampled residents (Resident 118) was treated with dignity and respect, when Resident 118 heard certified nursing assistant (CNA) 2 speaking negatively about her to licensed nurse (LN) 2. This failure resulted in Resident 118 feeling upset and crying, negatively impacting Resident 118's feelings of self-worth (the internal sense of being good enough and worthy of love and belonging from others) and self-esteem (how you value and perceive yourself, and the degree to which you think your qualities are positive). Findings: A review of Resident 118's admission Record, indicated Resident 118 was admitted to the facility in Fall 2023, with diagnoses which included obesity. During an interview with Resident 118, on 11/5/24, at 12:33 PM, Resident 118 stated CNA 2 called her fat. Resident 118, being tearful when recounting the situation, further stated CNA 2 told her that it hurt his arms to push her in her wheelchair because she was fat and asked her why she had to go outside all the time. Resident 118 stated it made…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 consult the physician for 1 of 41 sampled residents (Resident 50) when Resident 50's physician recommended exercise in response to Resident 50's request for help with weight loss, and the facility did not notify Resident 50's physician of his inability to participate in an exercise program. This failure had the potential for a delay in interventions to assist Resident 50 with his goals for weight loss and to experience feelings of hopelessness. Findings: Review of Resident 50's admission RECORD, indicated Resident 50 was admitted to the facility in 2022, with diagnoses including morbid obesity and abnormalities of gait and mobility. Review of Resident 50's [facility name] Fax Notification /Order Transmittal, dated 7/24/24, indicated, .To doctors .Primary Concern / Reason for the fax .The resident was researching weight loss medications and discovered [semaglutide; an anti-obesity medication used for long-term weight management] injections 1x [time] a week. The resident want [sic] to try it. Please advise .current weight…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2 of 41 sampled residents (Resident 89 and Resident 95) personal privacy and confidentiality of medical records when Resident 89's medical record contained Resident 95's personal health information (PHI). This failure resulted in Resident 95's PHI being available to Resident 89, violating Resident 95's right for confidentiality of his PHI. Findings A review of Resident 95's admission Record, indicated Resident 95 was admitted to the facility with diagnoses which included anxiety disorder and depression. A review of Resident 89's admission Record, indicated Resident 89 was admitted to the facility with diagnoses which included depression. A review of Resident 89's Electronic Health Record [HER] revealed a clinical document titled, Consultation Report, dated May 1, 2024, through May 16, 2024. The document belonged to Resident 95 and was filed in Resident 89's EHR. Resident 95's document contained PHI including Resident 95's birthdate, gender, a medication Resident 95 was receiving, and a recommendation for lab work…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2 of 41 sampled residents' (Resident 51 and Resident 102) Minimum Data Set (MDS -a federally mandated resident assessment and screening tool which identifies care needs) assessments reflected their current status when: 1. Resident 51's discharge MDS was not completed for discharge in July 2024 2. Resident 102's route of feeding was not correct on the MDS assessment. These failures had the potential for Resident 102's strengths and needs to go unassessed which could have resulted in inaccurate or missing individualized care plans, and led to Resident 51's health status upon discharge not being tracked in the MDS system. Findings: 1. A review of Resident 51's admission RECORD, indicated he was admitted to the facility in June of 2024. A review of Resident 51's clinical document titled, Wagner Notice of Transfer or Discharge, indicated, .Effective Transfer or discharge date .07/19/2024 . A review of a facility audit list of Resident 51's completed MDS assessments indicated, Discharge .7/19/2024…

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 interview and record review, the facility did not ensure 1 of 41 sampled residents (Resident 43) had her Preadmission Screening and Resident Review (PASARR- a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes) form updated after a significant change in a mental illness diagnosis. This failure resulted in Resident 43 not receiving an updated screening assessment that could have provided services needed to improve Resident 43's mental health condition and quality of life. Findings: A review of Resident 43's clinical record titled, Preadmission Screening and Resident Review (PASARR) Level 1 Screening, dated 11/3/23, indicated Resident 43 had a diagnosis of a serious mental illness, and therefore the Level I screening was positive and required a Level II screening (an evaluation to determine if the resident could benefit from specialized mental health services). A review of Resident 43's clinical record titled, admission Record (a document that contains demographic information), indicated Resident 43's diagnosis was updated on…

