Astoria Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow professional standards of nursing practice for one of three sampled residents (Resident 1) by failing to ensure licensed nurses appropriately assessed and monitored Resident 1's medical and psychosocial status ( a person's overall mental, emotional, and social well-being) following the resident's change of condition (COC) on 4/17/2026 related to an alleged physical abuse. This deficient practice had the potential to result in the failure to identify continued or worsening clinical and psychosocial deterioration, thereby placing Resident 1 at risk for adverse health outcomes and compromised safety.Findings: During a review of Resident 1's undated admission Record, the admission Record indicated the facility admitted the resident on 7/27/2017 with diagnoses including type 2 diabetes mellitus (a disease that occurs when the blood sugar level is too high), diastolic congestive heart failure (a condition where the heart's main pumping chamber becomes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow infection control prevention measures for two of three sampled residents (Resident 1 and Resident 2), by: 1. Failing to ensure Resident 1 and Resident 2's soiled linens from an isolation room were placed separately from other residents' soiled linens.2. Failing to ensure Certified Nursing Assistant (CNA) 1 wore gown and gloves when entering Resident 1 and Resident 2's contact isolation room.3. Failing to educate family members on precautions to take when entering a contact precaution isolation room.These deficient practices had the potential to result in transmission of communicable disease and infection to other residents and staff. Findings:During an observation on 4/29/2026, at 7:45 a.m., together with Licensed Vocational Nurse (LVN) 1, observed CNA 1 entering Resident 1 and Resident 2's contact isolation room without wearing gown and gloves, then removed Resident 1's food tray and placing the food tray together with other…

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

Based on interview and record review, the facility failed to implement its policy and procedure on infection control for one of seven residents (Resident 1). Resident 1 was diagnosed with having Clostridioides difficile (C.-diff, a highly contagious bacterial infection causing loose stools). The facility failed to expand infection prevention teachings to everyone entering Resident 1's room. This deficient practice increased the risks of exposure to and spread of infection to other residents and facility staff. Findings During a review of Resident 1's admission Record, undated, the admission Record indicated the facility originally admitted Resident 1 on 4/8/2026 with the diagnoses of acute respiratory failure with hypoxia (inadequate levels of oxygen in the blood leading to decreased function of tissues and organs in the body), pneumonia (lung infection leading to difficulty breathing), and cognitive communication deficit (impairments that disrupt a person's ability to communicate). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/14/2026,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow professional standards of nursing practice for one of three sampled residents (Resident 1) by failing to:1.Ensure licensed nurses monitored Resident 1's oxygen saturation (the amount of oxygen circulating in the blood) every shift from 3/14/2026 to 3/19/2026 (five days). 2.Ensure licensed nurse accurately assessed Resident 1's risk for falls following the resident's readmission on [DATE]. These deficient practices had the potential to result in the failure to identify continued or worsening clinical deterioration, thereby placing Resident 1 at risk for adverse health outcomes and compromised safety.Findings: During a review of Resident 1's undated admission Record, the admission Record indicated the facility admitted the resident on 4/2/2022 and readmitted on [DATE] with diagnoses including metabolic encephalopathy (a brain malfunction caused by chemical imbalances or toxins in the body, rather than a direct brain injury), pneumonia (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 the medical record of one of five sampled residents (Resident 1) was maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to ensure: 1.Resident 1's Change of Condition (COC) Evaluation indicated the correct date and time the COC happened. Resident 1 had a change of condition (COC) on 3/9/2026, afternoon shift. The COC Evaluation indicated Resident 1's COC occurred on 3/10/2026 during the night shift. 2. Accurate documentation regarding COC notification to Resident 1's Attending Physician (MD) 1 and family member. The COC evaluation indicated on 3/10/2026, Resident 1's Attending Physician (MD) 1 was notified at 9:20 p.m. and the resident's family member was notified at 9:15 p.m. 3. The licensed nurses completed and signed Resident 1's COC Evaluation timely. Resident 1's COC Evaluation was completed and signed on 3/11/2026. These deficient practices resulted in inaccurate information on Resident 1's medical records and had the potential for delayed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three of three sampled residents (Resident 1, Resident 5, and Resident 6) received care consistent with professional standards of practice to prevent pressure ulcers (PU, a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) by failing to ensure Residents 1, 5, and 6 were turned and repositioned. This deficient practice placed Resident 1, Resident 5, and Resident 6 at risk for the development of pressure ulcers.Findings: During a review of Resident 1's admission Record (undated), the admission Record indicated the facility admitted the resident on 7/1/2025 with diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]),…

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

Based on interview and record review, the facility failed to ensure the medical records of one of three sampled residents (Resident 1) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to ensure Licensed Vocational Nurse (LVN) 1 documented the level of care provided to Resident 1 while the resident was in the facility. LVN 1 documented the level of care she provided to Resident 1 on 12/13/2025. Resident 1 was discharged to the General Acute Care Hospital (GACH) 1 on 12/10/2025. This deficient practice resulted in incomplete and inaccurate information on Resident 1's medical records and had the potential for delayed medical interventions.Findings: During a review of Resident 1's admission Record (undated), the admission Record indicated the facility admitted the resident on 7/1/2025 with diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), type 2 diabetes mellitus (a chronic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 five sampled staff (Registered Nurse [RN] 1 and Licensed Vocational Nurse [LVN] 1) were competent (a combination of knowledge, skills, abilities, and behaviors that enable an individual to perform a task or role successfully) on dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney or kidneys have failed) care and assessment by:Failing to ensure newly hired staff had orientation (the process of introducing new employees to a company's culture, policies, colleagues, and their specific job role, typically in the first few days or weeks, to help them feel welcome, understand expectations, and integrate effectively into the organization) on dialysis care.Failing to ensure staff were in serviced on dialysis care before providing dialysis care.Failing to ensure staff were aware of dialysis site assessment.These failures had the potential to affect the care necessary to provide nursing care and related services to meet residents' needs…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 update the Facility Assessment Tool (an evaluation of the physical environment necessary to meet the needs of the residents) by:Failing to ensure the Facility Assessment indicated the approved facility's name of Skilled Nursing Facility 2 (SNF 2) after a change of ownership on 6/2025.Failing to ensure Facility Assessment was followed, on staff dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) care, training and competency (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully).Failing to ensure Facility Assessment indicated the type of electronic health information technology used by the facility.These failures had the potential to delay necessary care and services and misinformation.Findings:During a review of facility's Facility Assessment Tool, dated 6/1/2025, the Facility Assessment Tool indicated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's Minimum Data Set (MDS - a resident assessment tool), accurately reflected the resident's medical diagnoses for one of four sampled residents (Resident 1). This deficient practice had the potential to delay the provision of necessary care and services to Resident 1 and negatively affect Resident 1's well-being. Findings: During a review of Resident 1's admission Record, dated 12/26/2025, the admission Record indicated the facility originally admitted Resident 1 on 7/2/2021, and readmitted on [DATE] with diagnoses including end stage renal disease (ESRD- irreversible kidney failure), dependence on renal dialysis, anemia (a condition where blood lacks enough healthy red blood cells to carry adequate oxygen to the body) and acute on chronic combined systolic and diastolic heart failure (a long-standing heart problem affecting both the heart's ability to pump (systolic) and relax/fill (diastolic), leading to fluid buildup and inefficient…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement policies and procedures (P&P) for infection control for two of three sampled residents (Resident 1 and Resident 3) when Certified Nursing Assistant (CNA) 1 failed to change their gown after repositioning Resident 1 and before draining Resident 3's urinary catheter (also known as a Foley catheter, device that drains urine from the urinary bladder into a collection bag). This deficient practice had the potential for cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) between Resident 1 and Resident 3. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 5/22/2024, with a diagnosis of gastrostomy malfunction (the surgical creation of a new opening from the skin of the abdomen into the stomach, through which a tube can be inserted to provide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 nutritional care and services for one of three sampled residents (Resident 4) by failing to ensure Resident 4 was provided with breakfast and lunch on 11/6/2025, 11/7/2025 and 11/11/2025.This failure had the potential for Resident 4 to have a weight loss and potential for delays in the delivery of necessary care and services.Findings:During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 5/27/2013, with diagnoses that included unspecified (unconfirmed) heart failure (when the heart muscle doesn't pump blood as well as it should), unspecified atrial fibrillation (an irregular and often very rapid heart rhythm) and essential hypertension (high blood pressure that is not due to another medical condition).During a record review of Resident 4's Nutritional Screening and Assessment, dated 1/13/2025, the Nutritional Screening and Assessment indicated Resident 4 needed limited assistance and had chewing and swallowing difficulty.During a review of Resident 4's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its abuse policy for two of three sampled residents (Resident 1 and Resident 2) by not obtaining dated and signed witness statements (It is a written summary of the evidence of a witness).This deficient practice had the potential to result in inaccurate abuse investigations and had the potential to place Resident 1 and Resident 2 at risk for further abuse.Findings:a. During a review of Resident1's admission Record, the admission Record indicated the facility admitted Resident 1 on 9/15/2025, with diagnoses that included metabolic encephalopathy (a disorder that affects brain function), diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) and repeated falls.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 10/5/2025, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for 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.

