Delta Oaks Post Acute

Based on interview, and record review, the facility failed to report to the Department an injury of unknown source in accordance with the facility's abuse policy and procedure (P&P) for one of one resident (Resident 1) when on 2/2/26, Resident 1 was found with an unexplainable left shoulder dislocation (an injury that occurs when the upper arm bone pops out of the cup shaped socket near the shoulder blade).This failure denied the Department the ability to conduct a timely investigation and placed Resident 1 at risk for abuse. In addition, the facility failed to comply with federal and state reporting regulations.Findings:A review of Resident 1's admission RECORD, indicated that Resident 1 was admitted to the facility with diagnoses which included subarachnoid hemorrhage (SAH, a type of stroke characterized by bleeding in the space between the brain and the tissues that cover the brain), traumatic brain injury (a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head or penetrating head injury), and hypertension (a condition in which…

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

Based on interview, and record review, the facility failed to investigate an injury of unknown origin for potential abuse for one of one resident (Resident 1) when Resident 1 was found with an unexplainable left shoulder dislocation (an injury that occurs when the upper arm bone pops out of the cup shaped socket near the shoulder blade) on 2/2/26.This failure placed Resident 1 and other residents in the facility at risk for unidentified abuse and had the potential to hinder protection from ongoing abuse.Findings:A review of Resident 1's admission RECORD, indicated that Resident 1 was admitted to the facility with diagnoses which included subarachnoid hemorrhage (SAH, a type of stroke characterized by bleeding in the space between the brain and the tissues that cover the brain), traumatic brain injury (a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head or penetrating head injury), and hypertension (a condition in which the force of the blood pushing against the blood vessel walls is consistently too high and causes the heart 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 interview, and record review, the facility failed to complete and document a significant change in status assessment (Significant Change in Status Assessment, SCSA, refers to a comprehensive assessment that must be completed when the Interdisciplinary Team [IDT, a team of professional staff or a care team consisting of different disciplines who work together towards the goals of their residents] has determined that a resident meets the significant change guidelines for either major improvement or decline) for one of one resident (Resident 1) when Resident 1 was found with a left shoulder dislocation (an injury that occurs when the upper arm bone pops out of the cup shaped socket near the shoulder blade) on 2/2/26.This failure had the potential to result in unmet care needs for Resident 1 when the plan of care for Resident 1 was not current. This failure also had an increased risk on impacting the quality of care and the well-being for Resident 1. Findings: A review of Resident 1's admission RECORD, indicated that Resident 1 was admitted to the facility with diagnoses which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide adequate care and supervision (an intervention and means of mitigating the risk of an accident) for one out of two sampled residents (Resident 1) to ensure resident safety when, the facility staff did not take immediate action to locate Resident 1 when Resident 1 left the facility for more than four hours past his expected return time for a medical appointment on 10/16/25.This failure resulted in Resident 1 eloping from the facility on 10/16/25 and Resident 1 did not return to the facility until approximately 29 hours later. Resident 1 was transferred to hospital, was positive for illicit drug use (use of illegal drugs (e.g., heroin, cocaine) and/or inappropriate use of prescription medications), and missed scheduled intravenous (IV; administering fluids medication directly into a vein using a needle or tube in the hand) Ertapenem medication (an antibiotic used to treat severe infections like pneumonia, and urinary tract infections caused by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews, the facility failed to ensure a comprehensive person-centered care plan (a structured document that outlines a patient's healthcare needs, goals and the nursing interventions needed to achieve them), was developed for 1 of 3 sampled residents (Resident 2) when, an elopement care plan was not developed for Resident 2 after Resident 2 was identified as at risk for elopement on 12/24/25.This failure put Resident 2 at risk for elopement.Findings: A review of Resident 2's admission RECORD indicated Resident 2 was admitted to the facility with multiple diagnoses including but not limited to End Stage Renal Disease (the irreversible loss of 85-90% of kidney function, where the kidneys can no longer support life), dependence on renal dialysis (a life-sustaining treatment for kidney failure (renal failure) or advanced chronic kidney disease that filters toxins, waste, and excess fluid from the blood when kidneys can no longer perform these functions), and Sequelae of cerebral infarction (the lasting, long-term physical, cognitive, and psychological…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comprehensive pain management, for one of three sampled residents (Resident 1) when, Resident 1 had not been given the appropriate pain medication as per the pain assessment scale (a tool used to assess the level of pain) and provided pain medication as ordered by the physician.This failure resulted in Resident 1's pain not being effectively managed and Resident 1's pain not being treated per the physician's orders. Findings:A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility in mid-2024 with diagnoses which included polyneuropathy (a condition characterized by damage to multiple peripheral nerves, usually causing symmetrical numbness, tingling, weakness, and burning pain, often starting in the feet or hands) and gout (a common, painful form of inflammatory arthritis caused by high levels of uric acid in the blood (hyperuricemia) that form needle-like crystals in joints).A review of Resident 1's Order Summary Report, indicated a physician's order for .Acetaminophen Tablet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 refer one of two sampled residents (Resident 1) to a psychiatrist (a medical doctor who can diagnose and treat mental health conditions) as recommended by the Interdisciplinary Team (IDT, a group of professionals who have a role in the Resident's care) and ordered by the physician after Resident 1 had a behavioral manifestation of agitation during an altercation with another resident (Resident 2) on 10/24/25.This failure could potentially result in increased agitation episodes for Resident 1 and a risk of getting involved in another altercation incident.A review of Resident 1's admission RECORD, indicated Resident 1 was admitted with diagnoses which included muscle weakness and difficulty walking.A review of Resident 1's medical record titled IDT Care Conference dated 10/27/25, indicated, Resident 1 had an altercation with another resident (Resident 2) and the IDT recommended a psychiatric evaluation and treatment for episodes of agitation.A review of Resident 1's Order Summary, dated 10/29/25, indicated, .Psych Evaluation…

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

Based on observation, interview, and record review, the facility failed to ensure garbage and refuse was properly disposed of when 1 of 2 outside garbage dumpster lids were observed not adequately closed for a census of 112. This failure had the potential to expose the residents' environment to pests, odors, or diseases.Findings:During a concurrent observation and interview on 12/4/25 at 10:24 AM with the Central Supply (CS) in the outside dumpster area of the facility, a garbage dumpster was observed to have a lid open. The CS confirmed that the garbage dumpster's lid was open.During a concurrent observation and interview on 12/4/25 at 11:30 AM with Director of Staff Development (DSD) and Infection Preventionist (IP) in the outside dumpster area of the facility, a garbage dumpster was observed to have a lid open. The DSD and IP both confirmed that the garbage dumpster's lid was open.During an interview on 12/4/25 at 1:30 PM with the IP, the IP stated that the outside garbage dumpster lids should have both been closed when not in use. The IP also stated the purpose of keeping the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews the facility failed to provide a safe discharge process for one resident (Resident 1) when:1. Resident 1 was discharged home without a clear plan of care to support his activities of daily living (ADL, tasks of everyday life including eating, dressing, bathing, or showering, and using the bathroom; activities related to daily care) needs;2. Resident 1 was discharged home while facing foreclosure (the action of taking back the property that was bought with borrowed money because the money was not being paid back as formally agreed);3. Resident 1 was discharged home without sufficient education regarding self-administration of discharge medications and fingerstick blood glucose (sugar) monitoring (FSBS, pricking one's fingertip to place a drop of blood on a blood glucose meter [a device used to measure the level of glucose in your blood] to keep blood glucose levels within a healthy range); and,4. Resident 1 was discharged home without an Interdisciplinary Team (IDT, a group…

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Based on observation, interview, and record review, the facility failed to ensure residents' rights to be treated with dignity and respect were honored for seven of 35 sampled residents when:1. Staff were observed standing over Resident 25 and Resident 90 while assisting them to eat their lunch meal on 9/29/25; and,2. Resident 23, Resident 46, Resident 86, Resident 56, and Resident 4 who required the use of incontinent briefs (a type of absorbent material worn to soak up urine and/or contain feces) were told by unidentified nursing staff to urinate and/or defecate (feces) in their bed, due to the lack of available incontinent briefs during the weekend of Saturday 9/27/25 and Sunday 9/28/25. These failures had the potential to negatively impact Resident 25, Resident 90, Resident 23, Resident 46, Resident 86, Resident 56, and Resident 4's psychosocial well-being.Findings:1a. During an observation on 9/29/25, at 1:09 PM, in the shared dining room, Certified Nursing Assistant (CNA) 6 was observed standing over Resident 25, while Resident 25 was seated at the table, assisting Resident 25…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a safe and hazard free environment when:1. Safe water temperatures were not maintained in 2 of 4 sampled resident bathrooms; and,2. Resident 10's post mobility assessment was not done after she fell in the bathroom. These failures had the potential to cause physical injuries to residents who resided in the facility.Findings: 1. During a concurrent observation and interview on 10/1/25, at 2:59 PM, with the Regional Maintenance Consultant (RMC) and the Maintenance Director (MD), the MD stated they checked the water temperature monthly. Water temperatures were checked in different areas of the facility with the RMC and the MD. During the testing, water temperatures were found to be 80 degrees Fahrenheit (°F, a measurement of temperature) in room [ROOM NUMBER], 130°F in room [ROOM NUMBER], 125°F in the kitchen and laundry, 118°F in room [ROOM NUMBER], and 135°F in room [ROOM NUMBER]. The boiler tanks were set to 120°F for the subacute…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications which met the needs of 1 of 35 sampled residents (Resident 46) when on 10/2/25 the following medications were not administered and left on the residents bedside table:Nephro-Vite 1 tablet (used to treat vitamin deficiencies in people with kidney disease),Senna 1 tablet (used to treat constipation); and,Sevelamar - 2 tablets (used to treat high phosphate in the blood in people with kidney disease).This failure had the potential for Resident 46 to experience worsening kidney disease (a decline in kidney function over time), hyperphosphatemia (medical condition characterized by elevated levels of phosphate in the blood in people with kidney failure), and constipation (a condition in which there is difficulty in emptying the bowels or hard feces).Findings:A review of Resident 46's admission RECORD, indicated Resident 46 was admitted to the facility in 2024, with diagnoses which included, chronic kidney disease stage 4 severe (CKD -kidneys are severely damaged and their function is…

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

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 two out of three medication rooms and four out of five medication carts when:1. An external air-conditioning (ac) unit that had a filter with grayish colored dust and debris, was placed on top of a medication refrigerator in Medication Storage room [ROOM NUMBER],2. Two bottles of Drug Buster (an eco-friendly, liquid solution designed for safe and effective disposal of unwanted or expired medications. It dissolves pills, tablets, capsules, and other forms of medication on contact, rendering them non-toxic and safe for disposal in regular trash) were found soiled and in active use in two different medication carts,3. Four pill cutters (a device used to safely and accurately divide medication tablets, vitamins, and supplements) were found with white and grayish residue in three different medication carts,4. Medications were opened in a medication cart and medication room without being…