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

Based on interview and record review, the facility failed to ensure 2 of 41 sampled residents (Resident 54 and Resident 94) had individualized care plans (a document that indicates specific problems, goals, and interventions) developed and implemented when: 1. Resident 54's vision care plan was not developed to include admitting diagnoses of diabetic cataract (a clouding of the eye's lens that can lead to decreased vision and blindness) and glaucoma (a chronic eye disease that occurs when fluid builds up in the eye causing gradual loss of sight); and, 2. Resident 94's care plan to address falls was not developed. These failures could have resulted in Resident 54's care needs not being addressed, and Resident 94 could have sustained a preventable fall which could have resulted in an injury. Findings: 1. A review of Resident 54's admission Record indicated Resident 54 was admitted to the facility in 2024 with diagnoses which included diabetic cataract and glaucoma. During a review of Resident 54's Clinical Case Management Progress Note dated 6/5/24, the note indicated Resident 54…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assist 1 of 41 sampled residents (Resident 54) with obtaining vision services in a timely manner when the outside vision provider deemed Resident 54 ineligible to receive vision services through them and the facility did not follow-up and/or attempt to find another vision provider. This failure resulted in Resident 54 feeling frustrated about his vision and had the potential to negatively impact Resident 54's psychosocial well-being. Findings: A review of Resident 54's admission RECORD indicated Resident 54 was admitted to the facility in 2024 with diagnoses which included diabetic cataract (a clouding of the eye's lens that can lead to decreased vision and blindness), and glaucoma (a chronic eye disease that occurs when fluid builds up in the eye causing gradual loss of sight). During an interview with Resident 54 on 11/5/24 at 3:56 p.m. Resident 54 stated that he was legally blind (a statement that governments can grant you when you have severe vision loss) and had glaucoma and cataracts. Resident 54 stated that he felt…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 in accordance with professional standards of practice for two of forty-one sampled residents (Resident 111 and Resident 105) when: 1. Resident 111's medications, including controlled substances (a drug or chemical that is regulated by the government for its manufacture, possession, and use) were left at Resident 111's bedside; and 2. The facility did not ensure correct route of medication administration for Resident 105. These failures had the potential for Resident 111 not to receive his medication, and/or another resident to ingest medication not prescribed to them, and for Resident 105 to receive medications with an altered effect. Findings: 1. A review of Resident 111's admission RECORD indicated Resident 111 was admitted with diagnoses which included osteomyelitis right ankle and foot (infection of the bone), and diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). A review of Resident 111's Physician Order Summary 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 the medication error rate was less than 5% (% or percentage is a fraction of a number out of 100) during medication administration. The facility had a total of five errors out of 28 opportunities, which resulted in a facility wide medication error rate of 17.8%. Medication observations were conducted over multiple days, at varied times, in random locations throughout the facility. The five medication errors were identified in one resident (Resident 105) out of six residents observed for medication administration observation when Resident 105's medications were administered via gastrostomy tube (G-Tube-a tube inserted directly into the stomach for nutrition and medication administration) when they were ordered to be administered by mouth (PO). This unsafe medication administration practice could result in medication errors, negatively affecting the health and well-being of Resident 105. Findings: During a concurrent interview and medication pass observation, with licensed nurse (LN) 1, on 11/7/24, at 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 observation, interview and record review, the facility failed to ensure medications were stored in a clean and sanitary environment, when medications were found not to be in its bubble pack (a way to store single doses of medication). The unidentifiable medication was loose at the bottom of the medication cart drawer. This failure had the potential for medications to be unaccounted for, and increased the risk of medication error. Findings: During a concurrent observation and interview with licensed nurse (LN) 6, on 11/7/24, at 1:25 PM, a loose pill was observed at the bottom of the Station 2 Medication Cart. LN 6 stated she was not able to identify the pill. LN 6 explained the importance of ensuring there were no loose pills at the bottom of the medication cart drawer to ensure cleanliness and accountability. During an interview with the Assistant Director of Nursing (ADON) 1, on 11/8/24, at 12:29 PM, ADON 1 explained the importance of not having loose pills in the medication cart was a danger to the nurse and it was an infection control issue. A review of the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 preferences were honored for Resident 28 and Resident 101 during lunch on 11/7/24, when Resident 28's meal tray was prepared with carrots and ground beef and Resident 101 did not receive a protein portion on her meal tray. These failures had the potential to result in unintended weight loss and other adverse health effects for Resident 28 and Resident 101. Findings: A review of Resident 28's admission RECORD, indicated, she was admitted to the facility in the fall of 2022. A review of Resident 28's care plan, revised on 8/16/2024 indicated, .Altered nutrition and hydration (Risk) .Diet as Ordered .Honor food/fluid preferences . A review of Resident 101's admission RECORD, indicated she was admitted to the facility in the summer of 2022. A review of Resident 101's care plan, revised on 11/6/24, indicated, Altered nutrition and hydration (Risk) .11-2-2024: Significant weight loss: (5.1%) over ~1 month . Diet as ordered .Honor food/fluid preferences . A review of the lunch menu for 11/7/24 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 1 of 41 sampled residents (Resident 94) received rehabilitation services when Resident 94 was admitted to the facility and an order for Physical Therapy (PT; treatment that helps you improve how your body performs physical movements) and Occupational Therapy (OT; helps you improve your ability to perform daily tasks like getting dressed) was not initiated as indicated in Resident 94's hospital discharge summary. This failure had the potential to result in a decline in physical function for Resident 94. Findings: Review of Resident 94's admission RECORD, indicated Resident 94 was admitted to the facility in October 2024, with diagnoses which included hemiplegia (partial or total loss of muscle function on one side of the body) and hemiparesis (one-sided weakness but without complete loss of muscle function) affecting the left dominant side. During a concurrent interview and record review on 11/6/24 at 2:05 p.m., the Director of Rehab (DOR) confirmed Resident 94 had never been assessed for PT and OT and…

