Sunnyside Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the residents' right to privacy and dignity was maintained during care and while in common areas for one of three sampled residents (Resident 256).This failure resulted in Resident 256 being visibly exposed on multiple occasions, with legs and indwelling urinary catheter (foley catheter-a tube inserted into the bladder [tubing] drains the urine into a collection bag) tubing observable to others, which had the potential to cause embarrassment, decreased self-esteem and self-worth.Findings:During a review of Resident 256's admission Record, the admission Record indicated Resident 256 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a progressive disorder that affects movement), and atrial fibrillation (irregular heartbeat). During a review of Resident 256's History and Physical (H&P), the H&P indicated Resident 256 has limited decision-making capacity.During a review of Resident 256's Minimum Data…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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.Ensure three of four sampled residents (Resident 241,193, and 120) call light device was within reach to each resident.This deficient practice had the potential to result in the residents being unable to summon health care workers for assistance with care and services as needed.2.Provide a safe and appropriate bed frame for one of one sampled resident (Resident 58).This deficient practice placed the resident at risk for skin breakdown, discomfort, and an inability to safely position himself in bed, creating a potential for accident hazards. Findings: 1, During a review of Resident 241's admission Record, the admission Record indicated Resident 241 was admitted to the facility on [DATE] with diagnoses including overactive bladder (causes a sudden, uncontrollable urge to urinate), paraplegia, unspecified, (partial or complete paralysis of the lower half of the body), and anxiety disorder, unspecified (emotion characterized by feelings 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 ensure the Minimum Data Set (MDS- a resident assessment tool) accurately reflected the care and services provided to one of three sampled residents (Resident 7)This deficient practice resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS) regarding Resident 7's health status and individual healthcare needs.Findings:During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 7's diagnoses included 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 7's MDS dated [DATE], the MDS indicated Resident 7's cognition (ability to think, understand, learn, and remember) was severely impaired. The MDS indicated Resident 7 was dependent (helper does all of 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 that one of three sampled residents (Resident 139) received a bed bath and an incontinent (loss of the ability to control urine and feces) pad change on 4/7/2026. This deficient practice resulted in Resident 139 experiencing itching and scratching from a wet incontinent pad, lowered self esteem, and appearing emotional while in the facility.Findings:During a review of Resident 139's admission Record, the admission Record indicated Resident 139 was initially admitted to facility on 12/28/23 and readmitted on [DATE]. The admission Record indicated a diagnosis that included type 2 diabetes ( a disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (elevated blood sugar), long time use of insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) and hyperlipidemia (high level of oil/fat in the body).During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure Resident 242 received ferrous sulfate (iron - mineral) and carvedilol (blood pressure medications) as prescribed on 4/10/2026 at 9:00 a.m.This failure had the potential to prevent the medications from maintaining a therapeutic dose level (a level in the blood needed for the medication to work effectively) when medications are not administered according to the physician's orders.Findings:During an observation on 4/8/2026 at 9:28 a.m. in Resident 242's room, Licensed Vocational Nurse 4 (LVN 4) was observed preparing and administering the resident's 9:00 a.m. medications. LVN 4 did not prepare or administer Resident 242's 9:00 a.m. ferrous sulfate or carvedilol as ordered by the physician. The carvedilol was not administered because the medication was not available.During a review of Resident 242's admission Record, the admission Record indicated, Resident 242 was admitted to the facility on [DATE] and readmitted on [DATE]. 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 maintain a medication error rate of less than 5 percent % (percent) during medication pass for one of seven sampled residents (Residents 242) by failing to:1.Administer ferrous sulfate (iron-mineral) and carvedilol (blood pressure medication) as prescribed by Resident 242's physician.These deficient practices resulted in a medication administration error rate of 6.9%, which exceeded the 5% threshold and medications not to maintain a therapeutic dose level (maintain a certain level in your blood to work well) when not administering medications according to physician's orders.Findings:During a review of Resident 242's admission Record, the admission Record indicated, Resident 242 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 242 with diagnosis including anemia (a condition where the body does not have enough healthy red blood cells), hypertension (HTN-high blood pressure), 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 observations, interviews, and record review, the facility failed to ensure medications were stored safely and in accordance with manufacturer expiration dates and facility policy. The facility failed to:1.Remove expired medications, expired vaccines from medication rooms2. Replaced an outdated insulin emergency kit (Ekit- emergency medication used to treat high blood sugar) after it was last on 11/16/2025.These failure had the potential to result in ineffective treatment, delayed access to emergency medications, and compromised resident safety for residents who received these medications.Findings:During a concurrent observation and interview on 4/7/2026 at 11:00 a.m. with Registered Nurse Supervisor 3 (RNS 3), in medication room [ROOM NUMBER], observed a container of Gavilyte -G sol (laxative) with an expiration date of 6/16/2025. RNS 3 stated staff must discard expired medications because they may no longer be effective and should not be given to a resident.During a concurrent observation and interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dental services for one of three sampled residents (Resident 198).This failure had the potential to lead to weight loss, inability to chew effectively, pain, or infection of the mouth.Findings:During a review of Resident 198's admission Record, the admission Record indicated Resident 198 was admitted to the facility on [DATE] with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and hypertension (HTN- high blood pressure).During a review of Resident 198's Dental Care Consult Note dated 2/11/2026, the Dental Care Consult Note indicated Resident 198 had tooth pain and an infected tooth and agreed to a tooth extraction (removal).During a review of Resident 198's Minimum Data Set (MDS- a resident assessment tool) dated 2/13/2026, the MDS indicated Resident 198's cognition (ability to think, understand, learn, and remember) was moderately impaired. The MDS indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review the facility failed to ensure lunch trays for two of two sampled residents (Resident 24 and Resident 5) were served in a timely manner.This failure resulted in Resident 24 and Resident 5 receiving their lunch trays more than one hour late.Findings:During a review of Resident 24's admission Record, the admission Record indicated Resident 24 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of but not limited to diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypokalemia (abnormally low potassium levels), gastro-esophageal reflux (a chronic condition where stomach acid frequently flows back into the esophagus), and chronic kidney disease (a progressive, long-term condition where damaged kidneys cannot filter blood properly).During a review of Resident 24's History and Physical (H&P) dated 10/31/2025, the H&P indicated Resident 24 had the capacity to understand and…