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

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food per safety standards when:1. Three tomatoes were found with mold and a discolored, flattened, and mushy apple were in the walk-in refrigerator,2. Frozen fish fillets, beef patties, meatballs, and veggie patties were left open to the environment in the reach in meat freezer,3. Small wares (three bowls and a cutting board) were not replaced when worn,4. The cool down log was not followed; and,5. The two-compartment sink did not have an air gap (a break in the plumbing to prevent unsanitary water from flowing back into the sink). These failures had the potential to lead to cross-contamination and food borne illness for the 85 residents eating facility prepared meals.Findings:1. During the initial kitchen tour on 9/29/25, at 8:30 a.m., a discolored, flattened, and mushy apple was found in the walk-in refrigerator.During a concurrent observation and interview on 10/1/25, at 8:52 a.m., with the Certified Dietary Manager (CDM) 1. CDM 1 verified three moldy tomatoes with a receive date…

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

Based on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures for a census of 104, when:Urinals were found inside the trash can instead of being placed in the provided urinal receptacle and were not replaced with a clean urinal for Resident 62; and,Flying pests were found inside Resident 65's room; and,Licensed Nurse (LN) 4 did not clean, sanitize, and disinfect a glucometer (device used to measure blood sugar) per manufacturer guidelines.These failures had the potential to spread infections to residents residing in the facility, negatively impacting their health and well-being.1. Review of Resident 62's admission Record, indicated Resident 62 was admitted with multiple diagnoses which included but not limited to cerebral infarction (when part of the brain doesn't get enough blood causing brain cells in that area to die), heart failure (a condition where the heart cannot pump enough blood to meet the body's needs), and chronic kidney disease (kidneys are slowly losing their ability to clean your blood 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 develop a baseline care plan within 48 hours of admission as required, to address resident-specific care needs for 1 of 35 sampled residents (Resident 76).This failure placed Resident 76 at risk for not receiving effective person-centered care, and preventing to reach the highest potential for mental, emotional, and/or psychosocial health and well-being.Findings:A review of Resident 76's admission RECORD, indicated Resident 76 was originally admitted to the facility in 2017, readmitted in 2020 and then readmitted in 2021 with diagnoses including chronic obstructive pulmonary disease (COPD, a group of lung disease that cause progressive airflow obstruction and breathing difficulties), chronic diastolic congestive heart failure (a condition where the heart muscle is stiff and cannot relax properly during the filling phase called diastole. This prevents the heart from filling with enough blood, which can lead to symptoms of heart failure), hypertensive heart disease with heart failure (a condition where prolonged high blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a resident centered care plan for 2 of 35 sampled residents (Resident 65 and Resident 76) when:1. Resident 65 was taking a blood thinner medication and there was no care plan developed to monitor for potential side effects or risk of bleeding; and,2. Resident 76 did not have a care plan for blood thinning medications. These failures placed Resident 65 and Resident 76 at risk for potentially serious complications and not receiving effective and person-centered care. Findings: 1. Review of Resident 65's admission RECORD, indicated Resident 65 was admitted with multiple diagnoses which included but not limited to DVT (Deep Vein Thrombosis – when a blood clot forms in a deep vein, usually in the leg), hypertension (high blood pressure), and abnormalities of gait and mobility. During a concurrent interview and record review on 10/1/25, at 4:01 PM, with Licensed Nurse (LN) 3, LN 3 stated Resident 65 was taking apixaban (blood thinner medication) 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 appropriate treatment and services were provided when one of 35 sampled residents (Resident 97) did not receive the appropriate range of motion (ROM - the distance and direction a joint can move) services. This failure had the potential to result in decreased ROM, further functional decline, and/or pain and discomfort for Resident 97. Findings:During a review of Resident 97's clinical record titled, admission RECORD, the record indicated Resident 97 was admitted to the facility with a diagnosis that included hemiplegia (inability to move of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (a condition where blood flow to the brain is interrupted), and functional quadriplegia (a person is unable to move their arms and legs, and needed total care from nursing staff).A review of Resident 97's clinical record titled, Care Plan, dated 4/23/24, indicated Resident 97 was dependent on nursing staff for activities of daily living (ADL, basic self-care tasks…

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

Based on observation, interview, and record review the facility failed to ensure proper hydration (process of providing fluid to the body) for one of 35 sampled residents (Resident 5) when Resident 5's water was out of reach.This failure placed Resident 5 at risk of dehydration (condition where your body loses more fluid than it takes in, resulting in insufficient water for its normal functions). Findings:A review of Resident 5's, clinical record titled, admission RECORD, indicated Resident 5 was admitted to the facility with a diagnosis that included Chronic congestive heart failure (a condition where the heart can't pump blood efficiently, causing a backup of fluid in the body and leading to symptoms like shortness of breath, fatigue, and swelling).A review of Resident 5's clinical record titled, Care Plan, dated 4/24/25, indicated Resident 5 was at risk for dehydration because he used a diuretic medication (medications that increase urine output, helping the body eliminate excess fluid).During a concurrent observation and interview on 9/29/25 at 11:31 a.m., with Regional Minimum…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medically- related social services for 1 of 35 sampled residents (Resident 19) when the facility failed to honor Resident 19's requests and wishes to be transferred to a facility closer to home.This failure placed Resident 19's health and psychosocial well-being at risk for potentially serious complications which could have impacted his quality of life and could have lowered his self-esteem (confidence in one's own worth or abilities). Findings:A review of Resident 19's clinical record titled, admission RECORD, indicated Resident 19's admitting diagnoses included cerebral palsy (a group of disorders that affect movement, muscle tone, and posture due to brain damage) and paresthesia of skin (an abnormal sensation characterized by tingling, prickling, burning, or numbness in the skin).During an interview on 9/29/25, at 8:34 AM, with Resident 19, Resident 19 stated that before his admission to the facility, he lived in a different area of the state. Resident 19 stated that he was admitted to the facility in 2019 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 safe monitoring and assessment of blood pressure (BP -the force of your blood pushing against the walls of your arteries as your heart pumps blood and was measured as two numbers: systolic [when the heart beats] and diastolic [when the heart rests between beats]) and heart rate (HR -frequently of your heart beats per minute) for a medication used to treat low (hypotension) BP for two of six sampled residents (Resident 17 and Resident 80), when:1. Resident 17's physician prescribed hold parameters (a set of numbers that guide the nursing staff when to not give [hold] a medication) for Midodrine (a medication used to treat low blood pressure) were not followed 13 times between 8/15/25 and 10/1/25; and,2. Resident 80's physician prescribed hold parameters for Midodrine were not followed 13 times between 8/1/25 and 9/30/25.This failure had the potential to put Resident 17 and Resident 80 at risk of adverse drug effects including hypertension (HTN - high blood pressure) and increased Resident 17 and Resident 80's 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 medication administration practices when the medication error rate was more than 5% ( % percentage - number or ratio expressed as a fraction of 100) with a resident census of 104. Medication administration observations were conducted over multiple days, in random locations throughout the facility. The facility had a total of 2 errors out of 32 opportunities which resulted in a facility wide medication error rate of 6.25% for 2 of 6 residents (Resident 68 and Resident 17) observed for medication administration.These failures had the potential to result in unsafe medication use and medication errors affecting the resident's health and well-being.Findings:a. During a medication administration observation on 9/29/25, at 9:15 AM, with Licensed Nurse (LN) 4, the following medication was observed given to Resident 68:LN 4 was observed administering 4 units of Insulin Lispro (a human-made rapid acting insulin analog to treat high blood sugar levels) subcutaneously (applied under the skin) in the upper…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 offer, obtain informed consent and provide education to a resident or resident representative (RP) about influenza (or the flu, is a contagious viral infection of the respiratory system that can range from mild to severe, causing symptoms like fever, cough, sore throat, muscle aches, and fatigue) vaccine and pneumococcal (a serious bacterial infection that can cause respiratory illness) vaccine for two out of five sampled residents (Resident 13 and Resident 65) when:1. Resident 13 was not offered the flu vaccine for 2 years.2. Resident 65 was not offered the pneumococcal vaccine within 30 days of admission.These failures had the potential for Resident 13, Resident 65, and resident's responsible parties to not be fully informed about the risks and benefits, and potential side-effects of the pneumococcal vaccine and flu vaccine prior to receiving or declining the vaccination and it violated Resident's right to make an informed choice.1. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide COVID-19 vaccine, for one out of five sampled residents (Resident 65) when:1. Resident 65s' clinical record did not contain documented evidence that the COVID-19 vaccine was administered within 30 days upon admission.2. Resident 65's COVID-19 vaccine information history was not obtained and documented in the medical record.This deficient practice put Resident 65 at risk to be infected with COVID-19 virus that could lead to severe illness, hospitalization, and/or death.During a concurrent interview and record review on 10/1/25, at 12:49 PM, with the Infection Preventionist (IP), the IP stated the facility offered a COVID-19 vaccine to all residents upon admission. The IP stated that the admitting nurse is the one responsible for offering the COVID-19 vaccine and obtaining consent upon admission. The IP stated that once the consent was signed, the nurse would put the order in for the pharmacy to deliver the vaccine. The IP stated when a 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 Based on interview and record review, the facility failed to ensure interventions (actions, treatments, procedures, or activities designed to meet a residents goals) listed on a resident centered comprehensive care plan (a list of resident specific problems, goals, and interventions) were specific to the care and services that would be implemented for two of three sampled residents (Resident 1 and Resident 3) when, Resident 1 and Resident 3's gastrostomy tube (G-tube; a thin tube surgically inserted into the stomach area to provide a direct route for delivering nutrition, medications, and fluids) care plan intervention indicated to provide dressing to the g-tube site as ordered, however there was no physician order for Resident 1 or Resident 3 in regards to g-tube skin care and dressing instructions and/or frequency.These failures had the potential for Resident 1 and Resident 3 to experience skin breakdown and infection from the G-tube site.Findings: 1. Review of Resident 1's clinical record titled, admission…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 appropriate treatment and services were provided to prevent potential further decline in range of motion (ROM; the extent to which a joint can move through its entire range of motion without pain or restrictions) for one of three sampled residents (Resident 1), when Resident 1's ordered Restorative Nursing Program (program to help ensure that residents retain the skills gained in physical therapy and prevent declines that can impact the quality of a resident's life) to provide passive range of motion (PROM; when another person or a machine moves a patient's limb or joint through its full range of motion without the patient's active muscle contraction or effort) to Resident 1's bilateral lower extremities (BLE; both legs) was discontinued on 2/5/25 without an updated referral from the therapy department. This failure had the potential to result in decreased ROM for Resident 1 and for Resident 1's contractures (a body part that gets stuck in a bent or shortened position because of permanent tightening of muscles,…

