Oak Grove Post Acute

Based on interview and record review the facility failed to honor the resident's right to choose for 1 of 32 residents (Resident 27), when the facility failed to honor Resident 27's request for a schedule concerning when their room would be deep cleaned (an intensive, systematic disinfection process-often called terminal cleaning-that goes beyond daily cleaning to eliminate pathogens and prevent Healthcare Associated Infections) and by which housekeeping team member. This failure caused Resident 27 to experience psychosocial distress that included feeling harassed by housekeeping staff.Findings:On 3/30/26 at 3:15 PM the Department received a complaint from Resident 27 regarding concerns over a housekeeping (HSK) employee's continued attempts to enter Resident 27's room and talk about deep cleaning Resident 27's room even though the HSK had been told to not have any direct contact with Resident 27. Resident 27 stated in her complaint that the HSK had confronted her and made her feel uncomfortable and felt the facility was not looking out for her best interested. This reported…

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

Based on observation, interview, and record review, the facility failed to provide a safe and comfortable homelike environment to 4 of 32 sampled residents (Resident 24, Resident 51, Resident 57, and Resident 98) when: 1.Comfortable sounds were not maintained for Resident 24, Resident 57, and Resident 98 when Resident 55 yelled loud; and,2. Resident 24, Resident 51, and Resident 98's drawers were broken.These failures removed Resident 24, Resident 51, Resident 57, and Resident 98's right to a dignified homelike environment, with the potential to result in psychosocial harm.Findings:1.A review of Resident 24's admission RECORD indicated, Resident 24 was admitted to the facility with diagnoses which included anxiety disorder (mental health conditions characterized by excessive, persistent, and uncontrollable fear or worry that interferes with daily life, affecting job performance, schoolwork, and relationships. Symptoms include restlessness, rapid heart rate, fatigue, and muscle tension), and muscle weakness.During a review of Resident 24's Care Plan, initiated on 8/3/24, the 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 observation, interview, and record review, the facility failed to ensure a resident's right to be free from verbal abuse (using negative words and language that cause harm including demeaning, disrespecting, frightening, and threatening words) for one of thirty-two sampled residents (Resident 68) when Licensed Nurse (LN) 3 and Certified Nurse Assistant (CNA) 1 witnessed a contracted staff (staff who are usually not considered official company employee and are not on the traditional payroll but hired by another company for a specific responsibility) from the housekeeping department who made inappropriate and threatening remarks toward Resident 68 on 3/28/26. This failure had the potential to cause emotional distress and could negatively affect Resident 68's psychosocial well-being.Findings:On 3/29/26, at 10:02 a.m., the Department received a facility reported incident regarding an alleged employee to resident verbal abuse. This reported incident was investigated during the facility's annual recertification with a start date on 4/6/26.During a record review of Resident 68's…

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Based on observation, interview, and record review the facility failed to assess a change in condition for one of 32 residents (Resident 1) and notify the physician when Resident 1's arteriovenous (AV) fistula (a surgically created connection of an artery directly to a vein allowing high blood flow during hemodialysis (HD), a life-saving treatment that acts as an artificial kidney that removes waste and extra fluid from the blood and regulates blood pressure) was not properly functioning. These failures placed Resident 1 at risk of missing hemodialysis as scheduled.Findings:A review of Resident 1's admission Record, indicated he was admitted to the facility with diagnoses that included but not limited to hypertension (a chronic condition where the force of blood pushing against artery walls is consistently too high, forcing the heart to work harder), chronic kidney disease (a long term, irreversible loss of kidney function where the kidney cannot effectively filter waste and excess water from the blood), and dependance on renal (kidney) dialysis.A concurrent interview and 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 observation, interview, and record review the facility failed to implement an adequate activities program for two of 32 sampled residents, Resident 15 and Resident 54 when:1.Resident 15 was not provided with one-to-one activities from 3/11/26, to 3/17/26, and2.Resident 54 was not provided with one-to-one activities from 3/19/26, to 3/29/26.These failures had the potential to negatively impact the psychosocial wellbeing of Resident 15 and Resident 54.Findings:1. A review of Resident 15's admission Record indicated Resident 15 was admitted to the facility with diagnoses that included but not limited to traumatic brain injury, schizophrenia (chronic brain disorder that causes people to lose touch with reality, making it difficult to distinguish what is real from what is not), and insomnia (chronic inability to get enough sleep).A review of Resident 15's activity care plan dated 5/5/25, indicated, .the resident needs 1 to 1 bedside/in-room visits and activities if unable to attend out of room events.A review of Resident 15's Participation Record dated March 2026, indicated…

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

Based on observation, interview, and record review the facility failed to implement appropriate respiratory care when Resident 15 received supplemental oxygen without a physician's order.This failure had the potential for Resident 15 to experience adverse side effects of supplemental oxygen use.A review of Resident 15's admission Record indicated Resident 15 was admitted to the facility with diagnoses that included but not limited to traumatic brain injury, schizophrenia (chronic brain disorder that causes people to lose touch with reality, making it difficult to distinguish what is real from what is not), and insomnia (chronic inability to get enough sleep).During an observation on 4/7/26, at 12:30 p.m., Resident 15 was observed lying in bed with oxygen running through a nasal cannula (a lightweight, flexible plastic tube with two small prongs that sit just inside the nostrils to deliver extra oxygen).During a concurrent interview and record review on 4/7/26, at 12:35 p.m., Resident 15's Order Summary Report dated 4/7/26, was reviewed with the Assistant Director of Nursing (ADON).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 two sampled residents (Resident 1) who required hemodialysis (HD, a medical treatment that acts as an artificial kidney to filter blood by removing waste products, toxins, and excess fluids) received appropriate care when Resident 1's Physician was not notified when Resident 1's arteriovenous (AV) fistula (a surgically created connection of an artery directly to a vein allowing high blood flow during dialysis) was negative for thrill (vibration) and bruit (buzzing or swoosh sound) indicating a blockage or failure.These failures had the potential to result in Resident 1 to miss hemodialysis due to a malfunction of the AV fistula.A review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility with diagnoses that included but not limited to hypertension (a chronic condition where the force of blood pushing against artery walls is consistently too high, forcing the heart to work harder), chronic kidney disease (a long term, irreversible loss of kidney function where the kidney cannot…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pharmacy services were maintained for a census of 109 when non-narcotic (medications that are not opioids-not addictive) prescription medication destruction records were not co-signed by a licensed nurse in twenty-nine (29) out of twenty-nine (29) pages of destruction records reviewed during a medication room inspection in one of four medication room on 4/6/26.This failure had the potential risk for medication misuse and/or drug diversion (unlawful use of prescription drug by unauthorized individuals) of prescribed medications due to unsafe disposition practices.During a concurrent interview and record review on 4/6/26, at 7:35 a.m. with Licensed Nurse (LN) 10 in South Station Medication room [ROOM NUMBER], the non-narcotic prescription medication destruction records titled, MEDICATION DISPOSITION LOG-NON-CONTROLLED MEDICATIONS FOR FACILITY DESTRUCTION, with various dates on 3/4/26, 3/5/26, 3/8/26, 3/17/26, 3/20/26, 3/26/26, 3/27/26, 4/2/26,…

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

Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors (the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for one of eight sampled residents (Resident 92) during medication administration when, Resident 92 was administered an insulin (medication used to manage blood sugar levels in people with diabetes, a chronic condition where the body does not produce or use insulin properly leading to high blood sugar levels) that was prescribed for Resident 89 on 4/8/26.This failure resulted in a medication error and had the potential for Resident 92 to experience blood sugar fluctuations of hypoglycemia (when blood sugars are too low) and hyperglycemia (when blood sugars are too high), created a risk of transmitting bloodborne pathogens from one resident to another (bacteria that can cause disease), and increased risk for unsafe medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to administer the pneumococcal (a serious bacterial infection that can cause respiratory illness) vaccine and the 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 to one out of five sampled residents (Resident 46) when Resident 46 did not receive the pneumococcal and influenza vaccines. These failures had the potential for Resident 46 to go unvaccinated with the risk for serious health related illness and/or death.Findings:A review of Resident 46's record titled admission RECORD indicated, Resident 46 was admitted to the facility on [DATE], with diagnoses which included Myasthenia Gravis (a chronic autoimmune disorder causing fluctuating weakness in voluntary muscles, commonly affecting eye movements, facial expression, swallowing, and breathing), Moderate Persistent Asthma (a chronic condition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to administer Covid-19 (an infectious respiratory disease caused by the SARS-CoV-2 virus) vaccine to one out of five sampled residents (Resident 46) when Resident 46 did not receive the Covid-19 vaccine.This failure put Resident 46 at risk for serious health related illness and/or death. Findings:A review of Resident 46's record titled admission RECORD indicated, Resident 46 was admitted to the facility on [DATE], with diagnoses which included Myasthenia Gravis (a chronic autoimmune disorder causing fluctuating weakness in voluntary muscles, commonly affecting eye movements, facial expression, swallowing, and breathing), Moderate Persistent Asthma (a chronic condition characterized by daily symptoms, nightly awakenings more than once a week, and reduced lung function, requiring daily long-term control medication) and Muscle Weakness ( a reduced capacity to exert force, often causing a feeling of fatigue, heaviness, or difficulty moving limbs).A review of…

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

Based on interview, and record review, the facility failed to ensure allegations of abuse were reported within two hours for one of four sampled residents (Resident 1) when an allegation of staff to resident abuse on 2/20/26 was reported to the Department on 2/25/26.This failure had the potential for Resident 1 to experience continued abuse and not having an advocate available to protect Resident 1 rights.Findings:A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses which included muscle weakness and osteoporosis (a common disease that makes bones weak, brittle, and porous, significantly increasing the risk of fractures).A review of the facility document titled, REPORT OF SUSPECTED DEPENDENT ADULT/ELDER ABUSE [SOC 341], dated 2/20/26, for Resident 1, indicated it was not faxed to the department until 2/25/26 at 4:42 PM.During an interview on 3/11/26, at 9:57 AM, with the Director of Nurses (DON), the DON stated the facility did not have a fax confirmation indicating the SOC 341 was faxed to the Department and the Ombudsman (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 ensure one of four certified nursing assistants (CNAs) had the required competencies to work with residents in the facility, when CNA 2 was not provided orientation and did not have an employee file with the facility. This failure placed residents in the facility at risk for receiving care from staff that did not meet the competencies in skills and techniques required to care for resident needs residing in the facility. Findings:During a concurrent interview and record review on [DATE], at 2:23 PM, with the Account Payable/Payroll Coordinator (AP/PR Coord), the AP/PR Coord stated the facility did not have an employee file for CNA 2. A review of the facility document titled, EMPLOYEE FILE CHECKLIST, dated [DATE], indicated, .Hiring Documentation Application .Resume Reference Checks .Offer Letter .Background Authorization Form .Copy of License/Certificate License/Certificate website print out .Copy of CPR card .Picture ID .Orientation Checklist .Signed…

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

Based on interview and record review the facility did not maintain complete personnel records when the initial tuberculosis (TB, a contagious lung disease) screening was not done at the time of hire for one of three sampled nursing staff (Nursing Assistant 1).This failure had the potential to expose staff and residents to tuberculosis, negatively impacting their health and well-being.During a concurrent interview and record review on 3/4/26 at 12:16 p.m. with the Payroll Coordinator (PC), Nursing Assistant (NA) 1's employee personnel record (a structured, secure record that details an employee's relationship with the facility from hiring to offboarding) was reviewed. The PC verified NA 1 was hired on 11/25/25 and NA 1's initial TB test screening (a TB skin test or a blood test to detect infection) was not in NA 1's record.During an interview on 3/4/26 at 1:55 p.m. with the Infection Preventionist (IP), the IP stated testing the nursing staff for TB was important because the residents are immunocompromised (easily susceptible to infection) and risk of contracting TB.During a…

