Maclay Healthcare Center

Based on 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 2) by failing to develop a care plan on Resident 2's refusal for medication. This failure had the potential for delays in the delivery of necessary care and services to Resident 2.Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 9/27/2025, with diagnoses that included end stage renal disease (ESRD -irreversible kidney failure), unspecified chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), and essential hypertension (HTN-high blood pressure).During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool), dated 1/2/2026, the MDS indicated Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were…

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

Based on observation, interview, and record review, the facility failed to ensure the confidential personal information of residents were protected by failing to ensure documents (meal tickets) containing protected information (PHI - any health information that can be used to identify specific individual which must remain confidential to prevent harmful consequences) were not shredded prior to disposing in the waste container. This failure had the potential to violate 127 of 127 residents' rights for privacy and confidentiality of personal and medical records. Findings: During an observation on 1/14/2026 at 12:59 p.m., observed meal tickets in the trash by the dishwashing machine area. During an interview on 1/14/2026 at 1 p.m. with the Dietary Supervisor (DS), the DS stated the meal tickets come back to the kitchen after each meal and the meal tickets would be thrown out in the trash. The DS stated the meal tickets contained residents' name, diet, and room number and these are all protected information. The DS stated it was not appropriate for the staff to throw the meal tickets 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 provide a safe, comfortable, and homelike environment for five (5) of five (5) sampled residents (Residents 65, 55, 33, 39 and 72) by failing to: 1. Maintain the cleanliness of Resident 65's electric stand fan. 2. Ensure Resident 55`s electric fan was free from dust buildup on the fan blades and the front and back safety enclosure grill of the fan. These deficient practices had the potential to negatively affect Resident 65 and Resident 55's quality of life and had violated the residents' right to a safe, clean, comfortable and homelike environment. 3. Provide Residents 33, 39, and 72 with a homelike environment when their room was damaged due to water leaks. This deficient practice had the potential to prevent residents from enjoying the right to a clean dry and homelike environment free from water damaged floors and closet space. Cross-reference F880 and F921. Findings: 1) During a review of Resident 65's admission Record, the admission…

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

Based on 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 one (1) of 1 sampled resident (Resident 57) reviewed for physical restraints by failing to obtain a physician's order, informed consent, and complete a restraint assessment prior to placement of bed pad alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff). These deficient practices had the potential to result in the restriction of Resident 57's freedom of movement, a decline in physical functioning, psychosocial harm, physical harm from entrapment, and possibly death. Findings: During a review of Resident 57's admission Record (front page of the chart that contains a summary of basic information about 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 residents were free from unnecessary psychotropic medication (medications that affect the mind, emotions, and behavior) and the use of chemical restraints (any drug that is used for discipline or staff convenience and not required to treat medical symptoms) for two of five sampled residents (Residents 15 and 14) reviewed for unnecessary medications by failing to: 1. Ensure quetiapine fumarate (medication to treat symptoms of psychosis [occurs when a person becomes disconnected from reality]) and sertraline (medication used to treat depression [persistent feelings of sadness and loss of interest that can interfere with daily living]) was prescribed and monitored for specific, measurable behavioral manifestation for Resident 15. 2. Monitor for adverse effect (a harmful, unexpected, or unintended result of a medical treatment, such as a drug, surgery, or procedure) on the use of Depakote (a prescription drug used to control seizures, prevent migraine headaches, and stabilize mood swings in bipolar disorder, working 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards of care for two of two sampled residents (Residents 4 and 35) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin administration sites. The 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: 1. During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted the resident on 3/13/2017, and readmitted the…

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

Based on interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plans by failing to notify the physician when the resident's blood pressure measured higher than the established parameters of systolic blood pressure (SBP - measures the pressure in your arteries [pathway that carries blood away from the heart]) greater than (>) 140 millimeters of mercury (mmHg - measurement of pressure) on multiple shifts in 1/2026 for one of one sampled resident (Resident 5). This deficient practice had the potential to result in further decline of the resident's kidney (body part that filters blood) function. Findings: During a review of Resident 5's admission Record (AR), the AR indicated the facility admitted the resident on 4/7/2022 and most recently readmitted the resident on 9/14/2025 with hypertensive heart disease with heart failure (refers to heart problems that occur because of high blood pressure [HTN]), acute on chronic congestive heart failure (CHF - a heart disorder…

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

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 was free of accident hazards for eight (8) of nine (9) sampled residents (Residents 43, 53, 73, 18, 68, 111, 3, and 57) reviewed for accidents by failing to ensure: 1. Resident 43 did not have a furniture or equipment on top of the floor mat (specially designed mats provide cushioning and support to patients who are at risk of falling, helping to prevent serious injuries). 2. Resident 53 did not have frayed (torn) wires on the resident's bed remote control. This deficient practice increases the risk of accidents such as electrocution (the injury or killing of someone by electric shock) and falls with injuries on residents. 3. The facility followed the policy and procedure (P&P) to conduct Interdisciplinary Team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of their resident) meetings after Resident 73 fell on [DATE] and 12/19/2025. This…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that its medication error rate was below five (5) percent (%- one per hundred). Three medication errors out of 37 opportunities contributed to an overall error rate of 8.11% affecting two of four residents observed for medication administration (Residents 108 and 122). The medication errors were as follows: 1.a. Resident 108 was not instructed to chew before swallowing after the administration of aspirin (medication inhibiting platelet [blood cells aiding clotting] aggregation). 1.b. LVN 10 administered lidocaine 5% ointment to Resident 108 without a dose indicated in the physician order. 1.c. LVN 10 did not follow the manufacturer's instructions after the administration of lidocaine 5% to Resident 108. These deficient practices had the potential to result in Resident 108's health and well-being to be negatively impacted. 2. For Resident 122, LVN 4 failed to use apical pulse (AP, the heartbeat heard directly over the bottom tip…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for two of two sampled residents (Residents 4 and 35) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin administration sites. The 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 operate and execute overall safe and sanitary food and nutrition services operations when:1. The puree (pudding like consistency) pancake did not fall off the spoon during the spoon tilt test (a method used to determine the stickiness of the food and ability of the food to hold together) conducted by [NAME] 1 during breakfast service and there was no supervision available during the food preparation.2. Puree cranberry yogurt mousse did not fall off the spoon tilt test and was too thick during lunch service.These deficient practices had potential to cause the residents to not be able to eat their food and/or choke (when food gets stuck in your airway, blocking the flow of the air to your lungs) on the food to 11 of 11 residents on puree diet. 3. One (1) dented can was stored with non-dented cans 4. Storage racks have no physical barrier from the floor to prevent spills during mopping.5. The pitchers had sticker residues. 6. Pans were stored stacked wet.7. [NAME] dirt debris were on the clean pans. 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 follow the menu and did not meet nutritional needs when: 1. [NAME] 1 did not follow the recipe for green beans. 2. Residents on regular diet and therapeutic diet, including large portion diet (adding additional food to increase protein and calories) were not served three (3) ounces (oz - a unit of measurement) of pork. The menu did not clearly indicate portion size for pork and mushroom sauce. 3. Resident meal trays were not accurate:3.1 Resident 39 did not get puree oatmeal on resident's tray on 1/13/2026 3.2 Resident 46 did not have a bowl of puree oatmeal on the resident's tray on 1/13/2026. 3.3 Resident 66 did not have a cup of coffee on the resident's breakfast tray on 1/13/2026. 3.4 Resident 96 did not have margarine and jelly on the resident's breakfast tray on 1/16/20206. These failures had the potential to result in decreased food flavor, decreased food and nutrient intake for 125 of 127 residents on regular and therapeutic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved appearance, flavor and temperature when: 1. Herbed rice was hard on the outside and soft on the inside. 2. [NAME] beans were bland, no salt flavor and olive green in color. 3. Foods were not at a palatable temperatures: On 1/12/2026 during test tray (a process of tasting, temping, and evaluating the quality of food), peach pie at 66 degrees Fahrenheit ( F, degree of temperature), puree peach pie at 69 F. Pancake at 120 F, sausage patty 120 F, oatmeal 120 F, milk 48.8 F for breakfast on 1/13/2026. These failures had potential to result in 125 of 127 facility residents at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen. Findings: 1. During a review of Resident 6's admission Record, the admission record indicated the facility initially admitted Resident 6 on 3/27/2025 and readmitted on [DATE] with diagnoses including acute and chronic respiratory failure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 therapeutic diets were prescribed by the attending physician to one of three sampled residents (Resident 66) by failing to ensure that the resident's four (4) ounces (oz., the smallest measurement of weight and volume) of Magic Cup (a high-calorie, protein-packed, single-serving, pudding-style dessert designed for people who need extra nutrition, particularly in healthcare settings) or high protein nutrition (HPN, is a concentrated, convenient source of protein-usually in the form of powder, shakes, or bars-designed to help people easily increase their daily protein intake) had a physician's order. The deficient practice had a potential for residents to receive and consume foods in the form inappropriate for the resident to consume. Findings: During a review of Resident 66's admission Record (AR), the AR indicated the facility admitted the resident on 5/8/2021, and readmitted the resident on 9/6/2025, with diagnoses including type two (2) diabetes mellitus (DM, a disorder characterized by difficulty 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 observations, interviews, and record reviews, the facility failed to provide residents' meals at regular times scheduled in accordance with resident needs, preferences, and requests when lunch was served late on 1/12/2026 and breakfast was served late on 1/13/2026. This deficient practice had the potential to result in hunger and frustrations to 125 to 127 residents getting food from the kitchen. Findings: During a review of Resident 35's admission Record, the admission record indicated the facility initially admitted Resident 35 on 7/13/2010 and readmitted on [DATE] with diagnoses including end stage renal disease (the kidneys cease functioning on a permanent basis), type 2 diabetes (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), and hyperlipidemia (high fats in the blood). During a review of Resident 35's Minimum Data Sheet (MDS - a resident assessment tool), dated 12/3/2025, the MDS indicated Resident 35 understood others and make self-understood. 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.

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 when: 1.Food items were not properly labeled with the food item name. 2.Kitchen equipment and utensils were not free from dirt, dust, and food debris. a. Sticker residue on two (2) trays inside the walk-in refrigerator, walk-in freezer shelves, and dry storage room shelves. b. There was dirt, food, and food debris on the walk-in freezer floors. c. There were dried-up sauce spills on the dry storage walls. d. A cart with straw decoration (not cleanable surface) was used during trayline (an area where foods were assembled from the steamtable to resident's plate). e. Clean pans on the storage racks had rice grains and were not free from debris. f. Kitchen floors by pots and pans storage racks had dirt and food debris. 3. Five (5) dented cans were stored with non-dented cans. 4. Pans were stacked wet in the storage area. 5. Pot and pans racks did not have 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 maintain complete and accurate medical records in accordance with accepted professional standards for one of one sampled resident (Resident 11) by failing to document accurately the dialysis access site on the Dialysis Communication Records on 12/18/2025, 12/30/2025, 1/4/2026, and 1/6/2026. This deficient practice had the potential to result in Resident 11's dialysis access to go unmonitored and unchecked post-dialysis. Findings: During a review of Resident 11's admission Record (AR), the AR indicated that the facility originally admitted the resident on 10/15/2025, and readmitted on [DATE], with diagnoses including end-stage renal disease (ESRD- irreversible kidney failure), dependence on renal dialysis, and acute posthemorrhagic anemia (a type of anemia that develops suddenly after a person loses a large amount of blood quickly). During a review of Resident 11's History and Physical (H&P), dated 12/10/2025, the H&P indicated that the resident could…

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

Based on interview and record review, the facility failed to ensure necessary care was provided consistently for one (1) of two (2) sampled residents (Resident 3) reviewed for hospice services (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill) by: 1. Failing to ensure hospice staff including Licensed Vocational Nurse (LVN), and Hospice Aide (HA), provided nursing and visitation notes to the facility. 2. Failing to ensure LVN and HA visited Resident 3 as indicated in the calendar of visits provided by Hospice Provider (HP) 2 to the facility. These deficient practices had the potential to negatively affect Resident 3's physical comfort and psychosocial well-being resulting in the delay or lack of necessary hospice care and services. Findings: During a review of Resident 3's admission Record, the admission Record indicated the facility originally admitted the resident on 5/31/2017, with diagnoses including dementia (a progressive state of decline in mental abilities), anxiety disorder (a mental health condition where…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and 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: 1. Urinals (a portable container designed to collect urine from individuals who are unable to reach a toilet) were labeled with a resident identifier for two randomly sampled residents (Resident 109 and 91). 2. The resident's nasal cannula (NC - a small plastic tube, which fits into a patient's nostrils for providing supplemental oxygen) tubing and hand-held nebulizer (HHN, a small machine that turns liquid medicine into a mist that can be easily inhaled) were not touching the floor for one (1) out of eight (8) sampled residents (Resident 21) reviewed under infection control. 3. A bath blanket was not used to soak up leaking water from the laundry room floor affecting the adjacent resident occupied room 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its antibiotic stewardship program (a coherent set of actions which promote using antimicrobials responsibly) that includes antibiotic (ATB - a medicine that fights bacterial infections by killing bacteria or stopping them from multiplying) use protocols and a system to monitor antibiotic use for three of three sampled residents (Residents 35, Resident 7, and Resident 101) reviewed for antibiotic use by failing to ensure: 1. Resident 35's Cephalexin (also known as Keflex, a type of antibiotic that can treat various bacterial infections) and Fluconazole (a type of antibiotic that can treat various bacterial infections) had monitoring for its adverse effects (an undesired, harmful, or unexpected result caused by a medical treatment, such as a drug, surgery, or intervention). 2. Resident 7's Ertapenem (also known as Ivanz, a type of antibiotic that can treat various bacterial infections) and Zyvox (also known as linezolid, a type of antibiotic…

