Heritage Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide necessary dental services for four of four sampled residents (Resident 78,105, 6 and 10). This failure had the potential to lead to weight loss, inability to chew effectively, or infection of the mouth. Findings: During a record review of Resident 78's admission Record, the admission Record indicated Resident 78 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including mild protein-calorie malnutrition (a mild deficiency in the intake of both protein and calories, resulting in adequate nutrition), nausea with vomiting, and muscle wasting. During a review of Resident 78's History and Physical (H&P), the H&P indicated, Resident 78 he was able to express needs, communicate, follow commands and talk in full sentences. During a review of Resident 78's Minimum Data Set (MDS-a resident assessment tool), the MDS indicated, Resident 78 was dependent on nursing staff with transferring. The MDS 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately assess and code the Minimum Data Set (MDS, resident assessment tool) assessments for one of six sampled residents (Resident 32) by failing to ensure Section GG 0115A was coded accurately to indicate functional limitations in range of motion (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) of Resident 32's both arms. This deficient practice had the potential to result in delayed or missed identification of joint range of motion (ROM, full movement potential of a joint) changes, inaccurate care planning, and inadequate provision of services and treatments for Resident 32. Findings: During a review of Resident 32's admission Record, the admission indicated Resident 32 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including osteoarthritis (loss of protective cartilage that cushions 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 review and revise the comprehensive care plan for two of four sampled residents (Resident 50 and 61) by failing to: 1.Revise and update Resident 50's care plan after a fall on 4/19/2025. 2.Revise and update Resident 61's care plan after Resident 61 pulled out her nasogastric tube (NG tube- a thin flexible tube inserted through the nose, down the throat, and into the stomach) and conduct an Interdisciplinary Team (IDT) conference. These failures resulted in Resident 50 falling on 5/22/2025 and Resident 61 pulling out her NG tube multiple times. Findings: 1. During a review of Resident 50's admission Record, the admission Record indicated Resident 50 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), osteoporosis (weak and brittle bones due to a lack of calcium and Vitamin D), fractures of left and right humerus (the long bone of the upper arm), repeated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility staff did not administer Resident 120's benzonatate (a medication used to treat cough) capsules via gastrostomy tube ([G-tube] a soft tube surgically placed directly into the stomach for administration of medication and nutrition), for one of six sampled residents. This deficient practice failed to provide medication in accordance with professional standards of practice and had the potential to result in adverse effects and untreated cough for Resident 120. Findings: During a review of Resident 120's admission Record dated 6/10/2025, the admission Record indicated Resident 120 was admitted to facility on 5/22/2025 with diagnoses including but not limited to dysphagia (difficulty swallowing), aphasia (a disorder that makes it difficult to speak) following cerebral infarction (loss of blood flow to a part of the brain), pneumonia (an infection/inflammation in the lungs) due to methicillin susceptible staphylococcus…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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, interviews and record reviews, the facility failed to provide the necessary treatment and services to minimize the risk of development of pressure injuries (PIs, areas of damaged skin caused by staying in one position for too long) for one of three sampled residents (Resident 115) by failing to: a.Ensure the low air loss mattress (LALM - a pressure relieving mattress filled with air) remains inflated. This deficient practice had the potential for Resident 115 to develop new pressure injury and skin wounds to worsen. Findings: During a review of Resident 115's admission Record, the admission Record indicated the facility admitted Resident 115 on 4/21/2025 with diagnoses of muscle wasting and atrophy ( partial or complete wasting away of the body ), not elsewhere classified, multiple sites, pressure-induces deep tissue damage of sacral region ( pressure ulcer of lower back and spine), pressure-induces deep tissue damage of the left heel, pressure-induces deep tissue damage of the right heel and essential primary hypertension ( high blood pressure). During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to improve and/or prevent a decline in range of motion (ROM, full movement potential of a joint) for one of six sampled residents (Resident 39) by failing to provide Resident 39 with active assistive range of motion (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another person) exercises to the left ankle per Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and joint mobility) physician's orders and in accordance with Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) recommendations. This deficient practice had the potential to cause Resident 39 to have a decline in ROM leading to contracture (loss of motion of a joint) development and have a decline in physical functioning and mobility (ability to move). Findings: During a review of Resident 39's admission Record, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure two sampled residents (Resident 78 and Resident 95) were provided with a bowel and bladder retraining and/or toileting program ( aims to help individuals regain control over their bowel and bladder functions through a structured approach), to regain normal bowel and bladder function as much as possible and received appropriate treatment and services to restore continence. This failure had a potential risk for Resident 78 and Resident 95 to lose their ability to regain control of bowel and bladder function, which could result in loss of dignity. Findings: 1. During a record review of Resident 78's admission Record, the admission Record indicated Resident 78 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including mild protein-calorie malnutrition (a mild deficiency in the intake of both protein and calories, resulting in adequate nutrition), nausea with vomiting, and muscle wasting. During a review of Resident 78'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 one sampled resident (Resident 62) was provided with water at the bedside. This failure had the potential to put Resident 62 at risk for dehydration (occurs when your body loses more fluids than it takes in, leading to an insufficient amount of water for normal function.) Findings: During a review of Resident 62's admission Record, the admission Record indicated Resident 62 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including to constipation (digestive issue where bowel movements become less frequent, and stools become difficult to pass) diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), nausea with vomiting gastro-esophageal reflux (a condition in which acidic gastric fluid flows backward into the esophagus, resulting in heartburn.) During a review of Resident 62's Minimum Data Set (MDS - a resident assessment tool), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5% (percent) during medication pass for two of six sampled residents (Residents 30 and 47) by failing to: 1. Ensure administration of metformin (a medication used to treat high blood glucose) within one hour of its scheduled time of administration as per facility's policy and procedure (P&P) titled, Administering Medications, undated, affecting one of six sampled residents during medication administration (Resident 30). 2. Ensure Resident 47's aspirin [a medication used to prevent heart attack (flow of blood and oxygen is blocked) and stroke (loss of blood flow to a part of the brain)] chewable tablet was administered as a chewable according to manufacturer formulation specifications instead of being swallowed without chewing, on 6/10/2025, affecting one of six sampled residents during medication administration (Resident 47). These deficient practices of medication administration error rate of…

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

Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for one (Resident 30) of six sampled residents during medication administration, by failing to administer Resident 30's metformin (a medication used to treat high blood glucose) within one hour of its scheduled time of administration as per facility's policy and procedure (P&P) titled, Administering Medications, undated. This deficient practice failed to provide medication in accordance with the physician's orders or professional standards of practice and had the potential to result in hyperglycemia (high blood glucose) for Resident 30. Findings: During a review of Resident 30's admission Record (a document containing demographic and diagnostic information), dated 6/11/2025, the admission record indicated, Resident 30 was admitted to facility on 1/21/2021 with diagnosis including, but not limited to, Type 2 Diabetes Mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) without complications. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY During a review of Resident 19's admission Record, the admission Record indicated Resident 19 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), cardiomyopathy ( a long term condition that affects the heart muscle making it harder to pump blood), Covid -19 (highly contagious respiratory disease caused by Coronavirus which is transmitted thru coughing, talking , sneezing and touching contaminated surfaces ), and end stage renal disease (ESRD- irreversible kidney failure) with dependence on renal hemodialysis (procedure to remove waste products and excess fluids from the blood when kidneys stop working properly). The admission Record indicated the resident was discharged to a funeral home on 6/9/2025 at 10:25 a.m.