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

Based on interview and record review, the facility failed to ensure a physician order was in place to indicate the appropriate care of a gastrostomy tube feeding (G-tube; a thin tube surgically inserted into the stomach area to provide a direct route for delivering nutrition, medications, and fluids) for 2 of the 3 sampled residents (Resident 1 and Resident 3) to prevent potential complications of the feeding tube when, Resident 1 and Resident 2 did not have a physician treatment order to indicate the care needed for the G-tube site.This failure had the potential for Resident 1 and Resident 3 to experience skin breakdown and infection at the G-tube site.Findings:1. Review of Resident 1's clinical record titled, admission RECORD, indicated Resident 1 was admitted to the facility with diagnosis including but not limited to .ENCOUNTER FOR ATTENTION TO GASTROSTOMY [this diagnosis applies to routine tasks like cleansing, dressing changes, and managing the g-tube].During a concurrent interview and record review on 9/24/25, at 3:43 p.m., with Licensed Nurse (LN) 1, Resident 1's Order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 properly prevent the spread of COVID-19 when one direct care staff member, (Certified Nursing Assistant [CNA] 1) did not wear the required personal protective equipment (PPE, includes gowns, gloves, eye protection, face masks, or respirators worn to prevent the spread of germs and infection) prior to entering the room of residents who were COVID-19 positive (Resident 1 and Resident 2). This failure had the potential for CNA 1 to become infected with COVID-19 and to spread COVID-19 to other facility residents, staff, and visitors. A review of Resident 1's admission RECORD, indicated that Resident 1 was admitted to the facility in 2024 with diagnoses which included cerebral infarction (a result of disrupted blood flow of the brain due to problems with blood vessels that supply it, also known as a stroke), malignant neoplasm of left kidney (kidney cancer; occurs when healthy cells in the kidney grow out of control and form a lump), and anxiety disorder (a nervous disorder characterized by a state of 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 ensure adequate supervision and monitoring were maintained for one of six sampled residents (Resident 1) when staff did not verify Resident 1's Wanderguard (a monitoring device that alerts staff when a resident approaches a restricted area and attempts to exit a designated zone) placement every shift. This failure potentially contributed to Resident 1 leaving the facility on 4/7/25 without staffs' knowledge and placed Resident 1 at risk for injury.Findings:During a review of Resident 1's clinical record titled, admission RECORD, the record indicated Resident 1 was admitted to the facility with multiple diagnoses including cerebral infarction (long -term effect or complications following a stroke (blood supply to parts of the brain is blocked or reduced) and type 2 diabetes mellitus (high levels of sugar in the blood).A review of Resident 1's clinical record titled, Interdisciplinary Care Conference, (a meeting of a group of healthcare professionals for the purpose of discussing, identifying, addressing, implementing, 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 submit the investigation report of an allegation of abuse involving two of three sampled residents (Resident 1 and Resident 2) to the Department, within 5 days of the incident.This failure had the potential to result in the inability to protect Resident 1 and Resident 2 from further abuse.Findings:Review of Resident 1's admission RECORD indicated Resident 1 was admitted to the facility with diagnosis which included, but were not limited to, dementia (a group of conditions that affect the brain, causing a decline in a person's mental abilities, like memory, thinking, and reasoning skills).Review of Resident 2's admission RECORD indicated Resident 1 was admitted to the facility with diagnosis which included, but were not limited to, dementia.During a concurrent interview and record review on 6/25/25, at 1:54 p.m., with the Administrator (ADM) the undated facility document titled, 5 Day Summary was reviewed. The, Five Day Summary indicated an allegation of abuse was investigated between Resident 1 and Resident 2 and was…

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

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided for a census of 103 when several nursing staff were on their personal cellphones during work hours. This failure had the potential to cause psychosocial harm and/or potential injury to all residents.Findings: During a concurrent observation and interview on 6/13/25, at 3:15 p.m., Certified Nursing Assistant (CNA) 1 confirmed she was on her cellphone while working on the floor monitoring residents in the dining room across the Nurses' Station 3 and 4. CNA 1 stated being on the cellphone could affect the residents and lead to delay in the response times. CNA 1 further stated as per facility policy staff should not use their cellphones while working on the floor. During a concurrent observation and interview on 6/13/25, at 3:22 p.m., Licensed Nurse (LN) confirmed she was on her cellphone while working on documentation. LN stated being on the cellphone while working had the potential to not to meet residents' needs and provide proper care. During a concurrent observation…

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

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who was dependent on staff for activities of daily living (ADLs-routine tasks/activities such as bathing, dressing, grooming a person performs daily to care for himself or herself) received services to maintain personal hygiene when Resident 1 was not provided showers as scheduled from 1/9/25 through 3/11/25. This failure had the potential to cause discomfort, skin impairment, infection, and a decline in emotional and psychological well-being. Findings: During a review of Resident 1's clinical record titled, admission RECORD , undated, the record indicated Resident 1's diagnoses included acute respiratory failure with hypoxia (not enough oxygen in the body) and multiple injuries from motor-vehicle accident. A review of Resident 1's clinical record titled, Minimum Data Set , (MDS-an assessment tool) under section GG-Functional Abilities, dated 2/8/25, the record indicated Resident 1 was dependent on staff for showers and baths. A review of Resident 1's clinical record…

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

Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) was free from physical abuse when Resident 2 was alleged to have hit Resident 1 on the chin and stomach on 3/16/25 and was witnessed hitting Resident 1 on the face on 4/1/25. This failure caused Resident 1 to suffer emotional distress and had the potential to negatively affect her physical and psychosocial wellbeing. Findings: A review of Resident 1 ' s admission RECORD, indicated, she was admitted to the facility with diagnoses that included dementia (condition characterized by memory disorders, personality changes, and impaired reasoning). A review of Resident 1 ' s Brief Interview for Mental Status [BIMS], (a tool used to screen for cognitive impairment that uses a points system with ranges from 0 to 15 points: 0 to 7 points suggests severe cognitive impairment, 8 to 12 points suggests moderate cognitive impairment, 13 to 15 points suggests that cognition is intact) dated 2/21/25, indicated a score of 1. A review of Resident 1 ' s care plan revised 10/18/21, indicated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide the proper notice for discharge for 2 of 2 sampled residents (Resident 1, and Resident 2) when a written notice of discharge for Resident 1 and Resident 2 was not sent to the State Long-Term Care Ombudsman's office (a government appointed person who actively supports the rights of the long term care residents). These failures violated Resident 1 and Resident 2's rights from the Ombudsman being informed of the discharge decisions and removed the opportunity for the Ombudsman to advocate on behalf of Resident 1 and Resident 2 with the potential of having an inappropriate discharge. Findings: a. Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility in 2024 with diagnoses which included, but not limited to necrotizing fasciitis (a serious bacterial infection that destroys tissue under the skin), and acquired absence of left leg below knee (a condition where the leg is removed below the knee joint due to injury,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provided to one of three sampled residents (Resident 1) met professional standards when, Resident 1's medication ordered upon discharge from the hospital, insulin lispro (fast acting insulin to control the levels of sugar in the blood), was not continued at the skilled nursing facility upon admission. This failure had the potential for Resident 1 to have complications related to high blood sugar (normal fasting blood sugar range is 70 to 100). Findings: A review of Resident 1's admission documents indicated, Resident 1 was admitted to the facility with a diagnosis of dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). During a concurrent interview and record on 2/6/25 at 9:04 AM, Resident 1's untitled discharge documents from the hospital, dated 1/29/25, and Resident 1's clinical record was reviewed with Licensed Nurse (LN) 1. LN 1 confirmed Resident 1's discharge paperwork from the hospital indicated 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 safe use of a resident lifting machine for one of three sampled residents (Resident 2) when Certified Nursing Assistant (CNA) 1, used the lifting machine for Resident 2 without another CNA present to assist. This failure placed Resident 2 at risk for injury. Findings: A review of Resident 2's admission RECORD, indicated Resident 2 was admitted to the facility at the beginning of October 2024, with diagnoses which included diabetes (a disease affecting how the body uses blood sugar) and heart failure (when the heart muscle doesn't pump blood effectively). During an observation on 10/29/24, at 2:40 p.m., there was a resident lifting machine in Resident 2's room. CNA 1 was the only staff member in the room with Resident 2 in her wheelchair. During an interview with CNA 1, on 10/29/24, at 2:45 p.m., CNA 1 confirmed she was the only CNA in the room using the resident lifting machine and she placed Resident 2 in the wheelchair by herself. CNA 1 explained there should have been two CNA's using 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.

Based on observation, interview, and record review, the facility failed to provide medications which met the needs of one of three residents (Resident 2) when the following medications due at 9 a.m. were not administered and left at the bedside: Aldactone (used to treat heart failure), Digoxin (used to treat heart failure), Flagyl (an antibiotic used to treat infection), Furosemide (used to treat excess fluid in the body), and Tradjenta (used to treat diabetes - issues with blood sugar control) This failure had the potential for Resident 2 to experience elevated blood pressure, increased work of the heart, fluid retention, elevated blood sugar, and a worsening of her infection. Findings: A review of Resident 2's admission RECORD, indicated Resident 2 was admitted to the facility in the fall of 2024, with diagnoses which included diabetes and heart failure. During an observation on 10/29/24, at 2:50 p.m., outside of Resident 2's room, a small cup with medications was observed on Resident 2's bedside table. During a concurrent observation and interview with Licensed Nurse (LN) 1, on…

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

Based on observation, interview, and record review, the facility failed to maintain its infection prevention control program for one of three sampled residents (Resident 2), when Certified Nursing Assistant (CNA) 1: a. Did not use personal protective equipment (PPE) during care of Resident 2 who required contact precautions (protective measures taken for infections which spread by means of contact with the resident or their environment); b. Transported Resident 2 to the physical therapy room; and, c. Did not clean and sanitize the equipment used to lift Resident 2, which was shared with other residents. This failure had the potential to expose other residents and staff to Clostridium difficile (C. diff. is a communicable illness that can cause diarrhea and colitis, an inflammation of the colon, and can be life threatening) infection. Findings: During an observation on 10/29/24, at 2:40 p.m., CNA 1 was observed in Resident 2 ' s room. Signage indicated Resident 2 was on contact precautions. CNA 1 was not wearing any personal protective equipment (PPE) and stated she had transferred…