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

Based on observation, interview, and record review, the facility failed to ensure a functional and sanitary environment when water leaks were present in the laundry area, active water leaks from pipes resulting in wet floors a bath blanket used to soak up leaked water and wash basins placed under leaking pipes to catch water and soap suds. This deficient practice created a potential risk for slips, falls, and unsanitary conditions and had the potential to affect residents, staff and visitors. Cross-reference F584 and F880. Findings: During a concurrent observation and interview on 1/14/2025 at 12 p.m. with the Director of Maintenance (DOM), Resident 33, Resident 39, and Resident 72's room was observed with loose floorboards. The DOM pulled out a closet drawer containing a white substance. The DOM stated the closet drawer is dirty and stated the white substance was a result of water damage and can be a potential infection control issue for the residents in the room. During a concurrent observation and interview on 1/14/2026 at 2:30 p.m. with the Director of Maintenance (DOM), the…

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

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the food services department when a fly (a type of insect) was observed flying around the trayline (an area where foods were assembled from the steamtable to resident's plate), dishwashing area, and food storage area during lunch service.This failure had the potential to result in 130 of 132 residents, who received food from the kitchen, to acquire food borne illnesses (illness caused by consuming contaminated foods or beverages) by consuming potentially contaminated food.Findings: During an observation on 2/27/2026 at 11:12 a.m. of the dishwashing area, observed a fly flying around the area.During an observation on 2/27/2026 at 11:38 a.m. of the food storage area, observed a fly flying around the area. Observed the back door open.During a concurrent observation and interview on 2/27/2026 at 12:04 p.m. of the trayline area with the Dietary Supervisor (DS), observed a fly flying around the area. The DS stated there was a fly flying around the trayline area and he (DS) was trying…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 39) reviewed for dignity by failing to ensure Certified Nursing Assistant (CNA) 8 was not standing over the resident while assisting the resident during mealtime. This deficient practice had the potential to negatively affect Resident 39's psychosocial wellbeing. Findings: During a review of Resident 39's admission Record, the admission Record indicated the facility originally admitted Resident 39 on 7/21/2015 and readmitted in the facility on 6/2/2018 with diagnoses including dementia (a progressive state of decline in mental abilities), diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing), and muscle wasting and atrophy (weakening, shrinking, and loss of muscle). During a review of Resident 39's History and Physical (H&P), dated 5/4/2025, the H&P indicated Resident 39 had the capacity to understand and make decisions. During a review of Resident…

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

Based on observation, interview, and record review, the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach of one of two sampled residents (Resident 94) reviewed under environment task. The deficient practice had the potential to result in the resident`s inability to summon health care worker for help as needed. Findings: During a review of Resident 94's admission Record (AR), the AR indicated the facility admitted the resident on 1/20/2024, and readmitted the resident on 7/20/2025, with diagnoses including muscle weakness, history of falling, and cognitive communication deficit (trouble participating in conversations). During a review of Resident 94's History and Physical (H&P), dated 7/22/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 94's Minimum Data Set (MDS, a resident assessment tool), dated 10/10/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had intact…

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

Based on interview and record review, the facility failed to ensure resident'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 one of three sampled residents (Resident 14) reviewed for advance directive by failing to provide the advance directive formulation information to the resident or the resident representative (RP). The deficient practice violated the resident's rights and/or representative's right to be fully informed of the option to formulate their advanced directives. Findings: During a review of Resident 14's admission Record (AR), the AR indicated the facility admitted the resident on 4/18/2023, and readmitted the resident on 12/22/2025, with diagnoses including depressive episodes (a period of at least two weeks characterized by a persistent, intense low mood, loss of interest in activities (anhedonia), and low energy, which significantly interferes with daily life) and anxiety disorders (mental health conditions involving excessive,…

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

Based on interview and record review, the facility failed to document a significant change of condition (COC, is the formal written record of any significant, non-temporary change in a resident's physical, mental, or emotional health [e.g., sudden confusion, falls, weight loss]) on a resident's physical condition that had deteriorated for one of three sampled residents (Resident 81) by failing to do a change of condition documentation on a resident that was sent to the emergency room (ER) for right lower leg (RLL) venous ulcer (a shallow, slow-healing open sore that typically forms on the lower leg, usually around the ankle) with green exudate (a thick, protein-rich fluid that oozes out of blood vessels and collects in nearby tissues during inflammation, injury, or infection), fouls smell, with serosanguinous (a common type of fluid that drains from a healing wound, incision, or injury) drainage on 12/21/2025. This deficient practice had violated the resident's responsible party's right to be informed of the care services provided. Findings: During a review of Resident 81's…

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

Based on interview, and record review, the facility failed to develop and implement a baseline care plan (an initial, temporary care document that is developed within 48 hours of a resident's admission, providing essential, person-centered care instructions to staff to ensure safety and continuity of care while a more comprehensive plan is developed) on the use of Duloxetine (a medication to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]) for one of one sampled resident (Resident 130) reviewed for the use of antidepressant medication (prescription medications designed to treat depression, anxiety, and other mood disorders by balancing chemicals in the brain). The deficient practice had a potential for adverse effects (an undesired effect of a drug or other type of treatment, such as surgery) of the use of psychotropic medications (medications that affect the mind, emotions, and behavior) on residents. Findings: During a review of Resident 130's admission Record (AR), the AR indicated the facility admitted the resident on 1/9/2026,…

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 observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (is a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for: 1. One of three sampled residents (Resident 66) during random observations conducted for medication pass observation and dining observations addressing the resident`s enhanced barrier precautions (EBP, an approach to the use of personal protective equipment (PPE) to reduce transmission of Multidrug-Resistant Organisms (MDROs) between residents in skilled nursing facilities (SNFs)). This deficient practice had a potential for cross-contamination (the process of making something dirty or poisonous, or the state of containing unwanted or dangerous substances) of infections to residents. 2. One of nine sampled residents (Resident 73) reviewed during the Accidents care area by failing to develop and implement a CP for the resident`s fall that occurred 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 care consistent with professional standards of practice to prevent pressure ulcer/injury (ulcers that happen on areas of the skin that are under pressure from lying in bed, sitting in a wheelchair, or wearing a cast for a long period) to two of two sampled residents (Residents 130 and 72) reviewed for pressure ulcers by failing to: 1. Apply Resident 130's low air loss mattress (LALM, a special type of air mattress that uses a constant, gentle flow of air through microscopic holes to keep the skin dry and prevent pressure wounds) per physician's order. 2. Ensure Resident 72's LALM was set according to the resident`s weight or comfort. The deficient practices had the potential for development and worsening of pressure ulcers/injuries to residents. Findings: 1. During a review of Resident 130's admission Record (AR), the AR indicated the facility admitted the resident on 1/9/2026, with diagnoses including type two (2) diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 receiving enteral feeding (EF - also known as tube feeding, a method of supplying nutrients directly into the stomach) received appropriate care and services to prevent complications of enteral feeding for one (1) of one (1) sampled resident (Resident 72) reviewed for tube feeding when the water flush bag did not indicate the time the bag was started and the administration rate for the water flush. This deficient practice had the potential to result in altered nutritional status such as dehydration (when the body uses or loses more fluid than it takes in), malnutrition (a serious condition that happens when your diet does not contain the right amount of nutrients), and complications associated with enteral feeding such as gastrointestinal (GI - relating to stomach and intestines) problems such as abdominal pain and diarrhea. Findings: During a review of Resident 72's admission Record, the admission Record indicated the facility originally admitted Resident 72 on 1/26/2021,and readmitted in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pain management consistent with professional standards of practice and the resident's goals and preferences for one of five sampled residents (Resident 73) reviewed for unnecessary medication by failing to: 1. Ensure the Licensed Nurses (LN) administered as needed (PRN) acetaminophen (medication to treat mild pain) and hydrocodone - acetaminophen (an opioid [also called a narcotic - powerful pain-reducing medication) per the physician's orders and based on the assessed numeric pain rating scale (a standard pain scale with zero being no pain and ten [10] as the worst pain one can imagine) for Resident 73. 2. Ensure the LNs followed up with the physician to obtain an order for severe pain when Resident 73 complained of severe pain on the numeric pain scale. These deficient practices had the potential to result in mismanagement of resident pain resulting in limited resident participation in activities of daily living (ADLs…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 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 of two sampled residents (Resident 11) investigated during a review of dialysis care area, by failing to complete the post-dialysis assessments form on 12/23/2025 per facility policy. This deficient practice placed Resident 11 at risk for developing complications related to renal disease such as swelling, high blood pressure, and uncontrolled bleeding which could result in death. Findings: During a review of Resident 11's admission Record (AR), the AR indicated that the facility originally admitted the resident on 10/15/2025, and readmitted on [DATE] with diagnoses including end-stage renal disease (ESRD- irreversible kidney failure), dependence on renal dialysis, and acute posthemorrhagic anemia (a type of anemia that develops…

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

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) for one of one sampled resident (Resident 87) investigated under Medication Administration and Storage Labeling task by failing to ensure on 1/13/2026, Licensed Vocational Nurse (LVN) 3 documented the administration of oxycodone hydrochloride (a drug or chemical whose manufacture, possession, or use is regulated by a government) five (5) milligrams (mg- a unit of measurement) to Resident 87 immediately after administration in the Narcotic and Hypnotic Record (NHR - a document designed for dispensers of controlled substances to keep track of the pharmaceuticals as legally mandated). The NHR recorded a total of 10 tablets available, but only nine (9) tablets remained in the Resident 87`s oxycodone hydrochloride bubble pack (packaging that have a preformed plastic pocket or shell where a product sits securely in place). This deficient practice had the potential to result in the facility's…