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant (CNA 5) wear proper personal protective equipment (PPE-clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) and practice hand hygiene for one of two sampled resident ( Resident 119) who had Covid 19 ( highly contagious respiratory disease) before entering the room. This failure had the potential to transmit and spread infection among residents ,visitors and staff. Findings: During a review of Resident 119's admission Record, the admission Record indicated Resident 119 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) affecting the left non-dominant side following a stroke[occurs when a blood vessel that carries oxygen and nutrients to the brain is blocked by a clot or bursts]), Covid 19…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of five sampled residents (Resident 1 and 2) participated in care plan meetings to discuss her care and discharge goals. This deficient practice had the potential to violate Resident 1 and 2's right to be an active participant in her care. Findings: a. During a review of Resident 1's admission record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (one sided muscle weakness) following cerebral infarction (blood flow to a part of the brain is blocked that leads to tissue death) affecting right dominant side and aphasia. During a review of Resident 1's History and Physical (H&P) dated 4/5/2025, the H&P indicated Resident 1 has limited decision-making capacity. 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 observation, interview and record review, the facility failed to ensure Certified Nursing Assistant 1 (CNA 1) followed proper hand hygiene for contact isolation (the use of personal protective equipment [PPE - gown, mask, and gloves] for patients with diseases [illness or sickness characterized by specific signs or symptoms] caused by bacteria [germs] and viruses [a type of germ which causes disease] that are spread through direct and indirect contact) for Clostridioides difficile ([C. diff] a bacteria that causes diarrhea [the passage of three or more loos or liquid stools in one day or more frequent passage than is normal for the individual] and inflammation [the body ' s immune system ' s (body ' s protection against germs) response to an irritant] in the large intestine) for one of three sampled residents (Resident 2) when CNA 1 did not wash her hands with soap and water after providing direct care to Resident 2. This deficient practice has the potential to spread contagious bacteria and spores such…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and observe infection control practices by failing to: 1. Ensure Certified Nursing Assistant (CNA) 1 and 2, performed hand hygiene in between residents when passing lunch trays. 2. Ensure Restorative Nursing Aide 1 (RNA 1) use the appropriate cleaning agent to effectively clean and disinfect a cloth gait belt (safety device worn around the waist that can be used help safely transfer a person from one surface to another or while walking) after completing RNA walking exercises with Resident 96. These deficient practices had the potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and place residents at risk for the spread of infection. 3.Ensure Resident 3's nephrostomy tube (a drainage tube placed into the kidney to drain urine directly from the kidney) drainage should be below the level of the kidneys. This deficient practice had the potential…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure call light was within reach for two of four sampled residents (Resident 3 and Resident 22). This deficient practice had the potential for Resident 3 and 22 not to receive necessary assistance when needed, and experienced loss of self-esteem. Findings: During a review of Resident 3's admission Order, the admission Record indicated Resident 3 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses including paraplegia (paralysis that affects your legs, but not your arms), and unspecified epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures [involuntary muscle movements]) During a review of Resident 3's Minimum Data Sheet (MDS- a comprehensive assessment and care planning tool) dated 5/10/2024 indicated Resident 3 had moderate cognitive impairment (ability to learn, understand, and make decisions) and requires maximum assistance for toileting hygiene, shower/bathe…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an individualized person-centered plan of care with measurable objectives, timeframe, and interventions to meet the residents' needs for four of eight sampled residents (Residents 66 and 73, 9 and 103) by failing to: a. Develop a care plan for Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and joint mobility) services for Resident 66. b. Develop a care plan for RNA services for Resident 73 These deficient practices had the potential to negatively affect the delivery of necessary care and services for Residents 66 and 73. c.Follow the care plan interventions for Resident 9 and 103 who were at risk for bleeding while on Coumadin (blood thinner) therapy. This deficient practice had the potential to result in complications from the use of Coumadin such as bruising