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

Based on observation, interview, and record review, the facility failed to provide needed care and treatment to three out of six sampled residents (Resident 1, Resident 2, and Resident 3) when:1. Resident 1's clinical record did not indicate ADL (activities of daily living-essential self-care tasks such as bathing, dressing, eating) care was provided 12 out of 19 days during the day shift, 1 out of 19 days during the evening shift, and 5 out of 19 days during the night shift for a period from 2/1/26 through 2/19/26;2a. Resident 2's clinical record did not indicate treatment to a stage 3 pressure ulcer (a serious, full-thickness skin injury extending through the dermis into the subcutaneous fat layer) to coccyx (tailbone) was provided 3 out of 19 days from 2/1/26 through 2/19/26; and,2b. Resident 3's clinical record did not indicate treatment was provided to a stage 4 pressure ulcer (most severe level of skin damage, characterized by full-thickness tissue loss exposing underlying muscle, tendon, ligament, or bone) to left shoulder and left hip, and an unstageable (a severe…

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

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program when on 2/11/26 an inspection of the facility, the kitchen, and the food storage areas were not maintained per recommendations from the facility's pest control service for a census of 114.This failure had the potential to spread infection and disease. In addition, this failure increased the risk of unsafe and unsanitary living conditions for the residents, staff, and visitors.Findings:During a review of the pest control documents provided by the facility, dated 2/6/26, the following issues were identified in the kitchen and food storage/pantry areas in October 2025 that were still not addressed during the last inspection by the pest control company on 2/6/26: . Condition: Food debris on shelf. Date created 10/3/2025, Last inspected 02/06/2026.Recommendation: Clean and sanitize shelving to prevent pests and contamination.Condition: Food particles and debris under ovens, fryers [and] coolers provide food for rodents, ants and cockroaches. Date Created 10/03/2025, Last…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 activities of daily living (ADL) were provided to maintain good hand and fingernail hygiene for two of four sampled residents (Resident 2 and Resident 4) when on 2/11/26:1. Resident 2 had long fingernails with a brown substance embedded under them; and2. Resident 4 had dirty hands and fingernails with long sharp edges and contained a dark brown substance embedded under them. In addition, Resident 4 was not assisted, asked, or educated on why it was important to perform hand hygiene before eating his lunch meal.These failures had the potential for Resident 2 and Resident 4 to cut their own skin, or the skin of others, which could lead to infection from harboring microorganisms (bacteria, viruses, or fungus) due to poor hand and fingernail hygiene.Findings:1. A review of Resident 2's Minimum Data Set (MDS -an assessment and care screening tool) dated 1/26/26, indicated, Resident 2 was independent and able to make reasonable decisions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 foot care for one of four sampled residents (Resident 4) when Resident 4 had long, overgrown, and discolored toenails with sharp edges on his left foot, and staff did not follow their facility process and doctors order (a specific actionable instruction given by a healthcare provider for a patients treatment or care) to provide nail care.This failure resulted in Resident 4 not being able to wear a sock or shoe on his left foot due to the pain the long toenails caused. This failure had the potential to affect Resident 4's foot health.Findings:A review of Resident 4's admission record indicated Resident 4 was admitted to the facility with diagnoses that included but not limited to, hemiplegia and hemiparesis affecting the left non-dominant side (weakness or total loss of movement on one side of the body) and peripheral vascular disease (a slow progressive circulation disorder involving the narrowing, blockage, or spasms in the 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.

Based on observation, interview, and record review, the facility failed to properly dispose of and refuse their garbage for a census of 115 residents when:1. Garbage area was not maintained in a sanitary condition; there was a trash bag filled with residents' personal trash (used diapers and other trash) left on the ground outside of the garbage dumpster container,2. There were used Personal Protective Equipment (PPE- equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses such as gloves and masks) left scattered on the ground in the garbage area outside of the dumpster; and,3. Dumpsters were not covered, and left open with overfilled trash bags.This failure had the potential to harbor feeding of pests, and spread infection amongst residents, threatening their health and well-being.Findings:1. During an observation on 1/16/26, at 9:41 a.m., outside of the facility near the parking area, at the dumpster containers area, there was scattered trash noted (couple of used masks and gloves, baby/sanitary wipes) left on the ground. There was also a…

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

Based on observation, interview, and record review, the facility failed to ensure adequate storage and labeling of medications and biologicals (complex medicines made from living organisms that treat diseases by targeting specific part of the immune system) for a census of 115 residents when the treatment cart was left opened and unattended with residents' identifiable medications and biologicals.This failure had the potential for misuse of prescribed medications, risk for harm or injury to residents due to unsafe med storage practices. Findings:During an observation on 1/16/26, at 1:30 p.m., at the middle nursing station, near rooms 15A to 24B, the treatment cart was left opened and there were multiple residents observed pacing up and down the hallway floor. During an observation on 1/16/26, at 1:44 p.m., with Licensed Nurse (LN) 1, LN 1 walked down the hallway and locked the treatment cart.During a concurrent observation and an interview on 1/16/26, at 1:46 p.m., with LN 1, LN 1 confirmed, the treatment cart was left opened and it had prescription creams, Betadine (a widely used…

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

Based on observation, interview, and record review, the facility failed to provide adequate care and services to promote healing and prevent pressure ulcers (a localized injury to the skin and/or underlying tissue because of pressure) for two of three sampled residents (Resident 1 and Resident 2), when both residents were observed lying on low-air loss mattresses (LAL mattress, a mattress designed to prevent and treat pressure wounds that uses a continuous, gentle flow of air through a surface of tiny holes to reduce pressure helping to prevent and treat skin breakdown and pressure wounds) that were not correctly adjusted according to Resident 1 and Resident 2's individual weights.These failures had the potential to place Resident 1 and Resident 2 at increased risk for developing pressure ulcers and/or skin breakdown.Findings:a. Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility originally in 2020 and re-admitted in the Summer of 2025 with multiple diagnoses including encounter for palliative care (a patient-centered care that provider focuses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 a care plan to reduce the potential risk of pressure injury for one of three sampled residents (Resident 1) when a low air loss mattress (LAL mattress, a mattress designed to prevent and treat pressure wounds that uses a continuous, gentle flow of air through a surface of tiny holes to reduce pressure helping to prevent and treat skin breakdown and pressure wounds) was not included in Resident 1's care plans. This failure had the potential to place Resident 1 at risk for possible skin complications and not receiving effective and person-centered care. Findings: Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility originally in 2020 and re-admitted in the Summer of 2025 with multiple diagnoses including encounter for palliative care (a patient-centered care that provider focuses on improving quality of life for serious illnesses, managing symptoms such as pain, anxiety, fatigue, offering emotional/spiritual support, working alongside curative treatments), senile…

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

Based on interview and record review, the facility failed to protect the rights of two of 4 sampled residents (Resident 3 and Resident 6) to be free from physical abuse when:1. Resident 1 with a history of multiple resident-to-resident altercations, made racial slurs and pushed Resident 6 on 9/18/25; and,2. Resident 4 hit Resident 3 in the face on 8/30/25. These failures resulted in Resident 3 sustaining an injury to her mouth and Resident 6 falling from his wheelchair. Findings:1. A review of Resident 1' s medical record titled, admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses including paranoid schizophrenia (a mental health condition that is characterized hearing and seeing things that are not real), insomnia (persistent problems falling and staying asleep), major depression disorder ( a mental health disorder characterized by depressed mood or loss of interest in activities), and anxiety disorder (a mental health conditions characterized by excessive and persistent worry, fear, and nervousness).A review of Resident 1's medical record 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 Based on interview and record review, the facility failed to develop a comprehensive care plan for one of three sampled residents (Resident 1) when:1. Resident 1 was readmitted on [DATE] to the facility with new skin issues; and, 2. Resident 1 had known skin scratching behavior. These failures placed Resident 1 at risk for further skin breakdown and potential worsening of the existing skin issues due to the skin scratching behavior. Findings:1. Review of Resident 1's medical record titled, admission RECORD, indicated Resident 1 was admitted to the facility in mid-2025 with diagnoses that included type 2 diabetes mellitus (a condition when the body cannot control blood sugar levels), end stage renal disease (when they kidneys are no longer able to function on their own to filter waste and excess fluid from the body) and dependence on renal dialysis (a treatment to filter waste and excess fluid from the blood).Review of Resident 1's medical record titled, Body Check. dated 10/30/25, indicated .Body Check completed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 medical records were complete and accurately documented for one of three sampled residents (Resident 1 and Resident 2) when: 1. Resident 1's Treatment Administration Record (TAR) report for 11/2025 had missing documentation from a licensed nurse on multiple treatment orders; and, 2. Resident 2's TAR report for 11/2025 had missing documentation from a licensed nurse for the stage 3 pressure ulcer treatment to her coccyx (a deep wound on the tailbone area). These failures had the potential for both Resident 1 and Resident 2's medical records to have insufficient information to determine if treatment orders were being carried out as ordered and could place both residents at risk of complications. Findings:1. Review of Resident 1's medical record titled, admission RECORD, indicated Resident 1 was admitted to the facility in mid-2025 with diagnoses that included type 2 diabetes mellitus (a condition when the body is unable to regulate blood sugar levels), end stage renal disease (a condition when they kidneys are no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure one out of three sampled residents (Resident 1) was provided with adequate pain management when Resident 1's new pain medication order was not carried out by the facility for 35 days. This failure contributed to Resident 1 experiencing pain and had the potential to cause unnecessary psychosocial distress.A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses including palliative care (If an illness that cannot be cured, palliative care makes the person comfortable as possible by managing pain and other distressing symptoms), dementia (affecting a person's ability to remember, think, and make decision), mild neurocognitive disorder (a condition where a person's memory or thinking skills have slightly declined), history of falling, and legal blindnessDuring a phone interview on 9/23/25, at 12:37 PM, with Family Member (FM) 1, FM 1 stated she went to the facility on September 17 to visit…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 four sampled residents (Resident 1) was free from involuntary seclusion (a type of abuse that includes separation of a resident from other residents or from her/his room or confinement to her/his room) when Certified Nursing Assistant (CNA) 1, placed and sat in a chair in Resident 1's doorway, blocking Resident 1 from exiting her room during the 9/17/25 night shift (NOC shift).This failure had the potential to result in physical injury and psychosocial trauma (lasting emotional and psychological distress caused by a distressing event) for Resident 1.Findings:A review of Resident 1's admission RECORD, dated 9/22/25, indicated Resident 1 was initially admitted to the facility with diagnoses which included Alzheimer's Disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline), Dementia (a group of conditions that cause a gradual decline in cognitive abilities, such as memory,…

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

Based on interview and record review, the facility failed to report an allegation of abuse directly to the facility administrator and to the Department (a state agency that licenses, regulates, and inspects skilled nursing facilities (SNFs) to ensure they comply with state and federal regulations) within two hours after the suspicion of abuse was recognized on 9/18/25 by facility staff for one of four sampled residents (Resident 1).This failure delayed the facility and the Department's abuse investigation, potentially allowing continued abuse of Resident 1 and other residents, or causing further psychosocial harm.Findings:A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses which included Alzheimer's Disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline) Unspecified Dementia (a group of conditions that cause a gradual decline in cognitive abilities, such as memory, thinking, language, and judgment, severe enough to interfere with daily life), Moderate with Other Behavioral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate supervision for one of four sampled residents (Resident 1) with known Dementia (generally involves memory loss) and wandering behaviors when Resident 1 wandered into other resident rooms and walked throughout the facility without supervision.This failure placed Resident 1 at risk for elopement (when a resident leaves the facility without authorization, supervision, or a planned discharge), injury, and/or serious physical harm.Findings:During a telephone interview on 9/22/25 at 10:25 a.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated she worked on the night shift (NOC) at the facility and consistently observed Resident 1 wandering in the hallways of the facility. CNA 2 further stated, Resident 1 had known wandering behaviors while awake and staff would call Resident 1 by name. CNA 2 continued, Resident 1 would sometimes go into other resident rooms, but with redirection would go back into a hallway. CNA 2 stated,…

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

Based on interview and record review, the facility failed to protect one of three sampled residents (Resident 1) from abuse when Resident 2, who was assigned one-on-one supervision (a single staff member is assigned to be in constant physical proximity to a resident to ensure their safety and provide immediate assistance), was left alone for a period of time and Resident 2 entered Resident 1's room, hitting him with a wheelchair footrest on 8/20/25.These failures had the potential to negatively affect Resident 1's health and psychosocial well-being. Findings:A review of Resident 2' s medical record titled admission RECORD, indicated Resident 2 was admitted to the facility with diagnoses including paranoid schizophrenia (a mental health condition that can cause one to struggle to interpret what's real and what is not), insomnia (persistent problems falling and staying asleep), major depression disorder (a mental health disorder characterized by depressed mood or loss of interest in activities), and anxiety disorder (a mental health conditions characterized by excessive and persistent…