Based on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of three sampled residents (Resident 4) by failing to develop a care plan to address Resident 4's refusal of feeding assistance.This failure had the potential for Resident 4 to have a weight loss and potential for delays in the delivery of necessary care and services.Findings:During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 5/27/2013, with diagnoses that included unspecified (unconfirmed) heart failure (when the heart muscle does not pump blood as well as it should), unspecified atrial fibrillation (an irregular and often very rapid heart rhythm) and essential hypertension (high blood pressure that is not due to another medical condition).During a record review of Resident 4's Nutritional Screening and Assessment, dated 1/13/2025, the Nutritional Screening 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 provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Residents 4) by failing to follow Resident 4's physician order.This failure had the potential to result in Resident 4 experiencing hypotension (low blood pressure).Findings:During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 5/27/2013, with diagnoses that included unspecified (unconfirmed) heart failure (when the heart muscle does not pump blood as well as it should), unspecified atrial fibrillation (an irregular and often very rapid heart rhythm) and essential hypertension (high blood pressure that is not due to another medical condition).During a review of Resident 4's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 1/16/2025, the H&P…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to Ensure Certified Nurse Assistant (CNA) 1 implemented proper use of personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) for two of four sampled residents (Resident 2 and 4) who are on Coronavirus disease isolation precautions ( infection control intervention designed to reduce transmission of Coronavirus disease [COVID-19-a newly identified respiratory infectious disease] that uses disposable gown, eye protection, mask, and gloves use while in the resident's room and providing resident care). This deficient practice had the potential to result in the spread of COVID-19 among residents and staff. Findings:a. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a thorough investigation was completed following an allegation of financial abuse for one of three sampled residents (Resident 1).This deficient practice had the potential to place Resident 1 at risk for further financial abuse. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 12/11/2022 and was readmitted on [DATE] with diagnoses including Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (a common mental health condition characterized by excessive worry, fear, and unease). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 7/4/2025, the MDS indicated Resident 1 had the ability to understand and be understood. During a review of Resident 1 Visit and Patient Information dated…

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

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) received quality of care in accordance with professional standards of practice to meet Resident 1's physical, mental, and/or psychosocial needs (consists of the emotional and social requirements that individuals have to feel safe, supported, and function effectively in their environment), when an interdisciplinary (IDT) meeting did not timely occur after Resident 1's fall on 8/2/2025 and in compliance with the facility's own policy and procedure. This failure had the potential to result in a delay in investigating and determining the causative factors that resulted in Resident 1's fall on 8/2/2025. Findings: During a review of Resident 1's admission Record, dated 7/6/2025, the admission Record indicated Resident 1's diagnoses included atrial fibrillation (a condition where the heart's upper chambers beat irregularly and too fast, instead of in a coordinated way), congestive heart failure (a condition in which the heart is unable to pump enough blood throughout…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 medical record of one of two sampled residents (Resident 1) was complete and accurately documented when Resident 1's medical record did not contain a Post-Fall Assessment & Investigation that was required by the facility's own policy and procedure. This failure resulted in an incomplete medical record as the facility's policy and procedure mandates the completion of a Post-Fall Assessment & Investigation after a resident is discovered to have fallen.Findings: During a review of Resident 1's admission Record, dated 7/6/2025, the admission Record indicated Resident 1's diagnoses included atrial fibrillation (a condition where the heart's upper chambers beat irregularly and too fast, instead of in a coordinated way), congestive heart failure (a condition in which the heart is unable to pump enough blood throughout the body), and diabetes mellitus type 2 (a condition where the body does not properly use insulin, which is a hormone that helps adjust the blood sugar levels in the body). During a review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident's medical records were updated to show documented evidence that advance directives (a legal document indicating resident preference on end-of-life treatment decisions) were discussed with three of three sampled residents (Residents 94, 17, and 72). These deficient practices violated the resident's rights and/or representative's right to be fully informed of the option to formulate their advanced directives. Findings: 1. During a review of Resident 94's Face Sheet (admission Record), the Face Sheet indicated the facility admitted the resident on 12/6/2024, with diagnoses including acute respiratory failure (the lungs are having a hard time getting enough oxygen into the blood and/or removing carbon dioxide from the blood) with hypoxia (a shortage of oxygen reaching the body's tissues), pneumonia (an infection/inflammation in the lungs), and cerebral infarction (a condition where blood flow to the brain is interrupted, causing brain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, homelike environment for four of six sampled residents (Residents 537, 17, 14, and 107) reviewed during the Environment facility task, by failing to: 1). Ensure the wall clock was set to show the current time of day for Resident 537. This deficient practice had the potential to result in increased confusion, especially to residents with cognitive impairments (deficits in mental functions like memory, thinking, or problem-solving). 2). Ensure Resident 17's broken vertical blind slats were replaced and not left at the bedside while pieces of cardboard were used to prevent light from entering the resident's room. This deficient practice had the potential to negatively affect the residents' psychosocial wellbeing and make the residents feel uncomfortable in their living space. 3). Ensure Resident 14's fall mat/floor mat (designed to help prevent injuries by providing a soft-landing surface for patients who may accidentally…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for five (5) of 5 sampled residents (Residents 117, 28, 90, 14, and 102) reviewed for physical restraints care area by: 1. Failing to complete Resident 117's Physical Restraint Assessment form accurately to reflect that the resident was placed on bed pad alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) on 3/28/2025. 2. Failing to complete a restraint assessment, physician's order, obtained informed consent, and develop and implement a care plan (CP) for the use of bolstered mattress (a mattress designed with raised edges to help prevent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 d. During a review of Resident 121's Face Sheet, the Face Sheet indicated the facility admitted the resident on 2/18/2021, with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) with acute (sudden) exacerbation (worsening of the disease), schizophrenia and bipolar disorder. During a review of Resident 121's MDS, dated [DATE], the MDS indicated the resident had clear speech, makes self-understood, and had the ability to understand others. During a review of Resident 121's Physician Order, dated 5/2/2025, the Physician Order indicated Remeron 15 mg by mouth (PO) every hour of sleep (QHS) for depression manifested by poor appetite. During a review of Resident 121's H&P, dated 5/8/2025, the H&P indicated the residents can make needs known but cannot make medical decisions. During a concurrent interview, and record review on 5/9/2025, at 11:09 a.m. with MDS Nurse (MDSN) 1, Resident 121's physician orders were reviewed. MDSN 1 stated there were 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 b. During a review of Resident 121's Face Sheet (admission Record), the Face Sheet indicated the facility admitted the resident on 2/18/2021 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) with acute (sudden) exacerbation (worsening of the disease), schizophrenia (a mental illness that is characterized by disturbances in thought), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 121's Minimum Data Set (MDS-a resident assessment tool), dated 2/25/2025, the MDS indicated the resident had clear speech, makes self-understood, and had the ability to understand others. During a review of Resident 121's Physician Order, dated 5/2/2025, the Physician Order indicated to administer Remeron 15 milligrams (mg-a unit of measurement) by mouth (PO) every hour of sleep (QHS) for depression manifested by poor appetite.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comprehensive care plan (CP - a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs) was revised for one of five sampled residents (Resident 26) reviewed during the Infection Control task and two of two sampled residents (Resident 153 and 289) reviewed for pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) by failing to: 1. Review and revise the CP for Resident 26's precaution status (levels of infection control practices used in healthcare to minimize the spread of infections). 2. Review and update Resident 153 and 289's CPs on the use of low air loss mattress (LALM - a specialized medical mattress designed to help prevent and treat pressure ulcers) for preservation of skin integrity. These deficient practices had the potential to result in miscommunication among interdisciplinary staff, residents,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide care in accordance with professional standards for two (2) of 2 sampled residents (Residents 107 and 12) reviewed for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites. This deficient practice had the potential for adverse effect (unwanted, unintended result) of the same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat), and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross Reference F760 Findings: a. During a review of Resident 107s Face Sheet (admission Record), the Face Sheet indicated the facility originally admitted the resident on 3/23/2020 and readmitted in the facility on 7/26/2024, with diagnoses including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY c. During a review of Resident 117's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility admitted the resident on 3/28/2025, with diagnoses including history of falling and osteoporosis. During a review of Resident 117's MDS, dated [DATE], the MDS indicated Resident 117 had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicated Resident 117 required supervision or touching assistance with eating and oral hygiene; substantial/maximal assistance with upper toileting hygiene, bathing, and lower body dressing; partial/moderate assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 117's H&P dated 4/13/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review oof Resident 117's Physician…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 each resident receives necessary respiratory care and services in accordance with professional standards of practice for four of four sampled residents (Resident 175, 61, 94, and 291) reviewed during Respiratory care area, by failing to: 1. Store the Bilevel Positive Airway Pressure (BiPAP-a non-invasive ventilation therapy that uses a machine to deliver two different levels of air pressure to the patient during breathing) mask free in a manner that is free from contamination for Resident 175. 2. Store the nebulizer (a medical device that converts liquid medication into a fine mist that can be inhaled through the lungs) in a clear plastic bag, labeled with the resident's name and the date it was last changed for Resident 175. 3. Ensure the BiPAP was administered and documented according to the physician's order for Resident 175. 4. Ensure the BiPAP was cleaned according to the manufacturer's instructions for Resident 175. These…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for eight of 24 sampled residents (Residents 3, 62, 291, 95, 130, 440, 19, and 96) by: 1. Failing to ensure medication was administered as per physician order. Licensed Vocational Nurse (LVN) 1 administered 100 milligrams (mg - metric unit of measurement, used for medication dosage and/or amount) of docusate sodium (medication used to treat constipation [bowel movements are infrequent, and the stool is hard and difficult to pass]) to Resident 3 and the physician order was 250 mg. 2. Failing to ensure expired medication was not administered. LVN 2 administered expired docusate, dated 4/2025, to Resident 62 on 5/6/2025. 3. Failing to ensure medication was given one hour before or one hour after the scheduled time. LVN 2 administered eight morning medications, scheduled 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.