and bleeding. Findings: a. During a review of Resident 66's admission Record indicated Resident 66 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 observation, interview, and record review, the facility failed to provide treatments and services to five of eight sampled residents (Residents 23, 66, 84, 117, and 43) to prevent and/or limit a decline in joint (where two bones meet) range of motion ([ROM] full movement potential of a joint) and mobility (ability to move). a. For Resident 23, the facility failed to provide Restorative Nursing Aide ([RNA] nursing aide program that helps residents maintain their function and joint mobility) ROM exercises to Resident 23's both legs and assist with arm bicycle (stationary piece of equipment using a cycling motion for the arms to provide a cardiovascular and strength workout exercises, seven (7) times a week as ordered. b. For Resident 66, the facility failed to provide RNA ROM exercises to both arms and both legs, 7 times a week as ordered. c.For Resident 84, the facility failed to provide RNA services for: 1.ROM exercises to the left arm, 7 times a week as ordered. 2.Right arm strengthening exercises 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 interview and record review, the facility failed to provide adequate and sufficient nursing staff to provide care for residents requiring Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and joint mobility) services. This deficient practice had the potential for 95 residents with physician's orders for RNA to experience a decline in range of motion (ROM, full movement potential of a joint) and mobility (ability to move). Findings: During a review of the Order Listing Report of RNA orders for 6/2024 indicated 95 residents had physician's orders for RNA to provide either assistance with sit-to-stand transfers, ROM exercises to the arms, ROM exercises to the legs, application of splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and / or increase range of motion), ambulation (walking), stair climbing exercises, or exercises on the arm bicycle (stationary piece of equipment using a cycling motion for the arms to provide a cardiovascular and strength workout). 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.

Based on observations, interviews, and record review, the facility failed to: 1.Ensure to keep a separate log of uses from the emergency medication supplies. 2.Ensure the licensed nurses would document inventory count (cycle count) of narcotics (medication used to moderate to severe pain) stored in the Cubex (an automated dispensing cabinet with a computer-controlled system that stores and dispense medications) at change of shift. Twenty-four of 124 shifts did not have nurses' signatures, and the existing signatures of the remaining 100 shifts had identical signatures for the performing and witnessing nurses. 3.Ensure there were administration record of narcotic medications for three (3) of 30 sampled residents (Residents 5, 43, 239). 4.Ensure the facility's consent policy is outdated and did not match with current regulations. These deficient practices had the potential for loss of accountability, medication errors, issues in residents' rights, and/or diversions or theft of medications. Findings: 1. During a concurrent observation, interview, and record review on 6/11/2024 at…

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

Based on interview and record review, the facility's Quality Assessment and Assurance ([QAA] a group which develops and implements appropriate plans of action to correct identified quality deficiencies) committee and Quality Assurance Performance Improvement ([QAPI] a group who takes a systemic, interdisciplinary, comprehensive, and data driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families) committee failed to: 1. Ensure on-going assessment and reevaluation of physical restraints' continuous use were conducted. 2. Identify, assess, and implement interventions on residents with severe weight loss. 3. Identify, assess, and implement interventions on residents with pain during wound care treatment. 4. Ensure Restorative Nurse Aide services were implemented to residents as ordered. These deficient practices placed the residents at risk for not receiving the quality-of-care treatment necessary to adequately meet their highest practicable well-being and placed the residents. Findings: During an interview with 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 a comfortable room temperature on one of five sampled residents (Resident 25). This deficient practice had the potential to place Resident 25 at risk for disturbed sleep and can negatively impact resident's comfort and health. Findings: During a review of Resident 25's admission Record, indicated the Resident 25 was initially admitted on [DATE] and was readmitted on [DATE] to the facility with diagnoses including presence of cardiac pacemaker( small electrical device implanted in the chest to treat abnormal heart rhythms), end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis) , cardiomyopathy( heart muscles became stretched, weakened and unable to pump blood or function well) and diabetes( high blood sugar). During a review of Resident 25's Minimum Data Set ([MDS] standardized assessment and care screening tool) dated 4/25/2024, the MDS indicated Resident 25 had an 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 73) was free of unnecessary physical restraints (any object or device that an individual cannot remove easily which restricts freedom of movement) by failing to: 1.Ensure on-going assessment and reevaluation of physical restraints' continuous use were conducted and documented. 