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

Based on interview and record review, the facility failed to ensure resident medical records were complete and accurately documented for one of three sampled residents (Resident 2) when, Resident 2's every 15-minute safety checks were not consistently documented on by staff for the dates of 8/18/25, 8/20/25, and 8/25/25.This failure had the potential to result in information not being available to ensure accuracy or communication across health care professionals and did not provide for an accurate representation of actual events that occurred to ensure Resident 2's care plan goals and interventions were being met. Findings:A review of Resident 2' s medical record titled admission RECORD, indicated Resident 2 was admitted to the facility with diagnoses including paranoid schizophrenia (a mental health condition that can cause one to struggle to interpret what's real and what is not), insomnia (persistent problems falling and staying asleep), major depression disorder (a mental health disorder characterized by depressed mood or loss of interest in activities), and anxiety disorder (a…

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

Based on observation, interview, and record review, the facility failed to ensure necessary doctor's orders and equipment monitoring were in place for an implemented pressure ulcer/injury (PU/PI; refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence) intervention for one of three residents (Resident 4) when, Resident 4 did not have an order for a Low Air Loss Mattress (LAL - alternating pressure and air circulation, which improves blood flow) to include equipment settings (typically based on the patient's weight, pressure sore risk, and skin condition) specific to Resident 4 and there was no documented monitoring to ensure the proper overall function and correct settings of the LAL mattress Resident 4 was using.This failure had the potential for Resident 4 to experience further skin breakdown.Findings:During a review of Resident 4's admission RECORD, the record indicated Resident 4's admission diagnosis included acute respiratory failure with hypoxia (a condition wherein the lungs cannot adequately transfer oxygen to the 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.

Based on observation, interview, and record review, the facility failed to provide appropriate behavioral health treatment and services to meet the psychosocial needs for one of three sampled residents (Resident 1) when: 1. Resident 1 displayed episodes of anger, and repeated resident to resident altercations, and Resident 1's Psychiatric Initial Eval, (a comprehensive evaluation focused on the diagnosis, treatment and prevention of mental, emotional and behavioral disorders) dated 12/10/24, included treatment goals and recommended follow-up psychiatric visits were not provided, nor documented in Resident 1's clinical health record; 2. Resident 1's Physician Progress Notes, dated 3/14/25, 4/1/25, 4/29/25, 5/9/25, and 5/30/25 indicated an assessment and plan for monitor and follow-up with psychiatry, and Resident 1 was not provided psychiatry consultation or visits until 6/9/25; 3. Resident 1's PASRR Individualized Determination Report (PASRR - a federally required screening process designed to ensure that individuals with serious mental illness (SMI), intellectual disability (ID),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 respect the resident's right to personal privacy for one of three sampled residents (Resident 4) when Certified Nursing Assistant (CNA) 1 and CNA 2 performed social media live streaming (the real-time broadcasting of video and audio content over the internet, allowing viewers to interact with the content creator as it is happening) in Resident 4's room during resident care activities. This failure had the potential to result in Resident 4 feeling a lack of privacy and hopelessness.Findings:A review of Resident 4's admission Record indicated that Resident 4 was admitted to the facility in 2025 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), End Stage Renal Disease (failure of the kidneys to function normally), and Aphasia (loss of ability to produce or understand language).During a concurrent observation and interview, on 8/15/25, at 10:21 a.m., in Resident 4's room, Resident 4 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 provide appropriate care and services with the use of enteral feeding (tube feeding, TF - the delivery of nutrients through a tube inserted directly into the stomach) for one resident (Resident 4) when Resident 4's tube feeding bag and tubing (containing nutrients to be delivered by a mechanical pump delivery system at a prescribed rate of flow) did not indicate the date and time it was put into use.This failure had the potential to produce bacterial growth in the tube feeding solution resulting in an infection.A review of Resident 4's admission Record indicated that Resident 4 was admitted to the facility in 2025 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), End Stage Renal Disease (failure of the kidneys to function normally), and Aphasia (loss of ability to produce or understand language). A review of Resident 4's Physician Order Summary, dated 6/5/25, indicated, .every shift Nepro…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 environment remained free of accidents or hazards for one of five sampled residents (Resident 4) when, remnants of a broken rail on the wall near Resident 4's bed with splintered wood and protruding screws were not removed.This failure had the potential to result in injury to Resident 4, facility staff, and visitors.Findings:A review of Resident 4's admission RECORD, indicated that Resident 4 was admitted to the facility with diagnoses which included major depressive disorder (a persistent feeling of sadness and loss of interest that can interfere with activities of daily living) and spinal stenosis (happens when the space inside the backbone is too small. This can put pressure on the spinal cord and nerves that travel through the spine).During a concurrent observation and interview on 7/22/25, at 12:50 p.m., with Licensed Nurse (LN) 2 in Resident 4's room, there was two square wood pieces on the wall near Resident 4's bed with splintered wood and protruding screws. LN 2 stated that she did not…

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

Based on interview, and record review, the facility failed to maintain acceptable parameters of nutrition for four of four sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4) when:1. Resident 1's order for daily weight checks for one week and then twice a week weight checks for one month was not carried out, and;2. Resident 2, Resident 3, and Resident 4's weekly weight checks were not completed during their first month of admission.These failures had the potential for Resident 1, Resident 2, Resident 3 and Resident 4's weight loss or weight gain to go undetected, which could result in a delay in their treatment/interventions and have a negative effect on their health and functional status. Findings:1. A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility in 2025 with diagnoses that included congestive heart failure (CHF - a condition when the heart cannot pump enough blood well to supply the body), hypertension (high blood pressure), chronic kidney disease (CKD - a long term condition where the kidneys are not working…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure one out of three sampled residents (Resident 1) was assessed for risk of substance abuse (a condition characterized by use of substances, such as illicit drugs, despite negative consequences) when the electronic medical record did not reflect a history of substance abuse and no nursing plan of care was initiated upon admission. This failed practice may have contributed to health hazards when Resident 1 tested positive for possible illicit drug use as manifested by a sudden change in vital signs, mental status, and a hospital emergency room admission. Findings: During a review of Resident 1's electronic medical record titled, History and Physical (H&P), dated 9/3/24, the record indicated Resident 1 was admitted to the facility on [DATE], for generalized weakness, was wheelchair bound with back injury, had blood pressure and a history of methamphetamine use (often referred to as meth use, refers to the consumption of methamphetamine, a highly…

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

Based on observation, interview, and record review, the facility failed to protect four of nine sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4) to be free from abuse (verbal, mental, or physical abuse) when: 1. Resident 1 struck the left side of Resident 2's face on 3/10/25; 2. Resident 1 open handed slapped Resident 3's forehead on 3/18/25; 3. Resident 1 hit Resident 3's right ear on 3/24/25; and 4. Resident 4 had a verbal altercation with Resident 1 and Resident 4 kicked Resident 1's knee on 4/17/25. These failures removed Resident 1, Resident 2, Resident 3, and Resident 4's right to be free from abuse and had the potential to result in psychosocial outcomes. Findings: During an interview on 4/14/25, at 1:46 p.m., Resident 3 stated, . some Vietnam man tried to hit me here, Staff move him away from me . During an interview on 5/22/25, at 9:48 a.m., Resident 1 stated, .sometimes I get angry. Vietnamese guy make me angry . During an interview on 4/14/25, at 1:14 p.m., Certified Nurse Assistant (CNA) 1 stated, Resident 1 had been on one-to-one care (1:1; 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure residents remained free from neglect when activities of daily living (ADLs, essential self-care tasks related to personal care such as dressing, eating, bathing, grooming, and toileting) were not provided for two of the three sampled residents (Resident 1 and Resident 2) when: 1. Certified Nursing Assistant (CNA) 1 left Resident 1 in a soiled incontinent (involuntary loss of urine or feces) brief (adult diaper, provides maximum absorbency for incontinence) for two hours; and, 2. CNA 1 left Resident 2 without completing incontinent care and CNA 1 slapped/tapped Resident 2's right leg with an open hand after Resident 2 asked CNA 1 to not touch her legs due to pain. These failures resulted in Resident 1 and Resident 2 not being well-groomed and had the potential to cause skin breakdown (tissue damage caused by friction (when skin is rubbed or dragged over another surface such as bed sheets or clothing), shear (occurs when forces in opposite…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two out of three sampled residents (Resident 1 and Resident 2) were safe from accidental hazards when Activity Assistant (AA) 1 gave an illegal substance (joint/gummie/marijuana/cannabis) to Resident 1 and Resident 2. This failure posed potential risks to Resident 1 and Resident 2's safety, potential drug interactions with prescribed medications, risk for falls, and changes in level of consciousness for Resident 1 and Resident 2. Findings: A facility reported incident dated 4/8/25, indicated AA 1 provided an edible (cannabis gummy) to Resident 1 and Resident 2 over the weekend. a. Review of Resident 1 ' s admission RECORD indicated Resident 1 was admitted to the facility with diagnoses including hypertension (high blood pressure) and chronic obstructive pulmonary disease (COPD: a condition caused by damage to the airways or other parts of the lung), and diabetes mellitus with diabetic neuropathy (a type of nerve damage that occurs from high…

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

Based on observations, interviews, and record review, the facility failed to protect resident ' s right to be free from physical abuse by a resident for two of five sampled residents (Resident 1 and Resident 5) when: 1. Resident 2 splashed water on Resident ' s 1 face; and 2. Resident 2 spit on Resident 5. This failure resulted in Resident 1 feeling uncomfortable and had the potential to affect Resident 1 ' s and Resident 5 ' s psychosocial well-being. Findings: Review of Resident 1 ' s admission RECORD, indicated Resident 1 was admitted to the facility with a diagnosis of post-traumatic stress disorder (PTSD, a mental health condition that can develop after experiencing or witnessing a traumatic event) and bipolar disorder (a mental health condition characterized by significant and persistent shifts in mood, energy, and activity levels, often involving periods of extreme highs (mania) and lows (depression)). Review of Resident 2 ' s admission RECORD, indicated Resident 2 was admitted to the facility with diagnosis of major depressive disorder (persistently depressed mood or loss of…