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Based on observation, interview, and record review, the facility failed to follow the menu for 18 of 18 residents who received pureed diets (food that has been ground, pressed, and/or strained to a soft, smooth consistency, like pudding) during the lunch meal service on 9/23/24, when the vegetable served did not reflect what was listed on the menu. This failure had the potential for residents ' preferences not to be met and could result in decreased meal intake. Findings: During an observation on 9/23/24 at 11:36 AM in the kitchen, [NAME] 1 placed cooked carrots into the blender, poured thickener and hot water into the blender, and pureed the items together. [NAME] 1 poured the pureed carrots into a serving dish and placed it on the steam table. During an interview on 9/23/24 at 1:45 PM with [NAME] 1 in the kitchen, [NAME] 1 confirmed she pureed carrots instead of the squash listed on the menu. [NAME] 1 stated all the residents who were on a pureed diet received pureed carrots instead of squash for the lunch meal. [NAME] 1 stated they didn ' t puree the squash because she was just…

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Based on observation and interview, the facility failed to ensure food served from the kitchen was appetizing when, 1. Pureed foods (food that has been ground, pressed, and/or strained to a soft, smooth consistency, like pudding) were not prepared according to recipe directions for the lunch meal on 9/23/24 for 18 of 18 residents who received a pureed diet, resulting in an unappetizing texture; and, 2. The lunch meal served on 9/17/24 was served late and was not at an appetizing temperature for two of four sampled residents. This failure had the potential to result in decreased meal intake. A decrease in meal intake could result in weight loss and malnutrition over time. Findings: 1. During an observation on 9/23/24, at 11:36 AM, [NAME] 1 prepared pureed carrots for the lunch meal. [NAME] 1 placed cooked carrots into the blender, added an unmeasured amount of hot water and a thickening product, and turned the machine on, blending the items together. [NAME] 1 poured the contents of the blender into a serving dish on the steam table. During an observation on 9/23/24 at 11:48 AM in the…