2. Follow policy and procedure (P&P) regarding the use of restraints. These deficient practices had the potential to place Resident 73 at risk for unnecessary prolonged use of physical restraints, impaired blood circulation, skin injuries and contracture (permanent tightening of muscles that causes tissues and joints to become stiff and short). Findings: During a review of Resident 73's admission Record , indicated the Resident 73 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including unspecified dementia (loss of cognitive functioning such as thinking, remembering, 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 complete a preadmission screening and annual resident review (PASARR) I accurately for one of one sampled resident (Resident 50) who has a diagnosis of major depressive disorder (affects how you feel, think, and behave that can lead to a variety of emotional and physical problems). This deficient practice had the potential to result in inappropriate placement and delay of needed services for Resident 50. Findings: During a review of Resident 50's admission Record, Resident 50 was admitted to the facility on [DATE] with a diagnosis of major depressive disorder. During a review of Resident 50's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 4/5/2024, indicated Resident 50 was assessed in needing maximal assistance for all activities of daily living (ADL). During a review of Resident 50's Physician Order Summary Report, Resident 50 was prescribed Quetiapine Fumarate (medication used to treat certain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 label of a bubble pack (unit-dose card that packages doses of medication within small, clear, or light-resistant plastic bubbles) reflected the current dosage, and/or a change in dosage, for one (1) of 30 sampled residents (Resident 239). This deficient practice had the potential for medication error. Findings: During an observation on 6/12/2024 at 2:55 p.m. at the nursing station A medication cart, the Licensed Vocational Nurse (LVN 5) presented a bubble pack belonged to Resident 239. The pharmacy label on the bubble read: hydrocodone-acetaminophen (potent narcotic for the treatment of pain) 10-325 milligrams ([mg] unit to measure mass), take one tablet by mouth every eight hours for pain management. During a review of Resident 239's physician orders indicated Norco 10-325 mg, give 1 tablet by mouth every 6 hours as needed (PRN) for moderate to severe pain (pain level 6-10), ordered on 6/7/2024 at 12:13 p.m. During an interview on 6/12/2024 at 3:03 p.m., the Director of Nursing (DON) 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: 1. Ensure two of two clean linen carts did not have unnecessary items such as a box of gloves, trash bags, assignment sheets, and container of perfumed body fragrance noted inside of the clean linen carts. 2. Ensure a box of clean gloves did not have soiled gloves inside for one of three resident rooms. These deficient practices had the potential to result in cross contamination (process by which germs are unintentionally transferred from one object to another) and the spread of infections in the facility. Findings: During a concurrent observation and interview, on 4/2/2024, at 9:20 a.m., with Certified Nurse Assistant 2 (CNA 2), in the hallway, CNA 2 was observed to have trash bags, and an assignment sheet laying on top of clean linens inside of the clean linen cart. CNA 2 stated the gloves, trash bags, and assignment sheet were inside of the linen cart because there was no other place to put them. CNA 2 stated leaving the box of gloves, trash bags, and the assignment sheets inside of the linen cart 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 interview and record review, the facility failed to ensure one of five sampled residents (Resident 1), who was transferred from the facility to a General Acute Care Hospital (GACH) for evaluation and treatment following a change of condition (COC) that Resident 1 experienced on [DATE], was readmitted to the facility after the seven-day bed hold expired, Resident 1 was cleared by the GACH to return to the facility and there were multiple female beds available. This deficient practice resulted in Resident 1's unnecessary stay in a GACH after the Resident 1 was cleared by the GACH to return to the facility. This had the potential for Resident 1's continuity of care to be interrupted and inconsistently provided. Findings: During a review of Resident 1's admission Record (Face sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included spinal stenosis of the lumbar region (a condition of narrowing of the spinal canal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the care