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

Based on observation, interview and record review, the facility failed to discard Resident 116's Ativan (lorazepam - a medication used to treat anxiety and restlessness) when the bubble pack (packaging that have a preformed plastic pocket or shell where a product sits securely in place) slot number (#) 27 was damaged, the seal was broken, and covered with tape in one of three inspected medication carts (Medication Cart 1 Station 200). This deficient practice increased the risk that Resident 116 could have received medication that had become ineffective or toxic due to improper storage. Findings: During a concurrent observation and interview on 1/13/2026 at 11:12 a.m. with Licensed Vocational Nurse (LVN) 3, in Medication Cart 1 in Station 200, observed Resident 116's Ativan 0.5 milligrams (mg- a unit of measurement) bubble pack slot # 27 with damaged, the seal was broken, and was covered with tape. LVN 3 stated she (LVN 3) did not notice that the seal had been broken and covered with tape. LVN 3 stated this did not happen during her shift and she (LVN 3) does not know exactly when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1). On 8/29/2025 at approximately 4:15 p.m., while Resident 1 and Resident 2 were both in Room A (Resident 1 and Resident 2's shared room), Resident 2, using his (Resident 2) three fingers (did not specify which hand), pushed Resident 1's back, between the shoulder blades (a large, triangular-shaped bone located on the back of the upper rib cage, one on each side of the body). This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. As a result, Resident 1 fell on the floor in a semi-sitting position (a partially upright body position) leaning on his (Resident 1) right side.Findings: a. During a review of Resident 1's admission Record, the admission Record indicated the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse (the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or to their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability) for one of three sampled residents (Resident 1). On 8/23/2025 at around 6:30 a.m., Certified Nursing Assistant (CNA) 1 flipped off (describes the act of extending the middle finger as a rude and offensive gesture to express anger, contempt, or annoyance toward someone, particularly in a non-verbal way) using two middle fingers of both hands, yelled obscenities, and called a derogatory and racial insult at Resident 1. This deficient practice resulted in Resident 1 being subjected to verbal abuse by CNA 1 while under the care of the facility.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of verbal abuse (the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or to their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability) within two hours to the State Survey Agency (SSA). On 8/23/2025 at around 6:30 a.m., Certified Nursing Assistant (CNA) 1 flipped off (describes the act of extending the middle finger as a rude and offensive gesture to express anger, contempt, or annoyance toward someone, particularly in a non-verbal way) using two middle fingers of both hands, yelled obscenities, and called a derogatory and racial insult at Resident 1. The facility reported the verbal abuse incident on 8/26/2025 to the SSA. This deficient practice resulted in a delay in the investigation and placed Resident 1 at risk for further verbal abuse.Findings: During a review of Resident 1's admission Record, the admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement its policies and procedures (P&P) affecting two of five sampled residents (Resident 1 & Resident 2) by failing to: A. Notify Resident 1's doctor and responsible party on 6/30/2025 that Resident 1 encountered a change of condition with injury. B. Provide Resident 2 with the right to refuse room changes. These deficient practices denied the residents and their responsible parties' their rights, and to information needed to make decisions related to residents' care needs. Findings: A. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 4/7/2022 with the diagnoses including muscle weakness, dysphagia (having difficulty swallowing), and hemiplegia and hemiparesis following cerebral infarction (weakness or lack of movement to one side of the body after a brain injury) affecting the left side. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 inform the attending physician (MD) for one of three sampled residents (Resident 1) when: 1. The Skilled Nursing Facility (SNF) 1, was unable to provide Speech Therapy (ST) on 5/15/2025 when MD ordered an ST and swallow evaluation (a test done by a Speech-Language Pathologist (SLP) to figure out why a person is having trouble swallowing). 2. Resident 1 continued to have difficulty swallowing and pocketing (the act of storing food inside the mouth without swallowing it) after the Change in Condition (COC) on 5/15/2025. These deficient practices resulted in Resident 1 not receiving the ST evaluation resulting in Resident 1 having a COC on 5/24/2025 where Resident 1 was noted with inability to eat, coughing and pocketing requiring transfer to General Acute Care Hospital (GACH) 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 1/30/2024 and readmitted on [DATE] 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 interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received treatment and care in accordance with professional standards of practice when the facility failed to follow the Registered Dietitian's (RD- a food and nutrition expert who helps people improve their health through food choices and dietary changes) recommendations. This deficient practice had the potential for Resident 1 to have unplanned weight loss. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 1/30/2024 and readmitted the resident on 3/19/2024 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body, often affecting one arm, leg, and sometimes the face) following cerebral infarction (a brain attack where part of the brain's blood supply is blocked or severely reduced) affecting the right dominant side, dysphagia (difficulty swallowing) oropharyngeal (anything related to the middle…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 Speech Therapy (ST) on 5/15/2025 when the Medical Doctor (MD) ordered an ST and swallow evaluation (a test done by a Speech-Language Pathologist (SLP) to figure out why a person is having trouble swallowing) for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 not receiving the ST eval resulting in Resident 1 having a COC on 5/24/2025 where Resident 1 was noted with inability to eat, coughing and pocketing requiring transfer to General Acute Care Hospital (GACH) 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 1/30/2024 and readmitted the resident on 3/19/2024 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body, often affecting one arm, leg, and sometimes the face) following cerebral infarction (a brain attack where part of the brain's blood supply is blocked or severely reduced)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 medical records in accordance with accepted professional standards and practices for one of three sampled residents (Resident 1) when: 1. The facility failed to accurately document on Resident 1's medication administration Records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for calorie count for seven days. 2. The facility failed to accurately document Resident 1's Calorie Count. These deficient practices resulted in inaccurate documentation of Resident 1's records. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 1/30/2024 and readmitted the resident on 3/19/2024 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body, often affecting one arm, leg, and sometimes the face) following cerebral infarction (a brain attack where part of the brain's blood supply is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections by failing to ensure staff were not wearing gloves in the hallway after exiting the rooms of three of six sampled residents (Resident 1, Resident 2, and Resident 3). This deficient practice had the potential to spread infections and illnesses among residents and staff. Findings: During a review of Resident 1's Record of Admission, the Record of admission indicated the facility admitted the resident on 6/29/2020, with a diagnosis of hemiplegia (complete paralysis [loss of muscle function] on one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction (also known as a stroke, damage to the brain from interruption of its blood supply). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 3/27/2025, the MDS 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 observation, interview, and record review, the facility failed to ensure the confidential personal information of four of four sampled residents (Resident 9, Resident 10, Resident 11, and Resident 12) were protected by failing to: 1. Ensure Resident 9 ' s narcotic (a drug or other substances that affects mood or behavior) sheet was not left unattended, facing the hallway, on Nurse Station 3 ' s Telephone Orders Only bin. 2. Ensure the clinical records of Resident 10, Resident 11, and Resident 12 were not left unattended on Nurse Station 3 computer. These deficient practices had the potential to violate Resident 9, Resident 10, Resident 11, and Resident 12's rights for privacy and confidentiality of personal and medical records. Findings: 1. During a record review of Resident 9 ' s admission Record, the admission Record indicated the facility admitted the resident on 11/11/2021 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 face-to-face visit (a required in-person meeting between a healthcare provider and a resident) was made by a physician or alternate visits by a Nurse Practitioner (NP) was conducted timely according to the facility ' s policy and procedure on Physician Visits for three of four sampled residents (Resident 5, Resident 6, and Resident 8). This deficient practice had the potential to result in an undetected decline in Residents 5, 6, and 8's medical, health or psychosocial conditions and can lead to a delay in the necessary provision of care, treatment, and services. Findings: During a record review of Resident 5 ' s admission Record, the admission Record indicated the facility admitted the resident on 12/10/2024 with diagnoses including cellulitis (a bacterial infection of the skin and tissues, causing redness, swelling, and pain) of the left upper extremity (shoulder, arm and leg), type 2 diabetes mellitus (a chronic condition that affects 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 ensure the medical records of three of four sampled resident ' s (Resident 5, Resident 6, and Resident 7) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to: 1. Ensure Resident 5 and Resident 7 ' s physician telephone orders were dated and signed. 2. Ensure Resident 5, Resident 6, and Resident 7 ' s Attending Physician (MD) reviewed and signed the residents ' Order Summary every month. 3. Ensure Resident 6 ' s medical records do not contain blank worksheet forms and blank consent forms with Nurse Practitioner's (NP) signatures. These deficient practices had the potential for inaccurate medical interventions and inaccurate information on Residents 5, 6, and 7 ' s medical records. Findings: a. During a record review of Resident 5 ' s admission Record, the admission Record indicated the facility admitted the resident on 12/10/2024 with diagnoses including cellulitis (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 resident to resident altercation was thoroughly investigated for two of four sampled residents (Resident 1 and Resident 2). On 3/16/2025 at 8:26 a.m., Resident 1 and Resident 2, who were both in the facility ' s smoking patio (an outdoor area designed for residents to enjoy fresh air and engage in activities), had a verbal altercation (a noisy argument or disagreement) that led to a physical altercation (a confrontation or fight involving physical contact or force) in which Resident 2 used a knife in his (Resident 2) possession to cause an injury to Resident 1. This failure had the potential to place the residents at risk for further abuse. Findings: During a review of Resident 1 ' s admission Record (undated), the admission Record indicated the facility originally admitted Resident 1 on 9/15/2020 and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), schizophrenia (a mental illness…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) Level I Screening (preliminary screening to identify individuals potentially needing specialized services due to mental illness or intellectual/developmental disabilities) was completed for one of four sampled residents (Resident 2). This deficient practice had the potential to result in a delay of necessary care and services to Resident 2. Findings: During a review of resident 2 ' s PASSR Level I Screening, dated 7/12/2024, the PASSR Level I Screening indicated Resident 2 did not have serious mental diagnoses. The PASRR Level I Screening also indicated Resident 2 did not require PASRR Level II Screening (a comprehensive evaluation to confirm the diagnosis and determine appropriate placement and [NAME]). During…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 policy and procedure on safeguarding of all prescribed medications for one of three sampled residents (Resident 3) by failing to ensure Resident 3's prescribed medication was stored in the medication cart of the nursing station where Resident 3 was located. This deficient practice had the potential for non-authorized access to Resident 3's medications. Findings: During a record review of Resident 3's admission Record, the admission Record indicated the facility admitted the resident on 2/21/2024 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), essential hypertension (an abnormally high blood pressure that was not a result of a medical condition), and depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities). During a record review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 11/27/2024, the MDS indicated the resident'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 ensure one of three sampled residents (Resident 1) was free from significant medication errors by failing to ensure the physician orders were followed. Resident 1's medication dose was not clarified with the attending physician. This deficient practice placed Resident 1 at risk for medication administration error that had the potential to result in difficulty in breathing. Findings: During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 9/23/2021 and readmitted on [DATE] with diagnoses including metabolic encephalopathy (an alteration in consciousness due to brain dysfunction), chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor airflow), and muscle weakness. During a record review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/20/2025, the MDS indicated the resident's cognitive (refers to conscious…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 a system-wide method for pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of nine sampled residents (Resident 1) by failing to account for the exact whereabouts of Resident 1 ' s controlled substance (narcotics) medication. This deficient practice increases the risks for mishandling of a controlled substance increases the risks of diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of medications, staff working in an impaired state, or accidental exposure of controlled substances to other residents possibly resulting in respiratory depression (the inability to breathe) leading to hospitalization or death. Findings: A review of Resident 1 ' s admission Record indicated an admission date of 12/23/2024 with the diagnoses of aftercare following surgery for neoplasm (an abnormal growth of tissue in the body that can be cancerous 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 were treated with respect and dignity in a manner that promotes maintenance or enhancement of the quality of life for one of three sampled residents (Resident 1) by failing to ensure Resident 1's preference to self-administer a medication was honored. This deficient practice had the potential to affect the resident's sense of self-worth and self-esteem. Findings: During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 8/8/2024 with diagnoses including type 2 diabetes mellitus, depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). During a record review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/13/2024, the MDS indicated the resident's cognitive (refers to conscious mental activities including thinking, reasoning, understanding,…

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

Based on interview and record review, the facility failed to ensure a comprehensive assessment was done for one of three sampled residents (Resident 1) by failing to reassess Resident 1 for self-administration of medications. This deficient practice had placed Resident 1 at risk for medication administration error that had the potential to result in injection site infection and underdosage of the medication. Findings: During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 8/8/2024 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). During a record review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/13/2024, the MDS indicated the resident's cognitive (refers to conscious…

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

Based on interview and record review, the facility failed to ensure a comprehensive, person-centered care plan with measurable objectives and interventions for one of three sampled residents (Resident 1) was created and implemented that addressed Resident 1's self -administration of medication. This deficient practice had placed Resident 1 at risk for not receiving the necessary services and assistance that can result in resident injury or serious condition. Findings: During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 8/8/2024 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). During a record review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/13/2024, 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 interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) had a physician order to self-administer Trulicity (a medication used in the treatment of type 2 diabetes mellitus [a chronic condition that affects the way the body processes blood sugar]). This deficient practice had the potential to create confusion in the delivery of care and services to Resident 1. Findings: During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 8/8/2024 with diagnoses including type 2 diabetes mellitus, depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). During a record review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/13/2024, the MDS indicated the resident's cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and…

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

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from significant medication errors by failing to ensure the physician orders were followed. Resident 1 was allowed to self-administer a medication without an order for self-administration. This deficient practice placed Resident 1 at risk for medication administration error that had the potential to result in uncontrolled blood sugar. Findings: During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 8/8/2024 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). During a record review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/13/2024, the MDS 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 protect the resident's right to be free from physical abuse (intentional bodily injury) for one of eight sampled residents (Resident 1) when on 12/3/2024, Resident 7 witnessed Resident 2 hit Resident 1 left arm causing a scratch using Resident 2's left hand. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. Findings: During a review of Resident 1's Record of Admission, the Record of admission indicated the facility admitted the resident on 4/27/2024, with a diagnosis of saddle embolus of pulmonary artery with acute cor pulmonale (a life-threatening condition that occurs when a large blood clot blocks the main pulmonary artery, preventing blood flow to both lungs). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 11/1/2024, the MDS indicated that resident had moderate cognitive (relating to the mental process involved in knowing,…

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

Based on interview and record review, the facility failed to report an allegation of employee to resident abuse within two hours to the State Survey Agency (SSA), the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and law enforcement as per its policies on abuse for one of three sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 at risk for further abuse. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 2/15/2023, with diagnoses that included displaced intertrochanteric fracture of right femur (a hip fracture that occurs when the bone breaks between the bumps at the top of the thigh bone, and the injured leg is noticeably shortened and externally rotated), dysphagia (swallowing difficulty) and essential hypertension (persistently raised blood pressure with no secondary cause identified). During a record review of Resident 1 ' s History and Physical (H&P), dated 1/6/2024, the H&P 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 interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards of practice for one of three sampled residents (Resident 1). This deficient practice had the potential to result in confusion in the care and services rendered to Resident 1 and resulted in inaccurate information entered into Resident 1's medical record. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 2/15/2023, with diagnoses that included displaced intertrochanteric fracture of right femur (a hip fracture that occurs when the bone breaks between the bumps at the top of the thigh bone, and the injured leg is noticeably shortened and externally rotated), dysphagia (swallowing difficulty) and essential hypertension (persistently raised blood pressure with no secondary cause identified). During a record review of Resident 1 ' s History and Physical (H&P), dated 1/6/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure four of 11 sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4) were provided a safe and homelike environment. The facility failed to: 1a. Ensure Resident 1, 2, and 3 had a restroom with functioning plumbing system. b. Ensure safe and private alternative restrooms were provided for Residents 1,2, and 3's toileting needs. 2. Ensure Resident 4 was informed that other residents were directed to use Resident 4's restroom. These deficient practices resulted in Residents 1,2,3, and 4 not having a homelike comfortable and safe environment. Findings: During an interview on 10/23/2024 at 9:05 a.m. with the Director of Maintenance (DM), the DM stated station 4 had clogged drains since 1 p.m. on 10/22/2024. The DM stated resident rooms 1, 2, 3, and shower rooms B and C were affected by the clogged drains. During a concurrent observation and interview on 10/23/2024 at 9:27 a.m. with Maintenance Assistant 1 (MA 1), MA 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 ensure residents were treated with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life and by failing to: 1. Ensure Licensed Vocational Nurse 6 (LVN 6) knocked before entering the resident's room, requested permission to enter the resident's room, and did not loudly state the resident's name in a decibel heard 35 feet (a unit of measurement) away at Station A for one of three sampled residents (Resident 68) reviewed during the Dignity care area. 2. Ensure LVN 6 treated Resident 68, and an additional two of seven resident's present during the Resident Council task, with professionalism for one of three sampled residents (Resident 68) reviewed during the Dignity care area and two of seven additional residents interviewed during the Resident Council task. 3. Maintain resident privacy while undressing the resident for one of three sampled residents (Resident 83) investigated under the dignity care area. These deficient practices violated resident's rights 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 3. During a review of Resident 66's admission Record (AR), the AR indicated the facility admitted the resident on 12/21/2022, and readmitted the resident on 7/31/2024, with diagnoses including displaced fracture of the right femur (a break in the thigh bone where the bone fragments are not aligned), abnormalities of gait (manner of moving on foot) and mobility, and history of falling. During a review of Resident 66's History and Physical (H&P), dated 1/16/2023, the H&P indicated the resident had the capacity to understand and to make decisions. During a review of Resident 66's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/9/2024, the MDS indicated the resident has the ability to make self-understood and to understand others. The MDS indicated the resident had severe cognitive impairment (a condition where a person has difficulty with basic tasks and is unable to live independently) and was dependent to requiring substantial to maximal assistance on mobility and activities of…