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Based on observation, interview, and record review, the facility failed to prepare and serve pureed food (food that has been ground, pressed, and/or strained to a soft, smooth consistency, like pudding) at the correct texture for 18 of 18 residents who received a pureed diet, when pureed foods were not prepared according to recipe directions for the lunch meal on 9/23/24. This failure increased the risk of swallowing difficulty for residents who required a modified food texture and could also result in decreased meal intake. Findings: During an observation on 9/23/24, at 11:36 AM, [NAME] 1 prepared pureed carrots for the lunch meal. [NAME] 1 placed cooked carrots into the blender, added an unmeasured amount of hot water and a thickening product, and turned the machine on, blending the items together. [NAME] 1 poured the contents of the blender into a serving dish on the stream table. During a concurrent interview and record review on 9/23/24 at 11:44 AM with the Registered Dietitian (RD) in the kitchen, the RD confirmed water is not listed on the recipe while reviewing a facility…

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Based on observation and interview, the facility failed to store clean dishes in accordance with professional standards for food safety for a total of 144 residents who received food from the kitchen when: 1. Food trays were stacked and put away wet; 2. Plastic drinking glasses were stacked on a tray and still wet. This failure had the potential to put residents eating facility prepared meals at risk for foodborne illnesses. Findings: During an observation on 9/23/24 at 1:45 PM in the kitchen, clean dishes were observed coming out of the dishwasher and placed directly on trays, top side down. No air could circulate within the cups to allow them to air dry completely. During an interview on 9/23/24 at 1:45 PM with the Registered Dietician (RD) in the kitchen, the RD identified liquid on drying trays as water. The RD stated water should not be on the tray where dishes were placed to dry. The RD identified moisture build-up inside the plastic cups. The RD stated the problem it created was an environment for pathogen growth. The RD stated this could make residents sick. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 2) was examined by a physician at least every 30 to 60 days. This failure had the potential to result in unidentified medical conditions being untreated for Resident 2. Findings: A review of Resident 2 ' s admission RECORD, indicated she was admitted to the facility in mid-2023 with diagnoses which included malignant neoplasm of large intestine and rectum (rectal and intestinal cancer) and heart failure (chronic ocndition in which the heart does not pump blood as well as it should). During an interview on 6/26/24, at 11:22 AM, Resident 2 stated she had diabetes (a chronic disease in which the body has a shortage of insulin, a decreased ability to use insulin, or both which affects blood sugar levels) and her blood sugars were high off and on. Resident 2 further stated, I don ' t see a doctor here. About two months ago they said my doctor had been changed and I haven ' t seen him yet. A review of Resident 2…

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Based on interview and record review, the facility failed to provide medically related social services for one of four sampled residents (Resident 3) when Resident 3 ' s follow up appointments with medical specialists were not scheduled as ordered. This failure had the potential to adversely affect Resident 3 ' s health and well- being. Findings: A review of Resident 3 ' s admission RECORD, indicated she was admitted to the facility in February of 2024, with diagnoses which included fracture of the right pubis (most forward facing bone of the three hip bones), displaced (ends of the bone have come out of alignment) fracture of olecranon process (arm bone that forms the point of the elbow ) with intraarticular extension of right ulna ( fracture that extends into the joint of long thin bone in the lower arm), non displaced ( bone fracture in which the bone retains its proper alignment)Type II DENS fracture (neck bone fracture) and contusion of scalp ( a bruise under the skin of the head.) A review of Resident 3 ' s, Order Summary Report, indicated: .Aspen collar [device worn around…

