The Earlwood

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a person-centered care plan with measurable interventions was created and implemented for one of two sampled residents (Resident 11), when on 11/20/2025, the resident started vomiting and complained of generalized pain of 10/10. This deficient practice had the potential to negatively impact the delivery of necessary care and services for Resident 11.Findings: During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included irritable bowel syndrome (a condition that affects a person's stomach and intestines and can cause abdominal cramping, bloating [uncomfortable feeling of fullness, tightness, or swelling in the abdomen] and change in bowel habits) alcoholic cirrhosis of liver (when long term alcohol use severely damage the liver causing it to harden) with ascites (accumulation of fluid in the abdomen),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 revise, review and update the care plan for one of two sampled Residents (Resident 13) addressing Resident 13's risk for pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence).This failure had the potential to result in a recurrence of Resident 13's pressure injury in the coccyx (tailbone).Findings:During a review of Resident 13's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted to the facility with diagnoses including intrahepatic bile duct carcinoma (rare cancer that starts in the tiny tubes inside the liver that carry digestive fluid out of the liver to the small intestine) and mechanical complication of the bile duct prosthesis (when the tube used to keep the bile duct [small tube that carries digestive fluid from the liver and gallbladder to the small intestine to help digest fats and remove waste] open breaks, gets…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 11) who complained of stomach and arm pain rated at 10/10, on a pain scale rating of 0-10 (where 0 to 3= mild pain, 4 to 7 =moderate pain, 8 to 10 = severe pain, and 10 = the worse pain possible) was assessed, medicated and monitored. The facility failed to: 1. Ensure Registered Nurse Supervisor (RNS) 3 assessed and monitored Resident 11's pain after Resident 11 complained of severe pain of 10/10 on 11/21/25. 2. Ensure RNS 3 administered pain medication to Resident 11 when on 11/21/25 at 2:59 p.m., Resident 11 complained of severe pain rated at 10/10, as documented in the Nurses Progress notes on 11/21/25 at 2:59 p.m.3. Develop an individualized care plan for Resident 11 with interventions to monitor, prevent or manage Resident 11's pain. 4. Offer Resident 11, non-pharmacologic interventions (approaches that do not involve medications including heat, repositioning, relaxation, massage, exercise) per 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 timely completion of STAT (immediately) laboratory tests for one of two sampled residents (Resident 11) as ordered by the Nurse Practitioner on 11/22/25 at 7:13 p.m., without waiting until 11/23/25 at 8:00 a.m., (approximately 13 hours) after the orders were received. This failure had the potential to negatively impact Resident 11's health by delaying critical diagnostic information necessary for timely treatment decisions, increasing the risk of the resident's condition worsening, leading to complications, and compromising the overall quality of care.Findings: During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included irritable bowel syndrome (a condition that affects a person's stomach and intestines and can cause abdominal cramping, bloating [uncomfortable feeling of fullness, tightness, or swelling in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of two sampled residents (Residents 33 and 79) were provided with food that was appetizing, pleasing, and palatable. This failure had the potential to result in missed meals and subsequent weight loss. Findings: During a review of Resident 33's admission Record, the admission Record indicated Resident 33 was originally admitted to the facility on [DATE] and re-admitted 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 inability to move on one side of the body) following cerebral infarction (lack of adequate blood supply to the brain ) affecting the left non-dominant side, contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) on the left and right legs, end stage renal disease (ESRD- irreversible kidney failure), muscle wasting (weakening, shrinking, and loss of muscle) and atrophy (the wasting or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure that one of two sampled residents (Resident 77) was assessed for meal preferences, including likes and dislikes. This failure had the potential to result in Resident 77 refusing meals and experiencing weight loss.Findings: During a review of Resident 77's admission Record, the admission Record indicated Resident 77 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE], with diagnoses including severe protein malnutrition (refers to a nutritional status in which reduced availability of nutrients ), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), dysphagia (difficulty swallowing), cerebral infarction (damage to the brain from interruption of its blood supply) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 77's History and Physical (H&P), dated 2/7/2025, the H&P indicated Resident…

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

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 42) received a speech language pathology evaluation (assessment performed by a speech therapist [evaluates and treats speech language and swallowing difficulties] to determine whether a person has communication disorders, swallowing or feeding disorders) as ordered by a physician on 12/10/2025. This failure had the potential to result in delay of care and put the Resident 42 at risk for aspiration pneumonia (lung infection from inhaling foreign substances like food, liquid or vomit often due to swallowing problems causing inflammation and potential bacterial infection in the lungs) leading to hospitalization and or death.Findings:During an observation on 1/5/2026 at 10:37 a.m. in Resident 42's room, Resident 42 was lying in bed with head of the bed in 30 degrees angle and drinking a cup of water. Resident 42 was observed coughing after drinking few sips of water and took several seconds for…

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

Based on interview and record review, the facility failed to ensure their Quality Assessment /Quality Assurance and Performance Improvement (QA/QAPI- a data driven proactive approach to improvement used to ensure services are meeting quality standards) was utilized effectively for identifying resident care concern such as falls, quality of care and ineffective pain management.These failures had the potential to affect residents' quality of care, safety and life.Findings:During an interview on 1/8/2026 at 6:52 p.m. with the Administrator (ADM), the ADM stated the facility's QA/QAPI was currently focusing on falls and call lights by implementing the yellow star program. The ADM stated the facility placed a yellow star on the names of the residents' rooms who are identified as high risk for fall and investigate the reason why the residents are falling. The ADM stated corrective action plans are in progress and the facility will emphasize the importance of resident care concerns such as falls, quality of care and pain management. The ADM stated the facility will continue to educate all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure indoor temperatures were maintained between 71 to 81 degrees Fahrenheit (a temperature scale) for five of five sampled residents (Residents 1, 2, 3, 4, and 5). On 12/31/2025, temperatures were recorded between 66 to 68 degrees Fahrenheit in the activity room (state and federally mandated common area specifically designed, equipped, and furnished for residents to participate in a planned program of social, recreational, and educational activities) in the hallway serving resident rooms 1-10 and in resident rooms. This deficient practice resulted in Residents 1, 2, 3, 4, and 5 to feel cold and had the potential to