Baldwin Gardens Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review for one of three sampled residents (Resident 3), the facility failed to:a. Ensure the low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) was set accurately for Resident 3.b. Obtain a physician order for the use of LALM for Resident 3. These failures had the potential to impede healing and worsen Resident 3's wounds and cause further skin injuries. Findings:a. During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) and dementia (a progressive state of decline in mental abilities). During a review of Resident 3's History and Physical (H&P) dated 6/28/2025, the H&P…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility Administrator (ADM) and Director of Nursing (DON) failed to report an injury of unknown origin (IUO- injury in which the cause cannot be determined due to lack of witnesses and resident injured unable to express how the injury occurred) to officials including the State Survey Agency (SSA) and adult protective services (APS), immediately, but no later than 24 hours, and according to the facility ' s policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating for one of two sampled residents (Resident 1). This failure had the potential for IUO to occur to other residents without appropriate reporting and investigation. Findings: During a review of Resident 1 ' s admission Record (AR), the AR indicated the facility initially admitted Resident 1 on 3/7/2024 and was readmitted on [DATE] with diagnoses that included unspecified intellectual disabilities (a condition that limits intelligence and disrupts abilities…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 bathrooms (Bathroom Room [BR] 1) had a functioning call light. This failure had the potential to result in residents being unable to notify staff for assistance. Findings: During a concurrent observation and interview on 12/17/2024 at 12:07 PM with Certified Nursing Assistant 1 (CNA 1) in BR 1, the call light button was observed to not stay on (pushed down) when pressed. CNA 1 stated the call light does not stay on and stated the risk of not having a working call light button was that the staff would not know if the resident would need help in the bathroom. During an interview on 12/17/2024 at 12:15 PM with the Maintenance Worker (MW), the MW stated the call light button was not staying in place when pushed down and stated if the call light does not work then the resident would not be able to call staff for assistance. During an interview on 12/18/2024 at 11:05 AM with the Director of Nursing (DON), the DON stated the call light button in the bathroom should stay on (down) 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 ensure call lights were within reach for four of four sampled residents (Residents 7, 9,12 and 23). These deficient practices had the potential for Residents 7, 9,12 and 23 not to receive necessary care or receive delayed services, placing the residents at risk for falls or injury. Findings: a. During a review of Resident 12's admission Record (AR), the AR indicated Resident 12 was initially admitted to the facility on [DATE] and re admitted on [DATE] with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebral infarction (type of ischemic [deficient supply of blood] stroke [sudden death of brain cells in a localized area due to inadequate blood flow] resulting from a blockage in the blood vessels supplying blood to the brain) affecting left non-dominant side and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide information regarding Advance Directive (AD, a written preferences regarding treatment options, a process of communication between individuals and their healthcare agents when individuals are not able to make their own healthcare decisions) for two of two sampled residents (Residents 11 and 25) in accordance with the facility's Policy and Procedure (P&P) titled Advance Directives. This failure had the potential for the facility staff to provide services and treatment against the residents' choices. Findings: a. During a review of Resident 11's admission Record (AR), the AR indicated the facility admitted Resident 11 on 10/9/2021 and readmitted on [DATE] with diagnoses that included dependence on supplemental oxygen and gastrostomy (creation of an artificial external opening into the stomach for nutritional support) status. During a review of Resident 11's Minimum Data Set Minimum Data Set (MDS, a federally mandated resident assessment tool),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two of two sampled residents' (Residents 16 and 55) Minimum Data Set (MDS - a federally mandated resident assessment tool) reflected an accurate assessment, by failing to: a. Ensure Resident 16's discharge destination was coded correctly. Resident 16 was discharged to a Skilled Nursing Facility (SNF - care provided by trained registered nurses in a medical setting under a doctor's supervision) and was coded in the MDS assessment as being discharged to home or community. b. Ensure Resident 55's diagnosis was coded accurately. These deficient practices resulted in an inaccurate reporting to the Centers for Medicare and Medicaid (CMS, a federal agency that administers the Medicare program and works with state governments to administer the Medicaid and health insurance portability standards) Services agency and had the potential for Residents 16 and 55 not to receive interventions to address their specific care concerns. Findings: a.