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NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to respond to call lights in a timely manner for 7 out of 11 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, and Resident 9) when residents stated staff did not answer their call lights during the night shift. These failures caused the residents to have unmet needs, Resident 4 to experience an episode of incontinence (loss of bladder control), and Resident 6 and Resident 9 to remain in soiled briefs for over an hour. Findings: A review of Resident 1 ' s Minimum Data Set, (MDS, a resident assessment and screening tool), dated September 15, 2023, indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 14 out 15 which suggested intact cognition. During an interview on 11/21/23 at 1:29 PM, Resident 1 stated that on the midnight shift .you are lucky if staff answers the call light . Resident 1 further stated sometimes staff ignored the call light or turned it off without responding to her needs. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe medication storage and labeling practices in three out of eight medication/treatment carts and one out of four medication storage rooms when: 1.The E-Kit (Emergency Kit - a small quantity of medications stored in a locked box that can be dispensed when pharmacy services are not available) was not completely locked and the contents were accessible without breaking the seal. 2. Unopened Insulin (medication used to lower blood sugar) bottles were stored at room temperature. 3. Lorazepam (a controlled medication that is addictive and used to treat anxiety) was not stored in a secured location inside the refrigerator. 4. Prescription (drugs specifically ordered by doctor for individual residents) creams and shampoo on the treatment cart (a cart which stored topical medications for skin or wound care) were not properly labeled with resident's name and/or pharmacy label. 5. Valproic Acid liquid medication (or Divalproex, 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 oversight of the facility's nutrition services, when the Dietary Manager (DM) was not qualified, and the facility employed part time Registered Dietitian (RD) Consultants who did not meet the required fulltime 35 hours in a week to oversee the daily operations of the kitchen and food preparations. This failure had the potential to jeopardize the health and safety of a census of 146 residents. Findings: During an interview on 10/12/23, at 9:45 a.m., with the DM in the kitchen, the DM stated he had been in his position for six months, and he had been working as a cook for 11 years. The DM further stated he did not have the required certification as a DM. During a telephone interview on 10/13/23, at 10:33 a.m., the RD stated she was one of the part time consultants and was in the facility two days per week on Monday and Wednesday for eight hours. The RD further stated there was another part time RD consultant who came in the facility two days per week, Tuesday and Thursday for eight hours. A review of 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 safe food production for 139 residents of a census of 146 who received food service from the kitchen when: 1. Open food packages including produce as follows: A five gallon box of thickened water, five boxes of juice attached to a dispensing machine, a box of 40 bunches of celery, a 2.5 pound bag of ground beef, and one bag of fettuccini were not labeled with an open date and/or use by date. 2. Expired food products as follows: 19 health shake cartons, one bag of brussels sprouts, four bags of shredded cabbage, one bag of fettuccini, a 20 pound bin of pearled barley, a 10 pound box of couscous, and three boxes of 100 iced pops were not removed from kitchen and were available for use. 3. The walk-in refrigerator was not clean; and, 4. A cook was not wearing a hairnet while handling food. These failures had the potential to expose residents to food borne illnesses (illnesses caused by the ingestion of contaminated food or beverages). Findings: On 10/10/23, at 8:20 a.m., during an initial tour of 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 the needs were accommodated for 2 of 30 sampled residents (Resident 106 and Resident 8) when Resident 106 and Resident 8's call light (a device used to request assistance from facility staff) were not within reach. This failure had the potential for Resident 106 and Resident 8 to not have their needs met and delay in care. Findings: 1a. A review of Resident 106's admission Record indicated Resident 106 was admitted to the facility in 2022 with diagnoses which included dementia (impairment of brain function including loss of memory and judgment). During a concurrent observation and interview on 10/10/23, at 3:45 p.m., with Licensed Nurse (LN) 8 in Resident 106's room, Resident 106 was observed to be awake sitting in a wheelchair and the call light was clipped to the middle of the bed blanket not within reach. LN 8 confirmed Resident 106's call light was not within reach and should have been. A review of Resident 106's Care Plan titled, The resident has a communication problem r/t [related to] Hearing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 30 sampled residents (Resident 45 and Resident 67) were screened accurately for a mental disorder and/or intellectual disability, to determine the required level of care and services when: 1. Resident 67's Level 1 Preadmission Screening and Resident Review (PASRR-the initial tool used to evaluate all residents for mental illness and/or intellectual disability, to ensure the most appropriate setting and/or services are provided) was completed inaccurately, and the facility did not follow up to revise the evaluation; and, 2. Resident 45 was not re-evaluated for a Level 2 assessment (an evaluation to determine the need for specialized services) as required. These failures placed Resident 45 and Resident 67 at risk to not receive the care and services they were eligible for. Findings: 1. During an observation on 10/10/23, at 10:50 a.m., in the hallway where Resident 67's room was located, Resident 67 was eating in her room by the doorway, yelling loudly, throwing things on the floor, and cursing 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.