cause all other residents' discomfort, aggravate respiratory conditions, and increase the risk of hypothermia (low body temperature) for residents with impaired thermoregulation (body's natural process of maintaining a stable internal temperature).Findings:a. During a review of Resident 1's admission Record (Face Sheet), 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 one of three sampled residents (Resident 1) was seen by an oral surgeon (Dental specialist that performs surgery on mouth jaw and face).This deficient practice had the potential for Resident 1 to have gum disease, tooth loss and an overall poor quality of life.Findings:During a review of Resident 1's admission Record (Face sheet) dated 11/20/ 2025, the face sheet indicated that Resident 1was admitted on [DATE] and readmitted on [DATE] with the diagnosis including Bechet's disease (autoimmune disease-causing inflammation of blood vessels), depression ( a mood disorder affecting how a person thinks, feels and acts) and dementia (a progressive state of decline in mental abilities).During a review of Resident 1's History & Physical (H&P) dated 1/17/2025, the H&P indicated, Resident 1 was alert and oriented.During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/17/2025, the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure food preferences were honored for one of three sampled residents, (Resident1).This deficient practice violated Resident 1's rights and had the potential for malnutrition and weight loss.Findings:During a review of Resident 1's admission Record (Face sheet) dated 11/20/25, the face sheet indicated that Resident 1was admitted to the facility on [DATE] and readmitted on [DATE]with the diagnosis including Bechet's disease (autoimmune disease-causing inflammation of blood vessels), depression ( a mood disorder affecting how a person thinks, feels and acts) and dementia (a progressive state of decline in mental abilities).During a review of Resident 1's History & Physical (H&P) dated 1/17/2025, the H&P indicated, Resident 1 alert and oriented.During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/17/2025, the MDS indicated Resident 1's cognition was intact. The MDS also indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain resident's written consent and document in his chart the basis of why the move was required prior to a room change for one of four randomly selected residents (Resident 3). This deficient practice resulted in the lack of opportunity for Resident 3 to see the new location, meet the new roommate and ask questions about the move prior to the room changes. Findings: During a review of Resident 3's admission Record (Face Sheet), the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing), gastro-esophageal reflux disease ([GERD] a chronic condition that occurs when stomach contents move up into the esophagus, causing irritation), and muscle weakness (a lack of muscle strength). During a review of Resident 3's Minimum Data Set (MDS] a resident assessment tool), dated 8/2/2025, the MDS indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure four of four sampled residents (Resident 1, Resident 2, Resident 3 and Resident 4), who had orders in place for test and/or consultations, had those orders implemented. These deficient practices resulted in Resident 1's surgery being delayed for five months and had the potential to result in a delay in treatment and services for Residents 2, 3, 4.a. 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 end stage renal disease ([ESRD] irreversible kidney failure). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 7/21/2025, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired and Resident 1 required partial/moderate assistance (helper does less than half the effort) from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the physicians for four of four sampled residents (Resident 1, Resident 2, Resident 3 and Resident 4) when their appointments for test and/or consultations were missed or not scheduled. These deficient practices resulted in Resident 1's surgery being delayed for five months and had the potential to result in a delay in treatment and services for Residents 2, 3, and 4. a. 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 end stage renal disease ([ESRD] irreversible kidney failure). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 7/21/2025, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired and Resident 1 required partial/moderate assistance (helper does less than…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 four sampled residents (Resident 1), who had a consultation outside of the facility with a cardiologist (a doctor who specializes in the heart and blood vessels) on 3/24/2025, returned to the facility with progress notes and instructions for care that were available for review in Resident 1's medical record. This deficient practice resulted in a delay in scheduling Resident 1's micro laryngoscopy (a minimally invasive surgical procedure to diagnose and treat various conditions affecting the vocal cords and larynx ([voice box]) for vocal cord lesion removal and had the potential for complications occurring based on that delay in surgery.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 end stage renal disease ([ESRD] irreversible kidney failure). During a review of Resident 1's Minimum Data Set ([MDS] a 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 implement infection control measures for one of two sample residents (Resident 1) by failing to: 1. Ensure proper Personal Protective Equipment (PPE: equipment worn (gown, gloves, goggles) to help create a barrier between a healthcare worker and germs) was worn for Resident 1 that was on Enhanced Barrier Precaution (EBP: infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs).2. Ensure proper hand hygiene was performed during glove changes.3. Ensure Resident 1's indwelling catheter (or known as Foley catheter, a tube that allows urine to drain from the bladder into a bag that is usually attached to the thigh) drainage bag was not touching the floor.4. Ensure the rooms were deep cleaned after medication to treat Scabies (a contagious skin condition caused by tiny insects called mites that infest and irritate skin causing intense itching, inflammation, and red patches) were applied. These…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of the four sampled residents (Resident 1 and Resident 2) change of condition (COC: when there is an alteration in an individual's physical or psychosocial wellbeing) were implemented by: 1. Failing to monitor Resident 1 who was diagnosed with Scabies (a contagious skin condition caused by tiny insects called mites that infest and irritate skin causing intense itching, inflammation, and red patches) after treatment was administered. 2. Failing to initiate a COC on 2/19/2025 when there was a change in Resident 2's skin assessment These deficient practices had the potential to negatively affect the delivery of care and services necessary for Resident 1 who was being treated for scabies and resulted in Resident 2 developing a stage II pressure injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin). Findings: A.During a review of Resident 1's admission Record (Face Sheet), the admission Record indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one out of four sampled residents (Resident 2) received care to prevent pressure injuries (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) to the sacrococcyx area.This deficient practice resulted in Resident 2 developing a stage II pressure injury on the sacrococcyx (fused bone structure that consists of the sacrum [triangular bone at the base of the spine] and coccyx [tail bone]) area and had the potential for risk of infection and pain. During a review of Resident 2's admission Record (Face Sheet), the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including encephalopathy (any damage or disease that affects the brain), dementia (group of thinking and social symptoms that interferes with daily functioning), and difficulty walking. During a review of Resident 2's history and physical (H&P) dated 