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

Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs for 1 of 9 sampled residents (Resident 1) when Resident 1's call light (a device used to call for assistance) was not within reach. This failure had the potential to result in Resident 1 being unable to ask for needed assistance and placed Resident 1's safety at risk. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility with multiple diagnoses which included Encephalopathy (a disease in which the functioning of the brain is affected) and Hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). During an observation on 10/18/24, at 11:22 a.m., in Resident 1's room, Resident 1 was observed laying in his bed with no call light visible. Resident 1 was screaming for help. During a concurrent observation and interview on 10/18/24, at 11:30 a.m., with Licensed Nurse (LN) 1 in Resident 1's room, LN 1 confirmed Resident 1's call light was on the floor and out of reach. LN 1 stated when Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide one of nine sampled residents (Resident 1) with twice weekly scheduled bathing. This failure had the potential to negatively impact Resident 1's personal hygiene and psychosocial well-being as well as promote infection. Findings: A review of Resident 1's admission Record indicated, Resident 1 was admitted to the facility with multiple diagnoses which included Encephalopathy (a disease in which the functioning of the brain is affected) and Hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body. A review of Resident 1's Minimum Data Set (MDS, an assessment and care screening tool) the functional status section of MDS dated [DATE], indicated Resident 1 was dependent on facility staff for his personal hygiene and showers/bathing. During a concurrent observation and interview on 10/18/24 at 11:22 a.m. with Resident 1, Resident 1 was observed lying in bed on his back. Resident 1 stated, he had not been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 services that meet professional standards of quality for one of nine sampled residents (Resident 1) when Certified Nursing Assistant (CNA) 3 applied a discontinued, prescription (ordered by a physician) cream on Resident 1. These failures decreased the potential to provide safe, effective care and services to Resident 1. Findings: A review of Resident 1's admission Record indicated, Resident 1 was admitted to the facility with multiple diagnoses which included Encephalopathy (a disease in which the functioning of the brain is affected) and Hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body. 1.During a concurrent observation and interview on 10/18/24 at 11:30 a.m. with CNA 3, CNA 3 was observed holding a medication cup with white cream in it. CNA 3 stated the cream was given to him by Licensed Nurse (LN) 1 and he was instructed to apply the cream on Resident 1's back, arms, and legs. During an interview on 10/18/24 at 11:39 a.m., CNA 3 confirmed he put the cream on…

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

Based on observation, interview, and record review, the facility failed to ensure safe infection prevention and control practices were implemented for one of 9 sampled residents (Resident 7) when three bedpans (a container used to collect urine or feces, and it is shaped to fit under a person lying or sitting in bed) in Resident 7's shared bathroom, were soiled and unlabeled with a resident name and were left on the floor in a plastic storage basket. These deficient practices could contribute to the spread of infection. Findings: 1. During an observation on 10/17/24 at 2:47 p.m., in Resident 7's shared bathroom (shared with Resident 3), two grey colored and one pink used and soiled bedpans with no resident name were observed in a black storage basket on the floor. During a concurrent observation and interview on 10/17/24 at 10:30 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 confirmed the bedpans in Resident 7's shared bathroom were used, soiled, and did not have a name or other resident identifier placed on the bedpans. CNA 1 stated all soiled bedpans should have been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 practice appropriate infection prevention and control measures for a census of 104, when: 1. Multiple staff members did not wear the appropriate Personal Protective Equipment ([PPE] clothing and equipment that is worn or used in order to provide protection against hazardous substances or environments) while giving patient care, 2. Staff did not dispose of used PPE in an appropriate manner for Resident 2 and Resident 3; and, 3. Four resident rooms had trash cans that had garbage inside of them without liners being placed in the trash cans. These failures had the potential to spread infections to residents residing in the facility, negatively impacting their health and well-being. Findings: 1. During an interview on 9/24/24, at 10:59 AM, with the Central Supply (CS), the CS stated the facility did not have any disposable gowns on Monday morning (9/23/24). The CS further stated that the disposable gowns were out on both the sub-acute (a level of care needed by a patient who does not require hospital acute care…

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

Based on observation, interview, and record review, the facility failed to maintain a safe, clean, and comfortable living environment for one of seven sampled residents (Resident 1), when Resident 1 did not have a trash can in his room to dispose his trash. This failure had the potential to negatively impact Resident 1's homelike environment. Findings: A review of Resident 1's clinical record titled, admission Record, indicated Resident 1 was admitted to the facility in the spring of 2024. During a concurrent observation and interview on 9/24/24, at 11:25 AM, Central Supply (CS) confirmed that Resident 1 did not have a trash can located in his section of the room. During an interview on 9/24/24, at 11:51 AM, with Resident 1, Resident 1 stated he had been at the facility for a long time. Resident 1 further stated he did not have a trash can to use and he had to use his bedside table to place his trash on. During an interview on 9/25/24, at 11:27 AM, with the Director of Staff Development (DSD), the DSD stated that it could be an infection control risk if a resident had to place his…

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

Based on observation, interview, and record review, the facility failed to ensure professional standards of quality care were met for three of three sampled residents (Resident 1, Resident 2, and Resident 3) when, Resident 1 and Resident 3 ' s blood sugars (finger prick blood test to check blood sugar level) were not monitored before meals; and Resident 1, Resident 2, and Resident 3 ' s scheduled medications were not administered in a timely manner. These failures had the potential to negatively affect the therapeutic benefits of the medications prescribed to Resident 1, Resident 2, and Resident 3; and for Resident 1 and Resident 3 to receive unnecessary insulin (injectable medication used to manage blood sugar) doses. Findings: a. A review of Resident 1 ' s admission RECORD, indicated he was admitted to the facility in early 2024 with diagnoses which included, Type 2 diabetes mellitus ( long term condition in which body has trouble controlling blood sugar and using it for energy), atrial fibrillation ( irregular, often rapid heart rhythm that can cause poor blood flow), essential…

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

Based on observation, interview, and record review, the facility failed to follow their infection control policies and procedures for 1 of 30 subacute (require special medical equipment, supplies, and treatments) residents (Resident 1) when licensed nurse (LN) 6 was observed suctioning (a procedure that removes excess secretions from a patient's respiratory tract when they are unable to do on their own to clear the airway and improve breathing) Resident 1 on Enhanced Standard Precautions (EBP- set of infection control measures to reduce the transmission of resistant germs through gown and glove use during high-contact resident care activities) without the required personal protective equipment (PPE- gowns, gloves, eye protection, facemasks or respirators used to prevent the spread of germs). This failure could have resulted in the spread of multi- drug resistant organisms (MDROs- infections that are resistant to three or more drugs that kill infection) and the need for additional medical interventions (medications and/or treatments) for the subacute residents, visitors, and staff.…

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

Based on 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. A dented can was found in canned foods storage, 2. Expired foods were not discarded and available to be served to residents, 3. Cereal in dry storage was not covered, 4. Food preparation and service items were found dirty, 5. Food items were mislabeled, 6. Rental coffee machine had not been recently serviced and filter was more than three years old, 7. Nursing staff did not protect resident food and beverage during meal service, 8. Adequate utensils were not available during meal service, 9. Custard did not undergo the cool down process, 10. Staff unable to state manual dish washing process, and, 11. Hot food was not kept out of the temperature danger zone when cooked food had to be rotated off and on burners during meal production. This had the potential of leading to food borne illnesses in the 94 residents eating facility prepared meals. Findings: 1. During an observation on 7/29/24 at 8:30…

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.

Based on observation, interview, and record review, the facility failed to ensure four of 37 sampled residents had accommodations in place to have their needs met when: 1. Resident 11's call light was not within reach, and 2. Resident 37's side rails were not in the correct position for self-adjustment in bed, and 3. Resident 62's call light was not within reach, and 4. Resident 16's call light was not within reach. These failures could have resulted in injury, loss of physical function, and residents' needs not being met. Findings: 1. A review of Resident 11's clinical record titled, admission RECORD, (a document that contained the resident's demographic information), indicated Resident 11's diagnoses included respiratory failure (difficulty breathing on your own), heart failure, and muscle weakness. During a concurrent observation and interview on 7/29/24, at 10:08 a.m., with Resident 11, Resident 11 was in her bed with the call light above her head on the right side of the pillow. Resident 11 attempted to reach her call light and her arm was unable to reach above her head.…

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

Based on observation, interview, and record review, the facility failed to ensure respiratory care practices were consistent with professional standards of practices for five residents using oxygen in a sample of 37 when, 1. Resident 47's oxygen tubing was not changed and dated per facility standards of practice; 2. Resident 53's doorframe did not contain signage that indicated oxygen was in use; and, 3. Resident 84 and Resident 106's oxygen concentrator [a machine which converts room air to oxygen] filters contained a large amount of dust and debris; and Resident 64's oxygen concentrator had no filter, and the air intake contained a large amount of dust and debris. These failures put vulnerable residents ar risk for infection, and placed Resident 53 at risk for injury related to use of a flammable gas. Findings: 1. During a review of Resident 47's clinical record titled, admission RECORD (a document that contains the resident's demographic information), indicated Resident 47's diagnoses included sepsis (overwhelming infection), respiratory failure, history of Methicillin Resistant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication to meet the needs of 2 of 37 sampled residents (Resident 50 and Resident 67), when: 1. Resident 50's medications were signed off as given prior to administering to Resident 50, and were administered late; and, 2. Resident 67's medication to keep blood pressure from being too low was not administered per physician orders. These failures had the potential to result in Resident 50 experiencing increased pain and a drop in her blood pressure, and Resident 67 not receiving the therapeutic effect of her medication with a potential for abnormal blood pressure Findings: A review of Resident 50's clinical record, MEDICATION ADMINISTRATION RECORD (MAR) with a date range 7/1/24 -7/31/24 indicated as follows: Midodrine HCL [a medication used to increase blood pressure] Give oral Tablet 10 MG [mg- a unit of measure] . 1 tablet by mouth three times a day for hypotension [low blood pressure] . The MAR indicated the Midodrine HCL was scheduled for 9 a.m., 1 p.m., and 5 p.m. Gabapentin [a medication used to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect residents from significant medication errors when: 1. Resident 53 was given medication that was not ordered by the physician; and, 2. Resident 114's medications, including controlled substances, were left at Resident 114's bedside. These deficient practices had the potential for Resident 53 to suffer serious effects from a narcotic overdose, and had the potential for Resident 114 to miss or take her medications late, or for another resident to take them with the risk of serious effects. Findings: 1. Resident 53 was admitted to the facility in early 2024. Resident 53's admitting diagnoses included diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), malaise (a general feeling of discomfort, illness, or uneasiness whose exact cause is difficult to identify), and iron deficiency anemia (a condition where the body doesn't have enough healthy red blood cells due to low levels of iron 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 interview and record review, the facility failed to ensure implementation of their policy regarding personal food storage when there was not a microwave or refrigeration unit for the residents of the facility. This failure had the potential to limit resident rights and enjoyment of food brought by family and visitors as well as decrease the safety of food from both inside and outside the facility when proper storage and reheating was not available. Findings: During a review of the facility's policy and procedure titled, Personal Food Storage dated 4/17, in the section, Policy, indicated, . Food or beverage brought in from outside sources for storage in facility, refrigeration units, or personal refrigeration units will be monitored by the designated facility staff for food safety. During an interview on 7/29/24 at 2:55 p.m. with Licensed Nurse (LN) 4, LN 4 stated that refrigerators and resident microwaves have been gone for a while. During an interview on 7/29/24 at 2:58 p.m. with the Director of the Sub-Acute Unit (DSU), the DSU stated that there was not a microwave or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure safe infection prevention practices were used for a census of 118 when: 1. A bedpan (a container used to collect urine or feces, and it is shaped to fit under a person lying or sitting in bed) in Resident 43's shared bathroom was unlabeled with a resident name and was left on the floor, and 2. Resident 96's room contained clutter, unknown items, and trash. These failed practices could contribute to the spread of infection by cross-contamination in the facility. Findings: 1. During an observation on 7/29/24 at 10:28 a.m. in Resident 43's shared bathroom (shared with room [ROOM NUMBER]), a used bedpan with no resident name was observed on the floor. During a concurrent observation and interview on 7/29/24 at 10:30 a.m., with Certified Nursing Assistant (CNA) 5, CNA 5 confirmed the bedpan in Resident 43's shared bathroom was on the floor and did not have a name or other identifier placed on the bedpan. CNA 5 stated that the risk of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 2 of 37 sampled residents (Resident 71 and Resident 100) were treated with dignity when, 1. Dentures were not provided in a timely manner for Resident 71, and; 2. Certified Nursing Assistant (CNA) 4 stood over Resident 100 while assisting him with his meal. These failures resulted in Resident 71 having feelings of sadness, and not wanting to smile due to not having dentures and Resident 100 not receiving his meal with dignity. Findings: 1. A review of Resident 71's clinical record titled, admission RECORD (a document that contains the resident's demographic information), indicated Resident 71's diagnoses included mild protein - calorie malnutrition and major depressive disorder. During a concurrent observation and interview on 7/29/24, at 2:10 p.m., with Resident 71, Resident 71 was noted to not have teeth. Resident 71 stated she had dentures, and they broke three times. Resident 71 stated someone assessed her dental status…