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

Based on interview and record review, the facility failed to implement corrective action for one of five sampled residents (Resident 1) when the recommended services following a facility investigation related to a resident to resident physical abuse allegation when, the Interdisciplinary Team (IDT; a group of healthcare professionals) recommended a psychological evaluation (a comprehensive assessment of an individual's mental health and cognitive abilities conducted by a qualified mental health professional like a psychologist or psychiatrist) for Resident 1 following a resident-to-resident altercation that occured on 12/29/24 and Resident 1 had also requested a psychological evaluation, but the psychological evaluation was not initiated. This failure had the potential to negatively affect Resident 1's psychosocial well-being. Findings: Review of Resident 1 ' s admission RECORD, indicated Resident 1 was admitted to the facility with a diagnosis of post-traumatic stress disorder (PTSD, a mental health condition that can develop after experiencing or witnessing a traumatic event) 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 protect the rights of two residents (Resident 5 and Resident 6) to be free from unreasonable confinement when Certified Nursing Assistant (CNA 7) tied the room door with a garbage bag to prevent Resident 5 from leaving the room shared with his roommate (Resident 6). This failure had the potential to negatively impact Resident 5's and Resident 6's sense of dignity and well-being. Findings: A review of Resident 5's admission Record, indicated Resident 5 was admitted to the facility in 2024 with diagnoses which included dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), anxiety (a nervous disorder characterized by a state of excessive easiness and apprehension that interferes with daily living), and a history of falling. A review of Resident 5's electronic medical record (EMR) indicated that Resident 5's Responsible Party (RP, family member) and physician were notified of the incident on 2/5/25. A review of Resident 6'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 maintain a sanitary and comfortable facility interior for two of two sampled bathrooms when, two jack and [NAME] bathrooms (a bathroom shared between two bedrooms, with doors entering from each room) that were intended for use for eleven residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, and Resident 11) were noted in disrepair with large areas of peeling paint behind the toilet, an open gap behind the toilet, missing baseboards, and a chipped trim counter located at the front of the sink. These failures did not provide a homelike environment for Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, and Resident 11 with the potential to result in injury and/or negative psychosocial outcomes. Findings: During a concurrent observation and interview on 1/6/25, at 3:29 PM, the Maintenance Director…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 implement and revise a person-centered care plan for one of two sampled residents (Resident 1) when, Resident 1's fall care plan interventions of a bedrail, call light within reach, and the bed in the low position was not implemented. This failure had the potential to be a safety risk which could result in Resident 1 falling, negatively impacting Resident 1's health and wellbeing. Findings: Review of Resident 1's actual fall care plan, initiated on 5/13/24, in the section Focus indicated, .hx [history] of fall(s) w/ [with] recent major injury .poor memory, bouts of confusion, poor safety awareness, impulsive, attempts to get up and out of bed/chair without staff assistance . During a concurrent observation and interview on 1/6/25, at 3:01 PM, Licensed Nurse (LN) 1 confirmed Resident 1 was in bed and Resident 1's bed was not in the lowest position. LN 1 confirmed Resident 1's call light was draped in the bottom drawer in the nightstand located to the left of Resident 1's bed. LN 1 stated Resident 1 would not…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were maintained for food storage according to standards of practice and facility policy when: 1a. Resident drinking glasses were not clean; 1b. Utensils were stored in dirty utensil bins; 1c. A dirty vent was blowing into the food area; 2. Pantry contained expired foods; 3. Grilled cheese sandwiches were stored in the oven overnight and were available for resident consumption; 4. Food temperatures were not written down accurately on 12/11/24 for the breakfast meal; 5. Kitchen staff did not wear hair nets appropriately; 6. Incorrect portion sizes were plated for two residents (Resident 83 and Resident 22) for lunch on 12/11/24; and, 7. Lunch meal on 12/11/24 did not have safe food temperatures recorded. These deficient practices exposed 98 of 105 facility residents who consume food from the kitchen to potentially harmful substances which could have led to widespread foodborne illness. Findings: 1a. During a concurrent observation and interview on 12/9/24, at 9:40 AM, with…

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

Based on interview, and record review, the facility failed to ensure a process was in place to address and follow-up on resident concerns following Resident Council meetings (a gathering of residents who come together to discuss concerns, share information, and make decisions) for a census of 105. This failure resulted in multiple concerns from residents to go unresolved, with the potential to negatively impact their self-worth, self-esteem, and physical health. Findings: A review of the resident council notes supplied by the facility for May 2024, June 2024, July 2024, August 2024, September 2024, and November 2024, indicated concerns to be addressed by Maintenance, Dietary, Laundry/Housekeeping, Nursing, CNA [certified nursing assistants], and Activities. Of the six departments where residents indicated there were issues, one of six departments responded; Dietary in May, June and July. There was no documentation of responses from the other five departments, no consistency in listing residents who attended the meetings, and repeat issues were as follows: CNA: Timely personal 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 protect resident rights to be free from mental and sexual abuse and misappropriation of property for 3 of 41 sampled residents (Unsampled Resident 2, Unsampled Resident 1, and Resident 17) when: 1. Resident 82, with a history of inappropriate sexual behavior towards male staff and Unsampled Resident 2, was left alone with Unsampled Resident 2 in the dining/activity room on 7/22/24, at approximately 4 a.m., and touched his private area without his consent; 2. Licensed Nurse (LN) 2 videotaped Unsampled Resident 2 with her personal cell phone, without Unsampled Resident 2's consent, and posted the video, along with disparaging comments about Unsampled Resident 2's sexuality on a group text message which included twenty-three facility licensed nurses and two other staff members on 9/11/24 at 4:59 a.m.; and, 3. An undetermined amount of narcotic pain medication (used to treat moderate to severe pain and can be addictive) were found to be diverted (when healthcare providers obtain or use prescription medicines…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 three of 41 sampled residents (Resident 5, Resident 58, and Resident 89), per facility policy and each residents comprehensive plan of care when: 1. Resident 5 did not have available fluids to drink at bedside; and, 2. Resident 58 did not have available fluids to drink at bedside; and, 3. Resident 89 did not have available fluids to drink at bedside. These failures had the potential to result in altered hydration status, and complications associated with fluid imbalance (when the body loses or gains too much water/fluids) for Resident 5, Resident 58, and Resident 89. Findings: 1. During a concurrent observation and interview in Resident 5's room on 12/9/24 at 4:40 PM, Resident 5 was observed to not have any fluids to drink or available at bedside. During a concurrent observation and interview in Resident 5's room on 12/9/24 at 4:45 PM, Certified Nursing Assistant (CNA) 11 confirmed Resident 5 did not have water available to drink at 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 ensure: 1. Controlled substance medications (medication with a high potential for abuse and addiction) were accurately accounted for on the medication administration record (MAR) and the Controlled Drug Record (CDR) for two of two randomly selected residents (Residents 85 and 101); 2. Ensure the availability of routine medication for 1 of 41 sampled residents (Residents 65); and, 3. Hazardous medications (hazardous drugs (or HD), drugs that pose short- or long-term harm upon exposure to humans via skin or inhalation per manufacturer specification) were not labeled and handled safely with appropriate accessory and cautionary instructions. These failures resulted in the facility not safely handling hazardous medications, not having accurate accountability of controlled medications and potential for abuse or misuse of these medications, and the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions. Findings: 1. Resident 85 had a physician's order dated 8/5/23, for…

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

Based on observation, interview, and record review, the facility failed to ensure safe medication administration practices when the medication error rate was more than 5% (% or percentage- number or ratio that expressed as a fraction of 100) with a resident census of 105. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of five errors out of 33 opportunities which resulted in a facility wide medication error rate of 15.15% in 3 out of 10 residents (Resident 16, Resident 58, and Resident 65) observed for medication administration. These failures may result in unsafe medications use affecting residents' health and well-being. Findings: 1. During a medication administration observation, accompanied by Licensed Nurse (LN) 16, in facility's South station, LN 16 administered a total of 6 medications to Resident 16 including a pain medication called Tylenol (or acetaminophen) as requested by the resident. During a review of Resident 16's MAR (Medication Administration Record- a…

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

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled and stored in accordance with currently accepted professional principles for a resident census of 105 when: 1. Expired and used single-use medications were identified in medication carts and storage rooms; 2. Medications with shorter expiration dates after first use were not labeled with opened dates; 3. Medications requiring refrigeration were stored at room temperature; 4. Prescription medications with incomplete or missing labels were available for use in facility stock; and, 5. A treatment cart was left unlocked in the hallway during wound care. These failures could contribute to unsafe medication use, storage, and result in medication errors that could affect the well-being of the residents. Findings: 1. During a medication cart inspection on 12/9/24, at 10:31 AM, with Licensed Nurse (LN) 9, at the south nursing station, the south medication cart 1 was inspected. The following items were observed to have been expired and/or were single-use…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 105, when: 1. Resident 5, Resident 38, Resident 56 and Resident 48 had visibly soiled curtains in their rooms; 2. Resident 50, Resident 55 and Resident 75 had a missing bathroom vent cover (covering holes from the ventilation system); 3. Treatment Nurse (TN) did not perform hand hygiene when gloves were removed after wound care; 4. The facility did not ensure glucometers (device to measure blood sugar) were cleaned and sanitized; 5. The facility did not clean, sanitize, and disinfect an automatic blood pressure machine (a device to measure a person's blood pressure), after resident use; 6. The facility did not clean, sanitize, and disinfect the pill cutter (a device used to split a pill); and, 7. The facility did not clean, sanitize, and disinfect the pulse oximeter (a medical device that measures the oxygen in the blood) after resident use., These failures had the potential to spread infection and cause health problems for the…

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

Based on interview, and record review, the facility failed to provide documented evidence of education for immunizations (a process whereby a person is made resistant to a disease by the administration of vaccines (shots)) when five of five sampled residents (Resident 34, Resident 31, Resident 69, Resident 38, and Resident 85) clinical records did not contain documented evidence of education for receiving or refusing the COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) vaccination. This failure had the potential for Resident 34, Resident 31, Resident 69, Resident 38, and Resident 85 to not be aware or informed of the benefits, risks, and potential side effects of the COVID-19 vaccination prior to receiving or declining the vaccination. Findings: During a concurrent interview and record review on 12/11/24 at 10:15 AM, with the Infection Preventionist (IP), the IP completed a record review for Resident 34, Resident 34, Resident 69, Resident 38, and Resident 85 and confirmed that their medical records did not contain documented evidence of education for the COVID-19 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 there was a functioning call light system (system/device used by residents to call staff for assistance) for five of 41 sampled residents when: 1. Resident 35 did not have a functioning call light and an alternative means to call for assistance was not provided; and, 2. Resident 36 did not have a functioning call light; and, 3. Resident 5 did not have a functioning call light; and, 4. Resident 50 did not have a functioning call light and an alternative means to call for assistance was not provided; and, 5. Resident 58 did not have a functioning call light. These failures had the potential to result in Resident 35, Resident 36, Resident 5, Resident 50, and Resident 58 being unable to call staff for help when needed, and their physical and emotional needs not being met. Findings: 1. During a concurrent observation and interview in Resident 35's room on 12/9/24 at 8:57 AM, Resident 35 was observed crying. Resident 35 stated she was bed bound (someone who is unable to move around safely or confined 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 observation, interview, and record review, the facility failed to have an effective pest control program for six of forty-one sampled residents (Resident 36, Resident 50, Resident 55, Resident 75, Resident 84, Resident 100) when multiple live cockroaches were observed on the counter and floor in the residents' shared bathroom (three residents in each room with a shared bathroom between the rooms). This failure had the potential to spread a variety of diseases and bacteria throughout the facility to its residents, staff, and visitors. Findings: Review of [name redacted, Pest Control] Work Order Summary, dated, 9/20/24, indicated the service was an initial service and areas of the facility serviced were the dishwashing area, food storage/pantry area, kitchen, kitchen-stove/oven line, and offices. The summary indicated German cockroaches (most common species of cockroach) were found in the dishwashing area. During a concurrent observation and interview on 12/9/24, at 10:49 a.m., Resident 55 was observed in his room, lying in his bed, and stated this morning his certified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 1of 41 sampled residents (Resident 26), was treated with dignity and respect when a staff member stood over Resident 26 while assisting Resident 26 with the lunch meal. These failures had the potential to negatively impact feelings of self-worth and self-esteem for Resident 26 and posed a safety issue. Findings: During a review of Resident 26's clinical record titled, admission RECORD, indicated Resident 26's diagnoses included dysphagia (difficulty swallowing). During an observation on 12/11/24, at 1:03 p.m., the Minimum Data Nurse (MDS - nurse who completed comprehensive assessments on the residents) stood next to Resident 26 (who was seated in a wheelchair) and spoon fed Resident 26 her lunch meal. Additional staff members assisted other residents with their meals, but they sat at eye level with the residents. During an interview on 12/11/24, at 1:10 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated staff were supposed to sit at eye level with Resident 26 while she was assisted with her…

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

Based on interview, and record review, the facility failed to accurately maintain confidential medical information for 1 of 41 sampled residents (Resident 109), when Resident 109's progress notes were uploaded into Resident 110's medical chart. This deficient practice increased the potential for Resident 109's privacy and confidentiality of personal medical information to be violated. Findings: During a review of Resident 110's Progress Notes, it was noted that Resident 109's medical information was uploaded into Resident 110's chart. During a concurrent interview and record review on 12/12/24, at 8:42 AM, with the Social Services Director (SSD), Resident 110's Progress Notes, were reviewed. The SSD confirmed that she wrote the progress note for Resident 109. The SSD further confirmed that Resident 109's progress note was in Resident 110's medical chart. The SSD acknowledged that she forgot to correct the mistake. The SSD stated that placing incorrect notes into the medical charts could affect both residents. The SSD further stated that wrong or incorrect information may be relayed.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 home-like environment for 1 of 41 sampled residents (Resident 51), when Resident 51's room did not have a curtain to the sliding glass door, and the screen for the sliding glass door was propped outside of the room. This failure resulted in Resident 51 expressing feelings of dissatisfaction with the facility, with the potential to negatively impact feelings of self-worth and self-esteem. Findings: During a concurrent observation and interview, on 12/9/24, at 12:43 PM, in Resident 51's room, the room was observed not to have a curtain up on the sliding glass door. It was further observed that the screen for the sliding glass door in Resident 51's room, was propped on its side outside the sliding glass door. Resident 51 stated he felt the quality of the facility was not adequate. Resident 51 explained there were issues that needed to be addressed. During an interview with the [NAME] President of Operations (VPO), on 12/12/24, at 2:47 PM, the VPO stated the curtains on a sliding glass door were…