2/14/2025, the H&P indicated Resident 2 had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 notify one of three sampled resident's (Resident 2) physician and the facility's registered dietician (RD), when Resident 1, had a poor food intake, and refused to be weighed. These deficient practices resulted a delay in Resident 2's evaluation and care and had the potential for Resident 2 to become malnourished and lose weight. Findings: During a review of Resident 2 's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including surgical aftercare (care after surgery), malignant neoplasm (an abnormal tissue growth characterized by cells that can invade surrounding tissues and potentially spread to other parts of the body) of tongue and gastro-esophageal disease ([GERD] a condition in which the stomach contents (food or liquid) leak backwards from the stomach into the esophagus (the tube from the mouth to the stomach). This action can irritate the esophagus, causing heartburn and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the weights and food consumption for one of three sampled residents (Resident 2) was obtained and/or assessed. These deficient practices resulted in Resident 2's weights and food consumption being unknown and a delay in evaluation and care. These deficient practices placed Resident 2 at risk for malnutrition and weight loss. Findings: During a review of Resident 2 's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including surgical aftercare (care after surgery), malignant neoplasm (an abnormal tissue growth characterized by cells that can invade surrounding tissues and potentially spread to other parts of the body) of tongue and gastro-esophageal disease ([GERD] a condition in which the stomach contents (food or liquid) leak backwards from the stomach into the esophagus (the tube from the mouth to the stomach). This action can irritate the esophagus, causing heartburn and…

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

Based on interview and record review the facility failed to ensure their QA/QAPI (Quality Assurance/Quality Assurance and Performance Improvement, a data driven proactive approach to improvement used to ensure services are meeting quality standards) committee monitored interventions put in place related to delays in receiving resident care. This deficient practices resulted in the inability of the facility to determine if interventions put in place to improve resident care in a timely manner were affective and placed residents at risk for continued delay in care and services. Findings: During a review of the facility's Grievance Report dated 5/16/2024, the Grievance Report indicated Resident 4 had concerns related to answering of call lights (device used by resident to ask for assistance) in a timely manner. The Grievance Report indicated the facility will continue to address the concern during their QAPI meeting. During a review of the facility's Grievance Report dated 4/15/2025, the Grievance Report indicated Resident 4 had concerns related to resident care, call lights and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who had a history of elopement (act of leaving a facility unsupervised and without prior authorization) and wandering (moving from place to place) behaviors did not elope from the facility. This deficient practice resulted in Resident 1 eloping from the facility on 6/5/2025 at approximately 5:32 p.m., unbeknownst to staff. Resident 1 was returned to the facility on the same day after being found by a Good Samaritan at approximately 5:55 p.m. This deficient practice place Resident 1 at risk for harm as a result of in climate weather, motor vehicle accidents, fall, violence at the hands of others and death. This deficient practice resulted in Resident 1 eloping from the facility and placed Resident 1 at risk for the potential excessive changes in temperature, motor vehicle accidents, falls, violence and death. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 monitor two of two sampled resident (Resident 11 and Resident 12) after a change of condition occurred. This failure had the potential to result in a potential delay of care to Resident 11 and Resident 12. Findings: During a review of Resident 11's admission record, the admission record indicated Resident 11 was admitted to the facility on [DATE] with diagnoses including fracture of left femur (break or injury of the thigh bone or hip) and hypertension (high blood pressure). During a review of Resident 11 ' s Minimum Data Set (MDS - a resident assessment tool), dated 4/23/2025, the MDS indicated Resident 11 had no cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required set-up assistance when eating, and required maximal assistance (helper does more than half the effort) with toileting and bathing. During a concurrent interview and record review on 5/29/2025 at 1:54 p.m. with Licensed Vocational Nurse (LVN) 1,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure there was a physician's order before administering oxygen to one of three sampled residents (Resident 13). This failure had the potential to result in a potential for hyperoxygenation (too much oxygen) Resident 13. Findings: During a review of Resident 13's admission record, the admission record indicated Resident 13 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing). During a review of Resident 13 ' s Minimum Data Set (MDS - a resident assessment tool), dated 3/27/2025, the MDS indicated Resident 13 had no cognition (ability to learn, reason, remember, understand, and make decisions) impairment, required supervision when eating, and required maximal assistance with toileting and bathing. During a concurrent interview and record review on 5/29/2025 at 1:54 p.m., with Licensed Vocational Nurse (LVN) 1,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure licensed nursing staff were competent in administering oxygen. This failure had the potential to result in a potential for hyperoxygenation (too much oxygen) Resident 13. Findings: During a review of Resident 13's admission record, the admission record indicated Resident 13 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing). During a review of Resident 13 ' s Minimum Data Set (MDS – a resident assessment tool), dated 3/27/2025, the MDS indicated Resident 13 had no cognition (ability to learn, reason, remember, understand, and make decisions) impairment, required supervision when eating, and required maximal assistance with toileting and bathing. During a concurrent interview and record review on 5/29/2025 at 1:54 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 13 ' s orders and oxygen monitoring…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure four of 10 sampled residents, Resident 4, Resident 5, Resident 6, and Resident 7) were provided with a safe, clean, comfortable, and homelike environment. The facility failed to: 1.Provide a room for Resident 4, Resident 6, and Resident 7) with functional sliding glass doors that able to be locked from the inside. 2. Provide a safe environment for the staff and residents by locking the entrance doors (front door) to the facility during the night. 3.Maintain Resident 4 and Resident 5 rooms free from cockroaches. These deficient practices had the potential to affect the residents ' dignity, the residents ' mood, and the residents ' rights to have a homelike and safe environment. Findings: 1. During a review of Resident 4 ' s admission Record, the admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabeted mellitus (DM-a disorder characterized by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure four of 10 sampled residents, Resident 4, Resident 5, Resident 6, and Resident 7) were provided with a safe, clean, comfortable, and homelike environment. The facility failed to: 1.Provide a room for Resident 4, Resident 6, and Resident 7) with functional sliding glass doors that able to be locked from the inside. 2. Provide a safe environment for the staff and residents by locking the entrance doors (front door) to the facility during the night. 