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

Based on interview and record review, the facility failed to develop and implement a baseline care plan for one of eight sampled residents (Resident 385) during initial sampling by failing to develop and implement a care plan for the use of oxygen therapy (a t]treatment in which a storage tank of oxygen or a machine called a compressor is used to give oxygen to people with breathing problems), psychotropic medications (Donepezil, Mirtazapine, Trazadone [are drugs or substances that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior]), and anticoagulant (warfarin, an anticoagulant drug used to prevent and treat blood clots). The deficient practice had the potential to result in a delay in care and treatment decreasing quality of life. Findings: During a review of Resident 385's admission Record (AR), the AR indicated the facility admitted the resident on 10/3/2024, with diagnoses including chronic respiratory failure (a long-term condition that makes it difficult for the body to exchange oxygen and carbon dioxide), depression (a mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and/or implement a comprehensive person-centered care plan for two of nine sampled residents (Resident 102 and 107) investigated under the accidents care area, two of two (Resident 17 and 23) sampled residents investigated under the activities of daily living (ADL, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) care area, and two of five sampled residents (Resident 66 and 75) investigated under the unnecessary medications care area when the facility failed to: 1. Develop Resident 102's care plan for medication storage at the bedside. 2. Develop Resident 107's care plan for use of bed rails (also known as side rails, a type of safety device that can be attached to a bed frame to help prevent falls and provide support for getting in, out, or around the bed). 3. Implement Resident 17 and 23s' care plans for ADL care. 4. Develop and implement Resident 66's care plan 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's licensed nursing staff failed to provide care in accordance with professional standards for two of two sampled resident (Residents 70 and 75) reviewed under the insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) care area and one of one sampled residents (Resident 70) reviewed under the anticoagulant (a drug used to prevent blood clots) care area by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (SQ - beneath the skin) administration sites. These deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin and enoxaparin (a drug used to prevent blood clots) such as 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 environment was free of accident hazards for nine (9) of twelve (12) sampled residents (Residents 66, 75, 114, 70, 80, 103, 68, 80, and 96) investigated under accidents by failing to ensure: 1. Resident 66, 75, and 114's fall mat (a floor mat designed to reduce the risk of injury from fall by providing a soft-landing surface) did not have medical equipment or furniture on top of them for a longer period of time. These deficient practices had increased the chances of the resident incurring an injury such as falls with fracture (a break or crack in a bone) and even death. 2. Resident 70, 80, 102, 103, and 68's medications were not left unattended at the resident's bedside. These deficient practice increases the risks of harm to the resident from omitting the dose, double dosing, and mixing the medications that could cause adverse (unfavorable) or even fatal effects on the resident. 3. Resident 96's floor was not left wet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 who require dialysis (also known as renal dialysis and hemodialysis, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) receive services, consistent with professional standards of practice, for one of two sampled residents (Resident 19) investigated under the dialysis care area when Resident 19's pre and post dialysis weights were not documented into the electronic medical record. This deficient practice had the potential for the facility's ability to monitor the resident's drastic weight changes from dialysis. Findings: During a review of Resident 19's admission Record, the admission record indicated the facility originally admitted Resident 19 on 7/13/2010 and readmitted the resident on 12/23/2023 with diagnoses including, but not limited to, end stage renal disease (ESRD, irreversible kidney failure), dependence on renal dialysis, and generalized muscle weakness. During a review of Resident 19's Minimum Data Set (MDS, a federally…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assessed, including a review of risks including entrapment (when a resident is trapped in the spaces in between or around the bed rails [adjustable metal or rigid plastic bars that attach to the bed that are available in a variety of types, shapes, and sizes], mattress, or bed frame), provided and maintained a copy of the informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered), and failed to obtain a physician's order for the use of bed rails for three of seven residents (Resident 66, 90, and 61) investigated under the physical restraints care area and two of nine sampled residents (Resident 75 and 107) investigated under the accidents care area by failing to: 1. Discontinue the bedrails when not indicated, perform a quarterly bed rail assessment for entrapment, and to obtain a consent from the resident or resident…

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

Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for one of one sampled residents (Residents 70), investigated under insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) and enoxaparin (a drug used to prevent blood clots), by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites. The deficient practices had the potential to result in adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin and enoxaparin such as 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). Findings: Cross Reference F658 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 ensure kitchen staff were routinely trained and evaluated for competency skills when staff: a. Failed to maintain safety and sanitation in the kitchen when: 1. There were cracked racks in the walk-in freezer. 2. Mixer had food debris and residue. 3. Food preparation roof rack had food splatters and food buildup. 4. Chopping boards had scratches and stains. b. Failed to perform hand hygiene after picking up a potato on the floor then continued washing the other batch of potatoes in the preparation sink. c. Failed to follow menus for lunch on 11/20/2024 when [NAME] 1 cooked green peas with onions instead of seas greens without a Registered Dietitian approval. d. Failed to serve breads without hard crust on soft mechanical diets (diet that are soft and chopped). e. Failed to update the allergy list posted in the kitchen and in the electric medical record for Resident's 76. This failure had a potential to result in inaccurate food texture, ineffective therapeutic diets, difficulty swallowing, chewing, eating,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the menu and did not meet nutritional needs of 138 of 139 residents on regular texture diets (diet with no restrictions) when: a. The staff served pork BBQ without weighing portion sizes on all the diets, including Resident 105. b. The cook did not follow the recipe of baked beans for lunch service on 10/8/2024. c. The facility failed to follow the lunch menu on 10/9/2024 by omitting gravy from the mashed potatoes for Resident 74. These deficient practices had the potential to cause difficulty in eating, chewing, and swallowing to the residents, cause resident dissatisfaction, and decrease food and nutrient intake resulting to unintended (not done on purpose) weight loss. Findings: a. During a review of Resident 105's admission Record, the admission Record indicated the facility admitted Resident 105 on 9/17/2024 with diagnoses including type two diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 temperatures when breakfast food temperatures in Station Four (4) had the following temperatures: - Sausage patty 113 degrees Fahrenheit (°F, a degree of temperature) - Biscuit with gravy 108°F - Milk 49°F - Juice 45°F This deficient practice placed 138 of 140 facility residents, including Resident 19, on regular consistency texture (texture with no restriction) and texture modified diets at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen. Findings: During a review of Resident 19's admission Record, the admission Record indicated the facility originally admitted Resident 19 on 7/13/2010 and readmitted the resident on 12/23/2023 with diagnoses including end stage renal disease (ESRD, irreversible kidney failure), dependence on renal dialysis (also known as hemodialysis, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), and generalized muscle weakness.…

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

Based on observation, interview and record review, the facility failed to prepare foods in a form designed to meet individual needs when residents on soft mechanical-chopped diet (diet consisted of food that are chopped half inches ([in] a unit of measurement) and soft foods) received whole hard biscuit on the plate for lunch service. This deficient practice had the potential to cause coughing, choking (to keep from breathing the normal way) and death for 17 of 17 residents on soft mechanical chopped diet. Findings: a. During a review of Resident 135's admission Record, the admission record indicated the facility initially admitted Resident 135 on 10/1/2024 with diagnoses including, but not limited to chronic obstructive pulmonary disease (COPD, a common lung disease causing restricted airflow and breathing problems), chronic viral hepatitis C (long term liver inflammation and infection), and essential hypertension (high blood pressure). During a review of Resident 135's Minimum Data Sheet (MDS, a standard assessment tool that measures health status), dated 10/5/2024, 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, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: a. Two (2) vents had dust buildup in the walk-in refrigerator. b. Five (5) of six (6) blue racks were chipped, cracked and rusted in the walk-in refrigerator and one (1) of 6 racks was chipped in the walk-in freezer. c. There was an ice buildup in the walk-in freezer, curtains and door. d. Cook 1 was wearing a gold bracelet during food preparation. e. Internal parts of the mixer had dry food residue. f. Roof rack had dried food splatters and buildup. g. Chopping boards had scratches and were sticky to touch. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 138 of 139 medically compromised residents who received food and ice from the kitchen. Findings: a. During an observation on 10/8/2024 at…

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Based on observation, interview, and record review the facility failed to have a policy regarding the use and storage of food brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption when the policy did not include shelf life for prepared foods for storing food brought in by family and other visitors and there was no designated refrigerator for resident's outside food sources. This deficient practice had the potential to cause a decrease food intake resulting to unintentional (without trying) weight loss, frustrations, and psychosocial harm to 138 of 139 facility residents. Findings: A review of the facility's Policies and Procedures (P&P) titled Food for Residents from Outside Source dated 4/2024, indicated Policy Statement: Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. Policy interpretation and Implementation: Food bought by family/visitors is left with resident to consume…

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Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly by not maintaining the trash area free from trash, plastic, plastic cups, plastic containers, soiled gloves, paper bag of food, papers on the dumpster's (a large trash metal container designed to be emptied into a truck) floor. This deficient practice had a potential to attract birds, flies, insects, pest and possibly spread infection to 138 of 139 facility residents. Findings: During an interview on 10/9/2024 at 1:41 p.m with the Dietary Supervisor (DS), the DS stated the trashes from the kitchen were taken out to the dumpster after every meal. During an observation on 10/9/2024 at 2:45 p.m. in the dumpster area, while two kitchen staff were throwing the kitchen trash, it was observed that there were trashes such as paper bag of food, soiled gloves, plastic cups, plastic containers, papers were on the floor. During a concurrent observation and interview on 10/9/2024 at 2:49 p.m. with the Environmental Service Director (EVSD), EVSD stated they used the power wash the…

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NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. During a review of Resident 385's admission Record (AR), the AR indicated the facility admitted the resident on 10/3/2024, with diagnoses including chronic respiratory failure (a long-term condition that makes it difficult for the body to exchange oxygen and carbon dioxide), chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), and dependence on supplemental oxygen (a medical treatment that provides extra oxygen to people who have breathing problems or low blood oxygen levels). During a review of Resident 385's MDS dated [DATE], the MDS indicated the resident had intact cognition (the ability to maintain a relatively high level of mental functioning, including thinking, learning, memory, and perception). During a review of Resident 385's History and Physical (H&P), dated 10/11/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 385's Order Summary Report, the report indicated and order for:…

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Deficiency Text Not Available

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the food services department when seven (7) flies (a type of insect) were observed in the kitchen. This deficient practice had a potential to result in 138 of 139 residents, who received food from the kitchen, to acquire food borne illnesses (illness caused by consuming contaminated foods or beverages) by consuming potentially contaminated food. Findings: During an observation on 10/8/2024 at 8:05 a.m. one (1) fly was flying around the preparation area. During an observation on 10/8/2024 at 11:08 a.m. 1 fly was flying around the kitchen. During an observation on 10/8/2024 at 11:18 a.m. 1 fly landed on the back screen door. The back door had a little space for fly entry. During an observation on 10/8/2024 at 11:37 a.m. 1 fly landed on the food preparation area. During a concurrent observation and interview on 10/8/2024 at 11:58 a.m. with the Dietary Supervisor (DS), there was 1 fly flying around the tryline…

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Based on observation, interview, and record review, the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach of the resident for one of six sampled residents (Resident 112) investigated under environment facility task. The deficient practice had the potential to result in residents not being able to summon a health care worker for help as needed. Findings: During a review of Resident 112's admission Record (AR), the AR indicated the facility admitted the resident on 2/15/2024, and readmitted the resident on 2/29/2024, with diagnoses including encephalopathy (damage or disease that affects the brain) and anxiety disorder (a condition where a person has excessive and persistent feelings of fear, dread, and uneasiness). During a review of Resident 112's Order Summary Report, dated 2/26/2024, the report indicated to place a yellow arm band on the resident for fall precaution and monitor for presence. During a review of Resident 112's Care Plan (CP) titled The resident is high risk for falls…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 offer and assist the resident's choice to wear personal clothing for one of one sampled resident (Resident 23) investigated under the Choices investigative area. This deficient practice has the potential to result in a decline in the resident's self-esteem and self-worth. Findings: During a review of Resident 23's admission Record, the admission Record indicated the facility admitted the resident on 1/19/2023 with diagnoses including dementia (a progressive state of decline in mental abilities) and depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities). During a review of Resident 23's MDS, dated [DATE], the MDS indicated the resident's preferences to choose what clothes to wear was very important. The MDS indicated the resident was able to make self understood and usually understood others. The MDS indicated the resident required substantial/maximal assistance (helper does…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 received an accurate assessment, reflective of the resident's status at the time of the assessment, for one of one sampled residents (Resident 83) investigated under the communication-sensory care area when the facility failed to accurate assess Resident 83's ability to hear in the minimum data set (MDS, a federally mandated resident assessment tool). This deficient practice had the potential for the resident to not receive the appropriate interventions. Cross-reference F685. Findings: During a review of Resident 83's admission Record, the admission record indicated the facility admitted Resident 83 on 7/31/2023 with diagnoses including, but not limited to, heart disease, essential hypertension (HTN, high blood pressure), and history of falling. During a review of Resident 83's MDS, dated [DATE], the MDS indicated Resident 83 had difficulty understanding and making decisions, required setup assistance with eating,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 necessary services to maintain good grooming and personal hygiene for two of two sampled residents (Resident 17 and 23) when: 1. The facility failed to shave Resident 17's, a female resident, facial hair. 2. The facility failed to offer and assist Resident 23 to wear their personal clothing. These deficient practices had the potential to negatively affect the residents' psychosocial wellbeing. Cross-reference F656. Findings: a. During a review of Resident 17's admission Record, the admission record indicated the facility originally admitted Resident 17 on 5/30/2023 and readmitted the resident on 6/14/2023 with diagnoses including, but not limited to, acute respiratory distress syndrome (a life-threatening lung condition that occurs when the lungs are damaged and can't provide enough oxygen to the body), hemiplegia and hemiparesis (total paralysis of the arm, leg, and trunk on the same side of the body) following cerebral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 receive treatment and assistive devices to maintain hearing abilities for one of one sampled resident (Resident 83) investigated under the communication-sensory care area when the facility failed to refer Resident 83 to an otolaryngologist (ENT, also known as an ear, nose, and throat physician) and/or audiologist (physician who specializes in hearing, balance, and ear problems) for his impaired hearing. This deficient practice resulted in a delay in care for Resident 83. Findings: During a review of Resident 83's admission Record, the admission record indicated the facility admitted Resident 83 on 7/31/2023 with diagnoses including, but not limited to, heart disease, essential hypertension (HTN, high blood pressure), and history of falling. During a review of Resident 83's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/6/2024, the MDS indicated Resident 83 had difficulty understanding and making decisions, required setup assistance with eating, supervision or…