2b. During a concurrent observation and interview on 10/10/23, at 2:01 p.m., with LN 2 in Resident 9's room, LN 2 confirmed Resident 9's oxygen flow rate was at 3 LPM. LN 2 stated the oxygen flow rate for Resident 9 should be 2 LPM as ordered by physician. A review of Resident 9's Order Summary indicated, .Last Order Date 12/14/22 .Revision Date 10/10/23 .Order Description: Oxygen at 2/LPM continuous via Nasal Canula [ NC-a small flexible tube that contains two open prongs intended to sit just inside the nostrils] every shift for Shortness of Breath . A review of Resident 9's care plan titled, The resident has oxygen therapy initiated on 3/2/23, indicated interventions which included, .OXYGEN SETTINGS: O2[ oxygen] via NC at 2 l/min continuous . During an interview on 10/10/23, at 2:04 p.m., in Resident 9's room, Resident 9 stated his oxygen flow rate had been 3 LPM for months. During an interview on 10/11/23, at 9:45 a.m., the DON stated the expectation was staff should follow physician orders for oxygen flow rate. The DON further stated not following physician orders could…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 handling of hazardous drugs (drugs that may pose health hazard upon exposure during handling and capable of causing serious effects including toxicity, fertility problems, and birth defects) during medication administration when: The nursing staff did not wear proper Personal Protective Equipment (PPE - gloves, mask, gown) when administering and handling hazardous drugs for two out of 30 sampled residents (Resident 77 and Resident 88). This failure had the potential for unsafe drug exposure that could have affected the health and safety of the licensed nurses who handled the hazardous drugs. Findings: 1a. During a review of Resident 77's clinical record, titled admission RECORD (a document that contains the resident's demographic information) the record indicated Resident 77's diagnosis included seizure disorder (abnormal uncontrolled brain activity and body movement). During a medication administration observation on 10/10/23, at 8:40 AM, Licensed Nurse (LN) 3 administered Divalproex (a drug used…

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

Based on interview and record review the facility failed to ensure the adverse effects (side effects) of psychotropic drugs (drugs that affect mood and mind) were monitored and resources were readily available to guide the nursing staff for safe monitoring in 1 out of 30 sampled residents (Resident 116). This failure could pose health risks in monitoring the adverse effects of medications in a timely manner. Findings: During review of Resident 116's medical record, titled Medication Administration Record (or MAR, a document that listed the medications given and included nursing interventions and documentation for drug monitoring), dated October 2023, indicated orders for two different psychotropic medications (mind altering drug) called alprazolam (medication for anxiety) and duloxetine (medication for sad mood or depression) and a monitoring line in the MAR for side effects as follows: Alprazolam Oral Tablet 0.25 MG (same as Xanax; drug to treat anxiety; MG a unit of measure); Give 1 tablet by mouth every 12 hours as needed for anxiety for 30 Days m/b (manifested by) excessive…