3.Maintain Resident 4 and Resident 5 rooms free from cockroaches. These deficient practices had the potential to affect the residents ' dignity, the residents ' mood, and the residents ' rights to have a homelike and safe environment. Findings: 1. During a review of Resident 4 ' s admission Record, the admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabeted mellitus (DM-a disorder characterized by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1 and 2) were free from unnecessary physical restraints (any object or device that an individual cannot remove easily which restricts freedom of movement) as evidenced by: 1. Resident 1 and 2 ' s bed was against the wall. This deficient practice had the potential to place Residents 1 and 2 at risk for injury and the potential for entrapment (when an individual is trapped or unable to get out of a small, enclosed area). 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 cerebral infarction (loss of blood flow to part of the brain) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1 ' s Minimum Data Set ({MDS}- a resident assessment tool), dated 3/27/2025, the MDS indicated Resident 1 ' s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives, timeframes, and interventions for two of 10 sampled residents Resident 1and 2) by failing to: 1. Review and revise Resident 2 ' s care plan after each incident of fall. 2. Develop a care plan for Residents 1 and 2 ' s bed against the wall. These deficient practices had the potential to negatively affect the delivery of necessary care and services for Residents 1 and 2. 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 cerebral infarction (loss of blood flow to part of the brain) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1 ' s Minimum Data Set ({MDS}- a resident assessment tool), dated 3/27/2025, the MDS indicated Resident 1 ' s cognition (ability…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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} to develop and implement appropriate plans of action to correct identified quality deficiencies) and Quality Assurance Performance Approvement ({QAPI} designed to bring about constant measurable improvement in the services to provide at the facility for continual improvement of quality care) committee failed to monitor, review, and analyze data performance improvement of facility issues such as falls. This deficient practice had the potential to not identify systemic approach to improve services to the residents. Findings: During an interview on 5/4/2025 at 4:24 p.m., with the Director of Nursing (DON), the DON stated they are currently working on falls but have had an increase in falls and should implement new intervention for fall prevention in the facility. The DON stated they were unable to locate the QAPI binder to address the increase in falls from the previous administrator. During a review of the facility ' s policy and procedure (P&P) titled Quality Assurance and Performance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain a consistent and effective pest control program as evidenced by: 1. Multiple live cockroaches were found on the wall of Resident 4 and Resident 5 ' s room (room [ROOM NUMBER]). This deficient practice had the potential to affect the quality of life of Residents 4 & 5 and the potential of roaches spreading to other rooms in the facility. Findings: During a review of Resident 4 ' s admission Record, the admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), peripheral vascular disease (PVD- a slow progressive narrowing of the blood flow to the arms and legs), and cerebrovascular disease (condition that affects the blood vessels and blood flow to the brain, potentially leading to a stroke {loss of blood flow to part of the brain}). During a review of Resident 4…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 notify the physician when a resident experienced a change of condition([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death) for four of five sampled residents (Resident 1, 2, 3 and 4). The facility failed to: 1. Ensure licensed nurses notified Resident 1, 2, 3 and 4 ' s physician when Resident 1, 2, 3 and 4 did not receive their 9:00 a.m. scheduled medications on 4/19/2025. 2. Ensure licensed nurses documented a COC when schedule medications were not administered to Resident ' s 1, 2, & 4 on 4/19/2025 at 9 a.m. These deficient practices of not notifying the physician of the residents COC resulted in a delay of evaluation, care, treatment, and monitoring. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to have sufficient staffing on 4/19/2025 when one licensed nurse called off and one no call no show (an employee fails to report to work as scheduled and fails to notify their employer of their absence) to accommodate resident needs in administering medications timely. This deficient practice resulted in Resident 1, 2, 3 and 4 not receiving all scheduled medications on 4/19/2025 at 9 a.m. 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 cerebral infarction (stroke- loss of blood flow to part of the brain), atrial fibrillation (irregular and often very rapid heart rhythm), hypertension (HTN- high blood pressure), and pancytopenia (a lower-than-normal number of red and white blood cells and platelets in the blood). During a review of Resident 1 ' s Minimum Data Set (MDS- resident assessment tool) dated 3/21/2025 indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure four of five sampled resident (Resident 1,2,3, and 4) medications were administered within one hour of their scheduled administration time in accordance with the facility ' s policy and procedures titled Administering Medications, (undated). These deficient practices placed Residents 1, 2, 3, and 4, at risk to experience medication adverse reactions, and complications including a high blood pressure leading to stroke (damage to the brain from interruption of its blood supply), venous thromboembolism (blood clots in the veins), seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) and hospitalization. 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 cerebral infarction (stroke- loss of blood flow to part of the brain), atrial…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and interview, the facility failed to implement and maintain infection control practices when Certified Nurse Assistant (CNA) 1 and Licensed Vocational Nurse (LVN) 2 failed to perform hand hygiene between resident care and prior to entering and exiting resident rooms. These failures had potential of cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and placed residents and staff at risk for the spread of infection. Findings: During the initial tour of the facility on 4/25/2025, observed two of four resident rooms did not have hand sanitizing gel in the dispensers. Observed there were no hand sanitizing gel dispensers on the walls in the hallways. During a concurrent observation and interview on 4/23/2025 at 10:53 a.m., outside of resident room, LVN 2 was observed not performing hand hygiene prior to entering a resident ' s room to change an oxygen machine or prior to exiting the resident ' s room. LVN 2 stated she was supposed to perform hand hygiene before entering a resident room and prior 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 obtain laboratory tests per medical doctor (MD) order prior to resident scheduled appointment for one of three sampled residents (Resident 2). This deficient practice resulted in Resident 2 ' s medical doctor appointment to be canceled and had the potential delay in necessary care and services. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm (a cancerous tumor) of the right breast and bone and thrombocytopenia (low blood platelet count). During a review of Resident 2 ' s Minimum Data Set (MDS- resident assessment tool) dated 3/24/2025 indicated Resident 2 ' s cognition (ability to think, understand, learn, and remember) was intact and required moderate assistance (helper does less than half the effort) with toileting and dressing. During an interview on 4/24/2025 at 9:49 a.m., with Resident 2, Resident 2 stated she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 have an Infection Preventionist (IP) on staff with completed specialized training in Infection Control and Prevention. This deficient practice had the potential for failure to monitor and implement Infection Control and Prevention in the facility. Findings: During a record review of the Infection Prevention Nurse (IPN) certification, dated 12/30/2024, the IPN certification indicated it was from CDC Train certificate which did not indicate the hours completed. During an interview on 4/23/2025 at 3:23 p.m., with the IPN, the IPN indicated she began working at the facility on 11/2024 as a new graduate licensed nurse and has been the IPN since 2/2025. The IPN stated the CDC Train certificate was the one she was told she needed and was unable to locate the correct Infection Preventionist certificate. During an interview on 4/24/2025 at 4:36 p.m., with the Director of Nursing (DON), the DON indicated she was unaware that the IPN had the incorrect IP certificate. The DON stated it was important to have a full-time IP nurse with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received treatment and care by failing to: 1. Document on the Medication Administration Record (MAR) meclizine (medication used to help with dizziness) medication was given as ordered by the physician. 2. Initiate a plan of care and change of condition when a Resident 1 has new onset of cough . These deficient practices had the potential to cause Resident 1 side effects of the medication not being monitored and had to potential to miss treatment and care for new onset of cough. Findings: During a record review of Resident 1 ' s admission Record (AR), indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including atherosclerosis of aorta ( a build up of fat and other substances on the inner walls of the heart which can lead to hardening of the arteries in the heart), Klebsiella pneumoniae ( a bacteria found in the intestines ) and history of falling. During a record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an open container of apple sauce had an open date and a use by date on the container. b.Ensure an open container of beef base had an open date and a use by date on the container. c.Ensure frozen chicken tenders that were stored in a Ziploc bag had an open date and a use by date on the bag. d.Ensure that pork was defrosted safely, when pork was left in a bowl of standing water while defrosting in the sink. These failures had the potential to expose residents to a food-borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites). Findings: a. During an interview on 11/15/2024 at 2:15 p.m., with the Dietary Aide (DA) the DA stated all opened food container must have an open date and use by date on the container, so staff would know when the food was no longer good to use. DA stated there was a potential for a food born illness if food was used after the expiration date. During a concurrent observation and interview on 11/12/2024. at 8:05 a.m., with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accommodate the individual needs and preferences of two of 21 sampled residents (Resident 37 and Resident 179) by failing to: a. Address Resident 37's concern regarding insufficient space of his room which prevented him to move around comfortably and access his closet and wheelchair easily due to limited space. b. Address Resident 179's concern about the noise coming from resident's roommate which affected his sleep. These failures had the potential to affect Resident 37's and Resident 179's health, psychosocial wellbeing and safety. Findings: During a review of Resident 37's admission Record, the admission Record indicated Resident 37 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hyperlipidemia ( a condition in which there are high levels of fat in the blood), 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 ensure three of 45 sampled residents (Resident 6, 17, and 34), were provided privacy curtains to completely cover the residents during care. This failure prevented Resident 6, 17, and 34 from having complete privacy during care and had the potential to affect their dignity and self-worth. Findings: a. During a review of Resident 34's admission Record, the admission Record indicated Resident 34 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) following cerebral infarction (brain damage due to a loss of oxygen to the area), dysphagia (difficulty swallowing) affecting the left non-dominant side, and contracture (a stiffening/shortening at any joint that reduces the joint's range of motion) of the left leg. During a review of Resident 34's Care Plan titled Incontinence (involuntary loss of bladder or bowel control), initiated 11/15/2023, 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 revise the care plans for two of four sampled residents (Resident 6 and 20) with limitation in range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) concerns by failing to: a. Revise Resident 6's care plans and conduct an Interdisciplinary Team ([IDT] team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) conference with the resident's representative after discharge from hospice care (specialized care designed to give supportive care to people in the final phase of a terminal illness with a focus on comfort, quality of life rather than cure, and free of pain to live each day as fully as possible) on 1/13/2024. b. Revise Resident 20's care plan for Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) after…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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. Administer medications within one hour of their prescribed time as per facility's policy and procedure (P&P) titled, Administering Medications, dated 04/2019, affecting two of five residents observed during medication administration (Resident 1 and 228). 2. Accurately account for the administration of a combination medication, hydrocodone (a controlled substance [a medication with a high potential for abuse used to treat pain] and acetaminophen (APAP - a medication used to treat fever and pain) on Controlled Drug Record (CDR- a log signed by the nurse with the date and time each time a controlled substance is given to a resident) affecting one resident (Resident 332) in one out of two inspected medication carts (Medication Cart 3). These failures have the potential to result in hypertension (HTN - high blood pressure), stroke (loss of blood flow to a part of the brain), venous thromboembolism (blood clots in veins) and hospitalization…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 three sampled resident (Resident 25 and 29) was free from unnecessary medication. The facility failed to: a. Ensure Resident 25 continued use of antibiotic was reviewed when Resident 25 did not meet LOEB's criteria (set of guidelines used by healthcare providers in for long term care facilities to determine when a resident likely has a significant infection and needs antibiotics based on symptoms) indicating antibiotic use. This deficient practice of failing to ensure a continued need for antibiotics (medications that fight bacterial infections) increased the risk for Resident 25 to experienced antibiotic resistance (when bacteria change to resist antibiotics used to effectively treat them) from unnecessary antibiotic use. b. Ensure Resident 29 Tramadol (pain medication) was given according to physician orders. c. Ensure Resident 29 Morphine sulfate (pain medication) was given according to physician orders. These failures had the potential…

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

Based on observation, interview, and record review, the facility failed to: 1. Ensure Insulin Lispro prefilled pens [a type of insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) delivered via injection device] were stored and/or labeled in accordance with manufacturer's specifications and facility's policy and procedure (P&P) titled Medication Labeling and Storage, dated 02/2023 affecting two residents (Resident 4 and 62) in one of two inspected medication carts (Medication Cart 3). 2. Ensure a single dose vial of Retacrit (generic name - epoetin alfa-epbx, a medication used to treat anemia (a condition where the body does not have enough healthy red blood cells) was removed and/or discarded after being opened in accordance with manufacturer's specifications affecting one resident (Resident 50) in one of two inspected medication carts (Medication Cart 3). These failures have the potential to result in Residents 4, 50 and 62 receiving medications that had become ineffective or toxic due to improper storage or…