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

Based on observation, interview, and record review the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries (PI - localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) by failing to ensure the low air loss mattress (LALM- A mattress composed of inflatable air cushions that is used to relieve pressure on body parts) was set to the correct weight for one of four sampled residents (Resident 74) investigated under the Pressure Ulcer / Injury care area. This deficient practice had the potential to affect the redistribution capabilities (to evenly spread pressure to other areas across the body) of the LALM surface resulting in the development or worsening of pressure ulcers. Findings: During a review of Resident 74's admission Record, the admission Record indicated the facility admitted the resident on 9/11/2021 and most recently readmitted the resident on 5/18/2024 with diagnoses that included diseases of the liver (organ that removes toxins from the body's blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. During a review of Resident 66's admission Record (AR), the AR indicated the facility admitted the resident on 12/21/2022, and readmitted the resident on 7/31/2024, with diagnoses including cirrhosis of liver (a condition in which the liver is scarred and permanently damaged), encephalopathy (damage or disease that affects the brain), and viral hepatitis C (an inflammation of the liver caused by the hepatitis C virus). During a review of Resident 66's History and Physical (H&P), dated 1/16/2023, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 66's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 8/9/2024, the MDS indicated the resident had the ability to make self-understood and to understand others. The MDS indicated the resident was on a high-risk drug class antibiotic. During a review of Resident 66's Order Summary Report, dated 7/31/2024, the report indicated an order for Rifaximin tablet 550 mg. Give one tablet by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the entire medication regimen of the resident was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for two of five sampled residents (385 and 65) investigated under unnecessary medications review by failing to: 1. Obtain an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for Resident 385's use of psychotropic medication (Donepezil, used to treat dementia [memory loss and mental changes] associated with mild, moderate, or severe Alzheimer's disease [a disease characterized by a progressive decline in mental abilities]). 2. Monitor for adverse effects (a harmful or abnormal result) of Resident 65's use of antidepressant (Duloxetine, a medication used to treat major depressive disorder [a serious mental illness that can affect how a person feels, thinks, 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 maintain medical records with accepted professional standards to one of five sampled residents (Residents 57) selected for immunization review by failing to ensure to document vaccine (medications used to prevent diseases usually given by injection or by mouth) administration on the Medication Administration Record (MAR) when influenza vaccine (flu shot) and coronavirus disease-2019 (COVID-19 - a highly contagious respiratory illness capable of producing severe symptoms) vaccine they were administered. This deficient practice had the potential to result in inaccurate documentation in the medical record regarding Residents 57's immunization record. Findings: During a review of Resident 57's admission Record, the admission Record indicated the facility originally admitted the resident on 4/28/2021 and readmitted the resident on 9/12/2024 with diagnoses including orthopedic (relating to musculoskeletal system encompassing muscles, bones, tendons, ligaments, and joints) aftercare following surgical amputation (removal of all…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 mechanical, electrical, and patient care equipment in safe operating condition investigated during random observations by: 1. Failing to ensure the bed controller (device used to change the height and angle of the bed) cords for Resident 114 and Resident 22 did not have exposed wires. 2. Failing to ensure the call light (a device used by a resident to signal his or her need for assistance from staff) cord for Resident 104 did not have exposed wires. These deficient practices had the potential to place the residents at risk for injury. 3. Failing to ensure the Hoyer lift (a medical device that helps caregivers move patients from one place to another with minimal physical effort) was plugged in the wall outlet to charge when not in use. The deficient practice had the potential to result in the Hoyer lift to stop working while the resident was suspended in the Hoyer lift sling (a harness that attaches to a Hoyer lift to help move…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 protect the resident's right to be free from physical abuse for two of four sampled residents (Resident 3 and Resident 4) when on 9/1/2024 at 9:30 a.m.: 1. Resident 3 stated Resident 4 punched Resident 3 on the left side of his cheek. 2. Resident 3 stated he hit Resident 4 on his right cheek. 3. Resident 4 stated he punched Resident 3. This deficient practice resulted in Resident 3 and Resident being subjected to abuse while under the care of the facility. Findings: a. A review of Resident 3 admission Record indicated the facility admitted the resident on 9/19/2016 and was readmitted on [DATE] with diagnoses that included schizoaffective disorder (a mental health condition that is marked by a mix of schizophrenia [a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions] symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression) depressive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 readmit one of four sampled residents (Resident 4). This deficient resulted in Resident 4's rights to be violated. Findings: A review of Resident 4 admission Record indicated the facility admitted the resident on 12/04/2018 and readmitted the resident on 8/21/2024 with diagnoses that included insomnia (a common sleep disorder that can make it hard to fall asleep or stay asleep), essential (primary) hypertension (when the pressure in your blood vessels is too high [140/90 mmHg or higher]), and peripheral vascular disease (a circulatory condition that occurs when blood vessels outside of the brain and heart narrow, spasm, or become blocked). A review of Resident 4's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 6/6/2024, indicated Resident 4 had the ability to be understood and had the ability to understand. The MDS indicated Resident 4 had verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others) that occurred 4 to 6 days. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident for for two of seven sampled residents (Resident 1 & Resident 2). Resident 1 and Resident 2 were observed in the facility ' s surveillance camera recordings having a physical altercation with each other. This deficient practice affects the safety and well-being of the residents, exposing the residents to physical or mental trauma. Findings During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted the resident on 4/27/2023 with diagnoses of muscle weakness, unspecified dementia (a decline in mental capacity affecting thought and decision-making tasks), and personal history of transient ischemic attack (a temporary loss of blood flow to a part of the brain). During a review of Resident 1 ' s Minimum Data Set ([MDS] standardized assessment and care planning tool) dated 8/2/2024, the MDS indicated Resident 1 has severe impairment in…

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

Based on interview and record review, the facility failed to ensure resident had the right to receive an unopened package for one of five sampled residents (Resident 2). This deficient practice violated Resident 2's right to receive an unopened package and had the potential to negatively affect the resident's psychosocial wellbeing. Findings: During a review of Resident 2's admission Record indicated the facility admitted the resident on 8/8/2024 with a diagnosis of type two diabetes mellitus with hyperglycemia (a chronic condition that occurs when a person with type 2 diabetes has high blood sugar levels) During a review of Resident 2's Minimum Data Set (MDS- an assessment and care screening tool) dated 8/14/2024 indicated that Resident 2's cognition (mental process) was intact (not damaged). During an interview on 9/6/2024 at 9:25 a.m., Resident 2 stated not feeling safe in here because they open his package without his permission yesterday (9/5/2024) around 3 p.m Resident 2 further stated he was losing confidence and trust to this place and just wanted to leave. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident was not subjected to a physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for a second time by a resident who was physically abusive for one of three sampled residents (Resident 3). The facility failed to: 1. Ensure Resident 4 did not hit Resident 3 ' s left leg with his (Resident 4) wheelchair on 7/19/2023. 2. Ensure the facility ' s policy and procedures (P&P) titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, was followed to ensure Resident 3 was free form physical abuse. This deficient practice resulted in Resident 3 being subjected to physical abuse by Resident 4 while under the care of the facility resulting in Resident 3 ' s left leg pain requiring pain medication. Findings: During a review of Resident 3 ' s admission Record, the admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including depression (is a common…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prevention, investigation, and policies and procedures for one out of three sampled residents (Resident 3) by failing to complete a thorough investigation regarding allegations of abuse involving Resident 3. This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect residents from abuse. Findings: During a review of Resident 3 ' s admission Record, the admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including depression (is a common and serious medical illness that negatively affects how you feel, the way you think, and how you act), hypertension ([HTN] high blood pressure), and other abnormalities of gait (manner of walking or moving on foot) and mobility (the ability to move or be moved freely and easily). During a review of Resident 3's Minimum Data Set ([MDS] - a standardized assessment and care-screening tool), dated 7/3/2024,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Facility failed to ensure that staff followed proper infection control procedures when moving between isolation rooms for two of five sampled residents (Resident 5 and Resident 4). Staff did not remove their used PPE and put on new PPE before entering the isolation room (room [ROOM NUMBER]) of Resident 5 after being in Resident 4's isolation room (room [ROOM NUMBER]). Additionally, the Kitchen Aid (KA 1) threw his used gloves on the residents' coffee cart instead of disposing them in the trash can. This deficient practice had the potential of spreading infection to other residents. Findings: During a review of Resident 4's admission Record indicated the facility admitted the resident on 6/3/2024, with a diagnosis of rhabdomyolysis (a rare, serious, and potentially life-threatening condition that occurs when muscle tissue breaks down and releases its contents into the blood). During a review of Resident 4's Change of Condition Evaluation, dated 8/30/2024, indicated that Resident 4 had a Covid-19 (mild to severe…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect residents right to be free from abuse for two of three sampled residents (Resident 1 and Resident 3) by: 1. Failing to ensure Resident 1 was free from physical abuse inflicted by Resident 2. On 7/4/2024 at 3:45 p.m., Licensed Vocational Nurse 1 (LVN 1) witnessed Resident 2 punched Resident 1's right side of the head. 2. Failing to ensure Resident 3 was free from verbal abuse inflicted by Certified Nursing Assistant 2 (CNA 2). On 6/29/2024 at 2:05 a.m., CNA 1 heard CNA 2 telling Resident 3 to shut up and be quiet in a loud voice. These deficient practices resulted to: 1. Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. 2. Resident 3 being subjected to verbal abuse by CNA 2 while under the care of the facility. Based on the Reasonable Person Concept (refers to a tool to assist the team 's assessment of the severity level of negative, or potentially negative, psychosocial outcome the deficiency may…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 face-to-face visit was made by a physician or alternate visits by a nurse practitioner was conducted timely according to the facility ' s policy and procedures on Physician Visits for four of 17 sampled residents (Resident 14, Resident 15, Resident 16, and Resident 17). This deficient practice had the potential to result in an undetected decline in medical, health or psychosocial condition and can lead to a delay in necessary care, treatment, and services. Findings: A review of Resident 14 ' s admission Record indicated the facility admitted the resident on 9/2/2023 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), angina pectoris (chest pain or discomfort that kept coming back), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). A review of Resident 14 ' s Minimum Data Set (MDS - a standardized…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 eight of eight sampled facility staff (Director of Staff Development [DSD], Social Services Director [SSD], Licensed Vocational Nurse 7 [LVN 7], LVN 11, LVN 12, Certified Nursing Assistant 2 [CNA 2], CNA 16, and CNA 17) were competent to provide appropriate services to assure residents were free from abuse by failing to: 1. Provide in-service education that included sexual abuse prevention for the facility ' s resident population. 2. Ensure the in-services (staff training) lesson plan content was accurate. 3. Ensure annual competencies (measurable pattern of knowledge, skills, abilities, behaviors in order to perform occupational functions successfully) were completed for the SSD, LVN 11, CNA 16, and CNA 17. As a result, Resident 1 was subjected to sexual abuse from Resident 2. These deficient practices had placed other residents at risk for sexual abuse. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted 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 3a. A review of Resident 14 ' s admission Record indicated the facility admitted the resident on 9/2/2023 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), angina pectoris (chest pain or discomfort that kept coming back), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). A review of Resident 14 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 5/8/2024, indicated the resident ' s cognitive (problems with a person ' s ability to think, learn, remember, use judgement, and make decisions) skills were severely impaired. A review of Resident 14 ' s Physician Order for metoprolol tartrate (a medication that slows down the heart rate) 50 milligrams (mg – unit of measurement), dated 5/14/2024, did not indicate the time the physician order was written and the time the licensed nurse noted the physician order. The transcribed physician ' s order…

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

Based on interview and record review, the facility failed to provide reasonable accommodations for residents needs and preferences for one of six sampled residents (Resident 2), when Resident 2 requested for a room change. This deficient practice had the potential to negatively impact the psychosocial wellbeing of the resident. Findings: A review of Resident 2 ' s admission Record indicated the facility admitted Resident 2 on 9/15/2020, with diagnoses that included type two diabetes mellitus (blood glucose, or blood sugar levels are too high), unspecified (unconfirmed) dementia (not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and unspecified schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). A review of Resident 2 ' s History and Physical, dated 1/2/2024, indicated Resident 2 can make needs known but cannot make medical decisions. A review of Resident 2 ' s Minimum Data Set (MDS - a standardized assessment and care-screening…