plans for two 6 out of 27 sampled residents (5, 32, 53, 69, and 95) to eliminate or decrease the risks by: a. Resident 5 and 95, who were receiving hemodialysis ([HD] a treatment that does some of the things done by healthy kidneys. It is needed when your own kidneys can no longer take care of your body's needs) the facility failed to ensure Resident 5 and 95 had a HD emergency kit in their room. b. Resident 32, 53, and 93 who were a fall risk, the facility failed to ensure Resident 32, 53, and 93 had a fall wrist band. C. Resident 69 who had a weight loss, the facility failed to ensure Resident 69 received Prostat (a supplement) to manage weight loss. The deficient practice result in Resident 5, 32, 53, 69, and 95 not receiving individualized care which had the potential to result in Resident 5, 32, 53, 69, and 95 to suffer an accident such as a fall, major bleeding, and decline of function. Findings A1. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review facility failed to revise the care plan for 4 out of 4 residents (20, 5, 87, 95) to reflect the individualized professional standards of care. This deficiency has the potential to harm by negating plans and care specific to the individual's needs. Findings: a) During a review of the Charge Nurse (LVN/RN) job description, dated 2003, the document indicates that the charge nurse is to, Cooperate with other resident services when coordinating nursing services to ensure that the resident's total regimen of care is maintained. The job description also indicates, Transcribe physician's orders to resident charts, cardex, medication cards, treatment/care plans, as required. During a review of the Nurse Supervisor (RN) job description, dated 2003, the document indicates to, Assist in developing methods for coordinating nursing services with other resident services to ensure the continuity of the residents' total regimen of care. The job description also indicates, 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 review, the facility failed to respond promptly to a bed alarm and provide a hazard-free environment for 4 out of 4 sampled residents (61, 87, 20, 157). These deficient practices had the potential to cause falls and injuries to Residents 61, 87, 20, 157 and other residents in the facility. Findings: 1) During a review of Resident 61's admission Face Sheet dated indicated Resident 61 was admitted to the facility on [DATE] with diagnoses including epilepsy (a brain disorder that causes unconsciousness and fainting ), paraplegia (an inability to move and feel the lower legs and lower body ), and history of COVID-19 (a serious, life-threatening and highly contagious disease causing difficulty breathing). During a review of Resident 61's Minimum Data Set ([MDS] a care planning and assessment tool) dated 10/1/2020, indicated Resident 61 had a clear speech, was usually understood ,and able to understand others. During a review of Resident 61's Order Summary Report dated 7/2/21,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 have a Hemodialysis ([HD] process of purifying the blood of a person whose kidneys are not working normally) emergency kit (E-kit) available at the bedside for two of three residents (Residents 5 and 95) who were receiving Hemodialysis treatment. The deficient practice had the potential to result in Residents 5 and 95 not receiving lifesaving interventions for HD emergencies such as severe bleeding. Finding: a. During an interview on 7/7/21 at 9:23 a.m. with Resident 95, Resident 95 stated she had not seen a HD kit in her room. During an interview and concurrent record review on 7/8/21 at 8:04 a.m. with Licensed Vocational Nurse 7 (LVN 7), LVN 7 checked Resident 95's room and stated there was not a HD E-kit in the resident's room. LVN 7 stated Resident 95 should have an E-kit in the room to stop the bleeding from the HD site. LVN 7 stated Resident 95 could bleed to death if the HD site bled and was not controlled. During a review of…

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

Based on observation, interview, and record review, the facility failed to ensure licensed and unlicensed staff, in accordance with the nursing standards of practice, were able to identify residents requiring seizure (burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements [stiffness, twitching or limpness], behaviors, sensations or states of awareness) precautions, monitored residents at risk for seizures, and demonstrated the ability to care for residents during and after a seizure. This deficient practice had the potential to place residents at risk for seizures to result in serious harm or inadequate care and services. Findings: During a review of the Competency Evaluations dated 2001, the Competency Evaluations indicated the Certified Nurse Aides (CNA) must pass a skills check to determine competency upon hire, and this includes, but is not limited to: transferring and positioning, vital signs, intake and output, weighing residents, skin care, feeding techniques, bed making, and body mechanics. The Competency…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 to dispose of controlled ([C], medications that have the potential for abuse