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

Based on observation, interview, and record review, the facility failed to store and thaw food items safely. The facility failed to:1.Ensure garlic powder, corn starch, kosher salt, and macaroni were labeled with open dates.2.Ensure frozen chicken was thawed under cold running water.3.Ensure the temperature of milk on the breakfast tray line (where food is plated for service) was maintained below 41 degrees Farenheight ( F unit of measure).These failures had the potential to expose residents to food borne illnesses (any illness resulting from eating food contaminated with bacteria, viruses, or parasites).Findings:During an observation on 4/7/2026 at 8:10 a.m. in the kitchen, a open container of garlic powder, corn starch, kosher salt and macaroni, was observed without open dates. Frozen chicken was observed being defrosted in the sink in a container of stagnant water.During an observation on 4/9/2026 at 7:02 a.m. in the kitchen during breakfast tray line, the temperature of the milk was observed to be 55 F.During an interview on 4/10/2026 at 9:47 a.m. with the Cook, the [NAME]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurate and complete medication documentation for two of six sampled residents (Residents 214 and 242).1.For Resident 242, the MAR indicated the resident received ferrous sulfate (iron) on 4/10/2026 at 10:03 a.m., but the medication was observed not to have been administered during the medication pass.2.For Resident 214, the Medication Administration Record (MAR) documented that the resident received a COVID 19 vaccine (respiratory illness) and a pneumonia (PNA respiratory infection) vaccine on 3/12/2026 at 11:29 p.m.; however, both vaccines were observed in the medication refrigerator on 4/7/2026, indicating the vaccines were not administered as documented.These failures had the potential to result in inaccurate clinical records and place residents at risk for unmet medical needs and potential adverse health outcomes.Findings:During an observation on 4/8/2026 at 9:28 a.m. in Resident 242's room, Licensed Vocational Nurse 4 (LVN…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 coordinated and comprehensive hospice (compassionate care for people who are near the end of life provided at the person's home or within a health care facility) services for one of three sampled residents (Resident 7)The facility failed to:1. Develop and implement an individualized and person-centered care plan for Resident 7 by failing to ensure coordination of care between the facility and the hospice provider for Resident 7. 2.Ensure Resident 7 hospice eligibility were reassessed after showing clinical improvements.These failures had the potential for Resident 7 to receive care that did not reflect her current clinical condition, needs, or appropriate hospice eligibility.Findings:During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 7's diagnoses included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to:Ensure physician ordered laboratory test (a medical test of a sample oof blood) was collected in a timely manner for 2 of 10 residents (Resident 1 and Resident 9).Ensure the physician was notified the laboratory test ordered was not performed for 2 of 10 residents (Resident 1 and Resident 9).This failure had the potential to result in delay in diagnosis, lack of timely medical intervention, and worsening of residents' condition due to the physician not being notified that the ordered laboratory tests were not completed.Findings:A. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 12/8/2024 with diagnoses including chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), hypertension (HTN - high blood pressure), and hyperlipidemia (unhealthy high fat levels in the blood).During a review of Resident 1's History and Physical (H&P) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of three residents (Resident 1) was free from rough handling and treated with dignity and respect, while being assisted by Certified Nurse Assistant (CNA) 1. This deficient practice resulted in a purplish discoloration to the left thumb, emotional distress, and loss of dignity and trust in staff. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including multiple fractures (broken bones) of the ribs (right side), and motor vehicle accident (car accident). During a review of Resident 1's History and Physical (H& P) dated 9/19/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS]resident assessment tool) dated 9/14/2025, the MDS indicated Resident 1 had normal cognitive function and required dependent (helper does all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that required fall-prevention interventions were implemented for one of three residents (Resident 1) by failing to:1. Implement the Falling Star Program (is a fall prevention initiative used to identify and alert staff, that a patient or resident is at high risk of falling) upon admission.2. Ensure the use of floor mats (safety devices, often specifically designed to be low-profile and impact-absorbing, used to help prevent falls and reduce the severity of injuries if a fall occurs).3. Obtain a bed alarm (a safety device for residents at risk of falling, typically a pressure-sensitive pad placed on the bed).4. Revise Resident 1's care plan after the first fall.5. Notify the physician of Resident 1's unsafe behavior (repeatedly attempting to get out of bed). These failures resulted in Resident 1 having two avoidable falls on 11/7/2025 and 11/8/2025. Findings:During a review of Resident 1's admission Record, the admission Record 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 interview and record review, the facility failed to implement its abuse prevention policy by failing to report suspected abuse to the State Survey Agency within 2 hours after the allegation for one of three sampled residents (Resident 1). As a result of this deficient practice, facility residents including Resident 1 were placed at risk for potential continued abuse, injuries, psychosocial harm and delay in care and investigation.Findings: During a review of Resident 1's admission record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including acute kidney failure (a condition in which the kidneys no longer function normally) and chronic heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 9/17/2025, the MDS indicated Resident 1 had moderate cognitive (ability to learn, reason, remember,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three sampled residents (Resident 9), whose preference to have a shower instead of a bed bath, was honored. This deficient practice resulted in Resident 9 receiving bed baths on multiple occasions when his preference was to have a shower. This deficient practice had the potential for Resident 9 to feel disrespected and uncomfortable during his stay at the facility.Findings: During a review of Resident 9's admission Record (Face Sheet), the Face Sheet indicated Resident 9 was admitted to the facility on [DATE] with a diagnosis of orthopedic aftercare (ongoing care and treatment after a bone, joint, or muscle procedure to help with proper healing, regain strength and movement) following a left leg below the knee amputation ([BKA] a surgical removal of the portion of the leg below the knee. During a review of Resident 9's Minimum Data Set ([MDS] a resident assessment tool) dated 7/21/2025, the MDS indicated Resident 9 was able 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a care plan was created to include a Fall Management Program for one of two sampled residents (Resident 16), who was assessed at high risk for falls, per the facility's policy and procedure (P/P). This deficient practice resulted in the care needs for Resident 16 not being thoroughly addressed and placed Resident 16 at risk for falls and injuries. Findings: During a review of Resident 16's admission Record (Face Sheet), the Face Sheet indicated Resident 9 was admitted to the facility on [DATE] with diagnosis including cerebral infarction ([stroke] loss of blood flow to a part of the brain) with left side hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). During a review of Resident 16's Minimum Data Set ([MDS] a resident assessment tool) dated 8/4/2025, the MDS indicated Resident 16 was able to make decisions that were reasonable and consistent and she required a one person assist to complete her activities of…