2. During a review of Resident 107's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility originally admitted the resident on 3/23/2020 and readmitted in the facility on 7/26/2024, with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) following cerebral infarct (stroke, loss of blood flow to a part of the brain) affecting right dominant side, diabetes mellitus (DM 2-a disorder characterized by difficulty in blood sugar control and poor wound healing), and gastrostomy status (GT - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 107's History and Physical (H&P) dated 7/29/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 107's Minimum Data Set (MDS, a resident assessment tool), dated 3/26/2025, the MDS indicated Resident 107 had severely impaired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure safe provision of pharmaceutical services for three of four sampled medication storage (two medication carts in Station B and the medication room in Station A) by: 1. Failing to ensure medications were labeled inside the medication room. Medication room in Station A had two unlabeled meropenem (medication used to treat infection) vials (a small, usually cylindrical container, typically made of glass or plastic, designed to hold medicine), in the Intravenous (IV - within the vein) Cart. 2. Failing to ensure the medication cart does not contain expired medication. Station B medication cart had psyllium (medication used to treat constipation [infrequent or difficult bowel movements]) with an expiration date of 9/2024. 3. Failing to ensure the medication cart does not contain expired medication. Station B medication cart had docusate sodium (medication used to treat constipation) 250 milligram (mg - metric unit of measurement, used 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 prepare foods in a form designed to meet individual needs when puree mixed vegetables was too sticky and did not pass the spoon tilt test (a test used to determine the stickiness of the food and the ability of the food to hold together) for residents on puree diet (foods that are smooth with pudding like consistency)/International Dysphagia Diet Initiative (IDDSI-a framework for categorizing food textures and drink thickness level four (4). This deficient practice had the potential to result in difficulty in swallowing, chewing, decreased food intake and nutrient intake to 21 of 21 residents on a puree diet, resulting in unintended weight loss and aspiration (when something other than air gets into your airways). Findings: During a review of the facility's menu spreadsheet (a sheet containing the kind and amount of food each diet would receive), dated Thursday, 5/8/2025, the spreadsheet indicated residents on a dysphagia puree diet would include the following foods on the tray: - Pureed chicken alfredo #6…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen by failing to: 1. Dispose of tomato soup dated 5/2/2025. 2. Dispose of stewed prunes dated 3/2/2025. 3. Label one box mixed grapes, oranges, apple, and one carrot with an expired date and opened date 4. Label one Tutta [NAME] - Grated Parmesan Style Cheese, five (5) pounds (lbs.- a unit of measurement), received on 4/29/2025 with an opened date. 5. Ensure sliced cheeses were not mixed with avocadoes and grapes in one clear plastic bin. 6. Label one bin of purple cabbage with received date and expired date. 7. Label leafy lettuce with a received date and expired date. 8. Label the expiration date accurately on the unopened frozen pepperoni. 9. Label the opened sliced deli meat, roast beef with an expired date and opened date. 10. Ensure one of three plate warmer machines was clean and did not have dried food debris. 11. Label the thickener placed inside 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 g. During a review of Resident 175's admission Record, the admission Record indicated the facility admitted the resident on 4/14/2025 with diagnoses including acute respiratory failure (a condition where the respiratory system can't effectively exchange oxygen and carbon dioxide, leading to a buildup of carbon dioxide and a deficiency of oxygen in the blood), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 175's History and Physical (H&P), dated 4/14/2025, the H&P indicated the resident has the capacity to understand and make decisions. During a review of Resident 175's Physician Order, dated 4/14/2025, the Physician Order indicated BiPAP, apply at hours of sleep (HS), remove in AM (morning). During a review of Resident 175's Minimum Data Set (MDS-a resident assessment tool), dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 sufficient space for storage of equipment to provide adequate space for rehabilitative services provided in the Physical Therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) gym. This deficient practice had the potential to minimize the usable treatment space of the PT gym and create a cluttered, unhomelike environment. Findings: During an observation and interview on 5/7/2025 at 10:43 a.m. in the Physical Therapy gym, there was a therapy mat (wide treatment table) along one wall. On top of the therapy mat were two therapy balls, a broken chair seat, two restorators (a type of arm or leg bicycle for exercising), two sliding boards (board used for transferring from one surface to another without standing), an Occupational Therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) finger pinch exerciser set, seat cushion, and a variety of ambulation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one of three freezers (Freezer that stores milk) reviewed during Kitchen Task and maintain mechanical, electrical, and patient care equipment in safe operating condition for two (2) of 2 sample residents (Residents 65 and 107) reviewed under the Environmental Task, by failing to: 1. Ensure the light bulb was in working order in the freezer that stores milk. This deficient practice had the potential to result in poor visibility and sanitation concerns. 2. Ensure the base of Resident 65's bed controller (device used to change the height and angle of the bed) cord did not have exposed wires. 3. Ensure the wall sockets at the head of Resident 107's bed did not have a crack and were in disrepair. (Cross Reference F584). These deficient practices had the potential to place the residents at risk of incurring injury. Findings: 1. During an observation and interview on 5/6/2025 at 7:55 a.m. with DA 1, during the kitchen tour, DA 1 stated…

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

Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained a resident's dignity for one (1) of 1 sampled resident (Resident 115) reviewed for dignity by failing to ensure Certified Nursing Assistant (CNA) 3 was not standing over the resident while assisting the resident during mealtime. This deficient practice had the potential to negatively affect the residents' psychosocial wellbeing. Findings: During a review of Resident 115's Face Sheet (admission Record), the Face Sheet indicated the facility originally admitted the resident on 10/22/2023 and readmitted in the facility on 4/2/2025, with diagnoses including pneumonia (an infection/inflammation in the lungs), dementia (a progressive state of decline in mental abilities), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 115's History and Physical (H&P), dated 4/9/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of…

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

Based on observation, interview, and record review, the facility failed to ensure the resident and/or responsible party (RP) was informed in advance, of the risks and benefits of psychoactive medication (a drug that changes brain function and results in alterations in perception, mood, consciousness or behavior ) for one of one sampled resident (Resident 121) reviewed for informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) by failing to ensure Resident 121's Remeron (also known as mirtazapine, a medication used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]). This deficient practice violated the resident's right to make informed decisions regarding the use of psychoactive medication. Findings: During a review of Resident 121's Face Sheet (admission Record), the Face Sheet indicated the facility admitted the resident on 2/18/2021 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 medication self-administration was clinically appropriate and failed to honor the resident's right to self-administer medications for one of three sampled residents (Resident 96) reviewed under the Accidents care area by failing to perform a medication self-administration assessment when staff had knowledge that the resident kept medication at the bedside for self-administration. This deficient practice violated the residents' right to self-administer medications and had potential for the residents to experience adverse effects (an undesired effect of a drug or other type of treatment) of the medication. Cross-reference F689 Findings: During a review of Resident 96's Face Sheet (admission Record), the Face Sheet indicated the facility admitted the resident on 8/1/2020 and most recently admitted the resident on 3/24/2025 with diagnoses including polyneuropathy (a disorder of the peripheral nervous system that may result in pain, discomfort, and mobility issues), essential (primary) hypertension (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 observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) was connected to the wall plug for one (1) of 1 sampled resident (Resident 107) reviewed under the Environment task. This deficient practice had the potential to result in the delay of care and services and possible injury to residents when they are unable to call for assistance. Findings: During a review of Resident 107s Face Sheet (admission Record), the Face Sheet indicated the facility originally admitted the resident on 3/23/2020 and readmitted in the facility on 7/26/2024, with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) following cerebral infarct (stroke, loss of blood flow to a part of the brain) affecting right dominant side, aphasia (a disorder that makes it difficult to speak), and major depressive disorder (a mood disorder that causes 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 develop and implement a baseline care plan (the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) for: 1. One of four sampled residents (Resident 291) reviewed for respiratory care (helping people breathe easier when they have trouble with their lungs or airways) by failing to develop and implement a baseline care plan on oxygen therapy (a treatment that provides extra oxygen to breathe in). 2. One of one sampled resident (Resident 289) reviewed for anticoagulant (a substance that is used to prevent and treat blood clots in blood vessels and the heart) use by failing to develop and implement a baseline care plan on the use of anticoagulant (Pradaxa). These deficient practices had the potential for delays in the provision of essential healthcare services affecting the resident's well-being. Findings: 1. During a review of Resident 291's Face Sheet (admission Record), 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 follow up and schedule the resident's orthopedic (broad based medical and surgical specialty dedicated to the prevention, diagnosis, and treatment of diseases and injuries of the musculoskeletal system) appointment for Resident 112. This deficient practice had the potential to result in a delay of care and treatment for Resident 112. Findings: During a review of Resident 112's Face Sheet (admission Record), the Face Sheet indicated the facility admitted the resident on 3/22/2025 with diagnoses including disorder of bone, unilateral (affecting only one side of the body) primary osteoarthritis (a joint disease that causes pain, stiffness, and loss of mobility) on the right knee, and generalized muscle weakness. During a review of Resident 112's History and Physical (H&P), dated 3/24/2025, the H&P indicated the computed tomography (CT-a medical imaging procedure that uses X-rays and computer processing to create a detailed cross-sectional images of the body) results of the femur (the long bone located in the thigh, connecting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident received care consistent with professional standards of practice to prevent pressure ulcers/injury (the breakdown of skin integrity due to pressure) for two of two sampled residents (Residents 153 and 289) reviewed for pressure injury by failing to ensure the low air loss mattress (LALM, a special kind of mattress designed to help prevent and treat skin problems like pressure sores [bedsores]) was set according to the residents' weight. These deficient practices had the potential for development and worsening of pressure ulcers/injuries to residents. Findings: Cross Reference F657 1. During a review of Resident 153's Face Sheet, the Face Sheet indicated the facility admitted the resident on 3/13/2024, with diagnoses including type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic neuropathy (nerve damage that can occur due to diabetes), adult…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 six sampled residents (Resident 121) received appropriate Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) services to prevent a decline in range of motion (ROM, full movement potential of a joint) by failing to provide Resident 121 with active assisted range of motion (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another person) exercises to the left upper extremity (UE, shoulder, elbow, wrist, hand) during the 5/7/2025 RNA session, as ordered by a physician and according to Resident 121's care plan. This deficient practice had the potential for a decline in mobility, ROM, and overall functioning in Resident 121. Findings: During a review of Resident 121's Face Sheet (FS), the FS indicated Resident 121 admitted to the facility on [DATE] with diagnoses including but not limited to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the staff providing care and services to the resident who has a feeding tube (are soft plastic tubes through which liquid nutrition travels through the gastrointestinal tract [the series of organs that food and liquids pass through as they are digested, absorbed, and leave the body as feces]) are aware of, competent in, and utilize facility protocols regarding feeding tube nutrition and care for two of four sampled residents (Residents 53 and 107 ) reviewed for tube feeding by failing to ensure: 1. Resident 53's gastrostomy tube (g-tube, a feeding tube inserted through the abdomen into the stomach) Glucerna 1.2 (brand of formula feeding) was labeled with the time it was hung, and the water flush bag via pump had the time it was hung with its rate of infusion. 2. Resident 53's Lopez valve (a three-way stopcock used with feeding tubes, specifically to protect healthcare workers from accidental exposure to gastric fluids and other…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 staff competency (a combination of knowledge, skills, abilities, and behaviors that enable an individual to perform a task or role successfully) were performed annually (yearly) for one of six sampled staff (Certified Nursing Assistant [CNA] 1). This failure had the potential to affect the care necessary to provide nursing care and related services to meet resident needs safely. Findings: During a concurrent interview and record review, on 5/8/2025, at 7:58 a.m., with the Director of Staff Development (DSD), CNA 1's employee file was reviewed. CNA1's employee file indicated CNA 1 was employed by the facility on 11/8/2022. CNA 1's last skills competency was dated 1/2024. The DSD stated the next skills competency for CNA 1 will be on 11/2025 which is the month CNA 1 was hired. During an interview on 5/8/2025, at 8:10 a.m., with the DSD, the DSD stated she (DSD) was assigned to evaluate CNAs for skills competencies. The DSD stated CNA's skills and knowledge competencies were evaluated annually and as needed. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (% - one per one hundred), two medication errors out of 31 total opportunities contributed to an overall medication error rate of 6.45% affecting two of five sampled residents (Resident's 3 and 62), observed for medication administration by: 1. Failing to ensure Licensed Vocational Nurse (LVN) 1 administered docusate sodium (medication used to treat constipation [bowel movements are infrequent, and the stool is hard and difficult to pass]) 250 milligram (mg - metric unit of measurement, used for medication dosage and/or amount) to Resident 3 as per physician order. LVN 1 administered 100 mg on 5/6/2025. 2. Failing to ensure LVN 2 checked the docusate sodium 250 mg expiration date before medication administration to Resident 62. The docusate sodium bottle had an expiration date of 4/2025. These failures had the potential to result in Resident 3 and 62 experiencing adverse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a computed tomography scan (CT scan, medical imaging technique to create detailed cross-sectional images of the body) to one of 38 sampled residents (Resident 128) in a timely manner when a CT scan ordered on 9/9/2024 was not completed until 10/21/2024. This deficient practice had the potential to cause a delay in identification of diseases and delayed follow up orthopedic (medical specialty involving muscles and bones) care for Resident 128. Findings: During a review of Resident 128's Face Sheet (FS), the FS indicated Resident 128 admitted to the facility on [DATE] with diagnoses including, but not limited to, muscle wasting and atrophy (weakening, shrinking, and loss of muscle) and right humeral neck fracture (broken bone of upper arm). During a review of Resident 128's Physician's History and Physical Examination (H&P) dated 8/10/2024, the H&P indicated Resident 128 had the capacity to understand and make decisions. During a review of…