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

Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident 2) ' s Family Member 2 (FM 2) was notified of Resident 2 ' s change in condition when on 5/11/2024, Resident 2 ' s lips, left eye and left cheek were swollen. This deficient practice had the potential to result in delayed provision of necessary care and services. Findings: A review of Resident 2 ' s admission Record indicated the facility admitted Resident 2 on 9/15/2020, with diagnoses that included type two diabetes mellitus (blood glucose, or blood sugar levels are too high), unspecified (unconfirmed) dementia (not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and unspecified schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). A review of Resident 2 ' s History and Physical dated 1/2/2024, indicated Resident 2 can make needs known but cannot make medical decisions. A review of Resident 2 ' s Minimum Data Set (MDS - 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 implement its abuse policy and procedure by failing to thoroughly investigate a resident to resident sexual abuse for two of six sampled residents (Resident 1 and Resident 2) by: 1. Failing to interview and clarify written statements of witnesses (Certified Nursing Assistant 2 [CNA 2] and CNA 3). 2. Failing to interview and document Resident 1 and Resident 2 ' s roommates (Resident 6 and Resident 7). 3. Failing to verify one to one staff monitoring (involves a nurse or carer providing support specifically to one individual) were provided to Resident 2 as indicated in Resident 2 ' s Progress Note, Care Plan and Administrator ' s (ADM) facility Investigation Report. 4. Failing to document incident date correctly in the facility ' s Investigation Report. This deficient practices had the potential to result in unidentified abuse in the facility and failure to protect residents from abuse. Findings: A review of Resident 1 ' s admission Record 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive care plan for two of six sampled residents (Resident 1 and Resident 2) by: 1. Failing to implement one on one staff monitoring (involves a nurse or carer providing support specifically to one individual) to Resident 2 as indicated in Resident 2 ' s care plan on at risk for safety dated 5/27/2024. 2. Failing to develop a care plan to address Resident 1 ' s refusal to walk with Restorative Nursing Assistant (RNA) on 5/29/2024. These deficient practices had the potential for delayed provision of necessary care and services. Findings: a. A review of Resident 2 ' s admission Record indicated the facility admitted Resident 2 on 9/15/2020, with diagnoses that included type two diabetes mellitus (blood glucose, or blood sugar levels are too high), unspecified (unconfirmed) dementia (not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 professional standards of practice for one of six sampled residents (Resident 1) when Licensed Vocational Nurse 1 (LVN 1) and Registered Nurse 1 (RN 1) did not check Resident 1 ' s vital signs (measurements of the body's most basic functions that includes blood pressure [the force of your blood pushing against the walls of your arteries], heartrate, respiratory rate [the number of breaths a person takes per minute], oxygen saturation [amount of oxygen level of the blood], and temperature) when Resident 1 had a change in condition on 5/26/2024. This deficient practice had the potential to place Resident 1 at risk for undetected elevated high blood pressure, heart rate, respiration and temperature which could negatively impact the resident's healh and safety. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 1/12/2018 with diagnoses that included end stage heart failure (the final and most severe stage of heart failure, during which time a person experiences…

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

Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered plan of care with measurable objectives and interventions for one of three sampled residents (Resident 1). The facility failed to ensure Resident 1's care plan indicated the specific interventions addressing the resident's risk for falls. As a result, on 4/10/2024 at 9:30 a.m., Resident 1 fell while Certified Nursing Assistant 1 (CNA 1) was transferring the resident from the bed to the wheelchair and sustaining a left elbow skin tear and a right knee abrasion. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 2/13/2024 with diagnoses including hemiplegia (paralysis that affects one side of the body) and hemiparesis (one-sided muscle weakness) following a cerebral infarction (result of disrupted blood flow to the brain because of problems with the blood vessels that supply it) affecting the left non-dominant side, type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar), and essential…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was identified as high fall risk, was assessed after the resident had a witnessed fall from the wheelchair. This deficient practice had the potential to result in inaccurate assessment that can lead to Resident 1 not receiving timely medical interventions. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 2/13/2024 with diagnoses including hemiplegia (paralysis that affects one side of the body) and hemiparesis (one-sided muscle weakness) following a cerebral infarction (a result of disrupted blood flow to the brain because of problems with the blood vessels that supply it) affecting the left non-dominant side, type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar), and essential hypertension. A review of Resident 1's History and Physical, dated 2/16/2024, indicated the resident did not have 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 maintain complete and accurate medical records in accordance with accepted professional standards for one of five sampled residents (Resident 1). This deficient practice had the potential to result in confusion in care and delivery of services to Resident 1 and may result in medication error. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 4/4/2023 with diagnoses that included encephalopathy (symptoms you experience when your brain is not working normally that can appear as confusion, memory loss, personality changes and or coma in the most severe form), type 2 diabetes mellitus ( characterized by high levels of sugar in the blood due to problem in the way the body regulates and uses sugar as a fuel), and left foot pain. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 12/27/2023, indicated Resident 1 had intact cognition (mental action or process of acquiring knowledge and understanding). 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.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program regarding Coronavirus disease 2019 (COVID-19, a viral infection that is highly contagious and easily transmits from person to person, causing respiratory problems and may cause death) for three of ten sampled residents (Resident 5, Resident 7, and Resident 8) by failing to: 1. Ensure Housekeeping 1 [HKP 1], Activity Assistant 1 [AA 1], Patio Supervisor [PS], and Payroll Personnel [PRL 1]) wore the N95 mask (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) properly. 2. Ensure that a used facemask was not placed on a clean kitchen surface. These deficient practices placed other residents and staff at risk for exposure and contracting COVID-19. Findings: On 1/25/2024 at 9:20 a.m., during a concurrent observation and interview, observed HKP 1 ' s N95 mask was not properly worn. The elastic straps of HKP 1 ' s N95 mask were both on the lower back of the neck with visible space between…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 ten sampled residents (Resident 3) was treated with respect and dignity in a manner that promotes maintenance or enhancement of the quality of life by failing to ensure the urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) drainage bag was fully covered by the dignity bag (a dark colored bag that conceals the front and back of the urine drainage bag). This deficient practice had the potential to affect Resident 3 ' s sense of self-worth and self-esteem. Findings: A review of Resident 3 ' s admission Record indicated the facility admitted the resident on 12/27/2023. Resident 3 ' s diagnoses included urinary tract infection (happen when bacteria enter the urethra [the tube through which urine leaves the body] and infect the urinary tract [the organs that make urine and removes it from the body]), type 2 diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, was too high), and essential hypertension (abnormal 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 interview and record review, the facility failed to promptly notify the attending physician (MD 1) on a change of condition after an unwitnessed fall incident that required physician intervention for one of ten sampled residents (Resident 2). On 1/29/2023, during the night shift (11 p.m. to 7 a.m. nursing shift), Resident 2 had an unwitnessed fall as reported to Licensed Vocational Nurse 1 (LVN 1) on the morning change of shift report. LVN 1 documented Resident 2 ' s fall on the Change of Condition Evaluation Form (COC) at 1:18 p.m. on 10/30/2023. Resident 2 ' s physician was notified at 6 p.m. on 10/30/2023. This deficient practice had the potential for delayed medical interventions for Resident 2. Findings: A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 9/12/2023. Resident 2 ' s diagnoses included chronic obstructive pulmonary disease (COPD – a group of diseases that cause airflow blockage and breathing-related problems), type 2 diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, was too…

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

Based on interview and record review, the facility failed to ensure resident ' s pain was managed as indicated in the facility ' s Pain Assessment and Management policy for one of ten sampled residents (Resident 1), by failing to ensure Resident 1 ' s pain medication, oxycodone-acetaminophen (medication to manage moderate to severe pain) scheduled every 4 hours as needed, was administered according to the physician order. This deficient practice resulted in Resident 1 ' s unnecessary pain experienced during daily activities and had the potential to lead to Resident 1 ' s decline in the quality of life. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 6/29/2020. Resident 1 ' s diagnoses included epilepsy (abnormal electrical brain activity), hemiplegia (one-sided muscle paralysis or weakness), and polyneuropathy (occurs when multiple peripheral nerves become damaged). A review of Resident 1 ' s Care Plan on pain, revised on 7/20/2022, indicated that the resident had a pain on her left side of the body. The Care Plan interventions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 pain medications were available for one of ten sampled residents (Resident 1) by failing to acquire Resident 1 ' s pain medication, oxycodone-acetaminophen (medication to manage moderate to severe pain) scheduled every 4 hours as needed, as indicated in the facility ' s policy on medication refill. This deficient practice resulted in Resident 1 ' s unnecessary pain experienced during daily activities and had the potential to lead to Resident 1 ' s decline in the quality of life. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 6/29/2020. Resident 1 ' s diagnoses included epilepsy (abnormal electrical brain activity), hemiplegia (one-sided muscle paralysis or weakness), and polyneuropathy (occurs when multiple peripheral nerves become damaged). A review of Resident 1 ' s Care Plan on pain, revised on 7/20/2022, indicated that the resident had a pain on her left side of the body. The Care Plan interventions included to give analgesics as ordered by the 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.

Based on interview and record review, the facility failed to ensure medical records were complete and accurately documented for one of ten sampled residents (Resident 2). On 1/29/2023, during the night shift (11 p.m. to 7 a.m. nursing shift), Resident 2 had an unwitnessed fall as reported to Licensed Vocational Nurse 1 (LVN 1) on the morning change of shift report. LVN 1 documented Resident 2 ' s fall on the Change of Condition Evaluation Form (COC) at 1:18 p.m. on 10/30/2023. Resident 2 ' s physician was notified at 6 p.m. on 10/30/2023. Registered Nurse 1 (RN 1) documented Resident 2 ' s fall on 10/31/2023. This deficient practice resulted in inaccurate information on Resident 2 ' s clinical record and had the potential for delayed medical interventions for Resident 2. Findings: A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 9/12/2023. Resident 2 ' s diagnoses included chronic obstructive pulmonary disease (COPD – a group of diseases that cause airflow blockage and breathing-related problems), 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.

Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for one of three sampled residents (Resident 1) to address resident ' s refusal for nail care. This deficient practice had the potential to negatively affect Resident 1 ' s self-esteem and placed him at risk for infection. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 3/12/2021 with diagnoses that included bilateral osteoarthritis (joint disease in which the tissues in the joint, break down over time) of knee, repeated falls, seizures (a sudden, uncontrolled burst of electrical activity in the brain causing changes in behavior, movements and feelings) and vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). A review of Resident 1 ' s History and Physical, dated 9/14/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment 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 provide care in a manner that maintained or enhance a resident's dignity and respect in full recognition of their individuality for three of four sampled residents (Residents 281, 33, and 116) investigated for dignity by: 1. Failing to ensure that Resident 281 who had an indwelling urinary catheter (a tube that is inserted into the bladder, allowing urine to drain freely) had a privacy bag to cover the urinary catheter drainage bag. 2. Failing to ensure that Resident 33's privacy curtain was fully drawn, was wearing clothing, fully covered with sheets, and incontinence brief not exposed. 3. Failing to ensure Resident 116 was served her meal tray simultaneously with the other residents in the dining room during lunch. These deficient practices had the potential to affect the residents' self-worth and self-esteem. Findings: a. A review of Resident 281's admission Record indicated the facility admitted the resident on 9/24/2023 and readmitted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach of the resident for five out of five sampled residents (Resident 33, 55, 63, 98, and 104). This deficient practice had the potential to result in the residents not being able to call for facility staff assistance and increase their risk for injury or fall. Findings: A. A review of Resident 33's admission Record indicated the facility admitted the resident on 1/19/2023 with diagnoses including congestive heart failure (a condition in which the heart cannot pump blood well enough to meet the body's needs), difficulty in walking, generalized muscle weakness, and dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 33's History and Physical dated 1/23/2023, indicated the resident can make needs known but cannot make…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 had the right to receive mail for two of 10 sampled residents (Resident 50 and Resident 81). Resident 50 and Resident 81 stated they do not receive mail on Saturdays. This deficient practice violated the residents' right to receive mail on Saturdays and had the potential to negatively affect the resident's psychosocial well-being. Findings: During the with Resident Council meeting on 10/3/2023, at 2:09 p.m., Resident 50 and Resident 81 stated they do not receive mail on Saturdays. During an interview with Receptionist (RECP) 1 on 10/6/2023, at 9:43 a.m., RECP 1 stated mail is not delivered to residents on Saturdays. RECP 1 stated she does not work on the weekends and stated whoever is working as receptionist on the weekend places the incoming mail in a locked drawer at the receptionist drawer. RECP 1 stated when she comes in on Monday, she finds the mail delivered on the weekends in the drawer. RECP 1 stated the weekend receptionist inputs the incoming mail in the Mails and Delivery Log. RECP 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the residents were provided with a safe, clean, comfortable, and homelike environment for four of four sampled residents (Resident 34, 76, 118, and 27) by: 1. Failing to ensure electrical wire were not exposed on Resident 34's bed remote control. This deficient practice had the potential to place Resident 34 at risk for accidents such as electrocution. 2. Failing to maintain a clean, pleasant, and neutral-scent environment for Resident 76's who had a sticky bedroom floor with strong foul odor. This deficient practice had the potential negatively affect the resident's quality of life. 3. Failing to ensure Resident 118's bathroom sink was not loosely attached to the bathroom wall. This deficient practice had the potential to make residents feel uncomfortable and place residents at higher risk for accidents. 4. Failing to ensure Resident 27's tube feeding pole was free from dried feeding formula. 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 develop and implement a comprehensive plan of care with measurable objectives and interventions for six of six sampled residents (Resident 57, 88, 97, 101, 123, and 281) by: 1. Failing to develop a care addressing Resident 57's pain management. 2. Failed to implement Resident 88's care plan interventions of monitoring of medication, vital signs, and behavior on 9/28/2023. 3. Failing to implement Resident 97's care plan interventions to monitor for side effects of antipsychotic (medication for mental disorders) medication on 9/25/2023. 4. Failing to develop a care plan addressing Resident 101's smoking. 5. Failing to develop care plan for addressing Resident 123's activities. 6. Failing to ensure Resident 281 had a care plan that addressed the resident's use of urinary catheter (a tube that is inserted into the bladder, allowing urine to drain freely). These deficient practices placed the residents at risk for not receiving the necessary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nursing staff failed to provide care in accordance with professional standards to four out of five sampled residents (Residents 29, 57, 98, and 282) by: 1. Failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin (a hormone that lowers the level of sugar in the blood) administration sites to Residents 19 and 57. 2. Failing to rotate Lovenox (enoxaparin sodium injection) (medication that helps prevent the formation of blood clots) administration sites to Resident 98. The deficient practices had the potential for adverse effect of same site subcutaneous administration of insulin and anticoagulant medications such as lipodystrophy (abnormal distribution of fat). 3. Failing to ensure Registered Nurse 1 (RN) indicated the administration date and time on the intravenous antibiotic (medications that are administered directly into a vein so that the medicine can enter 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 staff failed to provide appropriate treatment and services for three (Resident 102, 117, and 76) of four sampled residents with an indwelling urinary catheter (a tube that is inserted into the bladder, allowing urine to drain freely) by: 1. Failing to provide daily catheter care and catheter assessments to Residents 102 and 117. 2. Failing to place a catheter tubing securement device (to secure an indwelling urinary catheter) on Resident 117. 3. Failing to assess Resident 76 prior to placement of an indwelling urinary catheter. These deficient practices had the potential for residents to develop catheter associated urinary tract infection (CAUTI, an infection of the urinary tract caused by a tube [urinary catheter] that has been placed to drain urine from the bladder). Findings: a. A review of Resident 102's admission Record indicated the facility admitted Resident 102 on 11/29/2022 and readmitted the resident on 4/11/2023, 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 Based on observation, interview, and record review, the facility failed to maintain the kitchen in a clean, safe, and sanitary condition in which food was stored, prepared, and served in accordance with professional standards of food service safety by: 1. Failing to ensure that a pack of fresh blueberries observed with white spots was discarded. 2. Failing to ensure an open bottle of non-alcoholic [NAME] cocktail mix was labelled with open date. 3. Failing to ensure open bags of French fries, white bread, and yellow bread were labelled with open date. 4. Failing to ensure yellow cheese in a container was labeled with the content and open date. 5. Failing to ensure white cheese in a container was labelled with the content and discarded past the date indicated 9/27/2023 - 9/31/2023. 6. Failing to ensure a bottle of a sports drink and Arizona tea belonging to a staff were not stored in the walk-in refrigerator. 7. Failing to ensure apple sauce, pudding, green gelatin in cups prepared in advance were labelled 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 staff failed to arrange provision of hospice services (a type of care and philosophy of care that focuses on the care of the terminally ill patients' pain and symptoms, and attending to their emotional and spiritual needs) for two of two sampled residents (Resident 76 and 124) by failing to ensure hospice staff, including registered nurse (RN), licensed vocational nurse (LVN), and hospice aide (HA) provided nursing visits based on the hospice calendar and failed to provide the hospice visitation notes to the facility. These deficient practices had the potential to negatively affect Residents 76 and 124's physical comfort, psychosocial well-being, and not receiving the needed and necessary hospice care services timely. Findings: a. A review of Resident 76's admission Record indicated the facility admitted the resident on 1/24/2023 with diagnoses including severe protein calorie malnutrition (refers to a nutritional status in which reduced availability 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 3. A review of Resident 25's admission Record indicated the facility admitted the resident on 6/18/2011 and readmitted the resident on 2/23/2020 with diagnoses including gastrostomy (gastrostomy (G-tube - a surgical procedure for inserting a tube through the abdomen wall and into the stomach and used for feeding or drainage), heart failure (a condition that develops when the heart doesn't pump enough blood for the body's needs, and dysphagia (difficulty swallowing). A review of Resident 25's History and Physical dated 9/26/2022, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 25's Minimum Data Set (MDS-a standardized assessment and screening tool) dated 9/1/2023, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision from staff with eating, total assistance from staff with bathing, and extensive assistance with all other activities of daily living (ADLs - basic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an effective pest control program so that the facility is free of pests (e.g. mosquitoes and flies) when the following occurred: 1. Flying insects were observed inside Resident 50 and Resident 118's room. Resident 118's bathroom window screen had a hole in it. 2. The conference room bathroom window screen had an opening, not sealed to the window, and multiple mosquitoes were observed on the ceiling and walls. These deficient practices resulted in Resident 50 unable to eat her dinner due to exposure to flies and Resident 118 feeling annoyed due to the pests. These also placed the potential for residents and staff to be exposed to mosquito bites. Findings: a. A review of Resident 50's admission Record indicated the resident was admitted to the facility originally on 10/13/2016 and was readmitted on [DATE] with diagnoses including hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body that can…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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's interdisciplinary team (IDT-a coordinated group of experts from several different fields who work together) failed to determine if self-administration was clinically appropriate for two of two sampled (Resident 89 and Resident 62) residents investigated under the self-administer medications care area by failing to: a. Ensure that the self-administration of medication assessment was completed for Resident 89. b. Ensure the medications were not left at the bedside for Resident 62, who was not capable to self-administer medications investigated under the self-administer medications care area. These deficient practices placed the resident at risk for unsafe medication administration or omission. Findings: a. A review of Resident 89's admission Record indicated the facility admitted the resident on 11/11/2021 and readmitted on [DATE] with diagnoses including diabetes mellitus type 2 (a condition that occurs when the blood sugar is too high), lumbar…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clinical records were updated regarding advance directive (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) for one of eight sampled residents (Resident 227) when Resident 227's Advance Directive Acknowledgement form was left blank. This deficient practice had the potential to cause conflict with a resident's wishes regarding their care. Findings: A review of Resident 227's admission Record indicated Resident 227 was admitted to the facility on [DATE] with diagnoses including abnormalities of gait and mobility, generalized muscle weakness, history of falling and deaf (lacking the power of hearing or having impaired hearing). A review of Resident 227's Minimum Data Set (MDS - an assessment and care screening tool), dated 9/29/2023, indicated Resident 227 was cognitively intact (able to understand and make decisions) 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 implement its abuse reporting policy and procedure (P&P) by failing to report an allegation of resident-to-resident altercation to the State Survey Agency (Department of Public Health) within two hours for two of eight sampled residents (Resident 67 and Resident 227). This deficient practice had the potential to result in an unidentified abuse in the facility and had the potential for the residents to experience further abuse. Findings: A review of Resident 67's admission Record indicated Resident 67 was admitted to the facility on [DATE] with diagnoses including abnormalities of gait (manner of walking) and mobility, generalized muscle weakness, and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A review of Resident 67's History and Physical (H&P), dated 7/24/2023, indicated Resident 67 can make her needs known but cannot make medical decisions. A review of Resident 67'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview the facility failed to ensure Minimum Data Set (MDS-a resident assessment and care screening tool) assessments accurately reflect the resident's status for three of four sampled residents (Residents 101, 60, and 125) by: 1. Failing to ensure the assessment did not indicate Resident 101 was receiving anticoagulant medication. This deficient practice had the potential to cause errors in medical treatment and care planning for the resident. 2. Failing to ensure the assessment did not indicate Resident 125 was discharged to acute hospital. This deficient practice had the potential to negatively affect Resident 125's plan of care and delivery of necessary care and services upon discharge. Findings: a. A review of Resident 101's admission Record indicated the facility admitted the resident on 7/16/2023 with diagnoses including acute (sudden) osteomyelitis (a condition where there is inflammation and swelling in a bone), left ankle and foot and type II diabetes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that a preadmission screening assessment was done for a resident who was diagnosed with a mental illness prior to admission in the facility for one of eight sampled residents (Resident 88). This deficient practice had the potential for not receiving the necessary and appropriate psychiatric level of treatment and evaluation in the facility. Findings: A review of Resident 88's admission Record indicated Resident 88 was admitted to the facility on [DATE] with diagnoses including major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). A review of Resident 88's Minimum Data Set (MDS - an assessment and care screening tool), dated 9/19/2023, indicated Resident 88 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a baseline care plan (initial written guide that organizes information about the resident's care) within 48 hours of admission for one out of seven sampled residents (Resident 281) investigated under care planning care area. This deficient practice had the potential for the resident not to receive appropriate care and treatment specific to his needs. Findings: A review of Resident 281's admission Record indicated the facility admitted the resident on 9/24/2023 and readmitted on [DATE] with diagnoses including congestive heart failure (CHF - a condition that develops when your heart does not pump enough blood for your body's needs), pneumonia (an infection of the lungs), and generalized muscle weakness. A review of Resident 281's History and Physical dated 9/25/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 281's Minimum Data Set (MDS - an assessment and care screening tool) dated 10/5/2023,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interdisciplinary team (IDT) review and revise the resident's care plan for two (Resident 55 and Resident 282) of two residents by: 1. Failing to indicate in the care plan an order by the physician to change the resident's peripherally inserted central catheter (PICC - a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) to a midline catheter (vascular access device placed into a peripheral vein) for Resident 282. 2. Failing to update the resident's care plan to reflect changes in the fall risk assessment for Resident 55 after readmission on [DATE]. These deficient practices placed the residents at risk for inconsistent implementation of the care plan that may lead to a delay in or lack of delivery of care and services. Findings: a. A review of Resident 282's admission Record indicated the facility admitted the resident on 9/18/2023 and readmitted the resident 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 observation, interview, and record review, the facility failed to ensure residents were provided a communication device to allow communication between staff and residents for one of eight sampled residents (Resident 227), when Resident 227 was not provided a dry erase marker for the white board that the resident uses to communicate with staff and visitors. This deficient practice had the potential to delay Resident 227's care and communication with staff and visitors. Findings: A review of Resident 227's admission Record indicated Resident 227 was admitted to the facility on [DATE] with diagnoses including abnormalities of gait and mobility, generalized muscle weakness, history of falling and deaf (lacking the power of hearing or having impaired hearing). A review of Resident 227's Minimum Data Set (MDS - an assessment and care screening tool), dated 9/29/2023, indicated Resident 227 was cognitively intact (able to understand and make decisions) and has moderate difficulty hearing. A review of Resident…

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

Based on observation, interview, and record review, the facility failed to ensure one (Resident 27) of one sampled resident investigated under the activities of daily living (ADL- basic tasks that must be accomplished every day for an individual to thrive) was provided care and services to maintain good grooming and personal hygiene. This deficient practice resulted in Resident 27 having poor grooming and personal hygiene. This had the potential to have a negative impact on the resident`s quality of life and self-esteem. Findings: A review of Resident 27's admission Record indicated the facility admitted the resident on 5/30/2014 and readmitted the resident on 6/14/2023 with diagnoses including heart failure (a condition in which the heart cannot pump blood well enough to meet the body's needs), dysphagia (difficulty swallowing), and gastrostomy (G-tube - a surgical procedure for inserting a tube through the abdomen wall and into the stomach and used for feeding or drainage). A review of Resident 27's History and Physical dated 6/15/2023, indicated the resident did not have 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 the necessary treatment and services consistent with professional standards of practice to two out of three sampled residents (Residents 102 and 117) by failing to consistently assess and document the pressure injuries (also known as pressure injuries, the breakdown of skin integrity due to pressure) of Residents 102 and 107. The deficient practice had the potential for infection, delayed healing of the pressure injuries and development of new pressure ulcer to residents. Findings: A review of Resident 102's admission Record indicated the facility admitted Resident 102 on 11/29/2022 and readmitted the resident on 4/11/2023, with diagnoses including unstageable (when the stage is not clear) pressure ulcer on the right heel, unstageable pressure ulcer on the left heel, and deep tissue damage (when there is no open wound, but the tissues beneath the surface have been damaged) of the sacral region (located below the lumbar spine and above 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 for one out one sampled resident (Resident 97) investigated for limited range of motion (ROM - movement of the joints) received the appropriate treatment and services to maintain ROM. This deficient practice placed the resident at risk for decline in mobility and range of motion. Findings: A review of Resident 97's admission Record indicated the facility admitted the resident on 8/4/2023 with diagnoses including acute pyelonephritis (occurs as a complication of an ascending urinary tract infection that spreads from the bladder to the kidneys), bipolar disorder (a serious mental illness that causes unusual shifts in mood, ranging from extreme high manic episodes to low depressive episodes), and muscle weakness (lack of muscle strength). A review of History and Physical, dated 8/7/2023, indicated that Resident 97 had the capacity to understand and make decisions. A review of Resident 97's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/11/2023, indicated that Resident 97 had intact…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 environment remains as free of accident hazards as is possible by failing to ensure the floor in for one of two (Resident 277) sampled residents reviewed under Accidents care area by failing to ensure the floor in Resident 277's room was kept dry and a wet floor sign placed on the floor to alert the resident that the floor was wet. This deficient practice placed the resident at risk for falls and serious injuries. Findings: A review of Resident 277's admission Record indicated the facility admitted the resident on 9/20/2023 with diagnoses including left rib fracture (broken rib), difficulty in walking, and hemothorax (a collection of blood in the space between the chest wall and the lung [the pleural cavity] from trauma). A review of Resident 277's History and Physical dated 9/22/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 277's Minimum Data Set (MDS-a standardized assessment and screening tool) dated 9/25/2023, indicated the resident…

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

Based on interview and record review, the facility failed to evaluate and address the needs of residents at risk or already experiencing impaired nutrition for one of eight sampled residents (Resident 118), when Resident 118's plan of care to perform weekly weights were not performed by the facility. This deficient practice had the potential for additional weight loss and resulted in Resident 118's delay in care to address his weight loss. Findings: A review of Resident 118's admission Record indicated the facility admitted Resident 118 to the facility on 7/21/2023 with diagnoses including hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (also known as an ischemic stroke - the disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting left non-dominant side, other abnormalities of gait (manner of walking) and mobility, generalized muscle weakness, and hypertension (high blood pressure). A review of Resident 118'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 Based on observation, interview, and record review the facility: 1. Failed to remove Resident 4's expired Albuterol solution (a medication used to prevent and treat breathing problems such as asthma) from Medication Cart A. The medication's expiration date was on 9/14/2023. 2. Failed to remove Resident 327's medication, Alendronate Sodium 70 mg tab (a medication used to help strengthen bones) from Medication Cart B. Resident 327 was discharged from the facility on 7/25/2023. These deficient practices had the potential for placing the residents at risk for receiving expired medications that can cause adverse effects (unwanted symptoms or side effects). Findings: a. A review of Resident 4's admission Records indicated the facility admitted Resident 4 on 8/21/2023 and readmitted the resident on 9/7/2023, with diagnoses including acute respiratory failure (a serious condition that makes it difficult to breathe) with hypoxia (a condition where you do not have enough oxygen in the tissues in your body) and dependent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 adverse side effects (any unexpected or dangerous reaction to a drug) of Lovenox (a type of medication used to prevent blood from clotting) every shift as ordered by the physician for one of two sampled residents (Resident 98). This deficient practice placed the resident at risk for unidentified or unreported side effects of Lovenox reactions including bleeding easily and bruising. Findings: A review of Resident 98's admission Record indicated the facility admitted Resident 98 on 7/31/2023, with diagnoses including heart disease, intertrochanteric fracture of right femur (a type of hip fracture or broken hip), and cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). A review of Resident 98's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/7/2023, indicated Resident 98 had the ability to make self-understood and understand others. The MDS indicated the resident was on an anticoagulant…