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

Based on interview and record review, the facility failed to ensure a QAPI (Quality Assurance/Quality Assurance and Performance Improvement - a data driven proactive approach to improvement used to ensure services are meeting quality standards) plan was implemented after being made aware of a deficient practice and failure of the facility, when one of three sampled residents (Resident 10), who was admitted to the facility from a General Acute Care Hospital (GACH) on 8/15/2025, was administered Baclofen (a medication that relaxes the muscles to relieve spasm, tightness, and cramps) with a known side effect of confusion, when: 1. Registered Nurse (RN) 1 did not review Resident 10's entire Discharge Instructions dated 8/14/2025 and 8/15/2025 for accuracy, prior to transcribing the orders in Resident 10's chart. 2. RN 1 did not review and clarify conflicting instructions outlined in the GACH's Discharge Instructions dated 8/14/2025 which indicated do not use Baclofen since caused confusion versus the Discharge instructions dated 8/15/2025, which indicated Medications to Continue to Take…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two sampled residents (Resident 1) was free from neglect when staff did not provide timely incontinence care and left Resident 1 soiled with urine and feces, with a towel placed between his legs and failed to perform incontinent care.This failure compromised Resident 1's dignity and created potential for harm including risk for skin breakdown, and infection. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including cerebral infarction (blockage of blood flow to the brain, leading to tissue damage or death), malignant neoplasm of rectum (cells in the rectal lining grow uncontrollably and abnormally), and vascular dementia (conditions that damage blood vessels in the brain). During a review of Resident 1's History and Physical (H& P) dated 10/18/2024, the H&P indicated Resident 1 did…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 treatment and services for one of two sampled residents (Resident 1), when Resident 1, who had an existing pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin), was left in urine and feces for an extended period of time.This failure had the potential for worsening of pressure ulcers and placed Resident 1 at risk for further skin breakdown, infection, and delayed wound healing.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including cerebral infarction (blockage of blood flow to the brain, leading to tissue damage or death), malignant neoplasm of rectum (cells in the rectal lining grow uncontrollably and abnormally), and vascular dementia (conditions that damage blood vessels in the brain). During a review of Resident 1'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 observation, interview, and record review, the facility failed to ensure a resident (Resident 2) who was incontinent (involuntary voiding of urine and stool) of bowel (stool) and bladder (urine), and had a urinary tract infection (UTI- an infection in the bladder/urinary tract) perineal care (the cleaning and maintenance of the area between the anus and genitals, which is essential for maintaining good hygiene, preventing infections, and promoting overall health and well-being) was properly provided for one of three sampled residents (Resident 2).This failure had the potential for Resident 2 to have an exacerbation (the worsening of a disease, symptom, or problem) of her current UTI which could result in unnecessary hospitalization and sepsis (a life-threatening blood infection). Findings:During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of three sampled residents (Resident 1) to address offloading (minimizing or removing weight placed on a bony prominence to help prevent and heal ulcers) while Resident 1 was up in the wheelchair daily. This deficient practice had the potential to contribute to the decline in Resident 1's unstageable (when the stage is not clear, the base of the wound is covered by a layer of dead tissue that may be yellow, grey, green, brown, or black) pressure injury (unrelieved pressure causes damage to the skin and underlying structures). Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including post laminectomy syndrome (failed back surgery syndrome which causes lingering pain), disease of the spinal cord, malignant neoplasm of the kidney (kidney cancer), and malignant neoplasm of 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, facility failed to ensure a resident (Resident 5) who had impaired mobility, orders for physical therapy ([PT] a healthcare specialty that focusses on restoring, maintaining, and improving physical function and movement) and occupational therapy ([OT] a healthcare specialty that focusses and helps people of all ages participate in meaningful daily activities) evaluation and treatment were carried out for one of five sampled residents (Resident 5). This deficient practice resulted in a 30-day delay in treatment and services for Resident 5 and placed Resident 5 at risk for further decline. Findings: During a review of Resident 5 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including muscle wasting (weakening, shrinking, and loss of muscle), atrophy (the decrease in size and wasting of muscle tissue), and muscle weakness (a lack of muscle strength). During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure Restorative Nurse Assistant 1 ([RNA 1] assists patient in maintaining and improving their physical and cognitive function, primarily focusing on maximizing their independence with activities of daily [ADLs] activities such as bathing, dressing and toileting a person performs daily) doffed (carefully removing personal protective equipment [PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments] to reduce the risk of contamination to self, other, or the surrounding environment) upon exiting a resident ' s room (Resident 4), who was on Enhanced Barrier Precautions ([EBP] involve gown and glove use during high contact resident care activities for residents at risk for Multidrug-Resistant Organisms ([MDRO] bacteria that have become resistant to certain antibiotics) for one of five sampled resident ' s (Resident 4). This failure had the potential to result in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled resident ' s (Resident 1) responsible party ' s (RP 1) complaint ' s regarding Resident 1 ' s Activities of Daily Living (ADLs – activities such as bathing, dressing and toileting a person performs daily) care was formally logged as a grievance (complaint) and investigated as indicated in the facility ' s policy and procedures (P&P) titled, Grievances/Complaints, Filing. This deficient practice resulted in a violation of Resident 1 ' s RP rights and a potential delay in the care and delivery of services to Resident 1. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure (airways that carry air to lungs become narrow and damaged), tracheostomy status (a surgical procedure to create an opening through the neck into the windpipe that provides an air passage to help you breathe 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 conduct an Interdisciplinary Team ([IDT] health care professionals who work together with the resident to plan the residents plan of care) meeting timely for one of three sampled residents (Resident 1) and failed to ensure Resident 1 ' s Responsible Party (RP1) was given the opportunity to meet with the IDT regularly per the facility ' s policy and procedure (P&P) titled, Care plans, Comprehensive Person Centered. These deficient practices resulted in a violation of RP1 ' s rights and had the potential to delay person centered care interventions to Resident 1. Findings: During a review of Resident 1's admission Record (Facesheet), indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure (airways that carry air to lungs become narrow and damaged), tracheostomy status (a surgical procedure to create an opening through the neck into the windpipe that provides an air passage to help you…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) received necessary care and treatment by failing to: a. Assess Resident 1's left foot after Restorative Nursing Assistant (RNA1) ' s water bottle fell on Resident 1's left foot on 9/3/2024. b. Reassess and monitor Resident 1's left big toe after a change of condition (COC- a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional condition relating to an infection) on 10/3/2024 when Resident 1 had worsening pain on Resident 1's left big toe with swelling, tender to touch and with yellow minimal drainage. These failures had the potential for Resident 1's left big toe wound to decline, affect the healing process, and not implement appropriate interventions in a timely manner. Findings: A. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was…