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

Based on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when one of one staff (Cook 1) was unable to verbalize and prepare puree mixed vegetables in a consistency that passed all established testing guidelines including spoon-tilt test (a test used to determine the stickiness of the food and the ability of the food to hold together) for residents on puree diet (foods that are smooth with pudding like consistency)/International Dysphagia Diet Initiative (IDDSI-a framework for categorizing food textures and drink thickness level four (4). These deficient practices resulted in an improper puree consistency which was too thick and did not pass the spoon-tilt test, which had the potential to place the residents at risk for aspiration (when something other than air gets into your airways). Cross-reference F805 Findings: During a review of the facility's menu spreadsheet (a sheet containing kind and amount of food each diet would receive), dated 5/8/2025, Thursday, the spreadsheet indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide Occupational Therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) treatments five times a week according to resident's OT plan of treatment and care plan for one of six sampled residents (Resident 128). This deficient practice had the potential for Resident 128 to not meet OT treatment goals and have a decline in function. Findings: During a review of Resident 128's Face Sheet (FS), the FS indicated Resident 128 admitted to the facility on [DATE] with diagnoses including, but not limited to, muscle wasting and atrophy (weakening, shrinking, and loss of muscle) and right humeral neck fracture (broken bone of upper arm). During a review of Resident 128's Physician's History and Physical Examination (H&P) dated 8/10/2024, the H&P indicated Resident 128 had the capacity to understand and make decisions. During a review of Resident 128's Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. During a review of Resident 128's Face Sheet (FS), the FS indicated Resident 128 admitted to the facility on [DATE] with diagnoses including, but not limited to, muscle wasting and atrophy (weakening, shrinking, and loss of muscle) and right humeral neck fracture (broken bone of upper arm). During a review of Resident 128's Physician's History and Physical Examination (H&P) dated 8/10/2024, the H&P indicated Resident 128 had the capacity to understand and make decisions. During a review of Resident 128's Minimum Data Set (MDS, resident assessment tool) dated 2/10/2025, the MDS indicated Resident 128 had moderate cognitive impairments (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving). The MDS indicated Resident 128 had functional limitation impairments in range of motion (ROM, full movement potential of a joint) on one side of the upper extremity (UE, shoulder, elbow, wrist, hand) and no impairments on the lower extremity (LE,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 the policy for antibiotic (medication used to treat infection) stewardship (efforts in doctors' offices, hospitals, long-term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate, means prescribing the right drug at the right dose at the right time for the right duration) for one of three sampled residents (Resident 42) by failing to ensure Resident 42's Antibiotic Log (record that involves the systematic collection, analysis, and interpretation of data related to infections within a healthcare setting) antibiotics use was accurately filled up on 4/2025. This failure had the potential to increase antibiotic resistance (the ability of bacteria and other microorganisms to survive exposure to an antibiotic that would normally kill them) from unnecessary or inappropriate antibiotic use. Findings: During a review of Resident 42's Face Sheet (admission Record), the Face Sheet indicated the facility admitted Resident 42 on 2/12/2025, with diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 a person-centered care plan for one of three sampled residents (Resident 1) by failing to ensure Resident 1's bed alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) was functioning as indicated in Resident 1's Care Plan for fall. This failure had the potential for Resident 1 to fall and placed Resident 1 at risk for injury. Cross reference F689. Findings: During a review of Resident 1's Face Sheet (admission Record), the Face Sheet indicated the facility admitted Resident 1 on 4/22/2025, with diagnoses that included unspecified (unconfirmed) fracture of the ninth and tenth thoracic vertebrae (a break in the bone of the spine, specifically in the middle back), history of fall, and unspecified dementia (a progressive state of decline in mental abilities). During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow its policy on fall prevention for one of three sampled residents (Resident 1) who had a history of fall and had an incident of fall on 4/23/2025 while admitted at the facility by: 1. Failing to ensure Resident 1's bed alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) was turned on and functioning. 2. Failing to accurately assess Resident 1's Fall Risk Assessment after incident of fall on 4/23/2025. These failures can potentially place Resident 1 at risk for further injury, fall, and accidents. Cross reference F656. Findings: a. During a review of Resident 1's Face Sheet (admission Record), the Face Sheet indicated the facility admitted Resident 1 on 4/22/2025, with diagnoses that included unspecified (unconfirmed) fracture of the ninth and tenth thoracic vertebrae (a break in the bone of the spine, specifically in the middle back), history of fall, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report injury of unknown origin within 24 hours to the State Survey Agency (SSA- the agency that inspects long-term care facilities for the purposes of survey and certification) and the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), as per its policies and procedures on abuse for one of three sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 at risk for an unidentified abuse while under the care of the facility. Findings: During a review of Resident 1's Face Sheet (admission Record), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included inflammatory polyarthorpathy (a condition characterized by inflammation in multiple joints), other low back pain, and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's History and Physical (H&P- a medical examination…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain accurate and complete medical records for one of three sampled residents (Resident 1). This failure had the potential to cause confusion in care and the medical records containing inaccurate documentation Findings: During a review of Resident 1's Face Sheet, the Face Sheet indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included inflammatory polyarthorpathy (a condition characterized by inflammation in multiple joints), other low back pain, and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's History and Physical (H&P- a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings) dated 2/27/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool) dated 3/5/2025, the MDS…

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

Based on observation, interview and record review, facility failed to maintain privacy of confidential information when Licensed Vocational Nurse 2 (LVN 2) left electronic health record (EHR- a digital version of a patient's paper chart) opened, unattended and out of view for one of three sampled residents (Resident 1). This deficient practice violated Resident 1 ' s right to privacy and confidentiality of their medical records. Findings: During a review of Resident 1 ' s Face Sheet (a document that summarizes a patient's personal information and health status) indicated the facility admitted Resident 1 on 10/12/2024 and readmitted the resident on 1/13/2025 with diagnoses including liver cell carcinoma (a type of cancer that develops when liver cells grow into a tumor [an abnormal mass of tissue that grows when cells divide too much or do not die when they should]), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), peripheral angiopathy (a term that may refer to peripheral artery disease (PAD), which is a 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 the necessary treatment and services for one of three residents (Resident 2) at risk for developing pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) received the necessary care and services to prevent pressure ulcers from developing, by failing to follow the manufacturer's guideline for low air loss mattress (LAL- a mattress that uses air to help prevent and treat pressure wounds and maintain a comfortable temperature and moisture level for the patient). This deficient practice had the potential for Resident 2's wounds to worsen. Findings: During a review of Resident 2's Face Sheet (admission Record) indicated the facility admitted Resident 2 on 12/5/2024 with diagnoses including bilateral (having or involving two sides) stage unspecified, contusion (a bruise) of right hip, and acute respiratory failure (ARF- occurs when your lungs can't remove carbon dioxide or release enough oxygen…