and may also lead to physical or psychological dependence) and non-controlled (NC) medications in a manner that is not retrievable, in the one inspected pharmaceutical waste bin (bucket used for disposing medication) inside the Director of Nursing (DON's) office. As a result, control and accountability of C and NC medications awaiting final disposition (process of returning and/or destroying unused medications) did not follow the facility policy and procedures. This deficient practice increased the opportunity for C and NC medication diversion (the transfer of medications from a lawful to an unlawful channel of distribution or use), and increased the risk that residents and staff in the facility could have accidental administration and exposure to harmful medications, possibly leading to physical and psychosocial harm and hospitalization. Findings: During a concurrent observation and interview on 7/7/21 at 3:30 PM with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five percent (%) due to two errors observed out of 26 total opportunities (error rate of 7.69 %). The medication errors were as follows: 1. Resident 606 received a form of calcium carbonate with vitamin D (a combination medication used to promote bone health, treat low blood calcium levels, and protect against osteoporosis [a condition where the bones become fragile and brittle from low calcium and vitamin D levels]) that was different than the one ordered by his attending physician. 2. Resident 610 received a form of multivitamin (a medication used as a dietary supplement to provide essential vitamins, minerals, and other nutritional elements) that was different than the one ordered by his attending physician. These deficient practices of failing to administer medication in accordance with the attending physician's orders increased the risk that Residents 606 and 610 could have experienced…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nursing staff accurately calculated and documented the total weekly intake and output (of fluids) for four out of four (4) sampled residents (Residents 7, 32, 53, and 76). This deficient practice resulted in inaccurate documentation of the residents' total weekly intake and output, and had the potential to place the residents at risk for inaccurate evaluation of the residents' progression or regression of the delivery of care services. Findings: During a review of Resident 7's admission Record (a document that provides patient information at-a-glance), dated July 15, 2021, indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including epilepsy (seizure disorder - sudden, uncontrolled electrical activity in the brain that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness), muscle wasting and atrophy, dementia (a decline in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure personal property was kept safe from loss or theft for one out of one (1) sampled residents (Resident 53). This deficient practice resulted in Resident 53 losing her diamond ring, which upset the resident, and had the potential to result in further loss of personal belongings. Findings: During a review of Resident 53's admission Record, dated July 15, 2021, indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including osteoarthritis (breakdown of cartilage in joints), type 2 diabetes mellitus, end stage renal disease (ESRD - permanent kidney function loss), dependence on renal dialysis (procedure to remove waste products from the blood when the kidneys no longer function), and major depressive disorder. During a review of Resident 53's Resident's Clothing and Possessions, dated September 7, 2019, indicated the resident only had one gown and one silver chain for keys documented as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the Minimum Data Set ([MDS] a standardized assessment and care screening tool) assessment accurately reflected the discharge status of 1 out of 3 sampled residents (108). Resident 108 who was discharge to the community and the MDS indicated she was discharged to the General Acute Care Hospital (GACH). This deficient practice had the potential to put Resident 1 at risk of not receiving optimal care for a safety discharge. Findings: During a record review, the Face Sheet, indicated Resident 108 was admitted on [DATE]. Diagnosis included left leg fracture (broken bone) and diabetes mellitus (abnormal blood sugar). During a record review the Skilled Nursing Facility Discharge Instructions dated 5/28/21 and timed 10:59 p.m., indicated Resident 109 was discharge home. During a record review the Progress note dated 5/28/21 and timed 11:24 p.m., indicated Resident 109 and the responsible party received discharge instructions prior to being discharge…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 out of two residents (Resident 87) who received oxygen (a gas used by a person to increase the amount of oxygen the lungs receive and deliver to the blood) had the nasal cannula (device used to deliver oxygen) properly place consistent with professional standards of practice. Resident 87 who was a total care and was dependent on the staff to ensure he received oxygen. The deficient practice had the potential