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

Based on observation, interview, and record review, the facility failed to provide a homelike environment for 1 of 37 sampled residents (Resident 43), when the facility did not ensure Resident 43's personal belongings were stored per the resident's preference. This failure placed Resident 43 at an increased risk for falls/accidents and potentially psychosocial distress. Findings: A review of Resident 43's admission Record indicated, Resident 43 was admitted in 2020, with diagnoses including Multiple Sclerosis (a disorder marked by weakness, numbness, a loss of muscle coordination, and problems with vision, speech, and bladder control) and repeated falls. A review of Resident 43's Minimum Data Set (MDS, an assessment and care screening tool) dated 6/2/24, indicated Resident 43 had the ability to understand and be understood by others with an intact memory and a Brief Interview for Mental Status (BIMS) score of 15 (The BIMS assessment uses a points system that ranges from 0 to 15 points: 0 to 7 points suggests severe cognitive impairment. 8 to 12 points suggests moderate cognitive…

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

Based on interview and record review, the facility failed to ensure that 1 of 37 sampled residents (Resident 30) was free from verbal abuse by facility staff when Certified Nursing Assistant (CNA) 7 called Resident 30 derogatory names. This failure caused an unsafe environment for Resident 30 in the facility, made her feel uncomfortable, and resulted in psychosocial distress. Findings: Review of a facility reported incident received on 7/18/24, indicated, .RESIDENTS . [Resident 30] .Alleged Perpetrator . [CNA 7] . Date of Alleged Event: 07/13/2024 .Resident reported to social services that CNA was harassing her verbally . A review of Resident 30's admission Record indicated Resident 30 was admitted in early 2024 and had diagnoses that included diabetes mellitus (inadequate control of blood sugar levels in the body), anxiety, and depression. A review of Resident 30's Minimum Data Set (MDS, an assessment and care screening tool) dated 7/2/24, indicated Resident 30 had the ability to understand and be understood by others with an intact memory and a Brief Interview for Mental Status…

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

Based on interview and record review, the facility failed to implement its abuse policy for one resident (Resident 30) who alleged verbal abuse by a staff member, in a sample of 37, when the facility did not initiate a timely investigation of the alleged verbal abuse incident which occured on 7/13/24, and did not send the results of the investigation to the Department within five working days of the incident. This failure placed Resident 30 and other residents in the facility at risk for unidentified abuse and hindered protection from potential ongoing abuse. Findings: Review of a facility reported incident received on 7/18/24, indicated, .RESIDENTS . [Resident 30] .Alleged Perpetrator . [Certified Nursing Assistant-CNA 7] . Date of Alleged Event: 07/13/2024 .Resident reported to social services that CNA was harassing her verbally . The Department had not received an investigative summary from the facility by the time an on-site visit was made on 7/29/24, 16 days after the alleged incident on 7/13/24. A review of Resident 30's admission Record indicated Resident 30 was admitted in…

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

Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR- to ensure that individuals with mental illness receive specialized services) Level ll (2) was completed for 1 of 37 sampled residents (Resident 89). This failure had the potential for Resident 89 to not receive adequate services to prevent mental health decline. Findings: A review of Resident 89's admission RECORD indicated Resident 89 was admitted in early 2024 with diagnoses including schizoaffective bipolar disorder (a mood disorder that affects your thoughts, mood, and behavior including hearing and seeing things that are not there), and schizophrenia (a serious mental health condition that affects the way people think and behave). A review of Resident 89's Preadmission Screening and Resident Review (PASRR) Level l Screening, dated 2/1/24 indicated, Result of level l screening .Positive . Hx [history] Schizophrenia . The individual has been prescribed psychotropic medication [A psychotropic describes any drug that affects behavior, mood, thoughts, or…

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

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a document describing agreed goals of care, and outlining planned medical, nursing and health activities for a resident) for 1 of 37 sampled residents (Resident 95) when Resident 95's mobility care plan interventions did not include items to assist Resident 95 to reach the care plan goal of using bedrails for mobility, and there were no bedrails present on Resident 95's bed. This failure placed Resident 95 at risk for loss of independence, falls and injury. Findings: A review of Resident 95's admission RECORD indicated Resident 95 was admitted to the facility in early 2024 with diagnoses of Acquired Absence of Right Leg Below Knee (surgical removal of right leg below the knee), abnormalities of gait and mobility (unstable when standing), and muscle weakness. During a concurrent observation and interview on 7/29/24, at 11:28 a.m., Resident 95 was observed sitting in her wheelchair next to her bed. Resident 95 mentioned she has requested to staff…

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

Based on observation, interview, and record review, the facility failed to ensure activities of daily living (ADL) were provided to maintain good hygiene for one of thirty-seven sampled residents (Resident 40) when Resident 40's fingernails were long with sharp edges and contained a black substance under the fingernails. This failure resulted in Resident 40's nails not being well groomed, and the potential for injury due to sharp edges, and infection due to harboring microorganisms (bacteria, virus, or fungus). Findings: A review of Resident 40's admission Record indicated Resident 40 was admitted in 2021 and had diagnoses that included hemi-plegia (inability to move one side of the body). A review of Resident 40's Minimum Data Set (MDS, an assessment and care screening tool) dated 6/19/24, indicated Resident 40 had the ability to understand and be understood by others, with an intact memory and a Brief Interview for Mental Status (BIMS) score of 15 (The BIMS assessment uses a points system that ranges from 0 to 15 points. 13 to 15 points suggests that memory is intact). A review of…

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

Based on observation, interview, and record review, the facility failed to ensure a living environment free from the potential of accidents and hazards for 2 of 37 sampled residents (Resident 95 and Resident 96), when: 1. Resident 96's room was full of clutter; and 2. Resident 95 was not provided a bed rail to assist with transfers and enhance mobility. These failures placed Resident 95 and Resident 96 at an increased risk for falls and possible injury. Findings: 1. During a review of Resident 96's clinical record titled, admission RECORD (a document that contained the resident's demographic information), indicated Resident 96's diagnoses included a history of a stroke (blood supply to part of the brain is blocked and the brain becomes damaged, resulting in a disability) and weakness on the left side of the body. During an observation on 7/29/24, at 10:01 a.m., Resident 96's room had eight large cardboard boxes, five large grey storage bins, one large black trash bag, seven grocery bags, and clothes and trash on top of the boxes lying on the floor. The items blocked the bathroom and…

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

Based on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status when care planned interventions and food preferences were not provided for one of four sampled residents (Resident 37) who had a history of unplanned weight loss. This failure had the potential for Resident 37 to have further weight loss, skin breakdown, and malnutrition. Findings: A review of Resident 37's admission record indicated the resident was admitted to the facility in early 2024, with diagnosis of, but not limited to, mild protein-calorie malnutrition, dysphagia (difficulty swallowing) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). During a review of Resident 37's clinical record, Weights and Vitals Summary report dated 7/31/24, the Weights and Vitals Summary report indicated Resident 37 lost 18.2 pounds (10.9% of his body weight) between the dates of 1/4/24 and 7/31/24 which was a severe weight loss. The Weights and Vitals Summary report indicated as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one of two sampled residents (Resident 375) with a peripherally inserted central catheter (PICC, a type of long catheter that is inserted through a peripheral vein, often in the arm, passed through to larger veins near the heart and used to give fluids, nutrition, drugs, or other treatments), when Resident 375's PICC line dressing was not changed for 12 days. This failure increased the risk of Resident 375 developing infection (the invasion and growth of germs in the body) and/or sepsis (a serious condition that happens when the body's immune system has an extreme response to an infection). Findings: A review of Resident 375's admission Record indicated Resident 375 was admitted in 2024 with diagnoses including infection and inflammatory reaction (when tissues are injured by bacteria, injury, or any other cause). 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 1 of 37 sampled residents (Resident 178) was administered PRN (as needed) pain medication when Resident 178 requested the medication. This failure resulted in Resident 178's pain being unrelieved, negatively impacting Resident 178's health and well-being. Findings: A review of Resident 178's clinical document titled, admission Record, indicated Resident 178 was admitted to the facility with diagnoses which included testicular and abdominal pain. During an interview with Resident 178 on 7/29/24, at 12:47 PM, Resident 178 stated he had asked for his pain medications around 10 AM. Resident 178 explained licensed nurse (LN) 4 stated he would get his pain medication for him and never did. Resident 178 stated his pain level was 7-8, on a pain scale of 10, with 10 being the highest level of pain. A review of Resident 178's clinical document titled, Order Summary Report, containing physician prescribed medications, indicated, Percocet [narcotic pain-relieving medication] Oral Tablet 10-325 MG [MG - Milligrams a unit of…