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

Based on observation, interview, and record review, the facility failed to provide care that was consistent with professional standards of care for one of three residents (Resident 2) when humidifier bottle (a medical device used to humidify oxygen which in turn increases the moisture) was observed with no water. This deficient practice had the potential for Resident 2 to be uncomfortable and a risk for bleeding due to the nasal passage and throat becoming dried out due to the use of pure oxygen. Findings: During a review of Resident 2 ' s Face Sheet (a document that summarizes a patient's personal information and health status) indicated the facility admitted Resident 2 on 12/5/2024 with diagnoses including bilateral (having or involving two sides) stage unspecified, contusion (a bruise) of right hip, and acute respiratory failure (ARF- occurs when your lungs can't remove carbon dioxide or release enough oxygen into your blood). During a review of Resident 2 ' s Physician Order Sheet January 2025, dated 12/5/2024 indicated oxygen (O2) at 2 liters per minute (L/min- a unit of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY d. A review of Resident 46's Face Sheet indicated the facility admitted the resident on 10/6/2023, with diagnoses including anxiety (feelings of fear, dread, and uneasiness that may occur as a reaction to stress), congestive heart failure (a long-term condition that happens when the heart cannot pump blood well enough to give the body a normal supply), and chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of Resident 46's History and Physical, dated 10/13/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 46's MDS dated [DATE], indicated the resident had impaired vision and cognition. The MDS indicated the resident required substantial to partial assistance in mobility. A review of Resident 46's Fall Risk Assessment, dated 4/18/2024, indicated the resident was high risk for falls with injury. A review of Resident 46's Care plan, titled Fall Risk, last reviewed on…

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

Based on observation, interview, and record review the facility failed to provide a safe, clean, and homelike environment to three out of six sampled residents (Resident 61, 7, and 135) investigated during review of environment facility task by failing to: 1. Ensure Resident 61's bed controls did not have exposed wires. The deficient practice placed the resident at risk for injuries such as electrical shock. 2. Maintain Resident 7 and Resident 135's bolsters (a long, thick pillow or cushion that can be cylindrical in shape or rectangular, with a cover that can be cleaned) in good condition. This deficient practice had the potential to make the residents feel uncomfortable, at risk for accidents, and can negatively affect the residents' quality of life. Findings: 1. A review of Resident 61's Face Sheet indicated the facility admitted the resident on 11/13/2023, with diagnoses including dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and hearing loss. A review of Resident 61's History and Physical (H&P), dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) to five out of five sampled residents (Residents 40, 46, 127, 31, 28, and 7) investigated during review of physical restraints care area by failing to: 1. Ensure Resident 40, 31, and 68's bed was not placed against the wall without obtaining an informed consent from the resident or the resident's representative. 2. Ensure Residents 46 and 127's bed was not placed against the wall, without assessing the need for use, obtaining informed consent, and obtaining an order from the physician prior to use. 3. Ensure Residents 31 and 68 bed was not placed against the wall and use of bilateral upper half siderails…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. To develop and implement a care plan on the use of a restraint (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body), placement of bed against the wall to two out of seven sampled residents (Resident 46, 127, 31, and 68) investigated during review of restraints care area. This deficient practice had the potential for the residents to not receive the proper and necessary care related to use of restraints. 2. To develop and implement a care plan addressing the resident's dialysis status to one of one sampled resident (Resident 162) investigated during review of dialysis care area, by failing This deficient practice placed Resident 162 at risk for not receiving the necessary services and treatment related to dialysis. 3. To develop and implement a 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure licensed nurses provide care in accordance with professional standards to three of three sampled residents (Resident 40, 18 and 124) investigated during review of insulin (a hormone that lowers the level of blood sugar in the blood) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin (a drug used to control the amount of sugar in the blood) injection sites. The deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs). Cross-reference to F760. Findings: a. A review of Resident 40's Face Sheet indicated the facility admitted the resident on 10/4/2021, with diagnoses including type 2 diabetes mellitus (a disease 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide services and treatments to maintain joint range of motion (ROM, full movement potential of a joint) for two of six sampled residents (Residents 28 and 92) by failing to: 1. Follow physician's orders for a Restorative Nursing program (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatments to apply left knee extension (straighten knee) splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) for maximum of three to four hours for Resident 28. 2. Provide Resident 92 with RNA treatments for active assistive range of motion (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another person) exercises to both upper extremities (BUE, shoulder, elbow, wrist, hand) once a day six times a week, passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents' environment remains as free of accident hazards as is possible and residents receive adequate supervision to prevent accidents by failing to: 1. Ensure two single-use vitamin A&D ointment (a medication to treat or prevent dry, rough, itchy skin) packets were not left unattended and readily available in the residents' shared room for two of two sampled residents (Resident 2 and 48) observed during the screening process. 2. Ensure the Oxygen in Use, sign was placed outside of the resident room entrance door while on oxygen therapy for one (1) out of two (2) sampled residents (Resident 68). These deficient practices had the potential to place residents at risk for hazard or injury and at risk for obtaining topical medication without staff knowledge resulting in accidental ingestion. Findings: 1.a. A review of Resident 2's Face Sheet (admission Record) indicated the facility admitted the resident on 11/22/2023 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 provide appropriate treatment and services to prevent complications of enteral feeding (EF - a form of nutrition that is delivered into the digestive system as a liquid) for three of three sampled residents (Residents 63,110, and 106) investigated during review of tube feeding (a medical device that delivers liquid nutrition directly into the stomach through a tube placed in the abdominal wall) care area by: 1. Failing to label Residents 63's water flush bag with the rate of administration and the date and time the water flush was administered. 2. Failing to label Resident 110's EF bag with the date and time the EF was administered. 3. Failing to change Resident 106's water flush bag every 24 hours. These deficient practices had the potential to place the residents at risk for complications related to enteral feeding such as diarrhea (loose, watery stools), or vomiting which may lead to dehydration (loss or removal of water). Findings: 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 residents who need respiratory care are provided care consistent with professional standards of practice for two of six sampled residents (Resident 28 and 38) investigated during review of respiratory care area by failing to: a. Ensure Resident 38 was administered as needed (PRN, when necessary) oxygen (O2) per physician orders, oxygen was documented when administered, and oxygen was monitored while in use. b. Ensure Resident 28's oxygen tubing was undated, not touching the floor, and did not have condensation inside the tubing while connected to the resident. These deficient practices had the potential to place residents at risk for respiratory distress. Findings: a. A review of Resident 38's Face Sheet (admission Record) indicated the facility admitted the resident on 11/27/2023 with diagnoses that included acute (present) respiratory failure (a serious condition that occurs suddenly when the lungs cannot get enough oxygen) with hypoxia (low oxygen in the blood), heart failure (a condition in which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Physicians Order for Life Sustaining Treatment (POLST, a form designed to improve patient care by creating a portable medical order form that records patients treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) were dated by the physician for three of nine sampled residents (Residents 164, 39, and 14) investigated during the Initial Pool process. This deficient practice had the potential for delay of necessary services, poor continuity of care and follow-up on the resident's status. Findings 1.a. A review of Resident 14's Face Sheet (admission Record) indicated the facility admitted the resident on [DATE] with diagnoses that included idiopathic peripheral autonomic neuropathy (damage to the nerves that control automatic body functions), dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere 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 interview and record review, the facility failed to implement the recommendations for one of one resident (Resident 28)'s Medication Regimen Review (MRR - a pharmacist's thorough evaluation of a resident's medication routine and recommendations). This deficient practice could result in Resident 28 receiving unnecessary anti-anxiety (medication for feeling of fear and worry) medication. Findings: A review of Resident 28's admission Record dated 11/2/2023, it indicated Resident 28 was admitted on [DATE] with a diagnosis including, but not limited to depression (loss of pleasure or interest in activities for long periods of time) and anxiety (a feeling of fear and worry). A review of Resident 28's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/5/2024, it indicated Resident 28 had mild cognitive (ability to think, understand and make daily decisions) impairment and needed assistance from facility staff for toileting, showering, and dressing. A review of Resident 28'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 3. A review of Resident 424's Face Sheet (admission Record) indicated the facility admitted the resident on 4/22/2024 with diagnoses that included Alzheimer's disease (a type of dementia [general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life]), encounter for palliative care (specialized medical care for people living with a serious illness), anxiety disorder, unspecified dementia with agitation, and bipolar disorder (a mental health disorder that causes extreme mood swings). A review of Resident 424's Minimum Data Set (MDS - an assessment and screening tool) dated 4/28/2024, indicated the resident usually was able to understand others and usually was able to make herself understood. The MDS further indicated the resident was dependent on staff for bathing; required substantial assistance with dressing; and required partial assistance with toileting and personal hygiene. The MDS indicated the resident was taking antianxiety…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 are free of any significant medication errors to three out of three sampled residents (Residents 40 18), and 104) investigated during review of insulin use by failing to rotate (a method to ensure repeated injections are not administered in the same area) insulin (a medication that regulates sugar in the blood) injections sites. The deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs). Cross-reference to F658 Findings: a.A review of Resident 40's Face Sheet indicated the facility admitted the resident on 10/4/2021, with diagnoses including type 2 diabetes mellitus (a disease that occurs when the glucose, also called blood sugar, is too high) with neuropathy (damage, disease, or dysfunction of one…

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

Based on observations, interviews, and record review the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills as followed: a. Staff failed to verbalize proper storage of food. b. Staff failed to verbalize and follow the manufacturer's guidelines of cleaner chlorine test paper (a type of test strip) when checking the chlorine (a chemical used to disinfect dishes) sanitizer concentration. These failures had a potential to result to cross-contamination (a transfer of bacteria from one object to another), unsanitized dishware and bacterial growth to food that could lead to foodborne illness (an illness caused by contaminated food and beverages) in 167 of 173 medically compromised residents who received food and ice from the kitchen. Cross Reference F812 Findings: a. During an initial kitchen tour observation of the walk-in refrigerator on 5/14/2024 at 8:37 a.m., there were uncovered fruit plates in the walk-in refrigerator shelves. During an interview with Lead Dietary Assistant (LDA), on 5/14/2024 at 8:39 a.m., LDA stated stored food needed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 of and did not meet nutritional needs of 79 of 173 residents on regular texture (diet with no texture restriction) and 22 of 38 residents on soft mechanical finely chopped diet (diet consisted of food that are chopped half inches ([in] a unit of measurement) or less and restrict food that are difficult to chew or swallow) by: a. Not following portion sizes for oven fried chicken based on facility spreadsheet. b. Not following menu for dessert for finely chopped diet. These deficient practices had the potential to cause difficulty in eating, chewing, and swallowing to the residents and decrease food intake resulting to unintended (not done on purpose) weight loss or increased food intake resulting to unintended weight gain. Findings: a. During an observation of the lunch trayline (an area where resident's food was assembled) on 5/14/2024 at 11:32 a.m. and interview with [NAME] 1, a pan contained different sizes of bone-in chicken. [NAME] 1 stated she would give big pieces to three (3) ounces…