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

Based on interview and record review, the facility failed to report the results of an investigation into an alleged resident-to-resident abuse incident to the Department, within 5 working days for two of 41 sampled residents (Resident 3 and Resident 79). This failure had the potential for the alleged abuse to reoccur and prevented the Department from initiating possible necessary action to protect Resident 3, Resident 79, and other residents in the facility. Findings: On 11/15/24 at 9:24 AM, the Department received notification of an alleged resident-to-resident physical abuse situation between Resident 3 and Resident 79, when during an argument in the hallway, Resident 3 allegedly poured water on Resident 79's head and pushed Resident 79 to the ground. During a concurrent interview and record review on 12/12/24 at 11:10 AM with the facility's Administrator (ADM), the ADM was unable to locate documentation of the five-day follow-up report. The ADM was also unable to find documentation or receipt the five-day follow-up was sent to the Department. The ADM further stated she 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a Comprehensive Care Plan (outlines a resident's care goals, interventions, and expected outcomes) for 3 of 41 sampled residents (Resident 52, Resident 89, and Resident 88) when: 1. A safety care plan was not developed for Resident 52 after Resident 52 left the faciity on 8/29/24 with an unauthorized caregiver without the facilities knowledge, was discovered at the hospital on 9/2/24, and was re-admitted to the facility again on 10/2/24; 2. Resident 88 did not have a hospice (special care given at the end of life) care plan in place; and 3. Resident 89 did not have a care plan developed to monitor for side effects and treatment of target behaviors related to the use of a medication called quetiapine (a medication to treat bipolar disorder-a serious mental illness). These failures had the potential for Resident 89, Resident 52, and Resident 88 to not receive appropriate care, services, and treatment. Findings: 1. Review of Resident 52's…

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

Based on observation, interview, and record review, the facility failed to ensure activities of daily living (ADL) were provided to maintain good hygiene for one of 41 sampled residents (Resident 56) when Resident 56's fingernails were long with sharp edges and contained a dark brown and yellow substance under the fingernails. This failure resulted in Resident 56's nails not being groomed, and the potential for injury due to sharp edges, and infection from harboring microorganisms (bacteria, virus, or fungus). Findings: A review of Resident 56's Minimum Data Set (MDS, an assessment and care screening tool), Functional Abilities, dated 10/8/24, indicated Resident 56 needed substantial/maximal assistance with personal hygiene and showering. During a concurrent observation and interview in Resident 56's room on 12/9/24 at 9:39 AM, Resident 56 was observed to be disheveled (untidy or disorderly) with matted hair, stains on his gown, and long, sharp, dirty finger nails with a dark brown and yellow substance under the nails. During an interview in Resident 56's room on 12/10/2024 at 2:41…

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

Based on observation, interview, record review, the facility failed to provide care and services for 1 of 41 sampled residents (Resident 50), when Resident 50 did not have a means to be mobile within the facility and was not fitted or provided a wheeled device to use. This failure had the potential to limit Resident 50's mobility within the facility, cause physical limitations and decline, and negatively impact his psychosocial (the mental, emotional, social, and spiritual effects of a disease) well-being. Findings: Review of Resident 50's admission RECORD, indicated Resident 50 was originally admitted to the facility in early 2021, with diagnoses including major depressive disorder (a persistent feeling of sadness and loss of interest that can interfere with activities of daily living), acquired absence (surgical amputation- surgical procedure that removes a part or all of a body part such as a limb, finger, toe, hand or foot) of other left toes, acquired absence (surgical amputation) of right leg above knee, hemiplegia and hemiparesis (weakness on one side of the body) following…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 implement interventions to manage pressure ulcers (areas of damaged skin caused by staying in one position for too long) for one of forty-one sampled residents (Resident 13), when Resident 13's pressure ulcer intervention of a wedge (a specially shaped pillow used to lift a specific part of the body off the bed to reduce pressure) was not replaced when the wedge was first identified as missing. This failure had the potential to further worsen Resident 13's pressure ulcer on his back. Findings: During a concurrent observation and interview with the Infection Preventionist (IP), on 12/12/24, at 12:09 PM, the IP verified that Resident 13 had a pressure ulcer on his back. The IP stated that Resident 13 had an order in place for using the wedge while in bed which was provided by hospice (compassionate care for people who are near the end of life). The IP confirmed that Resident 13 was laying on his bed without the wedge in place. The IP also confirmed that Resident 13 had a regular mattress with no other devices…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 forty-one sampled residents (Resident 50 and Resident 100) who had contractures (a permanent shortening of muscle, tendon, or scar tissue producing deformity or distortion) of their hands were wearing their hand splints as ordered by the physician, when, 1. Resident 50 had a physician order for a right hand splint (providing support and stability for the contracture area), dated 1/26/23, but never received it; and, 2. Resident 100 had a physician order for a brace for a hand contracture, dated 7/22/24, but never received it. These deficient practices placed the residents at risk of further loss of function and decline of their hand contractures. Findings: 1. Review of Resident 50's admission RECORD, indicated Resident 50 was originally admitted to the facility with diagnoses including but not limited to hemiplegia and hemiparesis (weakness on one side of the body) following other cerebrovascular disease affecting right dominant (after damage to one side of the brain, can cause memory and mobility issues).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 six of forty-one sampled residents were free from accidents and hazards when: 1. The facility did not provide adequate supervision to prevent an unauthorized care giver from taking Resident 52 without the facility's knowledge after the caregiver attempted twice to take Resident 52 out of the facility on 8/9/24 and 8/12/24; 2. Resident 51 did not have a safe and functioning mobility device installed in the bathroom. 3. The wanderguards (an alarm monitoring system) for four residents (Resident 91, Resident 60, Resident 79, and Resident 104) were not tested per manufacturers specifications. a. Resident 60 b. Resident 79 c. Resident 61 d. Resident 104 These failures could have resulted in the residents sustaining an injury by fire, entrapment (when a person is trapped by the bed rail in a position they cannot move from), falls, continuation of heath care not being delivered, and elopement (leaving the facility without the staff's knowledge). Findings: 1. Review of Resident 52's admission RECORD, indicated…

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

Based on observation, interview, and record review, the facility failed to ensure respiratory care provided was consistent with professional standards of practice for 2 of 41 sampled residents (Resident 14, and Resident 69) when an oxygen in use sign was not posted outside of the rooms for Resident 14 and Resident 69. These failures had the potential to result in negative impacts on the residents' health and safety. Findings: 1a. A review of Resident 14's clinical record titled, admission Record, indicated Resident 14's diagnoses included pneumonia (a lung infection that required supplemental oxygen for treatment). A review of Resident 14's clinical record titled, Orders, dated 11/18/24, indicated Resident 14 required 2 Liters (L=unit of measurement) of supplemental oxygen for shortness of breath. During an observation on 12/9/24, at 9:40 a.m., in Resident 14's room, an oxygen tank and compressor (used to produce supplemental oxygen) was observed on the floor by the right side of the bed. A review of Resident 14's clinical record titled, Care Plan, (a list of Resident 14's problems,…

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

Based on observation, interview, and record review, the facility failed to provide adequate pain management for one of 41 sampled residents (Resident 56) when Resident 56's pain medication was not given in a timely manner. This failure led to Resident 56 experiencing unnecessary pain and potentially affected his physical and psychosocial well-being. Findings: A review of Resident 56's admission Record, indicated he was admitted to the facility with diagnoses including, but not limited to, unspecified abdominal pain (pain in the abdomen where the cause is not identified) and other chronic pain (pain that lasts longer than three months). During an interview in Resident 56's room, on 12/9/24 at 9:29 AM, Resident 56 stated he was sore and in pain. Resident 56 pressed the call light (a device used to request assistance from staff) to request pain medication. At 9:32 AM Certified Nursing Assistant (CNA) 8 came into Resident 56's room. Resident 56 advised CNA 8 he was in pain and needed pain medication. CNA 8 stated to Resident 56 she would tell Licensed Nurse (LN) 9 about Resident 56's…

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

Based on observation, interview, and record review, the facility failed to provide appropriate behavioral health treatment and services to meet the psychosocial needs for one of forty-one sampled residents (Resident 50), when Resident 50 displayed episodes of anger and was refusing his treatments and medications, including his antipsychotic medication, and the resident's psychological evaluation (a comprehensive evaluation focused on the diagnosis, treatment and prevention of mental, emotional and behavioral disorders) and/or consultation was not provided as ordered by the physician on 10/29/22, 3/8/23, and 10/18/24. This deficient practice had the potential to negatively affect the Resident 50's psychosocial (the mental, emotional, social, and spiritual effects of a disease) well-being. Findings: Review of Resident 50's admission RECORD, indicated Resident 50 was originally admitted to the facility in early 2021, with a diagnosis including but not limited to major depressive disorder (a persistent feeling of sadness and loss of interest that can interfere with activities of daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure 1 of 41 sampled residents (Resident 89), was free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medication when Resident 89 received Seroquel (an antipsychotic to treat mental illness) without prescriber-documented rationale, attempted gradual dose reductions (GDR, a tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued), or implementation of non-pharmacological (non-drug) interventions in an effort to lower the dose or discontinue the medication. This failure had the potential to result in unnecessary use of medication. Findings: A review of Resident 89's medical record indicated she was admitted to the facility on [DATE] with diagnoses including vascular dementia (a type of cognitive decline caused by damage to the blood vessels in the brain) with other behavioral disturbance 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.

1. Based on interview, and record review, the facility failed to ensure 2 of 11 residents (Resident 33 and Resident 88) who received hospice care (end of life care) had their care coordinated between the facility and the hospice agency. These failures could have resulted in a failure to provide quality care to terminally ill residents (Resident 33 and Resident 88). Findings: 1a. During a review of Resident 33's clinical record titled, admission Record, indicated Resident 33's diagnoses included breast cancer and palliative care (comfort measures). A review of Resident 33's clinical record titled, Orders, dated 10/23/24, indicated Resident 33 was evaluated for hospice treatment. During an interview on 12/11/24, at 9:03 a.m., with Licensed Nurse (LN) 5, LN 5 acknowledged Resident 33 did not have any hospice progress notes in her Electronic Health Record (EHR) or in the hospice binder at the nurse's station. LN 5 stated there should have been hospice notes in the binder and the lack of coordination of care between the facility and hospice agency placed Resident 33 at risk for improper…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 four of five sampled residents (Resident 34, Resident, 31, Resident 38, and Resident 85) received vaccine (a process whereby a person is made resistant to a disease by the administration of vaccines) education when residents were offered or declined the Pneumococcal (vaccine to prevent pneumonia) and Influenza (a contagious respiratory illness cause by influenza viruses) vaccines, and failed to offer one of five residents (Resident 69) the influenza vaccine, when: 1. The facility did not provide education, regarding the benefits and potential side effects of the Pneumococcal or Influenza vaccines for Resident 34; 2. The facility did not provide education regarding the benefits and potential side effects of the Influenza vaccine for Resident 31; 3. The facility did not offer the Influenza vaccine to Resident 69; 4. The facility did not provide education regarding the benefits and potential side effects of the Influenza vaccine for Resident 38; and, 5. The facility did not provide education regarding the benefits 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 practice appropriate infection prevention and control measures for one of four sampled residents (Resident 1), when a staff member did not wear appropriate Personal Protective Equipment (PPE- refers to protective clothing, gloves, face shields, goggles, face masks and/or respirators or other equipment designed to protect from injury or the spread of infection) while providing care to Resident 1 who was on Enhanced Barrier Precautions (EBP- a set of infection control practices that use gowns and gloves to reduce the spread of multidrug-resistant (difficult to treat) organisms). This failure had the potential to spread infections to residents residing in the facility, negatively impacting their health and well-being. Findings: A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with multiple diagnoses including dysphagia (difficulty swallowing), and gastrostomy status (an artificial entrance to the stomach). During an observation on 12/2/24, at 4:06 PM, while in the…