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the residents had an environment free from accident hazards(risks) for two of five sampled residents (Residents 7 and 53) by failing to: a. Ensure Resident 7's bilateral 1/4 siderails were padded as ordered by the physician. b. Ensure Resident 53's floor mat (used to reduce fall related trauma if a patient gets up from bed, loses balance, and falls to the floor) was close to the bed and the resident's bed lowered at the lowest position. These failures had the potential to result in accidents and hazards for Residents 7 and 53. Findings: a. During a review of Resident 7's admission Records (AR), the AR indicated Resident 7 was admitted to the facility on [DATE] with diagnoses that included intervertebral disc disorder with myelopathy (a condition where the spinal cord is compressed), spondylosis (age-related wear and tear of the spinal disks), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care and services for gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition directly to the stomach) site as ordered by the physician and as indicated in the plan of care for three of four sampled residents (Residents 1, 26 and 36). These failures had the potential for complications related to tube feedings for Residents 1, 26 and 36. Findings: a. During a review of Resident 1's admission Records (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included gastrostomy (a surgical opening fitted with a device to allow feedings/medication to be administered directly to the stomach), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (muscle weakness on one side of the body). During a review of Resident 1's untitled Care Plan (CP), dated 8/1/2022, the CP indicated Resident 1 had the potential for skin…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 attempt the use of appropriate alternatives to siderails before its installation for two of two sampled residents (Residents 9 and 39 ). These failures placed Residents 9 and 39 at risk for entrapment and injury from the use of siderails. Findings: a. During a review of Resident 39's admission Records (AR), the AR indicated Resident 39 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included depression (loss of pleasure or interest in activities for long periods of time) and compression fracture (occurs when one or more bones in the spine weaken and crumple) of first lumbar vertebrae. During a review of Resident 39's Minimum Data Set (MDS, a resident assessment tool) dated 9/30/2024, the MDS indicated Resident 39 had intact cognition (ability to understand) and required partial/moderate assistance (helper did less than half the effort) with oral hygiene, upper body dressing and personal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the Low Air Loss (LAL) mattress (Alternating Pressure Mattress which provides alternating pressure and is designed to be used in the prevention, treatment and management of pressure injury [PI- a localized damage to the skin and underlying soft tissue usually over a bony prominence]) was set up accurately based on the resident's weight for one of two sampled residents (Resident 10). This failure had the potential risk for Resident 10 to develop PI. Findings: During a review of Resident 10's admission Record (AR), the AR indicated Resident 10 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing) and Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control). During a review of Resident 10's Order Summary Report (OSR) dated 11/1/2024, the OSR indicated Resident 10 had an order for LAL mattress…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care and services for a resident with Foley catheter (a medical device that helps drain urine from the bladder) in accordance with the facility's Policy and Procedure (P&P) on catheter care for one of one sampled resident (Resident 9). This failure had the potential to result in catheter-related complications for Resident 9. Findings: During a review of Resident 9's admission Records (AR), the AR indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included urinary tract infection (UTI- an infection of the bladder/urinary tract) and chronic kidney disease (characterized by progressive damage and loss of function in the kidneys). During a review of Resident 9's untitled Care Plan (CP) dated 11/20/2023, the CP indicated, Resident 9 had an indwelling catheter. The CP interventions included to check the tubing for kinks each shift. During a review of Resident 9'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 label and date the intravenous (IV, administered into a vein) site consistent with professional standards of practice for one of one sampled resident (Resident 157). This deficient practice had the potential to result in infection to Resident 157. Findings: During a review of Resident 157's admission Record (AR), the AR indicated Resident 157 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis (inflammation of bone and bone marrow due to infection) and left foot amputation (a surgical procedure that removes a limb or other body part). During a review of Resident 157's Order Summary Report (OSR), dated 11/13/2024, Resident 157 had an order of Ceftriaxone (Antibiotic-medication to treat infection) 2 grams (gm, a unit of measurement) IV, once a day for osteomyelitis to left foot amputation. During a review of Resident 157's Minimum Data Set (MDS, a resident assessment tool) dated 11/17/2024, 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 observation, interview and record review, the facility staff failed to label the nasal cannula (NC- tube which on one end splits into two prongs which are placed in the nostrils to deliver oxygen) tubing for one of two sampled residents (Resident 41). This failure had the potential to result in infection to Resident 41. Findings: During a review of Resident 41's admission Record (AR), the AR indicated Resident 41 was readmitted to the facility on [DATE] with diagnoses that included dependence on supplemental oxygen and dysphagia (difficulty swallowing). During a review of Resident 41's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 10/31/2024, the MDS indicated Resident 41 had no speech, rarely/never understood others, and rarely/never made self-understood. Resident 41 was dependent (helper does all of the effort) for personal hygiene and chair/bed-chair transfer. During a review of Resident 41's Order Summary Report (OSR) dated 11/1/2024, the OSR indicated Resident 41 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 follow up on the pharmacist's medication regimen review (MRR, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication.) recommendations of the physician evaluating the use of Cyclobenzaprine (muscle relaxant medicine) in the elderly for one of five sampled residents (Resident 10). This deficient practice had the potential to result in the resident receiving unnecessary medications and not maintaining the resident's highest practicable level of physical, mental, and psychosocial well-being and not preventing or minimizing adverse consequences related to medication therapy to the extent possible. Findings: During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was admitted on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing 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 interview and record review, the facility failed to offer pneumococcal vaccine that protects against serious and potentially fatal pneumococcal disease that is caused by bacteria called Streptococcus pneumoniae (pneumococcus)] based on the Centers of Disease Control and Prevention (CDC)'s recommended schedule guidelines for one of five sampled residents (Resident 10). This failure had the potential to result in leaving residents at risk of acquiring, transmitting, or experiencing complications from pneumococcal disease. Findings: During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 10's quarterly Minimum Data Set (MDS, a resident assessment tool) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide needed care and services by failing to: a. Assess one of one sampled resident (Resident 17) who developed edema (swelling caused by too much fluid trapped in the body's tissues) of the left lower leg. This deficient practice had the potential to result in delayed care and services to address Resident 17's edema. b. Complete a Situation, Background, Assessment, Recommendation (SBAR-a written communication tool that helps provide essential, concise information during crucial situations) report for one of one sampled resident (Resident 7), when Resident 7 was transferred to General Acute Care Hospital 1 (GACH 1) for a medical emergency. This deficient practice had the potential to result in Resident 7's health information not communicated between healthcare providers affecting the quality of care for Resident 7. Findings: a. During a review of Resident 17's admission Record, the admission record indicated Resident 17 was admitted to…

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

Based on observation, interview, and record review, the facility failed to ensure opened food items had use by date for one of one dry storage area in the kitchen. This deficient practice had the potential for foodborne illnesses. Findings: During an observation of the dry food storage area in the Kitchen on 12/1/23 at 5:18 pm, the following items were opened and did not have use-by-date label: One plastic storage container of breadcrumbs that was opened on 9/14/23. One plastic storage container of sweetened coconut flakes that was opened on 9/7/23. One bottle of onion powder that was opened on 12/16/22 and will expire on 8/15/25. One bottle of curry powder that was opened on 8/10/23 and will expire on 7/31/24. One bottle of black pepper that was opened on 9/24/23 and will expire on 4/24/25. One bottle of chili powder that was opened on 11/20/23 and will expire on 4/4/24. During an interview on 12/1/23 at 5:40 pm, the Dietary Services Supervisor (DSS) stated the kitchen staff needed to abide by the expiration date of the food item such as the expiration date of the breadcrumbs,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow its Policy and Procedure titled Confidentiality of Information and Personal Privacy by ensuring the resident's identifiable, personal, and medical information were not exposed on the computer screen unattended and in view of unauthorized persons for two of two sampled residents (Residents 1 and 47). This deficient practice resulted in Residents 1 and 47's violation of resident's right for privacy to keep their personal and medical records confidential and not readily observable and accessible by others. Findings: a. During a review of Resident 1's admission Record, the admission record indicated the facility admitted Resident 1 on 10/30/2023 with diagnoses that included muscle weakness, anemia (lack of red blood cells to carry adequate oxygen to the body's tissues), and hypertension (increase blood pressure). During a review of Resident 1's History and Physical assessment dated [DATE], the assessment indicated Resident 1 did not…

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

Based on observation, interview and record review, the facility failed to provide reasonable accommodation of needs for one of one sampled resident (Resident 46) who was at risk for fall, by failing to ensure the resident's call light was within reach as indicated in the facility's Policy and Procedure, titled Answering the Call Light and the resident's plan of care. This deficient practice had the potential for Resident 46 not to receive or received delayed care to meet the necessary services that could potentially result in falls and/or accidents. Findings: During a review of Resident 46's admission Record, the admission record indicated the facility admitted Resident 46 on 8/8/2021 with diagnoses that included epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain) and peripheral vascular disease ( a condition in which there is a build-up of fat and narrowing of arteries in the limbs, reducing blood flow). During a review of Resident 46's History…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an individualized person-centered plan of care (details why a person received care, assessed health or care needs, medical history, personal details, expected and aimed outcomes, and what care and support will be delivered, how, when and by whom) with measurable objectives, timeframe, and interventions to meet the residents' needs for one of one sampled resident (Resident 36) who had type 2 diabetes mellitus (DM - a chronic condition that affects the way the body processes blood sugar) and was on Humulin R (type of insulin [a hormone that works by lowering levels of sugar in the blood]) as indicated in the facility's Policy and Procedure titled Care Plans, Comprehensive Person-Centered. This deficient practice had the potential for Resident 36 to not receive the necessary care, treatment and/or services. Findings: During a review of Resident 36's admission record, the record indicated the facility admitted Resident 36 on 7/15/2022…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 activities in accordance with the resident's comprehensive assessment for one of two sampled residents (Resident 50). This deficient practice had the potential to not support the physical, mental, and psychosocial well-being of Resident 50. Findings: During a review of Resident 50's admission Record, the admission record indicated the facility admitted the resident on 10/11/23 with diagnoses that included metabolic encephalopathy (build-up of toxins causing brain