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

Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor when puree chicken did not taste like chicken. This deficient practice had a potential to cause unplanned weight loss, a consequence of poor food intake 21 of 173 facility residents on puree diet (a diet with smooth, pudding like consistency foods) getting food from the kitchen. Findings: During a test tray (process of taste testing food) of puree tray with Food Service Director (FSD) on 5/14/2024 at 1:04 p.m., puree chicken did not taste like chicken. FSD stated she did not get a strong chicken taste of the puree chicken after tasting it. During an interview with the FSD on 5/15/2024 at 7:13 p.m. FSD stated they did not have any concern about the puree chicken flavor however, flavors improve resident's intake and if the puree chicken did not taste like chicken, resident's food intake could be low causing potential weight loss. A review of the facility's recipe titled Puree Meats, Fish or Poultry undated, indicated ingredients: cooked meats, warm liquid (drained…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 distribute and serve food in accordance with professional standards for food service safety for one of two sampled residents investigated during a complaint investigation (Resident 146) when Resident 146 was not provided clean dishware during meal service. The facility also failed to ensure safe and sanitary food storage and food preparation practices in the kitchen and when: A. 1. Hygiene a. Staff were wearing jewelries during food handling and preparation. 2. Proper food storage a. Unlabeled food for expiration date in the walk-in refrigerator and in the kitchen. b. Uncovered fruit plates and key lime pie inside the walk-in refrigerator. c. One (1) dented can was stored in the dry storage area along with the undented cans. d. Residents' food from home/outside had no label and date and stored with the staff food in the resident's refrigerator. e. Blank refrigerator and freezer logs from 4/10/2024 to 5/15/2024. 3. Equipment, utensils, 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 dispose garbage and refuse properly by not completely covering two (2) of four (4) black dumpster (a large trash container designed to be emptied into a truck) for unknown amount of time. This deficient practice had a potential to attract flies, insects, cats, and other animals to the dumpster area placing 167 of 173 facility residents getting food from the kitchen cross-contamination (a transfer of harmful bacteria from one place to another). Findings: During a concurrent observation of the garbage area located outside the facility near the kitchen and interview with Lead Diet Aide (LDA) and Food Service Director (FSD) at 5/14/2024 5:32 p.m., two (2) of six (6) black trash bins and 1 (one) of 1 gray trash bin were not completely closed and covered. LDA stated it was important to keep the trash close as it could attract flies. FSD stated it was important to keep the trash lid close to prevent pest, flies, and rodents for infection control. During an interview with the Housekeeping Supervisor (HKS) 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.

b. A review of Resident 424's Face Sheet (admission Record) indicated the facility admitted the resident on 4/22/2024 with diagnoses that included Alzheimer's disease (a type of dementia [general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life]), encounter for palliative care (specialized medical care for people living with a serious illness), anxiety disorder, unspecified dementia with agitation, and bipolar disorder (a mental health disorder that causes extreme mood swings). A review of Resident 424's Minimum Data Set (MDS - an assessment and care screening tool) dated 4/28/2024, indicated the resident usually was able to understand others and usually was able to make herself understood. The MDS further indicated the resident was dependent on staff for bathing; required substantial assistance with dressing; and required partial assistance with toileting and personal hygiene. A review of Resident 424's physician orders indicated the following orders: -Admit to hospice with diagnosis Alzheimer'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 10. A review of Resident 28's Face Sheet indicated the facility admitted Resident 28 on 11/2/2023 with diagnoses including, but not limited to, acute (present) and chronic (long-term) respiratory failure (a condition where you don't have enough oxygen in the tissues in your body or when you have too much carbon dioxide in your blood), dependence on supplemental oxygen, and chronic obstructive pulmonary disease (COPD - a condition involving constriction of the airways and difficulty or discomfort in breathing). A review of Resident 28's MDS, dated [DATE], indicated Resident 28 had mild cognitive impairment (difficulty understanding and making decisions), required setup or clean-up assistance for eating, required maximal assistance with oral hygiene, upper body dressing, personal hygiene, and was dependent on staff for toileting hygiene, lower body dressing, putting on or taking off footwear, and rolling left and right, and is on oxygen therapy. A review of Resident 28's H&P, dated 11/18/2022, indicated 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 monitor proper temperatures of the resident's refrigerator and freezer from 4/10/2024 to 5/15/2024 in Stations one (1), two (2) and three (3). This deficient practice had the potential to result in danger zone temperatures (a range of temperature in which food-borne bacteria could grow) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) in 167 of 173 medically compromised residents who stored food in the resident's refrigerator and freezer. Cross Reference F812 Findings: During a concurrent observation of the resident's refrigerator and freezer in Stations one (1), two (2) and (3) and interview with LVN 6 on 5/15/2024 at 9:24 a.m., the temperature logs from 4/10/2024 to 5/15/2024 were blank. LVN 6 stated the supervisor who worked 11 p.m. to 7 a.m. was the one who monitored the refrigerator and freezer temperatures. LVN 6 stated it was important to monitor and maintain the refrigerator and freezer temperatures because foods needed to be in…

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

Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of their individuality for one of two sampled residents investigated under the dignity care area (Resident 80) when Resident 80's urinary catheter bag (device used to collect urine drained from the bladder via a urinary catheter [a tube inserted into the bladder through the urethra (duct that lets urine leave the bladder and body) to allow urine to drain]) was not covered with a privacy bag (also known as a dignity bag - device used to cover the contents or a urinary catheter bag). This deficient practice had the potential to negatively affect the resident's psychosocial wellbeing and loss of dignity. Findings: A review of Resident 80's Face Sheet (admission Record) indicated the facility admitted Resident 80 on 10/23/2023 with diagnoses including, but not limited to, multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves) and benign prostatic hyperplasia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN, a written notification to the resident or responsible party of the potential liability charges for services not covered when the resident was discharged from Medicare Part A services with benefit days remaining) in a timely manner for one of three sampled residents (Resident 425) investigated during review of the Beneficiary Notification task. This deficient practice had the potential to result in residents or responsible parties not being able to exercise their rights to make decisions regarding their care and their right to file an appeal. Findings: A review of Resident 425's Face Sheet (admission Record) indicated the facility admitted the resident on 1/22/2024 with diagnoses that included idiopathic peripheral autonomic neuropathy (damage to the nerves that control automatic body functions), pneumonia (infection in the lungs), and abnormalities of gait (manner of walking) and mobility. A review of Resident 425's Minimum Data Set (MDS - an…

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

Based on observation, interview, and record review the facility failed to ensure privacy for one of four sampled residents (Resident 159). This deficient practice had the potential to cause Resident 159 embarrassment and distress due to a lack of privacy. Findings: A review of Resident 159's Face Sheet dated 5/15/2024 indicated the facility originally admitted the resident on 1/10/2024 with diagnoses including but not limited to: hemorrhage (bleeding) of the anus and rectum, chronic cholecystitis (inflammation of the gallbladder), congestive heart failure (a condition where the heart can't pump enough blood to meet the body's needs), and major depressive disorder (a mood disorder that causes feelings of persistent sadness and loss of interest in activities). A review of Resident 159's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/16/2024, indicated he has intact cognition. The MDS also indicated Resident 159 needs substantial to maximal assistance with toileting, bathing, and dressing. He needs supervision with eating and oral hygiene. 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 update Resident 28's Restorative Nursing Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) Care Plan to reflect the current RNA orders. This deficient practice had the potential for Resident 28 to receive incorrect services and minimize the facility's ability to review the effectiveness of the RNA program. Findings: A review of Resident 28's Face Sheet indicated the facility originally admitted Resident 28 to the facility on 3/11/2021 and readmitted the resident on 11/2/2023 with diagnoses including but not limited to acute and chronic respiratory failure (any condition that affects breathing function and result in lungs not functioning properly), hemiplegia (weakness to one side of the body) following cerebral infarction (blockage of the flow of blood brain, causing or resulting in brain tissue death) affecting left nondominant side, and contracture (condition of shortening and hardening of muscles, tendons, or other tissue, often…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of two sampled residents investigated during a complaint (Resident 146), 10 of 10 resident council group attendees investigated under the resident council task, and for one of three sampled residents investigated under the activities of daily living care area (Resident 92) when the facility failed to: a. Temporarily move Resident 146 out of the room after his roommate (Resident 325) expired. b. Offer the resident council group attendees and Resident 92 to eat their meals in the dining room. These deficient practices resulted in or had the potential to: a. Resident 146 experiencing feelings of increased stressed and anxiety. b. Negatively affect residents' psychosocial wellbeing. Cross-reference F745 Findings: a. A review of Resident 146's Face Sheet (admission Record) indicated the facility admitted Resident 146 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the resident's choices to one out of three residents (Resident 172) investigated during review of closed record by failing to: 1. Ensure the admission orders address the resident's code status (refers to the level of medical interventions a resident wish to have started if their heart or breathing stops) Resident 172 had a previous code status of Do Not Resuscitate (DNR, refers to a medical order issued by a physician that directs healthcare providers not to administer CPR in the vent of cardiac or respiratory arrest)/Do Not Intubate (DNI) from General Acute Care Hospital 1 (GACH 1). 2. Complete the Physician Orders for Life Sustaining Treatment (POLST, are medical order forms that tell medical staff what to do if there was a medical emergency and are unable to speak for themselves) Form of the resident. 3. Verify the presence of advance directives or…