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

Based on observation, interview and record review, the facility failed to: a. Ensure Lysol bleach cleaner was not stored in the dry food storage area. b. Ensure the drain to the ice machine was free from dirt and debris. c. Ensure prepared food items in the refrigerator had the prepare date and the use by date. d. Ensure the freezer temperature logs were completed daily. These failures have the potential to expose residents to food-borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites) and put residents at risk for cross contamination (unintentional transfer of harmful bacteria from one object to another). Findings: During a concurrent observation and interview on 2/11/2025, at 8:27 a.m. with the Assistant [NAME] in the dry food storage area, a bottle of Lysol bleach cleaner was observed hanging off of a shelf. The Assistant [NAME] stated Lysol bleach cleaner should not be stored in the dry food storage there could be a chemical spill and leak into the product and could potentially be fatal. During a concurrent observation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two of six sampled residents (Resident 22 and Resident 100) by failing to: 1. Ensure call light (communication device used by residents to enable them to call for help from staff) was answered in a timely manner when Resident 22 was complaining of pain and screaming for help. 2. Ensure Resident 100's call light was within reach and not clipped in the curtain when resident was asking for someone to help her. These failures had the potential to put Resident 22 and 100 at risk for delayed treatment and care which lead to not meeting their needs. Findings: 1.During a review of Resident 22's admission Record, the admission Record indicated the resident was admitted on [DATE] to the facility with diagnoses that included hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, (total paralysis of the arm, leg, and trunk on the left side of the body following a stoke)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication error rate was less than five percent (%). Ten medication errors out of 29 total opportunities contributed to an overall medication error rate of 34.48 % for four of six residents (Resident 129, 80, 12, 230) observed during medication administration (MedPass). The facility failed to ensure: 1. Resident 129's Amlodipine (a medication used to treat high blood pressure) 5.0 (five) milligrams ([mg] - a unit of measure for weight) powder from the crushed medication was mixed with water before administration and medication cup was rinsed with water to ensure resident received the full dose via gastrostomy tube ([GT] - a soft tube surgically inserted into the stomach to administer medications, fluids, and nutrition). 2. Resident 80 was reassessed for abnormal blood pressure (BP) values (systolic blood pressure [SBP- top number] and diastolic blood pressure [DBP - bottom number] measured in millimeters of mercury ( [mm Hg]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one out of six sampled residents (Resident 12) was free of a significant medication error. The facility failed ensure Resident 12 was administered medication that included seizure (convulsions, is a sudden rush of abnormal electrical activity in your brain) medications, Phenytoin and Phenobarbital and an anticoagulant (blood thinner) medication Heparin was administered as ordered and not close to the next scheduled dose for Phenytoin and Heparin. (Cross reference: F759) The deficient practice of failing to administer medications in accordance with the physician orders increased the risk that Residents 12 may experience adverse reactions, complications, that could lead to a decline in the residents' condition, harm, or hospitalization. Findings: During a review of Resident 12's admission Record, the admission Record indicated Resident 12 was admitted to the facility on [DATE] and readmitted [DATE], with diagnoses including hemiplegia 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 observe infection control practices by failing to: 1.Ensure oxygen tubing and bags were changed and labeled weekly for Residents 126 and 500. 2.Ensure tube feeding and water bags were changed and labeled for Resident 218. 3.Ensure the licensed nurse removed her personal protective equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments.) when exiting Resident 517's room and prior to walking out into the hallway. 4.Ensure the Certified Nursing Assistant (CNA) will call housekeeping to properly clean the floor in Resident 106's room after feces are found scattered in the floor. 5.Ensure a visitor was educated and informed about the use of PPE) was worn when entering Resident 169's room who had Candida Auris(C. Auris- a yeast that can cause severe infections, including bloodstream infections and often resistant to antifungal medications , difficult to treat and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review , the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect on one of three sampled residents (Resident 17) by standing over the resident while assisting her during a meal. This failure had the potential to result in decreased self-esteem and self-worth on Resident 17. Findings: During a review of Resident 17's admission Record, the admission Record indicated the resident was initially admitted on [DATE] and was readmitted on [DATE] to the facility with diagnoses that included cerebral ischemia(condition that occurs when there is a reduction of blood to the brain), dementia( a progressive state of decline in mental abilities),and dysphagia(difficulty of swallowing). During a review of Resident 17's History and Physical (H&P),dated 7/26/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 17's Minimum Data Set (MDS- 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 Certified Nursing Assistance (CNA7) close the privacy curtain to ensure a resident would not be visually exposed to the roommates and others while providing personal care for residents 1 out or 10 sample resident (Resident 23). This deficient practice violated the resident's right for privacy. Findings: During review of Resident 23's admission Records , the admission record indicated Resident 23 was admitted to the facility on [DATE] with diagnoses anxiety (conditions that cause excessive and persistent feelings of fear or worry that can interfere with daily life), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 23's Minimum Data Set (MDS aresident assessment tool), dated 10/01/2024, the MDS indicated Resident 23'srequired dependent (helper does ALL 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 reassess the Preadmission Screening and Resident Review ( PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) for one of three sampled residents (Resident 3) by failing to ensure PASRR level 1 was submitted when the resident was diagnosed with mental illness and was placed on antipsychotic medicine (medicines used to treat mental illnesses ). This deficient practice placed Resident 3 at risk of not receiving necessary care and services they need. Findings: During a review of Resident 3's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] to the facility with diagnoses that included unspecified psychosis(a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), end stage renal disease…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure two of five reviewed residents (Resident 129 and 80) were administered blood pressure medications safely and in accordance with physician's orders and by failing to ensure: 1. Resident 129's Amlodipine (a medication used to treat high blood pressure) 5.0 (five) milligrams ([mg] - a unit of measure for weight) powder from the crushed medication was mixed with water before administration and medication cup was rinsed with water to ensure resident received the full dose via gastrostomy tube ([GT] - a soft tube surgically inserted into the stomach to administer medications, fluids, and nutrition). This deficient practice placed Residents 129 at risk for GT clogging leading to discomfort/pain and GT replacement and not receiving full dose of BP medication (Amlodipine). 2. Resident 80 was reassessed for abnormal blood pressure (BP) values (systolic blood pressure [SBP- top number] and diastolic blood pressure [DBP - bottom number] measured 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 3. During a review of Resident 28's admission Record, the admission Record indicated Resident 28 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or paralysis on one side of the body) following unspecified cerebrovascular disease (condition that affect the blood vessels in the brain and spinal cord) affecting left non-dominant side and unspecified asthma (chronic lung disease). During a review of Resident 28's MDS, dated [DATE], the MDS indicated Resident 28's cognition was not intact, and was dependent for eating, hygiene, and bathing. During a review of Resident 28's Physician Order Summary, the Physician Order Summary indicated an order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) milligrams (mg- a unit of measurement) /3 milliliters (ml - a unit of measurement), 3 ml inhale orally every 6 hours as needed for wheezing (a high-pitched, whistling sound that occurs when air…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 honor food request and food preferences of one of two sampled residents (Resident 76) by ensuring requested food is provided and accommodated. This failure had the potential to place Resident 76 at risk of not having her nutritional needs met. Findings: During a review of Resident 76's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] to the facility with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), pulmonary hypertension(a condition where the blood pressure in the lungs is higher than normal). During a review of Resident 76's Minimum Data Set (MDS- a resident assessment tool) dated 11/20/2024, the MDS indicated the resident had an intact cognition (thought process) and was dependent (helper does all the effort) on staff with toileting hygiene, bathing, lower body dressing ( the ability to…