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

Based on interview and record review, the facility failed to ensure their staff provided quality care according to standards of practice for one of four sampled residents (Resident 1) when; 1. The facility's health care providers did not ensure the facility received and reviewed Resident 1's discharge summary from [ACUTE CARE HOSPITAL NAME] on 8/29/24, 9/5/24, 9/28/24, 10/1/24, and 10/21/24 and the facility did not inquire if a urine culture and sensitivity (test the urine to see which antibiotic would be useful to fight the specific bacteria) test was completed on 8/29/24 and 10/2/24 while Resident 1 was at [ACUTE CARE HOSPITAL NAME]. 2. The facility's staff did not follow up in a timely manner for Resident 1's Gastroenterology (the study of diseases of the esophagus, stomach, small intestine, colon and rectum, pancreas, gallbladder, bile ducts and liver) consult. These failures could have resulted in Resident 1 not receiving effective medical treatment and experiencing prolonged pain. Findings: 1. A review of Resident 1's clinical record titled, admission Record (a document that…

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

Based on interview and record review, the facility failed to ensure infection prevention procedures were followed for three of five sampled residents (Resident 1, Resident 2, and Resident 3) when: 1. Resident 3 tested positive for Covid-19 (a potentially serious respiratory illness) on 8/17/24, and was not placed on isolation (precautions taken to prevent spread of disease) until 8/19/24; 2. The facility admitted Resident 2 into Resident 3 ' s room on 8/17/24, and Resident 2 did not have Covid-19; and, 3.The facility did not ensure testing following exposure to Covid-19 was carried out for Resident 1 and Resident 2, who shared a room with Resident 3, and were exposed to the disease for two days. These failures placed Resident 1 and Resident 2 at risk for contracting Covid-19 and had the potential for Covid-19 to spread throughout the facility to other residents and staff, resulting in potentially serious illness. Findings: 1. During an interview with the Infection Preventionist (IP) on 9/24/24 at 1:04 PM, the IP stated the process once a resident tested positive for Covid-19 was 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 ensure a change in condition and needs were addressed for one of three sampled residents (Resident 3) when Resident 3 tested positive for COVID-19 (a potentially serious respiratory illness) on 8/17/24, required isolation (precautions taken to prevent spread of disease), and the facility did not develop a care plan. This failure placed Resident 3 at risk for disease progression, spread of infection to other residents in the facility, and reduced care from staff. Findings A review of Residents 3 ' s admission RECORD indicated Resident 3 ' s diagnoses included Palliative Care (care focused on providing comfort) and Dementia (a condition that affects thinking, reasoning, decision making, and emotions). During a review of Resident 3 ' s clinical record titled, Progress Notes, the record indicated Resident 3 tested positive for COVID-19 on 8/17/24 and was placed in an isolation room on 8/19/24. During a review of Resident 3 ' s record titled, Care Plan, there was no evidence a COVID-19 and isolation care plan were developed.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 written notification of a room change for eleven of eleven sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, and Resident 11), when: 1. Resident 1, Resident 3 and Resident 4 were moved to another room on 7/29/24 without a written notification including the reason for the move and had no documentation of notice of room change in their record, 2. Resident 7's responsible party (RP) was not provided written notification of Resident 7's room change on 7/29/24, and 3. Resident 2, Resident 5, Resident 6, Resident 8, Resident 9, Resident 10, and Resident 11 were moved to another room on 7/29/24 without advanced verbal or written notification of room change to their RPs. These failures violated the rights of Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10 and Resident 11 to receive a written notice explaining the reason for the move before the room…

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

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one of four sampled residents (Resident 2) when a medication for Resident 2 was not ordered and administered for five days. This failure had the potential to cause a rash to spread further throughout the body. Findings: A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility in 2024, with a diagnosis of, but not limited to, allergic contact dermatitis (an itchy rash caused by direct contact with a substance or an allergic reaction to it). During a review of Resident 2's Order Summary Report, dated 7/22/24, indicated Hibiclens External Solution 4% (Chlorhexidine Gluconate [an antiseptic medication used to clean and disinfect the skin to prevent infections]) was ordered on 7/17/24 by the doctor. The order was to be started on 7/18/24 with the following directions: Apply to Entire Body topically [apply to a body surface such as skin] one time a day every Mon [Monday], Thu [Thursday] for Rash for 90 days Apply to entire body…

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

Based on interview, and record review, the facility failed to provide rehabilitation services and treatment for one of four sampled residents (Resident 1) when a speech therapy (ST) evaluation and treatment was not completed as ordered by the doctor. This deficient practice resulted in delayed treatment and services for Resident 1 and placed the resident at higher risk for further decline. Findings: A review of Resident 1's admission Record indicated Resident 1 was re-admitted to the facility in 2024, with a diagnosis of, but not limited to, dysphagia oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat). During a review of Resident 1's Order Summary Report, dated 7/22/24, indicated an ST eval and treatment was ordered on 6/26/24. During a review of Resident 1's Care Plan, dated 7/22/24, indicated Resident 1 was at Risk for and actual care SELF-CARE DEFICIT/DECLINE in ADLS. One of the interventions included Skilled therapy services and evaluation as ordered: treatment as indicated with a start date of 7/3/24. Further review of Resident 1's Care Plan,…

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

F-688 Based on interviews and record reviews, the facility failed to ensure services to prevent loss of mobility ordered by physician, were provided by restorative nursing assistants (RNA) to three of ten residents receiving RNA services (Resident 1, Resident 2, and Resident 3) when there was limited or no documented evidence of RNA services received, and there were insufficient RNA staff to provide the needed services. Based on interview and record review, the facility failed to ensure services to prevent loss of mobility ordered by a physician, were provided by restorative nursing assistants (RNA) to three of ten residents receiving RNA services (Resident 1, Resident 2, and Resident 3) when there was limited or no documented evidence of RNA services received, and there were insufficient RNA staff to provide the needed services. This failure had the potential to result in a decline in physical functioning for Resident 1, Resident 2, and Resident 3, negatively impacting their health and well-being. Findings: a. A review of Resident 1's admission Record , indicated Resident 1 was…

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

Based on interview and record review, the facility failed to ensure appropriate treatment and services were provided to one of three residents (Resident 3), when the restorative nursing assistant (RNA, a program that helps residents improve quality of life by increasing their level of strength and mobility) services were not implemented per the physician's order. This deficient practice had the potential to result in Resident 3's decline in range of motion (ROM-the range of joint movement). Findings: Review of Resident 3's Physical Functioning Deficit Care Plan, dated 3/10/20, indicated Resident 3 had limited mobility and limited range of motion. The care plan also indicated Resident 3 needed the RNA program as ordered by the physician. Review of Resident 3's Order Summary Report, with an order dated 2/5/24 indicated, RNA Program: Contracture [shortening of muscles] management .Passive range of motion (PROM) for bilateral [both] upper extremities [arms] and bilateral lower extremities [legs] x3/week [three times a week] indefinitely. During an interview on 6/10/24, at 1:58 p.m. with…

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

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was treated with dignity and respect when a Certified Nursing Assistant (CNA 6 ) sat on the lap of Resident 1's family member and made inappropriate remarks towards while the family member was visiting Resident 1. This failure had the potential to negatively impact the psychosocial wellbeing of Resident 1 and her family. Findings: According to the ' admission Record ' Resident 1 was admitted to the facility in 2023 with multiple diagnoses including heart failure and hypertension. The most recent Minimum Data Set (MDS, an assessment tool) indicated Resident 1 scored 15 out of 15 in a Brief Interview for Mental Status (BIMS, a tool that tests memory and recall with scores ranging from 0-15) which indicated she was cognitively intact. A report received by the Department on 1/22/24 indicated in part, CNA 6 had made inappropriate comments towards Resident 1 ' s family on 1/13/24 and had threatened Resident 1 not to report it. The report further indicated on 1/19/24, Resident 1…

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

Based on observation, interview, and record review, the facility failed to ensure a resident's right to be treated with dignity and respect was honored for one of six sampled residents (Resident 2) when a Restorative Nurse Assistant (RNA) answered Resident 2's call light (device used by residents to call for assistance) but did not follow up on her request to the nurse. Resident 2 waited a total of 47 minutes for the nurse to attend to her needs. This failure had the potential to negatively impact Resident 2's psychosocial well-being and physical health. Findings: Review of Resident 2's admission record indicated Resident 2 was admitted to the facility in late 2023 with diagnoses which included Congestive Heart Failure (heart disease causing fluid to back up into the lungs making it difficult to breathe). During a concurrent observation and interview on 12/27/23, at 12:19 p.m., Resident 2 was lying in bed, slightly short of breath. Resident 2 had her oxygen nasal cannula (a device that delivers extra oxygen through a tube into the nose) next to her on her bed. Resident 2 stated 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, interview, and record review, the facility failed to ensure proper infection control practices were performed for two residents (Resident 1 and Resident 3) of seven sampled residents when: 1. Resident 1 was observed in the dining room with an exposed urinary catheter drainage bag (a bag that collects urine from the tubing connected to the bladder) filled with yellow fluid and was touching the floor below his wheelchair; 2. Resident 3 ' s room did not have the proper contact-based precaution sign to alert staff and visitors of the required Personal Protective Equipment (PPE) to be used upon entry and provision of care; 3. Certified Nurse Assistant 1 (CNA 1) did not use proper PPE (a gown and gloves) during the transfer of Resident 3 to a wheelchair; and 4. Licensed Nurse 1 (LN 1) carried exposed dirty linens from Resident 2 ' s to the soiled laundry room without using a hamper. These failures reduced the facility's potential to prevent spread of infection among residents for a facility census of 109. Findings: 1. A review of Resident 1 ' s admission 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 observation, interview and record review, the facility did not ensure an Infection Preventionist (IP) was available to dedicate the time required to meet all the requirements of the position. This failure decreased the facility's potential to prevent the spread of infection among staff and residents. (Cross Reference F880) In an interview on 12/12/23 at 12:04 p.m. with Assistant Director of Nursing (ADON), the ADON stated the facility ' s former IP abruptly resigned yesterday and the Director of Staff Development (DSD), who was hired on 12/11/23 was IP certified. In an interview on 12/12/23 at 12:05 p.m., the DSD stated he was IP certified and had some prior IP experience; however, he was not able to provide a full list of residents currently on isolation at the facility. In an interview on 12/14/23 at 10:12 a.m., the LN 1 confirmed Resident 3 required a contact-based precaution sign (used to alert staff and visitors about required personal protective equipment (PPE) upon entry) and the sign was not in place this morning. She agreed if the facility had an active IP…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a safe, comfortable and sanitary environment for the facility census of 109 when: 1. Multiple restrooms in resident rooms were observed with cracks on the linoleum floor with yellow-black deposits; 2. The south wing shower room had broken, loose, and exposed floor tiles with sharp edges; 3. Resident 4 did not have running hot water in her restroom; and, 4. Resident 5 did not have a fully functioning bed controller. These failures decreased the facility ' s potential to provide residents a homelike environment. Findings: 1. During an observation on 12/14/23 between 9:22 a.m. and 9:39 a.m. in the south wing of the facility, the following resident rooms had bathrooms with cracked linoleum flooring and yellow-black deposits observed in the cracks: rooms [ROOM NUMBERS], rooms [ROOM NUMBERS], rooms [ROOM NUMBERS], room [ROOM NUMBER], rooms [ROOM NUMBERS], and room [ROOM NUMBER] and 42. In an interview on 12/14/23 at 11:39 a.m. with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure an electrical breakdown was fixed in a timely manner for 1 of 3 sampled residents (Resident 1) when electrical sparks and smoke from a power source was noted in his room and close to his bed and was not fixed until the following day, 13 hours later. Resident 1 shared the room with Resident 2 and Resident 3. This failure had the risk potential to result in electrical fire. Additionally, Resident 1 remained in a bed that could not be adjusted to his comfort until the power connection was repaired 13 hours later. Findings: A report received by the Department on 11/6/23 indicated in part, The resident room number [room number] almost caught fire. Sparks was all over the place. Nurses couldn't pushed [sic] the bed because it wasn't working. A review of Resident 1's 'admission Record' indicated he was admitted to the facility this year with multiple diagnoses including heart conditions, kidney disease and brain injury. Resident 1 scored…