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

Based on observation, interview, and record review, the facility failed to ensure a respiratory therapy treatment cart and a medication cart, in the facility's sub-acute area (offers more intensive care than what is provided in a skilled nursing facility) were locked and secured, for a census of 118, when: 1. A respiratory therapy treatment cart was left unlocked and unattended; and a medication cart was left unlocked and unattended in the sub-acute area of the facility. 2. The medication refrigerator for Station's 3/4 contained a basin with medications that were submerged or partially submerged in a clear liquid substance. These failures had the potential residents or unauthorized persons could access respiratory treatment supplies and medications they were not prescribed, with the potential for harmful effects; and had the potential for submerged medications to become contaminated and cause illness. Findings: 1. During an observation on 8/1/24, at 7:27 AM, in the sub-acute area of the facility, a respiratory therapy treatment cart, across the hall from the nursing station, was…

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

Based on observation, interview, and record review, the facility failed to ensure 1 of 37 sampled residents (Resident 71) was provided dental services to meet her needs when Resident 71 was not fitted for dentures in a timely manner. This failure resulted in Resident 71 not having dentures, and had the potential to impact Resident 71's quality of life and self esteem. Findings: During a review of Resident 71's clinical record titled, admission RECORD (a document that contains the resident's demographic information), the record indicated Resident 71's diagnoses included mild protein - calorie malnutrition and major depressive disorder. During a concurrent observation and interview on 7/29/24, at 2:10 p.m., with Resident 71, Resident 71 was noted to not have any teeth. Resident 71 stated she had dentures, and they broke three times. Resident 71 stated someone assessed her dental status approximately 6 months ago and discussed getting dentures, but she had not received an update. Resident 71 stated she wanted dentures, and she was sad that she had not received them. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to notify the physician when a change of condition occurred after one of five sampled residents (Resident 2) complained of chest pain. This failure resulted in Resident 2 not receiving medical tests or a higher level of care and could have resulted in serious injury (heart attack - heart stops beating). Findings: During a review of Resident 2's clinical record titled, admission Record, indicated Resident 2's diagnosis included respiratory failure (a condition that causes breathing problems), atrial fibrillation (irregular heart beat), heart failure, chest pain, and heart attack. A review of Resident 2's clinical record titled, Progress Notes, dated [DATE], at 8:35 p.m., by Licensed Nurse 3 (LN 3), indicated, Resident 2 called 911 [request for immediate attention from the paramedics] and the state [Department] to complain about his call light being on for 15 minutes. He said he was having chest pain. Vital signs [measurement of breathing, temperature,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 meet the needs of its residents in regards to the quality of laboratory services provided by failing to ensure the contracted (an agency hired by the facility to provide a service) laboratory technician provided quality of care (the degree to which health services for individuals and populations increase the likelihood of desired health outcomes) to one of five sampled residents (Resident 1), when a tourniquet (a band of rubber wrapped tightly around the arm for a short period of time for easier visualization of the veins during blood removal for testing) was not removed after the blood draw (removal of blood from the resident's vein to be tested for abnormalities) was completed. This failure resulted in the tourniquet remaining around Resident 1's arm for approximately three days and led to a skin injury. Findings: During a review of Resident 1's clinical record titled, admission Record, indicated Resident 1's diagnosis included quadriplegia (inability to move or have feeling in the arms and legs). A 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 interview, and record review, the facility failed to take timely action aimed at performance improvement after one of five sampled residents (Resident 1), received substandard (falling short from the norm) quality of care (the degree to which health services for individuals and populations increase the likelihood of desired health outcomes) according to professional standards of practice when a tourniquet (a band of rubber wrapped tightly around the arm for a short period of time for easier visualization of the veins during blood removal for testing) was left around Resident 1's right arm for approximately three days. This failure resulted in a delay in the identification of systemic failures and the implementation (putting a plan into effect) of new safety measures following laboratory blood draws (removal of blood from the vein for testing of abnormalities). Findings: During a review of Resident 1's clinical record titled, admission Record, indicated Resident 1's diagnosis included quadriplegia (inability to move or have feeling in the arms and legs). A 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 interview, and record review, the facility failed to allow one of three sampled residents (Resident 1) to obtain a copy of his medical records in a timely manner. This failure violated Resident 1's right to access his personal and medical records. This failure also could have resulted in a delay of care for Resident 1 regarding the removal of his Gastrostomy Tube (G-Tube- a tube inserted through the wall of the abdomen directly into the stomach which allows for the administration of drugs, medications, and liquid food) to be given to the patient). Findings: During a review of Resident 1's clinical record titled, admission Record, indicated Resident 1's diagnosis included colon cancer and colostomy status (surgery to create an opening for the colon (large intestine) through the abdomen). During an interview on 7/3/24, at 10:32 a.m., with the Director of Staff Development (DSD), DSD stated the process for Resident 1 obtaining his medical records was for him to sign a waiver release form and then the medical records department would request the documents from the appropriate…

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

Based on interview, and record review, the facility failed to ensure two of two residents (Resident 2 and Resident 3) were assessed for risk of falls after a fall occurred and regularly (with a constant or definite pattern, especially with the same space between individual items) per the facility policy and procedure, when a fall risk assessment had not been documented as completed for Resident 2 and Resident 3 after a fall occurred, nor on a regular basis. This failure had the potential for a census of 117 residents in the facility to not be identified as a risk for falls and/or had fall risks measures and/or interventions be put in place, changed and/or modified based off of identified fall risk assessment factors. Findings: During an interview on 6/4/24, at 1:39 p.m., Licensed Nurse (LN) 1 reviewed Resident 3's medical record and confirmed Resident 3 fell twice on 4/17/24. LN 1 stated residents at risk for falls had a bracelet that identified the residents as fall risks. LN 1 stated Resident 3 did not have a fall risk bracelet. LN 1 stated he did not conduct a fall 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 infection control practices were in place for one of twenty-eight residents on enhanced barrier precautions (infection control interventions to help stop the spread of germs resistant to medication treatment) when, there was no signage placed outside of Resident 1's room to indicate the type of personal protective equipment (PPE; such as gloves and gowns) for staff to put on prior to specific high contact resident care activities (such as but not limited to bathing, toileting, and wound care). This failure had the potential to spread MDRO's (Multidrug-Resistant Organisms; bacteria that have become resistant to certain antibiotics (medication to treat infections), and these antibiotics can no longer be used to control or kill the bacteria) to Resident 1 and to other residents residing within the facility. Findings: Review of Resident 1's admission RECORD, indicated Resident 1 was admitted with a diagnosis of gastrostomy (artificial opening to stomach, tube inserted to provide nutritional support and/or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure supervision to prevent accidents for one of seven sampled residents (Resident 4), when Resident 4 eloped (when a resident leaves without the facility ' s knowledge or supervision) and a wander management bracelet (WMB- a wearable device which alerts staff if a resident leaves the building) was placed on 3/22/24, but was not monitored for placement or functionality until 4/27/24. This failure increased the risk Resident 4 could leave the facility without staff knowledge and sustain injury or harm. Findings: A review of an admission record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses which included dementia (a loss of memory and problem-solving abilities which interfere with daily life), Alzheimer's disease (progressive disease that destroys memory and other important mental functions which interfere with activities of daily living), muscles weakness, and abnormalities of gait and mobility. A review of Resident 4 ' 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 interview, and record review, the facility failed to ensure that mandatory abuse training was provided to all facility staff when 62 out of 186 staff members did not complete their mandatory abuse training. This failure had the potential to result in an increased risk of failing to recognize and properly handle instances of abuse or neglect towards all the residents in the facility. Findings: During a concurrent interview and record review on 5/29/24, at 4:10 p.m., with the Director of Staff Development (DSD), Your Legal Duty SNF Clinic Report was reviewed. The SNF Clinic Report indicated, that 62 out of 186 staff members from various departments throughout the facility including nursing, admissions, dietary, maintenance, and activities did not complete the required abuse training. The DSD acknowledged the yearly mandatory abuse training had a deadline for completion by 5/8/24. The DSD stated that the risks for not completing the training would be that the staff would not know how to potentially report abuse. During an interview on 5/30/24, at 2:53 p.m., with the Assistant…