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

Based on interview and record review, the facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committee failed to establish a system for: 1. Medication Management and safety by reducing medication errors and ensure accurate medication administration to enhance resident safety. 2. Falls and fall -related injuries by minimizing the occurrence of falls among residents and reduce the severity of fall-related injuries. 3. Pressure ulcers monitoring for residents who are at risk for developing or acquiring pressure ulcers. These deficient practices resulted for residents not receiving medically related necessary care, resulting in medication errors, injury related to falls, lack of monitoring and document pressures injuries. Findings: During an interview on 02/15/2025 at 7:51 p.m. with the Administrator (ADM), the ADM stated all what they are working, but cannot proved how to prevent highest medication errors rate, how to present fall and injury, and how to over and present pressure injury. There were no safety measures in place to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement the antibiotic stewardship program policy when the antibiotic (a substance used to kill bacteria and to treat infections) did not meet Loeb's or McGeer's Criteria (criteria used to determine appropriate use of antibiotics) for two of three sampled residents (Resident 98) receiving ampicillin (antibiotic used to treat bacterial infections). This deficient practice had the potential to increase antibiotic resistance and provide antibiotics without justification. Findings: During a review of Resident 98's admission Record, the admission record indicated Resident 98 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or paralysis on one side of the body) following unspecified cerebrovascular infarction (CVA-stroke, loss of blood flow to a part of the brain) affecting left non-dominant side…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to offer, educate, and track influenza vaccinations for residents per facility's policy for one or five sampled residents (Resident 218). This failure had the potential to place all residents at risk for infection of influenza. Findings: During a review of Resident 218's admission record , the admission Record indicated Resident 218 was admitted to the facility on [DATE] with a diagnosis including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or paralysis on one side of the body) following unspecified cerebrovascular infarction (CVA-stroke, loss of blood flow to a part of the brain) affecting left non-dominant side. During a review of Resident 218's Minimum Data Set (MDS - a resident assessment tool), dated 12/20/2024, the MDS indicated Resident 218's cognition (ability to learn, reason, remember, understand, and make decisions) was moderately impaired and was dependent for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to offer, educate, and track coronavirus vaccinations for residents per facility's policy for two or five sampled residents (Resident 218 and Resident 121). This failure had the potential to place all residents at risk for infection of coronavirus. Findings: A. During a review of Resident 218's admission record, the admission record indicated Resident 218 was admitted to the facility on [DATE] with a diagnosis including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or paralysis on one side of the body) following unspecified cerebrovascular infarction (CVA-stroke, loss of blood flow to a part of the brain) affecting left non-dominant side. During a review of Resident 218's Minimum Data Set (MDS - a resident assessment tool), dated 12/20/2024, the MDS indicated Resident 218's cognition (ability to learn, reason, remember, understand, and make decisions) was moderately impaired and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement resident centered care plans for one of three sampled residents (Resident 1) who had a history of a craniectomy (procedure which permanently removes a portion of the skull to access the brain) and pressure ulcer/injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) by failing to: 1. Ensure Resident 1 ' s Responsible Party (RP) 1 was provided updates regarding Resident 1 ' s wound care treatments as agreed upon during the Interdisciplinary team meeting (IDT health care professionals from different professional disciplines who work together to manage resident goals) meeting held on 11/1/2024. 2. Ensure Resident 1 was wearing a helmet during her transport to the General Acute Care Hospital (GACH) 2 on 11/7/2024. These failures resulted in violating Resident 1 and RP 1 ' s rights to actively participate in Resident 1 ' s plan of care and had the potential for Resident 1 to have a head…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nursing staff did not reverse (incorrectly classifying a healing pressure ulcer/injury) a pressure ulcer/injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) for one of three sampled residents (Resident 2). These deficient practices resulted in inaccurate wound staging for Resident 2 and had the potential in a delay in care and services leading to a decline in Resident 2 ' s physical and psychosocial well-being. Findings: During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hypertensive heart failure (damage to heart due related to high blood pressure), muscle wasting (loss of muscle and strength) and peripheral vascular disease (PVD – a slow progressive narrowing of the blood flow to the arms and legs). During a review of Resident 2's Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a resident centered care plan for one of three sampled residents (Resident 1) who has a history of banging her arms against the side rails (a bar or board positioned at the side of the bed which help people get in and out of the bed and help reposition themselves in bed). This deficient practice placed Resident 1 at risk for skin bruising, skin tears and skin breakdown, and placed Resident 1 at risk for skin infection and a decline in health and wellbeing. Findings: During a review of Resident 1's admission Record (Face Sheet) the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), left hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 washed their hands with soap and water and wore the appropriate personal protective equipment ([PPE] specialized clothing or equipment that protects the wearer from infectious materials, injury, or the spread of illness) while providing care to one of four sampled residents (Resident 1) who was on contact isolation (direct or indirect contact with a resident and/or his or her environment including person's room or objects in contact with the person, that has an infection) due to a Clostridium difficile colitis ([C diff] inflammation of the colon caused by a bacteria) infection. These deficient practices resulted in facility staff not following infection prevention protocols and had the potential to spread infection amongst residents, staff, and visitors. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide necessary care and services for one of three sampled residents (Resident 1) by failing to: a.Notify the physician when Resident 1 had episodes of loose watery stool in a timely manner. b.Administer insulin ( medication used to treat high blood sugar) as ordered by the physician on 7/21/2024 at 12:00 p.m. dose. c.Notify the physician when Resident 1's blood sugar remained high despite administration of insulin. These failures had the potential for Resident 1 to have elevated blood sugar level that can lead to worsening of his condition. Resident 1 was transferred to general acute care hospital (GACH) for management of high blood sugar and infection. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) following cerebral infarction (damage…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observe infection prevention and control measures by failing to: a. Conduct fit testing (test to ensure they are wearing the proper size respirator to seal and prevent particles, that may cause infection, from entering the respiratory system) for a N95 mask (filtering facepiece respirator) on six of 10 staff members. b. Handle soiled linens in a safe and sanitary way by staff swinging the plastic linen bag back and forth towards the body before disposing it in a barrel outside the facility. These deficient practices had the potential to place residents at risk for the spread of infection and result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another). Findings: a. During a concurrent interview and record review with Infection Preventionist Nurse (IPN) reviewed N95 Mask Fit Test Log. IPN confirmed six staff members were not up to date with their N95 mask fit test (method of finding a right respirator that can provide a tight seal and protect…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement their antibiotic stewardship program (measures used by the facility to ensure antibiotics [drug to treat infection] are used only when necessary and appropriate) on one of three sampled residents (Resident 1) by failing to monitor and address antibiotic (a substance used to kill bacteria and to treat infection) use. This failure had the potential for the resident to receive an inappropriate antibiotic and develop clostridium difficile infection ([C diff] highly contagious bacterial infection of the colon and caused symptoms such as diarrhea, and stomach pain). Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the resident was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (partial weakness of the right side of the body after a stroke), , diabetes mellitus( high blood sugar), congestive heart failure( condition that…