to cause Resident 87 to not receive the needed oxygen to maintain physiological function. Findings: During a record review for Resident 87, the admission record indicated Resident 87 was originally admitted on [DATE] and readmitted on [DATE]. Diagnoses included epilepsy (seizure activity that causes a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements such as stiffness, twitching or limpness, behaviors, sensations or states of awareness), functional…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 monitor a certified nursing assistants (CNA 6) positions while feeding one of 27 residents, Resident 82. This failed practice had the potential to cause the resident to eat faster, have difficulty swallowing, and diminish the resident's dignity. Findings: During a concurrent observation and interview on 7/14/2021 at 7:43 in Resident 87's room, Resident 82 was observed lying in bed and CNA 6 was standing over the bedside table and feeding Resident 82. Surveyor further observed a beige folding chair in the corner. CNA 6 stated Resident 82 ate 75% of her breakfast, and standing over the resident while feeding her may make her feel uncomfortable. During a review of Resident 82's admission record (AR) indicated Resident 82 was re-admitted on [DATE] with diagnosis of Dementia (is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), gastro-esophageal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three out of three (3) sampled residents (Residents 93 and 25) received treatment and care in accordance with professional standards of practice to meet the residents' physical, mental, and psychosocial needs as evidenced by: 1. For Resident 93, nursing staff failed to notify the physician of, create an SBAR (abbreviation for Situation, Background, Assessment, Recommendation - a communication tool) for, and update the resident's care plan to reflect the resident's complaint of burning with urination; 2. For Resident 5, who had a recent history of seizure a burst of uncontrolled electrical activity between brain cells (also called neurons or nerve cells) that causes temporary abnormalities in muscle tone or movements (stiffness, twitching or limpness), behaviors, sensations or states of awareness), the facility failed to ensure Resident 5 receive proper seizure precaution the deficient practice had the potential to cause Resident 5…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 with the facility's Registered Dietician (RD) recommendations for weight loss for one of 21 residents (Resident 69) who had 23 percent (%) significant weight loss in one month. This deficient practice had the potential to cause Resident 69 to experience dehydration, loss of caloric intake, and more serious complications that may lead to immediate death. Findings: During a review of Resident 69's admission Record (Face sheet), the admission Record indicated Resident 69 was initially admitted to the facility on [DATE]. Resident 69's diagnoses included malignant neoplasm of the ileum (small intestinal cancer), type 2 diabetes mellitus with other specified complications (inability to metabolize glucose in the body causing elevated blood sugar levels), and anemia (low blood count). During a review of Resident 69's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 4/21/21, the MDS indicated Resident 69 had cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Label one Oxycontin (a medication used to treat pain) package, in accordance with federal, state requirements, and current professional principals, affecting one of four observed residents (Resident 81) for medication administration. 2. Store one insulin (medication used to regulate blood sugar levels) vial for Resident 80, and one ophthalmic (medication used for the eye) bottle for Resident 44 in accordance with the manufacturer's requirements in one of two inspected medication carts (Medication Cart Station A). These deficient practices increased the risk that Residents 44, 80 and 81, could have received medication that had become ineffective or toxic due to improper storage or labeling, without identification and instruction of use due to lack of proper labeling, possibly leading to accidental use, resulting in health complications, hospitalization or death. Findings: During a review of Resident 81's Order Summary Report, printed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (2) sampled residents (Residents 7 and 32) received laboratory blood draws/tests as ordered by the physician. This deficient practice had the potential to delay necessary care and services. Findings: During a review of Resident 7's admission Record (a document that provides patient information at-a-glance), dated July 15, 2021, indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including epilepsy (seizure disorder - sudden, uncontrolled electrical activity in the brain that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness), muscle wasting and atrophy, dementia (a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities), and quadriplegia (paralysis of all four limbs). During a review of Resident 7's Physician Order Summary, dated July 15,…

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