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

Based on interview, and record review, the facility failed to ensure an allegation of physical abuse was reported for one of five sampled residents (Resident 1) when the facility failed to report Resident 1's allegation of physical abuse. This failure resulted in a delay in the abuse investigation process and had the potential to affect Resident 1's physical and psychosocial well- being. Findings: During an interview on 5/29/24, at 2:35 p.m., with Resident 1, Resident 1 stated she felt scared when Certified Nurse Assistant (CNA) 3 was in the room. Resident 1 stated CNA 3 would put soap and hot water in her eyes while she was receiving a shower. Resident 1 further stated that she would feel safer if CNA 3 was not allowed in her room. During an interview on 5/30/24, at 3 p.m., with the Human Resources Director (HRD), the HRD stated that family member (FM) 1 expressed Resident 1's concerns that CNA 3 intentionally put soap and hot water into her eyes. The HRD explained she met with FM 1 on 5/19/24 and was told about the concerns Resident 1 had. The HRD stated that she sent an email…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 of four of six sampled residents (Resident 2, Resident 3, Resident 4, Resident 5) were accommodated when call lights (a device used by residents to call for assistance) were not within reach for Resident 2, Resident 3, and Resident 4. These failures had the potential to result in Resident 2, Resident 3, and Resident 4 being unable to ask for needed assistance and to negatively impact their physical and psychosocial well-being. Findings: During a concurrent observation and interview, on 5/23/24, at 11:41 a.m., Resident 2 was observed to be lying in bed and her call light was hanging on the wall out of reach. Licensed Nurse (LN) 1 confirmed the call light was out of Resident 2's reach and stated call lights were to always be within reach of the resident. LN 1 also stated Resident 2 would not have been able to call for assistance when needed if her call light was out of reach. LN 1 also stated Resident 2 could fall if her call light was not within reach. 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 observation, interview, and record review, the facility failed to ensure the needs of three of six sampled residents (Resident 2, Resident 3, Resident 5) were accommodated when water pitchers were not available at the bedside. These failures had the potential to result in potential health problems related to dehydration for Resident 2, Resident 3 and Resident 5. Findings: During a concurrent observation and interview, on 5/23/24, at 11:41 a.m., Resident 2 was observed to be lying in bed without a water pitcher at her bedside. LN 1 confirmed Resident 2 did not have a water pitcher at her bedside and stated if water was not available, Resident 2 could get dehydrated. During a concurrent observation and interview on 5/23/24, at 11:54 a.m., Resident 3 was observed to be lying in bed without a water pitcher at his bedside. LN 2 confirmed Resident 3 did not have a water pitcher and stated if water was not available, Resident 3 could get dehydrated. During a concurrent observation and interview, on 5/23/24, at 1:15 p.m., Resident 5 was observed to have a water pitcher on his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure dignity and respect was maintained for one of 3 sampled resident (Resident 1) when the facility failed to notify her family to collect her personal belongings after she was hospitalized and later died. This failure had the potential to prolong the grieving process for Resident 1 ' s family when their loved one's belongings were disposed of without being notified. Findings: A review of ' Intake Information ' reported received by the Department on [DATE] indicated Resident ' s family had gone to collect her belongings from the facility after she died and they were informed the possessions were thrown away. Resident 1 had lived at the facility for 5-6 years. According to the report, the family was not called to pick up her belongings and the resident had a ' purse in the facility ' and the family ' wanted to retrieve that , along with her clothing . According to the ' admission Record ' the facility admitted Resident 1 originally in 2018. 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 observation and interview the facility failed to ensure the needs of three of three sampled residents (Resident 1, Resident 2, and Resident 3) were met, when the facility failed to provide the appropriate size of incontinence briefs. This failure resulted in Resident 1, Resident 2, and Resident 3 wearing ill-fitting and uncomfortable briefs. Findings: a. A review of Resident 1 ' s admission RECORD, indicated she was admitted to the facility early 2024 with diagnoses which included morbid obesity. A review of Resident 1 ' s Minimum Data Set (MDS, a resident assessment and screening tool) Section C, Brief Interview for Mental Status (BIMS) dated 3/4/24, indicated a score of 8 which suggested a moderate cognitive impairment. b. A review of Resident 2 ' s admission RECORD, indicated she was admitted to the facility in 2022. A review of Resident 2 ' s MDS Section C, BIMS dated 12/15/2023, indicated a score of 15 which suggested intact cognition. c. A review of Resident 3 ' s admission RECORD, indicated she was admitted to the facility in 2016. A review of Resident 3 ' s MDS,…

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

Based on interview and record review, the facility failed to ensure continuing education was provided to certified and licensed staff on the sub-acute unit (a level of care that is defined as a level of care needed by a patient who does not require hospital acute care but who requires more intensive licensed skilled nursing care than is provided to most patients in a skilled nursing facility). This deficient practice had the potential for harm for twenty-six residents on the sub-acute unit when; 1. Four out of eleven Certified Nursing Assistants (CNA), ten out of twenty Licensed Nurses (LN), and seven out of seven Registered Respiratory Therapists (RRT) did not attend the OXYGEN DELIVERY in-service which was offered from 1/29/24 to 2/3/24. 2. Seven out of eleven CNA's and five out of twenty LNs did not document the date they attended the OXYGEN DELIVERY in-service which was offered from 1/29/24 to 2/3/24. 3. Three out of twenty LNs attended the in-service after the required attendance period for the OXYGEN DELIVERY in-service which was offered from 1/29/24 to 2/3/24. 4. Four out of…

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

Based on interview and record review the facility failed to provide sufficient nursing staff to meet residents' needs when a Registered Nurse (RN) was not scheduled to work on 12/25/23 during the night shift (12 AM- 7:30 AM) or the day shift (7 AM – 3 PM) for a census of 109. This failure had the potential to put the health and safety of clinically compromised residents at risk. Findings: A review of a facility document titled, SUB-ACUTE UNIT SIGN IN AND LABOR TRACKING SHEET, dated 12/25/23, indicated, .MIDNIGHT TO 7:30am .NO RN/RT [respiratory therapist] . and listed three Licensed Vocational Nurses (LVN's), three Certified Nurse Assistants (CNA's), and one RT on duty. The document further indicated, .7AM TO 3:30 PM .NO RN . and listed four LVN's, six CNA's, and one RT on duty. A review of a facility document titled, SKILLED UNIT SIGN IN AND LABOR TRACKING SHEET, dated 12/25/23, indicated, from .MIDNIGHT TO 7:30am . the document listed two LVN's and six CNA's on duty. In the section titled, .7AM TO 3:30 PM . the document listed six LVN's, two restorative nurse assistants (RNA's),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 111 residents when: 1. A facility staff entered a room requiring use of gown, N95 mask respirator (a type of mask that filters up to 95% of particles in the air), eye protection, and gloves wearing only an N95 mask on top of a surgical mask (a type of mask that protects the mouth and nose from splashes, sprays, and large droplets that may include microorganisms). 2. Three out of three sampled facility staff did not have a current N95 mask fit test (a test protocol conducted to verify that the specific type and model of N95 mask is both comfortable and provides the wearer with the expected protection) done. This failure resulted in increased risk for cross-contamination (movement or transfer of harmful bacteria from one person, object, or place to another), potential for exposure of germs and may cause infection among residents, staff, and visitors.…

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

Based on observation, interview and record review, the facility failed to promote personal hygiene for 1 of 6 sampled residents when Resident 1's showers were scheduled on a day when she went out for dialysis (a treatment for removing wastes products and excess fluids from the blood when the kidneys have failed) treatment. This failure resulted in Resident 1 not being given an opportunity to have a shower for 16 days in the 123 days reviewed. Findings: According to Resident 1's 'admission Record,' the facility admitted Resident 1 originally over 4 years ago with multiple diagnoses which included a stroke with right sided weakness, diabetes, and kidney disease. Resident 1 scored 13 out of 15 in a Brief Interview for Mental Status (BIMS, a cognitive assessment) contained in her quarterly Minimum Data Set (MDS, an assessment tool). This indicated she was cognitively intact. An 'Intake Information' report received by the Department on 10/23/23, indicated in part, Patient's hair was not cleaned or brushed. A review of Resident 1's 'ADLs' [activities of daily living including…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care in a manner that promoted dignity and respect for 3 of 4 sampled residents (Resident 1, Resident 2, and Resident 3) in the subacute unit when residents who were incontinent of bowels and/or urine were double briefed for staff convenience. This failure had the potential risk to minimize the resident's self-esteem and negatively impact their skin integrity. Findings: According to an 'Intake Information' report received by the Department on 10/17/23, the Certified Nursing Assistants (CNAs) were double briefing residents who were incontinent of bowel and/or urine on a regular basis. According to Resident 1's 'admission Record,' she was admitted to the facility over 3 years ago with multiple diagnoses which included brain injury and bleeding related to trauma. Resident 1's quarterly Minimum Data Set (MDS, an assessment tool), indicated he was always incontinent of bowel and bladder and was totally dependent on staff for his toileting needs. The MDS indicated the resident had long-term and short-term…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the necessary respiratory care and services in accordance with professional standards of practice, when: 1. Ventilators (machines that act as bellows to move air in and out of your lungs) for Resident 1 and Resident 2 were not checked according to the facility policy; and, 2. Two of seven sampled Licensed Nurses (LN 2 and LN 3) competencies were not current. These failures increased the risk of respiratory distress and unsafe practices. Findings: 1. Resident 1 was admitted to the facility in [DATE] with a diagnosis of acute respiratory failure with hypoxia (low oxygen level). A review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated [DATE], indicated her cognition was intact. A review of Resident 1's Care Plan titled, The resident is Ventilator dependent r/t [related to] Respiratory Failure, dated [DATE], indicated interventions that included monitor and document respiratory rate, depth and document as ordered. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to meet professional standards of quality when: 1. A physician's order to monitor resident's (Resident 71) fluid intake was not followed; 2. A physician's order was not obtained when Resident 63 was administered oxygen; 3. Facility staff borrowed medication from another resident's supply to give to Resident 2; and, 4. Resident 39 was given Alprazolam (medication used to treat anxiety and panic disorders) without a physician's order. These failures had the potential for residents to receive inaccurate and inadequate care for a census of 108. Findings: 1. Resident 71 was admitted with diagnoses including End Stage Renal Disease (the kidneys are no longer able to work at a level needed for day-to-day life), dependence on renal dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). During a record review of Resident 71's medical records, a physician's order, dated 8/24/22 indicated, .Monitor I/O…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 timely provision of assistance with activities of daily living (ADLs, which includes nail care and showers) for two of 30 sampled residents (Resident 39 and Resident 70) when: 1. Resident 70's nails were dirty and long; and, 2. Resident 39's skin was flaky and itchy, and she complained of not receiving her showers as scheduled. These failures had the potential to negatively impact the psychosocial well-being of Resident 70 and Resident 39 as well as promote infection. Findings: 1. A review of Resident 70's admission record indicated he was last admitted in the Spring of 2023 with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning). A review of Resident 70's MDS (Minimum Data Set, an assessment tool), dated 6/15/23, indicated Resident 70 required the extensive assistance of two persons for personal hygiene. In a concurrent observation and interview, on 7/18/23 at 10:38 a.m.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide rehabilitative care and services for two residents (Resident 10 and Resident 48) of 30 sampled residents, when: 1. Resident 48 was not quarterly re-assessed for splint (device that maintains in position a displaced or movable part) use and Restorative Nursing Assistant (RNA) program as indicated in the care plan and progress notes; and, 2. Physical Therapy did not follow-up on Resident 10's RNA referral. These failures decreased the facility's potential to maintain or improve the residents' range of motion (ROM) and prevent contractures (shortening and hardening of muscles, tendons, or tissues). Findings: 1. A review of an admission record indicated Resident 48 was admitted to the facility on [DATE] with diagnoses including cerebral palsy (abnormal brain development that affects a person's ability to control muscles), polyarthritis (five or more joints affected with pain and inflammation), and nerve injury at shoulder and upper…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete the annual performance reviews for five of six sampled certified nursing assistants (CNAs; CNA 4, CNA 5, CNA 6, CNA 7, and CNA 8). This failure increased the residents' potential to receive poor quality of care from CNAs. Findings: A review of an undated report indicated CNA 4's date of hire (DOH) was 12/99, CNA 5's DOH was 6/16, CNA 6's DOH was 7/19, CNA 7's DOH was 8/87, and CNA 8's DOH was 5/09. A review of CNA 4's Employee Performance Review, indicated CNA 4's last performance evaluation (PE) was completed on 12/18/17. A review of CNA 5's Performance Excellence Evaluation, indicated CNA 5's last PE was completed on 3/25/22. A review of CNA 6's Performance Excellence Evaluation, indicated CNA 6's last PE was completed on 3/24/22. A review of CNA 7's Performance Excellence Evaluation, indicated CNA 7's last PE was completed on 5/13/21. A review of CNA 8's Performance Excellence Evaluation, indicated CNA 8's last PE was completed on 3/10/21. During an interview on 7/20/23 at 10:38 a.m. with the Director of Staff…