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

Based on interview and record review, the facility failed to maintain complete medical records for 1 of 30 sampled residents (Resident 56) when the hospice (specialized in end-of-life care for all residents with an advanced, life-limiting illness) agency's nurse progress notes (provide an essential record of patient care that can help improve patient outcomes) were not contained in the clinical record. This failure had the potential to not provide sufficient information that reflected the condition, care, and services provided for Resident 56. Findings: During a review of Resident 56's Order Summary Report, dated 10/13/23, indicated, Resident 56 was admitted to Hospice Care in late 2021 with diagnosis of protein-calorie malnutrition. During a review of Resident 56's Minimum Data Set (MDS-an assessment tool) dated 9/6/23, indicated Resident 56 received Hospice Care while a resident in the facility. During a concurrent interview and record review on 10/12/23, at 10:17 a.m., with Licensed Nurse (LN) 4, Resident 56's [name of agency] Hospice Facility Visit Record and hospice clinical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1 of 12 residents (Resident 111) with an indwelling urinary catheter (a tube inserted into the bladder to drain or collect urine) when Resident 111's indwelling urinary catheter drainage tubing was on the floor. This failure had the potential for Resident 111 to have complications related to indwelling urinary catheter use and/or risk for infections. Findings: A review of Resident 111's admission Record indicated Resident 111 was admitted to the facility in 2022 with diagnoses which included hemiplegia (paralysis of partial or total body function on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (a result of disrupted blood flow of the brain also used with the term stroke), and presence of urogenital implants (injections of material into the urethra to help control urine leakage cause by a weak urinary sphincter (a muscle that allows your body to hold urine in the bladder). During a concurrent…

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

Based on observation, interview, and record review, the facility failed to maintain a sanitary environment when 2 of 30 sampled residents' room were observed with drywall damaged. The failure had the potential to cause infection from contamination. During an observation and concurrent interview, on 10/10/23, at 9:00 a.m., the wall behind Resident 124's bed was damaged. The paint had been removed and the drywall was exposed. Resident 124 stated it had been like that for a while. During an observation on 10/10/23, at 9:05 a.m., the wall behind Resident 102's bed was damaged. The paint had been removed and the drywall was exposed. During an interview, on 10/12/23 at 9:40 a.m., with the Maintenance Supervisor, he stated the damage to the wall is from the headboards banging against it, and stated, We are in the process of remodeling all residents' rooms including repairing drywall and painting behind beds. During an interview, on 10/12/23 at 10:31 a.m., the Infection Preventionist stated the exposed drywall behind the residents' beds would not be able to be cleaned properly and could…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care was provided to meet the needs of one of three sampled residents (Resident 1) when translation services or a communication board was not offered to Resident 1 for her communication needs. This failure removed Resident 1's ability to express her wants and needs in her native language of Portuguese to staff and had the potential for a negative physical and psychosocial outcome. Findings: During a concurrent observation and Interview on 8/21/23, at 12:23 p.m. in Resident 1's room, Certified Nursing Assistant (CNA) 1 shrugged her shoulders multiple times over the span of 14 minutes every time Resident 1 communicated to her in Portuguese. CNA 1 stated Resident 1 knew that staff did not know her language. CNA 1 further stated, she communicated with Resident 1 using gestures but most of the time she did not know what Resident 1 was saying. CNA 1 confirmed there was no communication board (a communication tool that allows a care team to convey to a patient the plan of care on a day-to-day basis) in Resident 1's room.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 five sampled resident's (Resident 3) right to be free from physical abuse by facility staff when, Certified Nursing Assistant (CNA) 8 grabbed Resident 3 by her shoulders and forced her to sit down on the wheelchair on 8/14/23. This failure caused an unsafe environment for Resident 3 in the facility, made her agitated and had the potential to cause physical and psychosocial harm. Findings: During an interview on 8/21/23, at 3:02 p.m., the Social Services Director (SSD) stated she observed Resident 3 walking in the activity room and CNA 8 was sitting in the corner. The SSD stated CNA 8 stood up and went to Resident 3 and grabbed Resident 3 by her shoulders and forced her to sit in a wheelchair. The SSD further stated, Resident 3 said no and stop, and CNA 8 did not stop. The SSD explained, she intervened and told CNA 8 to stop. The SSD stated she told CNA 8 that Resident 3 could walk and she had a right to walk. A review of a hand written note by the SSD, dated 8/14/23, indicated At approx [approximately] 4:30…

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