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

Based on observation, interview and record review, the facility failed to ensure a resident who was receiving a psychotropic (any drug capable of affecting mood, emotions, and behavior) medication was adequately monitored for the use of Sertraline HCl (medication to treat depression) as ordered by the physician for one of three sampled residents (Resident 64) by failing to: 1. Monitor and document the side effects of Sertraline HCl use every shift. 2. Monitor and document episode of depression m/b poor appetite AEB < 50 meal intake every shift. This deficient practice placed Resident 64 at risk of receiving unnecessary psychotropic medication without monitoring and evaluating the effectiveness of the medication. Findings: A review of Resident 64's admission Record indicated the facility admitted the resident on 11/9/2023 and readmitted the resident on 7/7/2023, with diagnoses including depression, chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), and insomnia (a common sleep disorder). A review of Resident…

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

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored appropriately by failing to label Resident 86's acetylcysteine (medication that helps thin and loosens mucus in the airways due to certain lung diseases) medication with an open date for one of four sampled medication storage refrigerator (Med Ref 1). This deficient practice had the potential to place the residents at risk for receiving medications that have become ineffective or toxic due to improper storage leading to health complications and negative outcomes. Findings: During a concurrent observation and interview on 10/6/2023 at 8:52 a.m., with the Quality Assurance (QA) Nurse, observed Resident 86's acetylcysteine medication vial, opened with no label indicating the open date. The QA Nurse stated it should have been labeled with an open date. During an interview on 10/6/2023 at 9:24 a.m., the QA nurse stated when the medication vial is opened it should have been labeled with an open date. The QA Nurse stated if the vial is not labeled then it should have been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide residents with food that is palatable (referring to the taste and/or flavor of the food) for one of eight sampled residents (Resident 123) when Resident 123 stated the broccoli served during lunch on 10/4/2023 was overcooked and mushy. This deficient practice had the potential for residents to not consume their meals. Findings: A review of Resident 123's admission Record indicated the facility admitted the resident on 9/11/2023 with diagnoses including endocarditis (an infection of the heart's inner lining, usually involving the heart valves) and generalized muscle weakness. A review of Resident 123's MDS, dated [DATE], indicated Resident 123 was cognitively intact (able to understand and make decisions). A review of Resident 123's Order Summary report, dated 9/11/2023, indicated an order for consistent carbohydrate diet (specialized diet that focuses on serving the same amount of carbohydrates [food consisting of or containing a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of 11 sampled residents (Resident 4) was free of any significant medications errors when Resident 4 was ordered Percocet (a type of pain medication containing oxycodone [an opioid pain medication used to treat moderate to severe pain] and acetaminophen [a pain medication used to treat minor aches and pain]) 5-325 milligrams (mg – a unit of measure) two tablets every four hours as needed for severe to worst pain and was administered Percocet 10-325 mg two tablets. This deficient practice had the potential for Resident 4 to experience signs and symptoms related to opioid overdose (a life-threatening event that includes symptoms including shallow breathing, confusion, lessened alertness, and loss of consciousness). There was also a delay in Resident 4's administration of the next scheduled pain medication. Findings: A review of Resident 4 ' s admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted…

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

Based on interview and record review, the facility failed to develop a comprehensive care plan for the use of the anticoagulant (blood thinner, medication used to prevent blood clot) Lovenox for one of three sampled residents (Resident 3). Resident 3 was injected Lovenox every 12 hours as ordered on 7/4/2023, but there was no care plan, from 7/4/2023 to 9/26/2023, to monitor for side effects including bleeding and bruising. This deficient practice placed the resident at risk for experiencing unidentified side effects. Findings: A review of Resident 3's admission Record indicated the facility admitted the resident on 7/3/2023 with diagnoses including metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood leading to personality changes), Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and hypertension (uncontrolled elevated blood pressure). A review of Resident 3's History and Physical exam, dated 7/13/2023, indicated the resident…

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

Based on interview and record review, the facility failed to ensure the resident's drug regimen is free from unnecessary drugs when used without adequate monitoring for one of four sampled residents (Resident 3). Resident 3 was receiving the anticoagulant (blood thinner, medication used to prevent blood clot) Lovenox every 12 hours as ordered on 7/4/2023, but the nursing staff were not monitoring Resident 3 for side effects including bleeding and bruising from 7/4/2023 to 9/26/2023. This deficient practice placed the resident at risk for experiencing unidentified side effects. Findings: A review of Resident 3's admission Record (Face Sheet) indicated the facility admitted the resident on 7/3/2023 with diagnoses including metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood leading to personality changes), Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and hypertension (uncontrolled elevated blood pressure). A review of Resident…

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

Based on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices by failing to ensure that one of three kitchen staff (Dishwasher 1 [DW 1]) was wearing a hair restraint (cover) while inside the kitchen. This deficient practice had the potential to compromise the integrity of food and placed the residents at risk for foodborne illnesses (illness caused by the ingestion of contaminated food or beverage). Findings: During a concurrent observation and interview on 9/23/2023 at 7:35 a.m. with Certified Nursing Assistant 1 (CNA 1), by the kitchen door. Observed Dishwasher 1 (DW 1) standing inside the kitchen with no hair restraint (cover). CNA 1 confirmed DW 1 was not wearing a hair restraint. During an interview on 9/23/2023 at 7:36 a.m., DW 1 stated she forgot to put on a hair restraint. During an interview on 9/23/2023 at 7:40 a.m., Registered Nurse 1 (RN 1) stated kitchen staff should wear a hair restraint, so it does not contaminate (any substance that is present in food and can potentially cause harm) the food. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its abuse policy by not conducting a thorough investigation for a resident-to-resident abuse for two of three sampled residents (Resident 1 and Resident 2) when Resident 2 hit Resident 1 with the wheelchair footrest on 9/16/2023. This deficient practice had the potential to result in unidentified abuse and placed the residents at risk for further abuse. Findings: a. A review of Resident 1's admission Record indicated the facility admitted the resident on 11/9/2021 with diagnoses that included gastrostomy (a surgical procedure used to insert a tube, often referred to as a G-tube, through the abdomen and into the stomach for food and medication), dysphagia (difficulty in swallowing) and chronic obstructive pulmonary disease (COPD- a group of diseases that cause airflow blockage and breathing-related problems). A review of Resident 1's History and Physical, dated 8/28/2023, indicated the resident had the capacity to understand and make…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 licensed nursing staff failed to follow professional standards of nursing practice for one of two sampled residents (Resident 1) by failing to notify the physician when Resident 1's systolic blood pressure (measures the pressure in the arteries when the heart beats) was greater than 180 millimeters of mercury (mmHg-measurement of pressure). This deficient practice had the potential to place Resident 1 at risk for complications of high blood pressure. Findings: A review of the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted the resident on 6/20/2023 with diagnoses that included paranoid schizophrenia (a subtype of this condition because paranoia commonly happens with schizophrenia. Paranoia is a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly), generalized anxiety disorder (an overwhelming, ongoing fear of being watched and judged by others), pain…

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

Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for two of three sampled residents (Resident 1 and Resident 4) by failing to document holding the medications despite physician ' s order. This deficient practice may result in confusion in the care and services rendered to residents and may result in inaccurate information entered into residents ' medical records. Findings: a. A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 1/30/2023 with diagnoses that included hemiplegia (mild or partial weakness or loss of strength on one side of the body), hemiparesis (severe or complete loss of strength or paralysis on one side of the body), encephalopathy (general term that refers to brain disease, damage, or malfunction), muscle weakness, dementia(impaired ability to remember, think, or make decisions that interferes with doing everyday activities), hypertension (uncontrolled elevated blood pressure), and repeated falls. 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, interview, and record review, the facility failed to implement infection control practices for two of three sampled residents (Resident 1 and Resident 5) by failing to ensure Restorative Nursing Assistant 1 (RNA 1), wore N95 mask (respiratory protective device designed to achieve a very close facial fit) covering her nose and mouth while inside the dining area during a Coronavirus Disease- 2019 (COVID-19, a highly contagious respiratory illness in humans capable of producing severe symptoms) outbreak (a sudden rise in the number of cases of a disease). This deficient practice had the potential to result in the spread of COVID-19 to staff and residents. Findings: a. A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 1/30/2023 with diagnoses that included hemiplegia (mild or partial weakness or loss of strength on one side of the body), hemiparesis (severe or complete loss of strength or paralysis on one side of the body), encephalopathy (general term…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure call lights were within residents ' reach while in bed for two out of three sampled residents (Resident 2 and Resident 3). This deficient practice had the potential to result in resident falls and residents not being able to summon health care workers for assistance when needed. Findings: a. A review of Resident 2 ' s admission Record indicated the facility readmitted the resident on 8/11/2023 with diagnoses that included metabolic encephalopathy (broad term for any brain disease that alters brain function or structure), sepsis (life-threatening complication of an infection), and pneumonia (lung inflammation caused by bacterial or viral infection). A review of Resident 2 ' s Minimum Data Set (MDS- a standardized assessment and screening tool), dated 7/18/2023, indicated Resident 2 had severely impaired cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills…

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

Based on interview and record review, the facility failed to ensure one of three sampled resident (Resident 5) was seen by attending physician at least every 60 days while in the facility. This deficient practice had the potential to result in an undetected decline in medical, health or psychosocial condition and can lead to a delay in necessary care, treatment, and services. Findings: A review of Resident 5 ' s admission Record indicated the facility admitted the resident on 1/12/2007 with diagnoses that included hemiplegia (mild or partial weakness or loss of strength on one side of the body), epilepsy (repeatedly uncontrolled electrical activity in the brain, which may produce a jerking movement of a part or the entire body), dementia (a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities) and liver cirrhosis (a condition in which the liver is scarred and permanently damaged). A review of Resident 5 ' s History and Physical, dated 2/22/2022, indicated the resident did not have the capacity to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that a resident was assessed by a Registered Nurse (RN) after an unwitnessed fall incident that occurred on 8/20/2023 for one of three sampled residents (Resident 1). This deficient practice had the potential for Resident 1 to receive an inaccurate assessment and can lead to a delay in necessary care, treatment, and services. Findings: A review of Resident 1 ' s admission Record indicated the facility originally admitted the resident on 1/30/2023 and readmitted on [DATE] with diagnoses including hemiplegia (paralysis that affects only one side of your body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) following a cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it that deprives brain cells of oxygen and vital nutrients which can cause parts of the brain to die off)…

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

Based on observation, interview, and record review the facility failed to ensure one of three sampled staff (Payroll Staff [PS]), wore mask (a loose-fitting, disposable device that creates a physical barrier between the mouth and nose of the wearer and potential contaminants in the immediate environment) while seated in front of Dietary Supervisor (DS) inside the payroll room. This deficient practice had the potential to result in the spread of Coronavirus Disease 2019 (COVID-19- highly contagious respiratory infection that spreads from person to person when an infected person coughs, sneezes or talks) to staff and residents. Findings: During a concurrent observation and interview on 8/31/2023 at 3:39 p.m., with Receptionist 2 (RCP 2), in the facility ' s lobby. Observed Payroll Staff (PS) not wearing a mask while talking to Dietary Supervisor (DS). RCP 2 stated all staff should wear a mask while inside the facility because the facility had Coronavirus Disease 2019 (COVID-19- highly contagious respiratory infection that spreads from person to person when an infected person coughs,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 manage pain for two of three sampled residents (Resident 1 and Resident 2) by: 1. Failing to notify the physician when Resident 1 had pain level of four (0- no pain, 10 severe pain) on [DATE]. 2. Failing to follow physicians order for tramadol hydrochloride (HCL, medication used to treat pain) by mouth as needed for severe pain level of seven to ten when Resident 1 complained of pain level seven on [DATE]. 3. Failing to follow physician order for oxycodone HCL (medication used to treat pain) 10 mg by mouth as needed for severe pain level of seven to ten when Resident 2 complained of pain level seven on [DATE], [DATE] and [DATE] and pain level of eight on [DATE] and [DATE]. 4. Failing to follow physician order for oxycodone HCL 10mg by mouth as needed for severe pain level of seven to ten when Resident 2 complained of pain level seven on [DATE] at 12:04 a.m. These deficient practices had the potential to negatively affect the residents' physical comfort…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physicians order for one of three sampled residents (Resident 1) by failing to ensure Toprol XL (medication used to treat high blood pressure, chest pain and abnormal rhythms of the heart) was not administered to the resident when the resident ' s systolic blood pressure (sbp-pressure in the arteries when the heart beats) was below 110. This deficient practice may potentially lower Resident 1 ' s blood pressure. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on [DATE] with diagnoses including atherosclerotic heart disease (thickening or hardening of the arteries [blood vessels that supply oxygen rich blood from the heart]), muscle weakness and end stage renal disease (ESRD- a medical condition in which a person's kidneys stops functioning on a permanent basis leading to the need for a regular course of long-term dialysis [treatment that helps your body remove extra fluid and waste products from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 medical records were complete, accurately documented, readily accessible and systematically organized for one of four sampled residents (Resident 1). Licensed Vocational Nurse 1 (LVN 1) did not accurately document the location of Resident 1's eye redness and discharge. This deficient practice had the potential for delayed medical interventions for Resident 1 and potential for error. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 7/27/2023, with diagnoses including type two diabetes mellitus (occurs when the blood sugar is too high), osteoporosis (a condition that causes bones to become weak and lose their strength, making them break more easily than normal bones), and essential hypertension (occurs when a person has abnormally high blood pressure that was not the result of a medical condition). A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 7/30/2023, indicated the resident's cognitive (conscious…

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