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

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 spread and transmission of infection. The facility failed to: a. Ensure hand hygiene was performed at appropriate times during a gastrostomy tube ([GT]- a tube inserted through the wall of the abdomen directly into the stomach) site dressing change for Resident 6. b. Observe Contact Precautions ( are set of safety measures used when a resident has a disease that can be spread thru contact with the patient or patient's environment) before entering Resident 22's room who had a methicillin resistant staphylococcus aureus ( MRSA-type of bacterial infection that is resistant to many antibiotics) and Candida Auris(C. Auris- type of yeast or fungus that can cause serios infections and are difficult to treat because it is resistant to many antifungal medications). c. Ensure laundry staff performed hand hygiene (any action of hand cleansing) and used Personal Protective Equipment ([PPE] clothing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 respect and dignity to one of three sampled residents (Resident 57) by standing over the resident while assisting them during a meal. This failure had the potential to result in decreased self-esteem and self-worth for Resident 57. Findings: During a review of Resident 57's admission Record, the admission Record indicated Resident 57 was admitted to the facility on [DATE] with diagnoses including unspecified dementia(a progressive state of decline in mental abilities) without behavioral disturbance, cerebral infarction without residual effects ( stroke without lasting impairments or resident had recovered after the event), and oropharyngeal dysphagia (difficulty of swallowing that occurs when the food or liquid is moved from the mouth to the esophagus). During a review of Resident 57's Minimum Data Set (MDS- a resident assessment tool) dated 8/6/2024, the MDS indicated Resident 57 had moderately impaired cognitive skills (ability…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 change of condition (COC), was completed when Resident 30 developed a urinary tract infection ([UTI]- an infection in any part of the urinary system). This failure had the potential to result in the inability to determine the improvement or worsening of the infection leading to Resident 30 not receiving the appropriate care. Findings: During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was admitted to the facility 6/4/2021 with diagnoses including obstructive uropathy (urine cannot drain through the urinary tract) and benign prostatic hyperplasia ([BPH]- enlarged prostate). During a review of Resident 30's Minimum Data Set ([MDS]- a resident assessment tool) dated 9/29/2024, the MDS indicated Resident 30's has intact cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 30 required partial/moderate assistance (helper does less than half the effort) with toileting, bathing, and dressing. During a review of Resident 30's Medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 accurately complete a Preadmission Screening and Resident Review (PASARR-a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) I for one of three sampled residents (Resident's 18). This failure had the potential to result in an inappropriate placement and delay of needed services for Resident's 18. Findings: During a review of Resident 18's admission Record, the admission Record indicated Resident 18 was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including paranoid schizophrenia (a mental illness that is characterized by disturbances in thought) and major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy). During a review of Resident 18's Minimum Data Set ([MDS]- a resident assessment tool) dated 8/15/2024, the MDS indicated Resident 18 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the necessary services and care to two of four sampled residents (Resident 18 and Resident 45) by failing to: a.Ensure Resident 18 was provided the necessary medications for constipation (a condition in which stool becomes hard, dry, difficult to pass and bowel movements become infrequent) when the resident had no bowel movement (movement of feces through the bowel and out the anus) for five days. b. Monitor occurrence of bowel movement for Resident 45 and provide necessary medications for constipation as ordered by the physician. These failures had the potential to put Resident 18 and Resident 45 at risk for fecal impaction (hardened stool that's stuck in the rectum or lower colon) that could lead to bowel obstruction (partial or complete blockage of small or large intestines which is life threatening). Findings: a.During a review of Resident 18's admission Record, the admission Record indicated Resident 18 was admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5% (percent) during medication pass for two of five sampled residents (Resident 1 and 228) by failing to provide medications within one (1) hour of the prescribed time of administration as per facility's policy and procedure (P&P) titled, Administering Medications, dated 04/2019. This deficient practice of medication administration error rate of 25.93% exceeded the five (5) percent threshold. Findings: 1. During a review of Resident 1's admission Record (a document containing demographic and diagnostic information), dated 11/13/2024, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to, acute embolism (a blockage in blood vessel) and thrombosis (blood clotting) of unspecified deep veins of left lower extremity, personal history of transient ischemic attack (a brief episode where blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for two (Resident 1 and 228) of five sampled residents, by failing to administer: 1. Resident 1's Amlodipine (a medication used to treat high blood pressure), Eliquis (Generic name - apixaban, a medication used to prevent cerebrovascular accident [CVA] - stroke, loss of blood flow to a part of the brain) and Hydralazine (a medication used to treat high blood pressure) within one (1) hour of the prescribed time of administration as per facility's policy and procedure (P&P) titled, Administering Medications, dated 04/2019. 2. Resident 228's Amlodipine, Escitalopram (a medication used to treat depression and mood disorders), Heparin (a medication used to prevent blood clots) and Hydralazine within one (1) hour of the prescribed time of administration as per facility's P&P titled, Administering Medications, dated 04/2019. These failures had the potential to result in hypertension…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) Records for one of four sample residents (Resident 17) with limitation in range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) indicated Resident 17's refusal to wear the right elbow splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) on 11/12/2024. This failure resulted in the inaccurate provision of care recorded in Resident 17's clinical records. Findings: During a review of Resident 17's admission Record, the admission Record indicated Resident 17 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (brain damage due to a loss of oxygen to the area), aphasia (loss of ability to understand or express speech as a result 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 implement antibiotic stewardship program (measures used by the facility to ensure antibiotics [drug to treat infection] for one of three residents (Resident 25). This failure had the potential to put Resident 25 at risk for antibiotic resistance (not effective to treat infection) and inappropriate use of antibiotic. Findings: During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was admitted to the facility 4/19/2022 with diagnoses including diabetes mellitus ([DM]- a disorder characterized by difficulty in blood sugar control and poor wound healing) and cerebral infarction (a part of the brain has been damaged because it wasn't getting enough blood supply). During a review of Resident 25's Minimum Data Set ([MDS]- a resident assessment tool), the MDS indicated Resident 25 had moderate cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 25 was dependent with bathing, toileting, and transferring. During a review of Resident 25's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure four out of 40 resident rooms measured at least 80 square feet ([sq. ft.]