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

Based on observation, interview, and record review, the facility failed to implement and maintain infection control procedures when Certified Nurse Assistant (CNA) 3 and CNA 1 failed to perform hand hygiene in between resident ' s care and prior to entering and exiting resident room. This deficient practice had the potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and spread of diseases and infection to the facility staff, residents, and visitors. Findings: During an observation on 6/21/2024 at 9:32 a.m., CNA 3 was observed not performing hand hygiene between resident care or when entering and exiting a resident room. During an interview on 6/21/2024 at 9:42 a.m., CNA 3 stated, she was rushing so she did not perform hand hygiene while providing resident care. CNA 3 stated she should have performed hand hygiene to prevent the spread of infection. During a concurrent observation and interview on 6/21/2024 at 10:05 a.m., CNA 1 was observed entering and exiting a resident ' s room without…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide care consistent with professional standards for one of three sampled residents (Resident 1). The facility failed to: a. Inform Resident 1's physician regarding the removal of Resident 1's Peripherally inserted central catheter ([PICC] thin, soft tube inserted into the resident's vein for long term medication, nutrition, and blood draws) line. b. Monitor and assess the PICC line site after removal. This deficient practice placed Resident 1 at risk for bleeding and infection after the removal of the PICC line. Findings During a review of Resident 1's admission Record, the record indicated Resident 1 was admitted on [DATE] with the diagnosis of osteomyelitis (swelling of bone tissue that is usually the result of an infection) of the vertebra (spine). During a review of Resident 1's Minimum Data Set ([MDS]- a standardized assessment and care screening tool), dated 4/10/2024, the MDS indicated Resident 1's cognition (the mental action or process of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one of 36 sampled residents (Resident 145), were not left with feces (solid waste passed out of the body of a human or animal) on her clothing and stomach (belly) upon returned to the facility from general acute care hospital (GACH). This failure resulted in Resident 145 feeling of helplessness, neglect, and frustration. Findings: During a review of Resident 145's admission Record, indicated Resident 145 was admitted to the facility on [DATE], with diagnoses including type 2 diabetes mellitus (chronic condition that affects how the body process sugar), hemiplegia (loss of the ability to move that affects only one side of your body), and cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area). During a review of Resident 145's History and Physical (H&P), dated 1/19/24, indicated, Resident 145 had the capacity to understand and make decisions. During a review of Resident 145's Minimum Data Set [(MDS),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide needed care and services for three of eight (8) sampled residents (Resident 141, 155 and Resident 164) by failing to: 1.Answer the call light for 30 minutes to three hours for Resident 141 when she called for help and failing to change incontinence brief ( diaper) after being soiled wet withy urine for hours in the bed. 2.Failing to provide privacy and towel to cover Resident 141 after showering. 3.Failing to change Resident 155 after the suprapubic catheter (a hollow flexible tube that is used to drain urine from the bladder through a cut in the abdomen) leaked urine on Resident 155 gown for hours. These failures had the potential risk for Resident 141 and 155 to develop pressure ulcers ( an injury that breaks down the skin and underlying tissue), urinary tract infection (infection in any part of the urinary system) , generalized itching and burning all over her body and the potential for feelings of depression, anger 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 licensed nurses failed to ensure pharmaceutical services included procedures to ensure accurate dispensing, administering of all drugs and biologicals to meet the needs of two of seven sampled residents (Resident 83 and 480) by failing to: 1.Ensure a licensed nurse administer the three Lidocaine 4% patches (medication used to help relieve pain) to the left hip, left knee and right knee on 2/6/2024 to Resident 83. This failure had the potential to result in ineffectively managing Resident 83's chronic pain. 2.Ensure three Lidocaine 4% patches were not left on Resident 83's bedside table unattended by a licensed nurse. This failure had the potential for other staff, visitors, or residents to access prescription medications at any time 3.Ensure Certified Nursing Assistant (CNA) 7 and CNA 8 did not administer the Lidocaine patches (a prescription medication) to Resident 83 outside their scope of practice(the activities that an individual health care…