dysfunction,) and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). During a review of Resident 50's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 11/6/23, the MDS indicated Resident 50 was rarely/never able to express ideas and wants and rarely/never understands verbal content. The MDS indicated Resident 50 was dependent in all activities of daily living. During an interview on 12/2/23 at 5:24 pm, the Activities Director (AD) 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 assess and monitor the presence of white sediments (visible particles in the urine that may contain red or white blood cells, casts or bacteria that could indicate infection) in the urine for one of four sampled residents (Resident 36) with suprapubic catheter (a hollow flexible tube that is inserted into the bladder through a cut in the abdomen used to drain urine from the bladder) as indicated in the facility's Policy and Procedure, titled Suprapubic Catheter Care and the resident's plan of care. This deficient practice had the potential for Resident 36 not to receive care or delayed care and treatment for urinary tract infection (UTI, condition in which bacteria invade and grow in any part the urinary system), hospitalization or sepsis (severe infection). Findings: During a review of Resident 36's admission record, the admission record indicated the facility readmitted Resident 36 on 10/27/23 with diagnoses that included dementia (long…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 head of bed was kept elevated to 30 to 45 degrees for one of two sampled residents (Resident 16) with ongoing G-tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach) feeding. This deficient practice had the potential to result in complications from aspiration (food, liquid, or other material enters a person's airway and lungs by accident). Findings: During a review of Resident 16's admission Record, the admission record indicated Resident 16 was readmitted to the facility on [DATE], with diagnoses that included pneumonia (respiratory infection), metabolic encephalopathy (a brain disorder) and type 2 diabetes mellitus (a long-term medical condition resulting in unusual blood sugar levels). During a review of Resident 16's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 10/10/2023, indicated Resident 16 had clear speech, sometimes understood others, and sometimes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administration of medication for one of three sampled residents (Resident 7) during medication pass administration. Licensed Vocational Nurse 4 (LVN 4) crushed Alfuzosin (medication used to treat symptoms of an enlarged prostate in men, including difficulty urinating) Hydrochloride (HCL) Extended Release (ER-medications that slowly released over a period of time, that do not immediately release the active ingredients of the medication into the body, through the use of enteric coating which should not be crushed) and administered the medication to Resident 7 through the G-tube (external opening into the stomach for medication/nutritional support). This deficient practice had the potential to result in rapid absorption of a large dose of the drug that was intended to be released slowly over many hours which can cause harm to Resident 7. Findings: During a review of Resident 7's admission Record, the admission record indicated…

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

Based on observation, interview and record review, the facility failed to ensure nectar-thickened fluid (liquid having the same thickness as vegetable juices and milkshakes) was provided to one of one sampled resident (Resident 21) in accordance with the physician's order. This deficient practice had the potential for aspiration (accidentally swallowing food or liquid into the lungs) for Resident 21. Findings: During a review of Resident 21's admission Record, the admission record indicated the facility admitted the resident on 8/1/2022 with diagnoses that included dysphagia (difficulty swallowing). During a review of Resident 21's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 10/18/23, the MDS indicated Resident 21 rarely/never able to express ideas and wants and rarely/never understands verbal content. The MDS indicated Resident 21 was totally dependent with all activities of daily living. During an observation on 12/3/23 at 9:50 am, Certified Nursing Assistant 3 (CNA 3) delivered a pitcher of water to Resident 21's bedside table. During a review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure dietary supplement was served as ordered for one of one sampled resident (Resident 22). This deficient practice had the potential to affect the resident's dietary intake which could result in inadequate nutrition or further weight loss of Resident 22. Findings: During a review of the facility's admission Record, the admission record indicated Resident 22 was admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure) and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). During a review of Resident 22's care plan for nutritional and dehydration risk, initiated 4/13/2023, the care plan interventions included for staff to provide Ensure Clear twice a day with lunch and dinner. During a review of Resident 22's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/6/2023, 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 the nasal cannula tubing (a device used to deliver oxygen to a resident) did not touch the floor for one of six sampled residents (Resident 58) in accordance with the facility's Policy and Procedure, titled Departmental (Respiratory Therapy) - Prevention of Infection. This deficient practice had the potential to increase the risk of infection to Resident 58. Findings: During a review of Resident 58's admission Record, the admission record indicated the facility admitted Resident 58 on 10/5/2023 with diagnoses that included chronic respiratory failure (condition in which not enough oxygen passes from the lungs into the blood) with hypoxia (low levels of oxygen in the body tissues), dependence on supplemental (treatment that provides with extra oxygen to breathe) oxygen and congestive heart failure (CHF, heart disease that affects the pumping action of the heart muscle). During a review of Resident 58's History and Physical (H&P), dated 10/5/2023, the H&P indicated Resident 58's had the capacity to 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.