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

Based on observation, interview, and record review, the facility failed to: 1. Ensure accurate accountability and effective storage of controlled medications (those with high potential for abuse or addiction) when random controlled medication audits for one out of four residents (Resident 39) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but were not documented accurately on the Medication Administration Record (MAR) to indicate they were given to the residents. 2. Have an efficient system in place to accurately document and secure emergency medications (E-Kit) for a census of 108. 3. Ensure the availability of routine medications for two of 30 sampled residents (Residents 2 and 65) These failures resulted in the facility not having accurate accountability of controlled medications and potential for abuse or misuse of these medications, the potential for emergency medications to be unavailable when needed, and the potential for not meeting the residents' therapeutic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 had a 12% error rate when three medication errors out of 25 opportunities were observed during a medication pass for three of seven residents (Residents 2, 3 and 65). These failures resulted in medications not given in accordance with the prescriber's orders which resulted in residents not receiving the full therapeutic effect of the medications or worsening of their medical conditions. Findings: During a medication pass observation on 7/17/23 at 8:25 a.m. with Licensed Nurse 3 (LN 3), LN 3 was observed preparing two medications for Resident 65. A review of Resident 65's medical record indicated a physician's order, dated 10/15/21, for Farxiga (a medication to treat diabetes) 10 milligrams (mg, a unit of measurement), 1 tablet by mouth one time a day for diabetes. During a concurrent interview and record review on 7/17/23 at 2:39 p.m. with LN 3, Resident 65's July 2023 Medication Administration Record (MAR) was reviewed. LN 3 confirmed Resident 65 did not receive Farxiga on 7/16/23 and 7/17/23. LN 3 confirmed she did…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 of seven sampled residents (Resident 2) was free of a significant medication error when she was not administered multiple doses of amlodipine (a medication to treat high blood pressure), then was administered medication from another resident's supply for two doses and was administered an incorrect dose of the same medication. These deficient practices had the potential for causing headaches, nausea, nervousness, increased heart rate from not receiving scheduled doses, potential for receiving incorrect medication that was not prescribed for her and worsening of her medical condition due to not receiving the correct dose. Findings: A review of Resident 2's medical record indicated she was admitted to the facility on [DATE], with diagnoses which included hypertension (high blood pressure), myocardial infarction (heart attack), atrial fibrillation (irregular, often rapid heart rate), and cerebral infarction (stroke). During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications were stored and labeled appropriately when: 1. Medications did not have an open date, or did not have a patient-specific label; and, 2. Medication Storage Room temperatures exceeded acceptable limits for extended periods of time. These failures had the potential for medication errors and/or medications being used past its effective date, and potential for loss of medications and loss of drug potency due to high temperatures. Findings: 1. On [DATE] at 11:48 a.m., an inspection of the Station 4 Medication Cart alongside Licensed Nurse 2 (LN 2) identified three loose tablets, a Stiolto Respimat (a medication used to treat lung disease) 2.5/2.5 microgram (mcg, a unit of measurement) inhaler, and a QVAR RediHaler (a medication used to treat asthma) 40 mcg inhaler. LN 2 looked at the Stiolto inhaler and confirmed the manufacturer indicated on the packaging that it expired three months after first use. She confirmed 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 maintain the cleanliness of the coffee percolator in the kitchen when it was observed to to have a build up of greyish dust adhering to the the coffee machine. This failure increased the potential for spreading food-borne illnesses by dust contamination of the food preparation area of the residents. The facility census was 108 residents. Findings: During a concurent observation and interview on 7/19/23 at 10:30 a.m. with the Dietary Manager (DM) in the kitchen, the coffee machine's back was observed to have a thick covering of blackish grayish colored dust covering the tubing and filter. There was a brush hanging by the water filter covered with dust. Food preparation were performed near the coffee percolator's location and the dust build up. The DM confirmed dust covered areas on the backside of the machine and stated dust should not be there. The DM confirmed the coffee percolator with the dusty buildup was within the food preparation area of the kitchen. Review of the facility's policy and procedure titled,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2. A review of Resident 7's admission record indicated he was last admitted in Summer of 2022 with diagnoses including aphasia (a language disorder that affects a person's ability to communicate), depression (a persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety (a feeling of fear, dread, and uneasiness). A review of Resident 7's Activities of Daily Living (ADL) care plan, revised 6/15/22, indicated, BATHING: The resident is totally dependent on staff to provide a bath (3x a week) and as necessary .The resident requires (1) staff participation with bathing. A review of Resident 7's MDS, dated [DATE], indicated Resident 7 was cognitively intact and totally dependent on assistance for bathing. In an interview on 7/17/23 at 11:57 a.m., Resident 7 communicated via writing using paper and pen and stated concerns about regularity of his showers. He stated that showers are periodically skipped on him and staff chart as if it was refused, but he never…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 QAPI (Quality Assurance Performance Improvement) Committee met at least quarterly when documentation of quarterly meetings could not be provided. This failure had the potential to negatively impact the quality of resident care. Findings: In an interview, on 7/20/23 at 2:09 p.m., the Administrator (ADM) stated the QAPI Committee met on 6/14/23 and prior to her arrival in 3/23 the last meeting was held in 8/22. The ADM confirmed there had not been at least quarterly QAPI meetings over the last year. A review of the facility's document titled, QAPI Plan, revised 9/23/22, indicated the QAPI Committee would meet on at least a quarterly basis.

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Resident 39's suction equipment was left at the bedside undated with a full suction canister and covered in dust; 2. Sharps containers on medication carts were filled above the fill line; and, 3. Licensed Nurse (LN 3) did not sanitize and disinfect a blood pressure cuff between resident use. These failures had the potential to expose residents and staff to infectious agents. Findings: 1. A review of Resident 39's admission record indicated she was last admitted in Spring of 2020 with diagnoses including respiratory failure (a serious condition that makes it difficult for a person to breathe on their own), tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs), and diabetes (a chronic condition that affects the way the body processes blood sugar). A review of Resident 39's minimum data set (MDS, an assessment tool), dated 7/4/2023, indicated Resident 39 was cognitively intact and required…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 of residents were accommodated for three of 30 sampled residents (Resident 14, Resident 45, and Resident 106) when call lights were not within reach for Resident 14, Resident 45 and Resident 106. These failures had the potential to result in residents being unable to ask for needed assistance and to negatively impact their physical and psychosocial well-being. Findings: In a concurrent observation and interview, on 7/17/23 at 8:24 a.m., Resident 45 was lying in bed and her call light was hanging on the wall behind her bed. Certified Nursing Assistant 2 (CNA 2) confirmed the call light was out of the resident's reach and stated call lights were to always be within reach of the resident. In a concurrent observation and interview, on 7/17/23 at 10:15 a.m., Resident 106 was lying in bed and his call light was hanging on the wall behind his bed. CNA 3 confirmed the call light was not within the resident's reach. In a concurrent observation and interview, on 7/18/23 at 8:19 a.m., Resident 14 was…

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

Based on observation, interview, and record review the facility failed to accommodate one of 30 sampled residents (Resident 31) choice for a shower time based on the resident's preference. This failure resulted in Resident 31's preferences and choices not being honored and respected. Findings: A review of Resident 31's face sheet indicated Resident 31 was admitted to the facility in the latter part of 2021 with diagnoses including morbid obesity (more than 100 lbs. over your ideal body weight) and chronic obstructive pulmonary disease (COPD, breathing-related problem). A review of the Minimum Data Set (MDS, standardized assessment and care screening tool), dated 6/6/23, indicated Resident 31 had a BIMS (Brief Interview of Mental Status, an assessment tool) score of 15 indicating her cognition was intact. Resident 31 required total assistance with transfers and bathing. During an interview on 7/18/23, at 12:49 p.m., with Resident 31, Resident 31 indicated it had been a long time since she had a nice shower. She was scheduled to have showers two times a week at night but preferred to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise a care plan for one of 30 sampled residents (Resident 70) when the resident had a g-tube (gastrostomy tube, a tube inserted through the belly that brings nutrition directly to the stomach) inserted and was NPO (nothing by mouth). This failure had the potential to result in unmet nursing needs. Findings: A review of Resident 70's admission record indicated he was last admitted in the Spring of 2023 with diagnoses including dysphagia (difficulty swallowing). A review of Resident 70's clinical record included the following documents: A GACH (General Acute Care Hospital) Social Work Note, dated 5/26/23, indicated Resident 70 had been admitted on [DATE] for aspiration pneumonia (occurs when food or liquid is breathed into the airways or lungs, instead of being swallowed), and had a g-tube placed on 5/25/23 while at the facility. A Physician's order, dated 5/31/23, indicated Resident 70 was on an NPO diet. A risk for altered nutrition/hydration status…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three of 30 sampled residents' (Resident 25, Resident 84, and Resident 73) tube feedings (TF, nutrition delivered directly to the stomach using a tube) were not set to the administer the correct volume of formula. This failure increased the residents' potential for not receiving the appropriate amount of nutrition to meet their dietary needs and goals. Findings: A review of Resident 25's admission record indicated Resident 25 was admitted early in 2021 with diagnoses including cerebral palsy (neurological disorder that permanently affects body movement and muscle coordination) and on TF status for nutrition. A review of Resident 25's Order Summary Report (OSR), dated 6/23, indicated an order for enteral (tube) feed, two times a day at 60 ml/hr (milliliter/hour, units of measurement) for 20 hrs a day to provide 1200 ml, 1440 Calories (Calories, unit of measurement) and 66 g (grams, unit of measurement) protein. Start at 12 p.m., off at 8 a.m., or when dose is completed. In an observation, on 7/17/23 at…

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

Based on interview and record review, the facility failed to ensure one of 30 sampled residents (Resident 14) was free of unnecessary medications when the resident was prescribed a psychotropic medication (any drug that affects behavior, mood, thoughts or perception) without adequate indication. This failure had the potential to result in the use of an unnecessary psychotropic medication that could cause adverse consequences. Findings: A review of Resident 14's admission record indicated she was admitted in 6/23 with diagnoses including cerebral infarction (stroke) and acute respiratory failure. A review of Resident 14's MDS (Minimum Data Set, an assessment tool), dated 6/25/23, indicated she had no mood issues including feeling down or depressed and trouble falling or staying asleep. A review of her active diagnoses indicated she did not have a diagnosis of depression. A review of Resident 14's clinical record included the following documents: A physician's order, dated 6/19/23, for trazadone (an antidepressant) tablet, 50 mg (milligram, a unit of measurement), give 25 mg 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.