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

Based on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of microorganisms (an organism that can be seen only through a microscope) that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins) by failure to: 1. Ensure foods stored in kitchen reach in refrigerator were dated, labeled, and discarded before the used by date (expiration dates). This failure had the potential to affect residents and result in pathogen (germ) exposure and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization. Findings: During a concurrent observation and interview on 2/6/2024 at 8:15 a.m. with the dietary aid (DA), observed food items inside the reach in refrigerator not labelled with open date. DA stated when 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 one of one sampled resident (Resident 3) was treated with respect and dignity when Resident 3's roommate's visitor failed to knock and request permission before entering Resident 3's room during personal care. This failure had the potential to affect Resident 3's sense of self-worth and self-esteem and unnecessarily exposed resident to others. Findings: During a review of Resident 3's admission Record, indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including polyneuropathy (multiple peripheral nerves become damaged), morbid obesity (the weight is more than 80 to 100 pounds above their ideal body weight), diabetes mellitus (a disorder in which the amount of sugar in the blood is elevated), low back pain, chronic pain syndrome (pain that lasts for over three months) and osteoporosis (a disease in which bones become fragile and more likely to break (fracture). During a review of Resident 3's History and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide foot care for one of eight sampled residents (Resident 74). This failure resulted in Resident 74's toenail untrimmed and long with yellow substance under the toenails and had the potential to cause infection of the toenail and degrade self-esteem. Findings: During a review of Resident 74's admission Record, the admission Record indicated Resident 74 was admitted to the facility on [DATE], with diagnoses including hemiplegia (one-sided paralysis) and hemiparesis (one-sided muscle weakness) following cerebral infarction (a disease in a result of disrupted blood flow to the brain which may cause parts of the brain to die off), heart failure (a condition when your heart does not pump enough blood for your body's needs), and atrial fibrillation (irregular, often rapid heart rhythm). During a review of Resident 74's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/22/2024, 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: 1. Perform weekly weights, nutritional re-assessment and provide revised interventions for one of seven sampled residents (Resident 155) when Resident 155 lost 20.2 pounds from April 2023 to July 2023. This failure placed Resident 155 at risk for continued weight loss, and potential for malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough). 2. Provide breakfast tray and assistance during mealtime on 2/6/2024. This failure resulted in Resident 155 not having a breakfast meal tray on 2/6/2024 and felt neglected by facility staff and had the potential for depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act). Findings: During a review of Resident 155's admission Record indicated Resident 155 was admitted to the facility on [DATE] with diagnoses including quadriplegia (a form of paralysis that affects all four limbs, plus the torso),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 manage residents' pain for two of two sampled residents (Resident 110 and 460) by: 1.Failure to assess for pain prior to providing personal care. This failure resulted in Resident 110 suffer with pain while receiving personal care with facility staff. 2. Failure to follow physician order when Resident 460 was given acetaminophen with a pain scale (way to rate or measure resident pain) level of five (1-4 mild pain, 5-7 moderate pain) on 2/6/2024 and seven on 2/8/2024. This failure had the potential to not alleviate the pain for Resident 460. Findings: 1. During a review of Resident 110's admission Record, indicated Resident 110 was admitted on [DATE] and readmitted on [DATE] with diagnoses including Alzheimer's disease (a progressive brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out simple task) , diabetes mellitus (a condition in which the body fails to metabolize (process) glucose…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1.Ensure that a licensed nurse administer the three Lidocaine 4% patches (medication used to help relieve pain) to the left hip, left knee and right knee on 2/6/2024 to one of seven sampled residents (Resident 83) and not left on Resident 83's bedside unattended. This failure had the potential to result in ineffectively managing Resident 83's chronic pain and had the potential for other staff, visitors ,or residents to access prescription medications at any time. Findings: During an observation on 2/6/2024 at 1:25 p.m. at Resident 83's bedside, observed three (3) lidocaine patches were left on Resident 83's bedside table by the Licensed Vocational Nurse (LVN) 4. During a review of Resident 83's admission Record indicated Resident 83 was admitted to the facility on [DATE], with diagnoses including chronic pain syndrome (long term pain), polyneuropathy (simultaneous malfunction of many peripheral nerves throughout the body) and chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure food served was palatable (food and drink pleasant to taste) and/or at the proper temperature for one of five sampled residents (Residents 71). This failure had the potential for Resident 71 to feel upset, affect her wellbeing, and poor meal intake that can lead to weight loss. Findings: During a review of Resident 71's admission Record indicated Resident 71 was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnosis including hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body), diabetes mellitus (insufficient insulin (hormone that helps regulate blood sugar), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and chronic kidney disease (progressive loss of kidney function over a period of time). During a review of Resident 71's the Minimum Data Set (MDS - a comprehensive assessment and care screening 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 staff failed to perform hand hygiene (hand washing using soap and water, and cleaning hands with waterless or alcohol-based hand sanitizers) during medication administration for one of three sampled resident (Resident 168). This failure placed Resident 168 at risk for spread of infection between residents and staff had a potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another). Findings: During a review of Resident 168's admission Record, indicated Resident 168 was admitted to the facility on [DATE], with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), dysphagia (difficulty swallowing), and hypertension (high blood pressure). During a review of Resident 168's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 11/15/2023, 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 interview and record review, the facility failed to implement antibiotic stewardship program (measures used by the facility to ensure antibiotics [drug to treat infection] are used only when necessary and appropriate) for one of 36 sampled residents (Resident 148), by prescribing an antibiotic without meeting the criteria of their protocol (checklist or guide to initiate antibiotic) for urinary tract infection ([UTI] infection in any part of the urinary system). This failure had the potential to put Resident 148 at risk for antibiotic resistance (not effective to treat infection) and inappropriate use of antibiotic. Findings: During a review of Resident 148's admission Record, indicated Resident 148 was admitted to the facility on [DATE], with diagnoses including type 2 diabetes mellitus (a condition in which the body fails to metabolize (process) glucose (sugar) correctly) and hypertension (high blood pressure). During a review of Resident 148's History and Physical (H&P), dated 7/28/23, indicated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure dignity was maintained for one of three sampled residents (Resident 1) when the facility failed to provide timely incontinence (having little or no control over urination or defecation) care (assistance in cleaning up a resident after toileting in a brief [adult diaper]) to Resident 1. Resident 1 was left to sit in a soiled, wet adult brief for at least an hour. (Cross referenced to F690) This deficient practice resulted in Resident 1 feeling uncomfortable, frustrated, fearful of getting a pressure sore (injuries to the skin and underlying tissue due to prolonged pressure and exposure to moisture) and deterred Resident 1 from eating her lunch at mealtime. Findings: During a review of Resident 1's admission Record AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including cellulitis (infection of the skin) of left lower limb, diabetes mellitus (disease of too much sugar in the bloodstream),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1 ) who was enrolled in the facility ' s bowel training program and assessed to be frequently incontinent (little or no control over urincation and/or bowel movements) of bowel and bladder, received the care and services to prevent urinary tract infections and maintain as much normal bladder and bowel function as possible. The facility failed to: 1. Ensure the nursing staff assisted Resident 1 timely after toileting in her incontinence briefs( adult diaper) (cross referenced to F550) 2. Ensure Resident 1 was involved in her care planning process involving bladder management which included the possibility of using a bedside commode for urination. 3. Provide Resident 1 the opportunity to participate in the facility toileting program and or bladder management retraining program. These failures resulted in 1.Resident 1 being left to sit in a wet soiled brief which led to Resident 1 to have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review facility failed to ensure Licensed Vocational Nurses (LVN) 1 doffed (removed) personal protective equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) after exiting resident's rooms of COVID 19 positive resident, and perform hand hygiene This failure had the potential of cross contamination and spread of infection with other residents, staff, and visitors. Findings: During an observation on 11/21/23 at 12:34 pm, with LVN 1, observed exiting one of residents' rooms of COVID 19 positive resident with face shield and mask and doffed outside the resident room. LVN 1 did not do hand hygiene after taking care of COVID-19 positive resident in the room. During an interview on 11/21/23 at 12:42 p.m., with infection preventionist (IP), stated staff in all areas of the facility must wear N95, and anyone assigned to the COVID 19 positive area must don PPEs before entering resident rooms and doff inside resident and wash hands before coming out of the resident room. During an…