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

Based on interview and record review, the facility failed to provide the services of a full time Director of Nursing (DON) to effectively guide and direct nursing care. This failure decreased the facility's potential to provide accurate and safe care per nursing professional standards for a census of 109 residents. Findings: During an interview with the Medical Records Director (MRD) on 11/7/23 at 9:40 a.m., the MRD stated the facility has been without a Director of Nursing since the second week of October, 2023. The MRD stated the DON plays a vital role in patient care in the facility. The MRD further stated there was currently no DON or temporary DON to oversee the Nursing Department. In an interview with the Assistant Director of Nursing (ADON) on 11/7/23 at 9:45 a.m., the ADON confirmed the facility did not have a full time employed DON since approximately the second week of October 2023. The ADON stated the facility had no temporary DON while a replacement DON was found. The ADON confirmed the DON fulfilled an important function in the nursing care of the residents. During a…

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

Based on interview, and record review, the facility failed to ensure a request for resident records was fulfilled in a timely manner for one of three residents (Resident 3) when an outside agency's written request for medical records on 9/27/23, on behalf of Resident 3, was not fulfilled within two working days. This failure resulted in a delay of receipt of the specified requests for Resident 3 and denied the resident's right to their medical record request being honored in a timely manner. Findings: During a concurrent interview and record review on 10/16/23, at 1:34 pm, with the Medical Records Director (MRD), Resident 3's scanned authorization to release records, dated 9/27/23, was reviewed. The MRD confirmed the record request from the outside agency was received on 9/27/23. The MRD further confirmed he sent Resident 3's records to the outside agency on 10/4/23. When asked why it was important to provide copies of records to the requestor within the 48-hour timeframe, the MRD stated the requestor may need them right away. The MRD further stated it was important to follow their…

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

Based on interview, and record review, the facility failed to ensure professional standards of practice were followed for two of three sampled residents (Resident 1 and Resident 2) when: 1. Resident 1's Physician Orders for Life Sustaining Treatment (POLST - a document which directs which type of treatment a patient wants in case of an emergency) was not signed by the resident, the resident representative, or the attending physician; and, 2. Resident 2's POLST was not signed by the resident or the resident representative. These failures had the potential for Resident 1 and Resident 2's wishes and/or preferences to not be followed regarding their option to receive or not receive life sustaining treatment. Findings: 1.During a review of Resident 1's Physician Order for Life Sustaining Treatment (POLST) document, dated 3/31/20, the POLST did not contain signatures of the resident, resident representative, or physician. Resident 1's POLST indicated that facility staff documented a verbal order on the POLST form, noting Family Member 1 as the designated representative. The POLST…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 accurately complete Resident 1's Wandering Assessment (a rating system to assess risk for wandering: low, moderate, or high) for 1 of 17 residents (Resident 1), after Resident 1 eloped (a vulnerable resident who leaves a facility unnoticed) from the facility on 9/16/23. This failure resulted in Resident 1 receiving an inaccurate Wandering Assessment score on 9/16/23 and could have resulted in inadequate supervision which could have led to resident injury or death. Findings: During a review of Resident 1's clinical record titled, admission RECORD (a document that contains the resident's demographics) indicated Resident 1 was admitted with diagnoses which included Alzheimer's disease (causes brain cell changes resulting in loss of memory, behavioral changes, and loss of knowledge of current location) and dementia (a condition which causes a decline in memory, reasoning, and other thinking skills). A review of Resident 1's clinical record titled, Nursing Note, dated 9/16/23, indicated Resident 1 was last seen at the facility…

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

Based on observation, interview, and record review, the facility failed to ensure adequate supervision for 1 of 17 residents (Resident 1) at risk for elopement (a vulnerable resident who leaves a facility unnoticed) when, Resident 1 left the faciity on September 16, 2023, through a nonfunctioning alarmed door, without the staff 's knowledge. This failure jeopardized the health and safety of Resident 1, which could have resulted in injury or death. Findings: A review of Resident 1's clinical record titled admission RECORD, (a document that contains the resident's demographics) indicated Resident 1 was admitted with diagnoses which included Alzheimer's disease (causes brain cell changes resulting in loss of memory, behavioral changes, and loss of knowledge of current location) and dementia (a condition which causes a decline in memory, reasoning, and other thinking skills). A review of Resident 1's clinical record titled, Nursing Note,, dated 9/16/23, indicated Resident 1 was last seen at the facility around 4:30 PM by the receptionist who ushered Resident 1 back to the center nursing…

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

Based on observation, interview and record review, the facility failed to provide adequate supervision to ensure the safety for one of seven residents identified at risk for wandering (Resident 1) when he left the facility unsupervised, wandered to a busy street, was found by a bystander who called the police, and the resident was taken to the hospital. This failure had the risk potential to jeopardize Resident 1's health and safety. Findings: According to Resident 1's 'admission Record,' he was admitted by the facility recently with multiple diagnoses which included non-traumatic intracranial hemorrhage (brain bleeding) and schizoaffective disorder (a mental condition marked by hallucinations, delusions, and mood problems). Resident 1 scored 3 out of 15 in a Brief Interview for Mental Status (BIMS, a tool that tests memory and recall) contained in his MDS (Minimum Data Set, an assessment tool) assessment, dated 8/30/23. A review of Resident's physician 'Order Summary,' dated 8/30/23 indicated, Resident seen by MD [Medical Doctor], per MD evaluation, resident does not have mental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 showers were provided for 4 of 5 sampled residents (Resident 2, Resident 3, Resident 4, and Resident 5). This failure had the potential to diminish the resident's dignity and self-esteem, and the potential to fail to identify skin issues when showers or bathing were not done on a regular basis. Findings: 1. According to Resident 2's 'admission Record,' he was admitted recently with diagnoses which included muscle weakness, abnormalities of gait and mobility, and need for assistance with personal care. Resident 2 scored 13 out of 15 in a Brief Interview for Mental Status (BIMS, tests memory and recall) contained in his most recent Minimum Data Set (MDS) assessment. This indicated he was cognitively intact. The MDS indicated the resident needed physical help of one staff in bathing or showering. A review of the facility's undated 'PM SHIFT SHOWERS' schedule indicated Resident 2's showers were to be provided twice per week on Monday and Thursday. During an observation and interview with Resident 2 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 interviews and staffing record review, the facility failed to meet the State staffing requirements for care and services for a census of 104 residents. This failure had the potential to negatively impact the quality of nursing care provided to residents. Additionally, 4 out of 5 sampled residents did not receive showers as scheduled 2 times per week (see also F677). Findings: A review of an 'Intake Information' report received by the Department on 8/16/23, indicated in part, Short of help everyday . Not able to give showers. According to Resident 2's 'admission Record,' he was admitted recently with diagnoses which included muscle weakness, abnormalities of gait and mobility and need for assistance with personal care. Resident 2 scored 13 out of 15 in a Brief Interview for Mental Status (BIMS, tests memory and recall) contained in his most recent Minimum Data Set (MDS) assessment. This indicated he was cognitively intact. The MDS indicated the resident needed physical help of one staff in bathing or showering. A review of the facility's undated 'PM SHIFT SHOWERS' schedule…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 sanitary environment when staff did not perform hand hygiene after contact with residents' belongings while passing lunch trays between four of seven sampled residents (Resident 2, Resident 3, Resident 4, and Resident 5). This failure had the potential to spread infections. Findings: During an observation and concurrent interview, on 7/19/23, at 12:45 p.m., Certified Nurse Assistant (CNA 1) was observed passing lunch trays to four residents (Resident 2, Resident 3, Resident 4, and Resident 5). CNA 1 did not perform hand hygiene after touching all four resident's personal belongings on their overbed tables when making room for their lunch trays, including cups. CNA 1 did not perform hand hygiene before going into the rooms or upon coming out of the rooms. CNA 1 stated she was supposed to be using hand sanitizer after touching resident cups and setting up their meal trays. CNA 1 stated she forgot to perform hand hygiene. During an interview, on 7/19/23, at 2:20 p.m., the Infection Preventionist stated…

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

Based on observation, interview, and record review, the facility failed to follow the menu for one of three sampled residents (Resident 2) when a therapeutic diet was not served to Resident 2 as ordered for the lunch meal on 7/19/23. This failure had the potential to result in a negative health outcome for Resident 2. Findings: A review of Resident 2's admission RECORD indicated, Resident 2 was admitted in early 2022 with multiple diagnoses which included Type 2 Diabetes Mellitus (A chronic condition that affects the way the body processes blood sugar or glucose). A review of Resident 1's Minimum Data Set (MDS - A resident Assessment and Screening tool) dated 5/9/23, indicated, Resident 1 had no cognitive impairment. During a concurrent observation and interview, on 7/19/23 at 12:37 p.m., in Resident 2's room, Resident 2 was served a lunch tray. Resident 2's meal tray included Barbequed chicken, baked sweet potato, spring blend vegetables, bread roll with butter, and biscuit berry shortcake. Resident 2 stated, she was diabetic, but she was served a piece of shortcake. Resident 2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 honor a food preference for one of three sampled residents (Resident 1) when, Resident 1 was served fish for the lunch meal on 7/13/23 even though fish was a documented dislike in Resident 1's clinical record. This failure increased the potential for Resident 1 to have an unpleasant dining experience and had the potential to result in altered nutrition. Findings: A review of Resident 2's admission RECORD indicated, Resident 1 was admitted in Mid-2023 with multiple diagnoses which included Type 2 Diabetes Mellitus (A chronic condition that affects the way the body processes blood sugar) and anxiety disorder. A review of Resident 1's Minimum Data Set (MDS - A resident Assessment and Screening tool) dated 6/7/23 indicated, Resident 1 had no cognitive impairment. During an interview on 7/19/23 at 2:07 p.m., in Resident 1's room, Resident 1 stated, she disliked fish, but she was served fish on 7/13/23 and that made her anxious. A review of a facility document from the kitchen titled, Menus Week at a Glance 2023 June 18-July 22…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the South Station of the building, with a census of 46, maintained a safe comfortable level of temperature for one of 5 residents (Resident 5), between 71- and 81-degrees Fahrenheit when the facility air conditioner failed to operate. This failure resulted in Resident 5 taken to the hospital for possible dehydration (loss of water from the body), and the potential for dehydration and hyperthermia (overheating) to other residents. Findings: During an observation and concurrent interview with LN 3 on 7/18/23 at 12:30 p.m., LN 3 wearing a wet wash towel over her neck indicated the facility air conditioner is not working, and it is very hot in here. One resident (Resident 5) went to the hospital this morning for rehydration. According to the facility ' s Facesheet, Resident 5 was admitted with diagnoses including heart failure (heart does not pump blood as it should), Diabetes Mellitus (high blood sugar), depression, pulmonary edema…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 and Control Program for a census of 116 residents when: 1. Licensed Nurse did not clean and sanitize a glucometer (a device that measures the level of sugar in the blood) after each resident use, based on standards of practice and manufacturer recommendation for Resident 27, and Resident 82. 2. The laundry services staff stored clean clothes and linens in the dirty area of the laundry room; 3. The facility did not develop a water management program used to prevent the build up and spread of waterborne pathogens (bacteria, viruses, microorganisms that can cause diseases); and, 4. There was no evidence of an active Infection Prevention and Control Committee, nor was there evidence of infection surveillance analysis and reporting to the Quality Assurance and Performance Improvement (QAPI) Committee. These failures increased the risk of transmitting infectious diseases between residents in the facility. Findings: 1a. During a medication pass observation, on 12/06/22, at 12:15 PM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 their Antibiotic Stewardship Program (a program designed for the safe use of antibiotics) for a census of 116 residents when there was no evidence of a system for documenting and monitoring trends in antibiotic use in the facility in accordance with their Antibiotic Stewardship Program. This failure increased the potential for inappropriate antibiotic therapy resulting in the development of antibiotic resistant bacterial infections. Findings: During an interview and concurrent record review with the Infection Preventionist (IP) on 12/9/22, at 10 a.m., the IP presented her Antibiotic Stewardship log. The log included data since June 2022 when the IP began in her role. When asked if the IP analyzed the data in the Antibiotic Stewardship log for trends, such as, antibiotic resistant bacterial infections, secondary infections, adverse effects, orders for culture and sensitivity, and practitioner prescribing practices, the IP stated she did not. When asked if the IP investigated the possible sources of infections, she…