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

Based on interview and record review the facility failed to ensure residents receive treatment and services to maintain vision to one out of four sampled resident (Resident 18) investigated during review of communication/sensory care area for vision by failing to schedule an optometrist/ophthalmologist (eye care specialist) appointment Resident 18. This deficient practice had the potential to result in worsening of the resident's vision that could negatively affect their daily activities and overall well-being. Findings: A review of Resident 18's Face Sheet indicated the facility admitted the resident on 1/9/2024, with diagnoses including lack of coordination, type 2 diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, is too high), and abnormal posture. A review of Resident 18's History and Physical (H&P), dated 1/11/2024, indicated the resident had the capacity to understand and make decisions. A review of Resident 18's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/15/2024, indicated the resident had 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 residents who were incontinent (lacks voluntary control over urination) of bladder (organ in the pelvis that stores urine) received appropriate treatment and services to prevent urinary tract infections (UTI, common infections that happen when bacteria infect the urinary tract) for two out of four sampled residents (Resident 80 and 146) reviewed under the urinary catheter (a tube that is inserted into the bladder, allowing urine to drain) care area by failing to keep Resident 80 and Resident 146's urinary catheter tubing from coiling and allowing the contents to flow freely into the urinary catheter bag (container that connects to a urinary catheter and collects urine). This deficient practice had the increased potential for residents to obtain a UTI. Findings: a. A review of Resident 80's Face Sheet (admission Record) indicated the facility admitted Resident 80 on 10/23/2023 with diagnoses including, but not limited to, multiple…

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

Based on interview, and record review, the facility failed to ensure that a resident who was receiving dialysis (clinical purification of blood as a substitute for the normal function of the kidney) treatment received services consistent with professional standards of practice for one (1) out 1 sampled resident (Resident 162) investigated during review of dialysis care area by failing to complete the post dialysis assessment on 5/11/2024 per facility policy. This deficient practice placed the resident at risk for developing complications related to renal disease such swelling, high blood pressure and shortness of breath. Findings: A review of Resident 162s admission Record indicated the facility admitted the resident on 5/2/2024 with diagnoses including cerebral infarction (also known as a stroke - refers to damage to tissues in the brain due to a loss of oxygen to the area), hemiplegia (paralysis affecting one side of the body following cerebral infarction), and difficulty walking. A review of Resident 162's History and Physical (H&P) dated 4/23/2024, indicated the resident had the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide medically-related social services (services provided by the facility's staff to assist residents in attaining or maintaining their mental and psychosocial health) to maintain the highest practicable psychosocial well-being for one of two sampled residents reviewed during a complaint investigation (Resident 146) when the social services department did not provide follow-up visits to Resident 146 after his roommate (Resident 325) expired. This deficient practice had the potential for the resident's stress and anxiety to increase. Cross-reference to F675. Findings: A review of Resident 146's Face Sheet (admission Record) indicated the facility admitted Resident 146 on [DATE] with diagnoses including, but not limited to, quadriplegia (paralysis of all four limbs), neuromuscular dysfunction of bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems), and benign prostatic hyperplasia (BPH - enlarged prostate [male…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that an unlabeled, and unpackaged medication pill was labeled or disposed of in medication room [ROOM NUMBER]. This deficient practice had the potential for an unknown medication to be administered to a resident. Findings: During a concurrent observation and interview on 5/16/24 at 9:20 a.m., in medication room [ROOM NUMBER], with Licensed Vocational Nurse (LVN) 3, an unpackaged, and unlabeled white, round, scored pill, with the symbols AZ 011 was found in an unlocked metal container. LVN 3 stated all wasted pills must be disposed of in the incineration bin or the pill could be accidently given to the wrong resident. During an interview on 5/16/24 at 9:30 a.m. with the Assistant Director of Nursing (ADON), ADON stated the medication room must be organized and checked frequently to prevent medication errors. ADON stated if medications are not disposed of correctly, the risk is that an unidentified pill can be given to any 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 safe provision of pharmaceutical services by failing to ensure two unlabeled cephalexin (an antibiotic [medication used to treat bacterial infections in different parts of the body]) capsules were not stored and readily available for use in Medication Cart #2 for one of three medication carts (Medication Cart #2) inspected during review of the Medication Storage and Labeling task. This deficient practice had the potential to result in medication being administered to the wrong resident possibly resulting in allergic reactions and the loss of resident medication. Findings: During an inspection of Medication Cart #2 on 5/15/2024 at 7:30 a.m. with Licensed Vocational Nurse 5, observed in the top left drawer of the cart two cephalexin 250 milligram (mg, a unit of measurement) capsules in the manufacturer's packaging. LVN 5 stated the capsules were not labeled for a resident and she did not know the reason the capsules were stored in the top left drawer. LVN 5 stated she did not know where the capsules came…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 meet resident's (Resident 17) food preferences when there were missing items on the resident's tray. This deficient practice had the potential to cause frustrations and decrease food intake resulting to unintended (not done on purpose) weight loss. Findings: During a concurrent dining observation on 5/14/2024 at 12:44 p.m. and interview with Resident 17, Resident's 17 meal ticket for lunch indicated avocado slices as food preference. Resident 17 stated her tray did not have any avocado slices. A review of Resident 17's admission Record, indicated Resident 17 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (a lung disease causing restricted airflow and breathing problems), hypertensive heart disease with heart failure (a heart disease caused by high blood pressure that is present over a long time), and chronic kidney disease stage 3 (a disease when kidneys do not work well as they should to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident received care consistent with professional standards of practice to prevent pressure ulcer (PU-a localized injury to the skin and or underlying tissue usually over a bone prominence as a result of pressure or pressure in combination with shear [occur between the internal body structures and skin tissues typically moving in opposite directions and may lead to deep tissue injury]) for one of three sampled residents (Resident 1) by: 1. Failing to accurately monitor and ensure Resident 1's skin was assessed for pressure ulcer. 2. Failing to ensure there were appropriate number of linens between Resident 1 and the air pressure redistribution mattress (APM - [air mattress] a mattress composed of inflatable air cushions that is used to relieve pressure on the body parts) per manufacturer's guidelines. These deficient practices placed Resident 1 at risk for the development of pressure ulcer. Findings A review of Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to observed infection control measures for two of three sampled residents (Resident 1 and Resident 2) by failing to ensure oxygen tubing was not touching the floor. This deficient practice resulted in contamination (the process of making something dirty) of the residents' care equipment and placed the residents at risk for infection. Findings: a. A review of Resident 1's admission Record indicated the facility admitted the resident on 11/30/2023 with diagnoses that included unspecified (unconfirmed) fracture (break in the bone) of left femur (thigh bone), pulmonary hypertension (a serious condition where there is abnormally high pressure in the blood vessels between the lungs and the heart) and chronic obstructive pulmonary disease (COPD- is a long-lasting lung disease where the small airways in the lungs are damaged, making it harder for air to get in and out). A review of Resident 1's History and Physical dated 11/30/2023 indicated the…

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

Based on interview and record review, the facility failed to ensure accurate records of administration of all controlled drugs (prescription medications that are designated by law and whose manufacture, possession and use is regulated by the government) for one of three sampled residents (Resident 3). On 11/27/2023, Licensed Vocational Nurse 3 (LVN 3) did not document the administration of hydrocodone/acetaminophen (Norco, a combination opioid [work in the brain to produce a variety of effects, including pain relief]). This deficient practice resulted in inaccurate reconciliation of the controlled medication and placed the facility at potential for inability to readily identify loss and drug diversion (illegal distribution of abuse of prescription drugs or their use of unintended purposes) of a controlled medication. Findings: A review of Resident 3's admission Record indicated the facility admitted the resident on 9/22/2023 with diagnoses including encephalopathy (damage or disease that affects the brain), muscle wasting and atrophy (decrease in size or wasting away of a body part…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 clinical records in accordance with accepted professional standards and practices for one of one sampled resident (Resident 3) by, failing to maintain documentation of the follow-up notes for Resident 3, subsequent to their transfer to the general acute care hospital (GACH). This deficient practice had the potential to result in gaps in the Resident 3's medical history and could lead to delays or errors in providing appropriate medical care. Findings: A review of Resident 3's Face Sheet (admission Record), indicated the facility readmitted the resident on 8/11/2023 with diagnoses including chronic obstructive pulmonary disease (COPD, a condition characterized by airflow limitation and difficulty breathing usually caused by smoking or long-term exposure to irritants) and pneumonia (a lung infection characterized by inflammation and fluid buildup in the air sacs causing symptoms such as cough and difficulty breathing). A review of Resident 3's Physician Order indicated the resident transferred via ambulance 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: 1. Maintain the facility ' s roof in good repair, at all times. 2. Follow its own policy by not submitting work orders to the Director of Maintenance. These deficient practices had the potential to result in accidents and negatively affect the health and safety of all residents, staff, and visitors. Findings: During an interview on 8/24/2023 at 9:35 a.m., with the Administrator (ADM) and Director of Maintenance (DM), the DM stated that it started raining on Sunday (8/20/2023) and there was a small leak from the roof in Resident 2 ' s room. He had to puncture a hole on the ceiling in Resident 2 ' s room to drain the water. During an interview on 8/24/2023 at 10:03 a.m., with the ADM and the DM, the DM stated that since he started working in the facility January of 2023, rainwater had leaked into the facility five or six times in different areas of the facility. The DM added, we had fixed most of them. The ADM stated that the facility currently does not have an open project with the Department of Healthcare…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement interventions as indicated in residents' individualized care plans, for two out of two sampled residents investigated under the care area of care planning as evidenced by: 1. Resident 46's fall care plan indicated to provide floor mattress and set bed in low position to reduce and minimize potential injuries from falls and was observed not being implemented. This deficient practice placed the resident at risk for serious injuries in the event of a fall incident. 2. Resident 46's activity care plan indicated to provide 1:1 or group activities that meets his needs and interests as was not implemented. This deficient practice has the potential to result in resident feeling isolated and depressed. 3. Resident 14's activities of daily living (ADL) care plan indicated to provide basic needs. Resident 14's fingernails were observed to be long, jagged, and with black substances under the nail bed. This deficient practice resulted 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, and record review, the facility failed to ensure all residents have a right to a dignified existence by failing to ensure a resident (Resident 225) had a privacy bag over the urinary drainage bag (bag used to collect urine) for one of one resident reviewed under the care area of dignity. This deficient practice had the potential to affect Resident 225 right to a dignified existence. Findings: A review of Resident 225's Face Sheet indicated the resident was originally admitted to the facility on [DATE], with diagnoses including Parkinson's disease (a disorder of the central nervous system that affects movement), difficulty in walking, and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). A review of Resident 225's Minimum Data Set (MDS-a standardized assessment and screening tool), dated 10/19/2021, indicated the resident usually made self-understood and usually understood others. The MDS indicated the resident had severely…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the resident's advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were readily accessible in the physical chart for one of three sampled residents (Resident 84). This deficient practice had the potential to delay emergency treatment or the potential to force emergency, life-sustaining procedures against the resident's personal preferences. Findings: A review of Resident 84's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis (chronic disease that affects the central nervous system [brain and spinal cord]), major depressive disorder (mood disorder that causes persistent feeling of sadness and loss of interest), and anxiety disorder (excessive and persistent worry and fear about everyday situations). A review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide maintenance services to maintain a safe and homelike environment for two of two sampled residents (Residents 23 and 65) by failing to seal the gap around the pipe connecting to the toilet for Resident 23 and 65's room. This deficient practice had the potential for Residents 23 and 65 to be exposed to pest infestation and an unsafe environment. Findings: A review of Resident 65's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis of one side of the body) following cerebral infarction (damage to tissues in the brain due to lack of adequate blood supply to the area) affecting left nondominant side, rheumatoid arthritis (chronic inflammatory disorder that affects the joints), and hypertension (elevated blood pressure). A review of Resident 65's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 8/17/2021, indicated the Resident 65 has…