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

Based on interview and record review the facility failed to ensure Certified Nursing Assistant 3 (CNA 3) documented Activities of Daily Living (ADL) task provided on 9/12/2023 at 7:00 am to 3:00 p.m. for one of two (Resident 1) residents sampled. The deficient practice resulted in inaccurate depiction of care rendered and received by the residents. Findings: During a review of Resident 1 ' s admission Record (face sheet), the face sheet indicated Resident 1 was admitted at the facility on 8/26/2023 with a diagnosis that included generalized muscle weakness, cerebral infraction (a condition that occurs when the blood supply in the brain is interrupted or reduced, preventing the brain tissue from getting oxygen) without residual effects and history of falling. During a review of Resident 1 ' s Minimum Data Set (MDS), a standardized health screening assessment tool, dated 9/2/2023, the MDS indicated Resident 1 was able to verbalize her needs and make decisions that were reasonable and consistent. The MDS indicated the resident needed extensive assistance with personal hygiene and 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 implement infection control practices to prevent the development and transmission of communicable diseases and infections. The facility failed to: 1. ensure visitors and contractors including paramedics (emergency medical technician) wore N95 mask (a face mask that covers the wearer's nose and mouth to achieve a very close facial fit that filters particles from the air) during a Covid- 19 (a potentially severe respiratory illness caused by a coronavirus and characterized by fever, coughing, and shortness of breath [SOB]) outbreak (occurrence of cases of disease that is more than expected) in the facility started on 8/8/2023, 2. ensure Certified Nursing Assistant 2 (CNA 2) doff (remove) gown and gloves that she wore inside the room of Resident 1, Resident 2 and Resident 3 (COVID 19 positive residents) prior to exiting residents' room and walking in the hallway of the resident care areas. 3. ensure Licensed Vocational Nurse 2 (LVN 2) perform…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Medical Doctor (MD) was notified when one of three sampled residents (Resident 8) had a change of condition (COC) of low blood pressure, responsive only to pain stimuli and responsible party refusal to send Resident 8 to general acute care hospital (GACH) on [DATE]. This failure resulted in delay in diagnosis, care, treatment, and transfer of Resident 8 to a general acute care hospital (GACH). Findings: During a record review of Resident 8's admission Record (Face Sheet), the Face Sheet indicated Resident 8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including atrial fibrillation (irregular heartbeat), asthma (a condition in which your airways narrow and swell and may produce extra mucus), and hypertension (high blood pressure). During a record review of Resident 8's History and Physical (H&P), the H&P indicated Resident 8 was not able to express needs or communicate, to follow commands, or talk in full…

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