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

Based on observation, interview and record review, the facility failed to complete a quarterly care conference (a meeting which provides opportunities for the residents and/or their representative, and professional disciplines to revise the residents' care plans) for 2 of 43 sampled residents (Resident 16 and Resident 63). These failures had the potential for unmet care needs for Resident 16 and Resident 63. Findings: 1. A review of Resident 16's admission Record indicated Resident 16 was admitted to the facility in late winter of 2019 with diagnoses which included dementia (a general term for loss of memory, language, problem- solving and other thinking abilities that are severe enough to interfere with daily life) and cognitive communication deficit (problems with verbal and non-verbal communication). During an interview on 12/7/22, at 12:31 p.m., family member (FM) 2 stated she only remembered attending a few of Resident 16's care plan conferences because she was receiving last minute notices from the facility. FM 2 further stated that she felt like she was not involved 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record, and facility policy review, the facility failed to provide restorative (RNA-nursing intervention to increase or maintain resident's mobility and to prevent further decline in mobility) treatment and services to three of 43 sampled residents (Resident 35, Resident 65, and Resident 102) when: 1. The recommendation from the Occupational Therapy for restorative nursing services was not carried out for Resident 35; and, 2. Restorative nursing care was not implemented in a timely manner for Resident 65 and Resident 102. These failures placed Resident 35, Resident 65, and Resident 102 at risk for not maintaining their highest practicable level of range of motion (ROM-the degree of movement that occurs at a given joint during an exercise) and mobility functioning. Findings: 1. Review of Resident 35's admission Record indicated Resident 35 was admitted to the facility in late 2018 with diagnosis of multiple sclerosis (a condition that affects the brain and spinal cord that could…

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

2. A review of Resident 20's admission Record indicated Resident 20 was admitted to the facility in the Fall of 2021. A review of Resident 20's medical health record titled, Social History, dated 4/15/22, indicated, .Smoking history .SMOKES CIGARETTES . A review of the facility document titled, [Facility Name] RESIDENT SMOKING LIST, dated 11/28/22, indicated there were eighteen residents who were considered smokers in the facility. Further review of the document indicated, .[Resident 20's name] . During an observation on 12/7/22, at 1:55 p.m., Resident 20 was observed to be smoking a cigarette while seated in her wheelchair outside in the designated smoking area next to a male resident. When asked, Resident 20 stated she did not use a smoking apron. During a concurrent observation and interview on 12/7/22, at 1:57 p.m., with the laundry aide (LA) outside in the designated smoking area next to Resident 20, LA was observed handing Resident 20 a cigarette. LA stated she took out a cigarette for Resident 20 from the facility locked box that stored cigarettes for the resident smokers. LA…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: 1. Address weight loss in a timely manner for two residents, Resident 57 and Resident 77; and, 2. The facility did not ensure the kitchen had a diet supplement order for Resident 77. These failures had the potential to increase the weight loss for Residents 57 and Resident 77, negatively impacting their health and well-being. Findings: 1a. A review of Resident 57's admission Record indicated Resident 57 was admitted to the facility in the Spring of 2019 with diagnoses which included dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 57's electronic health record titled, Weights, indicated the following: 11/16/22-116 Lbs (pounds) 10/7/22-120 Lbs 9/1/22-124 Lbs 8/5/22-127 Lbs 7/4/22-127 Lbs 6/20/22-130 Lbs…

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

Based on observation, interview, and record review, the facility failed to provide appropriate care and services for two of seven residents (Resident 3 and Resident 16) requiring tube feeding (method of providing nutrients via a tube directly into the stomach or intestine when a person is unable to eat by mouth) when: 1. Resident 3's tube feeding bottle was not changed in 24 hours and the same bottle was used the following day with Resident 3 receiving inadequate caloric intake; 2. Resident 16's tube feeding bottle label did not indicate the name of the resident, room number, date, start time of the feeding and the rate of the feeding; and, 3. Resident 16's head of bed (HOB) was not elevated to an angle of 30 to 45 degrees (unit of measurement) while the resident was receiving their tube feeding. These failures had the potential for the residents to have complications related to tube feedings and/or risk for infections. Findings: 1. A review of Resident 3's admission Record (contains clinical and demographic data), indicated Resident 3 was admitted to the facility in the Summer 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 respiratory care was provided in accordance with professional standards of practice for a census of 116 when: 1. Oxygen in use signs were not posted outside of the rooms for Resident 19 and Resident 50, 2. Oxygen therapy was provided without a physician order for Resident 50; and, 3. The oxygen flow rate was not followed per physician order for Resident 19. These failures had the potential to result in negative impacts on the residents' health and safety including risks for ineffective oxygen therapy, and respiratory distress. Findings: 1a. A review of Resident 19's admission Record indicated Resident 19 was admitted to the facility in the Winter of 2014 with diagnoses which included chronic obstructive pulmonary disease (COPD: a group of lung diseases that block airflow and make it difficult to breathe). According to the Minimum Data Set (MDS - an assessment tool) dated 11/20/22, Resident 19 used oxygen therapy. During an…

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

Based on interview and record review, the facility failed to ensure a specific psychiatric diagnosis (mental health illness) and associated behaviors which could endanger a resident or others, were documented in the medical record based on standards of practice and the facility's policy, for three of seven sampled residents (Resident 20, Resident 37, and Resident 39) when: 1. Resident 20's medical record did not have a specific diagnosis for use of mind-altering medication called risperidone (or also known as Risperdal, a medication used for mental health). 2. Resident 37's medical record did not have specific diagnosis for use of mind- altering medication called quetiapine (also known as Seroquel, a medication used to treat mental health) and resistive to care was listed as the targeted behavior for monitoring when it did not pose harm to resident or others. 3. Resident 39's medical record did not have specific diagnosis for use of mind- altering medication called quetiapine (also known as Seroquel, a medication used to treat mental health) and resistive to care was listed as 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 store and prepare foods in accordance with professional standards for food safety for 109 residents who received food from the kitchen when: 1. There was no air gap (a break in the plumbing to prevent unsanitary water from flowing back into the sink) under the food preparation sink, under the ice machine and under the dishwashing sink; 2. Dry food items were found undated, unlabeled and/or expired; and, 3. Kitchen appliances were not cleaned. These failures had the potential to contribute to foodborne illnesses among residents who received meals from the kitchen. Findings: 1. During a concurrent observation and interview on 12/6/22, at 9:47 a.m., there was no air gap under the food preparation sink, under the ice machine and under the dishwashing sink. The Assistant Dietary Manager (ADMgr) confirmed there was no air gap. The ADMgr stated, With no air gap, it will cause cross contamination and we have to throw everything out. During an interview on 12/6/22, at 4:10 p.m., the Maintenance Consultant (MC)…

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

Based on observation, interview, and facility policy review, the facility failed to ensure the call light system (a system that provide direct communication from the resident to the staff to call for staff assistance) was functioning for one of 43 sampled residents (Resident 260) when the light outside the room above the door was not working and no alternative device was provided to call staff for assistance. This failure had the potential for unmet needs and delayed care for Resident 260. Findings: Review of Resident 260's admission Record indicated Resident 260 was admitted to the facility in late 2022 with diagnoses of multiple sclerosis (a condition that affects the brain and spinal cord that could lead to loss of mobility and balance) and epilepsy (a disorder in which nerve cell activity in the brain is disturbed). During a concurrent observation and interview with Resident 260 and Resident 260's family member (FM) 3 on 12/6/22, at 1:28 p.m., FM 3 stated Resident 260 was admitted to the facility about a week ago and Resident 260's call light had not been working since the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of 43 sampled residents (Resident 261) was treated with respect and dignity, when Resident 261 was uncovered on an unmade mattress on the floor, with the curtain and door left open, and without a means to call for help or communicate his needs for assistance. This failure had the potential to result in psychosocial harm. Findings: A review of Resident 261's face sheet (a synopsis of the resident's admission information) indicated Resident 261 was admitted to the facility on [DATE] with a diagnosis (medical condition) of non-traumatic intracerebral hemorrhage (bleeding in the brain when weakened blood vessels rupture). During an observation in Resident 261's room, on 12/06/22, at 8:00 AM, the door to Resident 261's room was open. Resident 261 was lying on a mattress on the floor next to the bed. Resident 261 was wearing a hospital type gown that was wrapped around his waist and was wearing an adult incontinence brief. He 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a schizophrenia (a mental disorder in which people interpret reality abnormally and may result in hallucinations, delusions, and extremely disordered thinking and behavior) diagnosis for antipsychotic medication (mind and mood-altering medication) use was accurately documented and/or followed the standards of practice (a professional guide for healthcare) and the facility's policy in one out of 43 sampled residents (Resident 62). This failure could contribute to unsafe medication use and adverse effects of mind-altering medications. Findings: Review of Resident 62's medical record from previous hospitalizations (Hospital A), titled Physician H&P (H&P-medical History and Physical), dated 1/7/20, indicated Resident 62 had history of bilateral strokes [means brain injury to both side of the brain] in 2019, . who presents with progressive cognitive [problem with memory] decline, found to have a new acute infarct [stroke] .He has been progressively…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 treatment and services were provided for one of 43 sampled residents (Resident 13) when: Resident 13 was not monitored for signs and symptoms (s/s) of low or high blood sugar irregularity and how to manage those s/s while on five anti-diabetic medications (drugs to help the body to lower blood glucose [sugar] levels). This failure had the potential to place Resident 13 at risk for hypo/hyperglycemia (blood sugar level lower or higher than the standard range) to be unrecognized and untreated. Findings: Review of Resident 13's admission Record indicated Resident 13 was admitted to the facility in early 2014 with a diagnosis of diabetes (a condition that results in too much sugar in the blood). During an interview with Resident 13 on 12/7/22, at 5:09 p.m., Resident 13 confirmed he was on multiple anti-diabetic medications taken by mouth and injected under the skin. Resident 13 stated, Sometimes I get dizzy. During a concurrent interview and record review of Resident 13's Physician's Order 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 hazardous medication (medications that may pose a health hazard when not handled appropriately) were safely handled by nursing staff during medication administration based on manufacturers specifications and nursing standards of practice. This failure may result in unsafe medication handling and chemical exposure to nursing staff. Findings: During a medication pass observation on 12/7/22, at 8:50 AM, accompanied by licensed nurse (LN) 7, in South Hall, LN 7 administered one medication called finasteride (also known as Proscar, a hormone like medication used to treat prostate disease) with an ungloved hand. Review of the finasteride bubble pack (a sealed compartment for every pill on a flat cardboard container) pharmacy label (medication label on bubble pack with resident name, drug name, direction for use and the precautionary label) on 12/7/22, at 8:50 AM, the label indicated as follows: . Finasteride tab 5 mg (milligram unit of measure for weight) . filled 11/02/22 . 30 tablets . Take 1 tablet 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 observation, interview, and record review, the facility failed to ensure safe medication storage practices in one out of three medication storage areas when: 1. The refrigerated Emergency kit (E-Kit, a sealed and labeled medication box for emergency use) contained an outdated vial of Insulin (a medication for high blood sugar) and the E-Kit par level (amount of medication expected to be in the E-Kit) was less than expected and had not been replaced by the provider pharmacy in five months. 2. The medication refrigerator had excessive ice accumulation or frost around the freezer portion of the refrigerator, and it touched the container of Glargine Insulin (a long-acting form of blood sugar medication) which could render the medication ineffective. 3. Discontinued narcotic medications (controlled medications for pain and subject to abuse) were stored in an unsecured drawer in the main medication room. 4. Pharmaceutical non-narcotic medication disposition log was not co-signed by two licensed nurses; and the pharmaceutical waste bin was not secured and the medications it…

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