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

Based on observation, interview, and record review, the facility failed to ensure one out of one sampled resident (Resident 14) was provided care and services to maintain good grooming and personal hygiene. This deficient practice resulted in Resident 14 having long and unkept fingernails that had the potential to result in a negative impact on the resident`s self-esteem and self-worth. Findings: A review of the Face Sheet (admission record) indicated that Resident 14 was admitted to the facility, on 06/30/2021, with diagnoses that included chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), acute kidney failure (occurs when your kidneys suddenly become unable to filter waste products from your blood), and hypertension (a condition in which the force of the blood against the artery walls is too high). A review of the Minimum Data Set (MDS - an assessment and care screening tool), dated 07/12/2021, indicated Resident 14`s cognitive skills (cognition refers to conscious mental activities, and include thinking,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 on-going activities that incorporate the resident's interests based on the comprehensive assessment for one out of one sampled resident (Resident 46). This deficient practice had the potential to affect the Resident 46`s sense of self-worth and psychosocial well-being. Findings: A review of the Face Sheet (admission record) indicated Resident 46 was admitted to the facility, on 09/11/2018, with diagnoses that included history of falling and dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of the Minimum Data Set (MDS - an assessment and care screening tool), dated 08/10/2021, indicated Resident 46`s cognitive skills (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily decision-making were severely impaired. The MDS indicated that the resident required extensive assistance on staff for dressing, toilet 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of four sampled residents (Residents 9 and 101) received treatment and care in accordance with professional standards of practice by: 1. Failing to ensure current doctor orders were in place for treatment of gangrenous toes (a condition in which body tissue dies from not getting enough blood) for Resident 101. 2. Failing to ensure blood sugar monitoring was completed on 09/13/2021 for Resident 9. These deficient practices had the potential to result in a delay of healing for Resident 101's gangrenous toes, and placed Resident 9 at risk for undetected hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) that can result in nausea and vomiting, blurred vision, lightheadedness, or shakiness that can lead to falls and injuries. Findings: a. A review of Resident 101's Face Sheet (admission record) indicated resident was admitted on [DATE] and was readmitted on [DATE] with diagnoses that included encephalopathy (brain disease 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the low air loss mattress (LALM, a pressure-relieving mattress used to prevent and treat pressure ulcers [a wound that occurs as a result of prolonged pressure on a specific area of the body]) was properly set between 120-150 pounds (lbs - unit of measurement) based on the resident's weight for one of four sampled residents (Resident 44). This deficient practice placed Resident 44 at risk for skin breakdown and development of pressure ulcers. Findings: A review of Resident 44's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE] with diagnoses that included rhabdomyolysis (potentially life-threatening condition caused by the breakdown of muscle tissue), diabetes mellitus type 2 (chronic condition characterized by high blood sugar), and history of falling. A review of Resident 44's Minimum Data Set (MDS - an assessment and care screening tool), dated 8/5/2021, indicated resident has 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 c. A review of the Face Sheet (admission record) indicated Resident 46 was admitted to the facility on [DATE], with diagnoses that included history of falling and dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 08/10/2021, indicated that Resident 46`s cognitive skills (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily decision-making are severely impaired. The MDS also indicated that the resident requires extensive assistance on staff for dressing, toilet use, personal hygiene, and bathing. A review of Resident 46`s Fall Risk assessment dated [DATE], indicated that the resident is considered to be high risk for potential falls. A review of Resident 46`s Fall Risk Care Plan dated 05/22/2021 and with re-evaluation date of 11/2021,…

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

Based on interview and record review, the facility failed to document the pain assessment for one out of one sampled resident (Resident 92) to ensure the resident received effective pain management. This deficient practice had the potential for the resident to endure and suffer from unrelieved pain. Findings: A review of the Face Sheet (admission record), indicated Resident 92 was admitted to the facility, on 05/31/2021, with diagnoses including muscle weakness, pain in leg, and heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). A review of the Minimum Data Set (MDS- an assessment and screening tool), dated 06/07/2021, indicated Resident 92 had moderately impaired cognitive skills (refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily decision-making. The MDS indicated Resident 92 was totally dependent on staff for dressing, toilet use, personal hygiene, and bathing. During an observation and interview, on 10/18/2021 at 3:30 p.m., Resident 92 was in bed, awake 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Narcotic and Hypnotic Record (accountability record of controlled medications that are considered to have strong potential for abuse) coincided with the number of doses in the bubble pack (blister pack, medication package with compartments of single doses), and failed to ensure the licensed nurse documented the administration of controlled medication on the Narcotic and Hypnotic Record for Resident 231. These deficient practices resulted in inaccurate reconciliation of the controlled medication (hydrocodone-acetaminophen [Norco] - narcotic) and placed the facility at potential for inability to readily identify loss and drug diversion (illegal distribution of abuse of prescription drugs or their use of unintended purposes) of controlled medication for Resident 231. Findings: A review of Resident 231's Face Sheet indicated the resident was admitted to the facility on [DATE], with diagnoses including peripheral autonomic neuropathy (weakness,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure to indicate a duration or to limit an as needed (PRN) physician's order for the psychotropic medication (medication that affects behavior, mood, thoughts, or perception) Lorazepam (medication to relieve anxiety) to 14 days for one out of seven sampled residents reviewed addressing unnecessary meds (Resident 87). 2. Failed to document specific indication for the use of Klonopin (medication used to treat anxiety and panic disorders) for one out of seven sampled residents reviewed addressing unnecessary meds (Resident 84). These deficient practices had the potential to place the residents at risk for adverse side effects (any unexpected or dangerous reaction to a drug) associated with the use of psychotropic medications and inconsistent monitoring of behaviors. Findings: a. A review of Resident 87's Face Sheet (admission record) indicated the resident was readmitted to the facility on [DATE], with diagnoses including, dementia (a group 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: 1. Remove and discard three expired insulin (a hormone that lowers the level of glucose in the blood) vials. 2. Store two opened Basaglar Insulin Pen (long acting insulin that helps to control blood sugar levels) in room temperature according to the manufacturer's guidelines. 3. Label two opened Humulin Insulin (short acting insulin that helps to control blood sugar levels) vials with open date. These deficient practices had the potential to compromise the effectiveness of insulin if stored outside the required temperature range and had the potential for the resident potentially receiving an out-of-date insulin that may affect the residents' health conditions. Findings: a. On [DATE], at 10:00 a.m., during a medication storage room observation in Station 4, there was one medication refrigerator inside the room. In the presence of the Assistant Director of Nursing (ADON), found one expired Novolog Insulin (a rapid-acting insulin [a hormone…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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's licensed nurses failed to maintain accurate Medication Administration Record (MAR) for one out of three sampled residents (Resident 26). The licensed nurses failed to document when they held (not administer) Resident 26's hydralazine (a medication to lower blood pressure). This deficient practice had a potential for creating confusion to staff and placed the resident at risk for not receiving appropriate care. Findings: A review of Resident 26's Face Sheet indicated the resident was admitted to the facility on [DATE], with diagnoses that included essential hypertension (high blood pressure) and pathological fracture (a break in a bone that is caused by an underlying disease). A review of Resident 26's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 7/26/2021, indicated the resident rarely/never make self-understood and had the ability to understand others sometimes. The MDS also indicated the resident needed total assistance 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 d. A review of Resident 52's Face Sheet (admission record) indicated the resident was admitted into the facility on 4/29/2021 with diagnoses that included chronic kidney disease stage 3 (moderate kidney [organs involved in filtering wastes and excess fluids from the blood] damage), diabetes mellitus type 2 (a chronic condition that affects the way the body processes blood sugar), and dementia (group of symptoms affecting memory, language, problem-solving, and other thinking abilities). A review of Resident 52's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 8/6/2021, indicated the resident had the ability to sometimes make self understood and had the ability to sometimes understand others. The MDS further indicated Resident 52 required extensive assistance to total dependence on staff with most areas of activities of daily living (ADLs- term used in healthcare to refer to daily self-care activities). A review of Resident 52's Physician Order, ordered on 5/4/2021, indicated to keep…

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