- unit of area equal to a square foot long on each side) per resident in multiple resident rooms. Rooms one and 23 house two residents per room and Rooms two and four housed four residents per room. This deficient practice had the potential to result in inadequate nursing care to the residents. Findings: During an observation on 11/12/2024 at 9:30 a.m., the following rooms were observed, Rooms one, two, four, and 23 did not meet the requirement of 80 square feet per resident. During a concurrent observation and interview on 11/12/2024, at 3:32 p.m., in Resident 37's room, Resident 37's bed was near the closet area with a small space in between the closet and resident's bed. Resident 37 stated he hated the small living space of the room because it affected his mobility especially when the staff member would provide care to his roommate because they would occupy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 developed that addressed the behaviors of yelling, screaming and refusal of care for one of four sampled residents (Resident 2). This deficient practice resulted in Resident 2's care needs not being addressed and had the potential for non-continuity of care. Findings: During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was initially admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included functional quadriplegia (the complete inability to move due to severe disability but without injury to the brain or spial cord), spinal stenosis (a narrowing of the spinal canal in the lower back that can put pressure on the spinal cord and nerves) of the lumbar region, a displaced traverse fracture of the shaft of the right tibia (a break in the shinbone where the bone pieces moved out of alignment, creating a gap), a displaced fracture of the lateral condyle 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 The facility failed to ensure two of nine sampled residents (Resident 6 and 9) oxygen tubing (device that delivers oxygen [air essential to living things to survive] through a tube to the nose) were labeled and dated. This failure has the potential for the oxygen tubing to lose patency that could negatively affect and delay delivery of care and services to Resident 6 and Resident 9. Findings: During a review of Resident 6's admission Record (Face sheet), the face sheet indicated Resident 6 was admitted to the facility on [DATE] with diagnosis including chronic obstructive pulmonary disease (a common lung disease that causes restricted airflow and breathing problems) and chronic respiratory failure (a serious condition where the lungs cannot get enough oxygen in the blood making it difficult to breathe). During a review of Resident 6's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 2/26/2024, the MDS indicated Resident 6's cognition (ability to think, learn, remember, use…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain the roof in good repair for one of one sampled residents (Resident 1), when Resident 1 ' s room had leaking water. This deficient practice resulted in Resident 1 being exposed to an unsanitary environment and violated Resident 1 ' s right to be provided with a safe, clean, and comfortable homelike environment. 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 polyneuropathy (damaged nerves), muscle wasting (decrease in size of muscle tissue) and Type 2 diabetes mellitus (disease where level of sugar in blood too high). During an interview on 2/8/2024, at 3 p.m., with Maintenance Supervisor (MS), the MS stated Resident 1 ' s room had water leaking from the ceiling vent during the recent rainstorm during the days between 1/29/2024 through 2/1/2024. The MS stated, Resident 1 could not stay in his room because of the leak. The MS stated the…

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

Based on interview and record review, the facility failed to provide necessary care and services for one of four sampled residents (Resident 1) when: a. The facility failed to immediately transfer Resident 1 to GACH (General Acute Care Hospital) after Resident 1 had a change of mental function on 11/26/2023. Resident 1 had an order to transfer to GACH at 12:37 p.m. Resident 1 was transferred to GACH at 3:23 p.m. b. The facility failed to ensure Licensed vocational nurse 1 (LVN 1) and Registered Nurse Supervisor (RNS 1) assessed Resident 1's neurological status (a series of tests that assesses mental status, reflexes, movements and more) immediately after the change of condition and frequently until Resident 1 was transferred to GACH three hours after the change of condition. c. The facility failed to ensure Resident 1's vital signs (temperature, respiration, heart rate and blood pressure measurement) was documented when Resident1's mental status changed at 12:37 p.m. and monitored frequently after the change of condition until Resident 1 was transferred to GACH three hours after 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 store and prepare 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) for 60 out 66 total residents in the facility by not: a. ensuring facility staff changed gloves and washed their hands between tasks in the kitchen. b. ensuring facility staff with a beard used a beard cover while handling food in the kitchen. c. ensuring food stored in the resident refrigerator was stored for the correct time frame. These deficient practices had the potential to affect all 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 address the following for three of seventeen sampled residents (Resident 40 and Resident 10), including: 1. failed to develop and implement a comprehensive and resident-centered care plan regarding Resident 40's communication needs, visual deficits, and visual deficits. 2. failed to ensure there was a care plan developed to monitor and address resident's behavior related to the use of a psychotropic, for one (1) of 31 sampled residents (Resident 10). These deficient practices have the potential to delay care or services provided for Resident 40 and Resident 10. Findings: 1. During a review of Resident 40's admission assessment (face sheet), the face sheet indicated Resident 40 was admitted to the facility on [DATE] with diagnosis of diabetes mellitus (a disease that causes inappropriate levels of blood sugar) and paraplegia (can not move the legs and lower body). The face sheet indicated Resident 40's primary language was Spanish. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to a. revise one of 17 sampled residents' (Resident 19) care plan to reflect Resident 19's current Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) orders and treatment plan. b. implement the comprehensive care plan for one of one sampled resident (Residents 54) who sustained a fall on 10/9/2023. This deficient practice had the potential for Resident 19 to not receive the most current RNA treatment plan and staff may not know the correct services to provide the resident. This deficient practice had the potential to place Resident 54 at risk for recurrent falls. Findings: a. During a review of Resident 19's admission Record , the admission record indicated Resident 19 initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure: 1. Medications were administered within one (1) hour of their prescribed time for Resident 3, one of 31 sampled residents. On 10/25/23, Resident 3 received 10 oral medications 2 hour after the prescribed time. Also, Resident 3 were scheduled to receive 71 doses intravenous (IV, to the vein) Zyvox (a potent antibiotic medication to treat severe systemic infection) administrations as of 10/26/2023; however, and 18 of those 71 doses were documented more than 1 hour late. (Also see F760) 2. Nurses documented in MAR after administering medications, and /or reason it was missed for 2 of 31 sampled residents (Residents 3 and 470). For Resident 3, there was no administration documentations for 12 doses of IV Zyvox. For Resident 470, there was no administration documentation on 2 doses of IV ceftriaxone (a potent antibiotic medication to treat severe systemic infection), out of 5 scheduled doses. These deficient practices had the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure antipsychotic (medications that treat psychosis [a severe mental condition that affects thoughts and emotions and causes a break with reality]-related conditions and symptoms) and psychotropic (medications that affect a person's mental state) medication orders for three (3) of 31 sampled residents (Residents 26,10, and 12). For Resident 26, the antipsychotic medications did not have documented rationale for the use of Abilify (an antipsychotic) to treat a specific, diagnosed, and documented behavior. The facility also failed to ensure there was a monthly report of consolidated behavioral data available to the prescribersFor Resident 10, resident's psychotic medication order did not have an indication (a reason) of use or treat a specific and documented behavior. For Resident 12, the facility failed to indicate rationale for use of psychotropic medication and no care plan was developed. These deficient practices had the potential of misuses 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, interviews, and record review, the facility failed to ensure: 1. Medications were administered within one (1) hour of their prescribed time for Resident 3, one of 31 sampled residents. On 10/25/23, Resident 3 received 10 oral medications 2 hour after the prescribed time. Also, Resident 3 were scheduled to receive 71 doses intravenous (IV, to the vein) Zyvox (a potent antibiotic medication to treat severe systemic infection) administrations as of 10/26/2023; however, and 18 of those 71 doses were documented more than 1 hour late. (Also see F760) 2. Nurses documented in MAR after administering medications, and /or reason it was missed for 2 of 31 sampled residents (Residents 3 and 470). For Resident 3, there was no administration documentations for 12 doses of IV Zyvox. For Resident 470, there was no administration documentation on 2 doses of IV ceftriaxone (a potent antibiotic medication to treat severe systemic infection), out of 5 scheduled doses. These deficient practices had the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain complete and accurate medical records by failing to ensure the following: a. Resident 21's Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatment provided on 10/25/23 was accurately documented by Restorative Nursing Aide 2 (RNA 2), the RNA who performed the RNA treatment session. b. Resident 47's Interdisciplinary Therapy Screens (facility's resident's functionality screening documentation) dated 6/23/23 was included in Resident 47's medical record. c. Resident 28's Interdisciplinary Therapy Screens dated 9/29/23 and 10/25/23 was included in Resident 28's medical record. These failures had the potential for the residents to have inaccurate medical records and could affect their care planning and services received at the facility. Findings: a. During a review of Resident 21's admission Record, the admission record indicated Resident 21 was admitted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement its infection prevention and control program for two of two sampled residents (Resident 3 and Resident 30) by failing to: 1. Ensure the Certified Nursing Assistant 8 (CNA 8) and two visitors followed Resident 3's transmission-based precautions (TBP- residents who are known or suspected to be infected or colonized with infectious agents) to prevent spread of infections. 2. Offer personal protective equipment(PPE- equipment worn to minimize exposure to hazards) and inform the visitor why Resident 30 is on enhanced barrier precaution. These deficient practices had the potential to result in the spread of diseases and infection to the facility residents, staff, and the community. Findings: a. During a review of Resident 3's Face Sheet (admission record), the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with diagnosis including multiple sclerosis (disease that makes your immune system attack your own nerve…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 reasonable accommodations to meet the resident's needs by failing to ensure the resident room was not cluttered and the grab bar (a safety device attached to the wall designed to enable a person to maintain balance) was not easily within reach for Resident 18 who used a wheelchair. This deficient practice had the potential for delay of care in case of emergencies and not meet the Resident 28's daily needs. Findings: During a review of Resident 28's admission record, the admission record indicated Resident 28 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus (insufficient insulin (a checmical that helps regulate blood sugar), end stage kidney disease, dependent on renal dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly), osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 appropriately assess and monitor one of one sampled resident (Resident 54) during the use of a concave mattress (a fall prevention mattress to minimize risks of falling out of the bed) to prevent the resident from sliding off the bed. This deficient practice had the potential for Resident 54 restricts freedom of movement or activity while in bed. Findings: During a review of Resident 54's Face Sheet (admission record), the Face Sheet indicated Resident 54 was admitted to the facility on [DATE] with diagnosis including, Parkinson's disease (chronic disorder that causes the brain to break down neurons that produce chemical messengers to the brain), hypertension (high blood pressure), and dementia without behavioral disturbance (impaired ability to think or make decisions without exhibiting behaviors such as agitation and depression). During a review of Resident 54's Minimum Data Set [(MDS) a standardized 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 failed to accurately assess and code for Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) for one of 19 sampled resident's (Resident 21) Minimum Data Set assessment (MDS, a standardized assessment and care-screening tool). This deficient practice had the potential to cause inaccurate care planning and inadequate provision of rehabilitation therapy and restorative nursing services for Resident 21. Findings: During a review of Resident 21's admission Record, the admission record indicated Resident 21 admitted to the facility on [DATE] with diagnoses including but not limited to hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body), left hand contracture (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), left ankle and foot contracture, left elbow…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 five sampled residents (Resident 16) had an accurate preadmission screening and annual resident review ([PASRR], is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) to determine the facility's ability to provide any special needs for the resident. This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 16. Findings: During a review of Resident 16's admission record (face sheet), the face sheet indicated Resident 16 was admitted to the facility 3/16/2016 and readmitted [DATE] with diagnosis of schizoaffective disorder, bipolar type (a mental illness that affects our mood and thoughts), major depressive disorder (persistent feeling of sadness and loss of interest), anxiety disorder (persistent and excessive worry), and bipolar disorder (a mental illness that causes unusual shifts in 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 arrange for provision of vision services for three (3) of four (4) sampled residents (Resident 4, Resident 26 and Resident 28). This deficient practice resulted in Resident 4 not having vision evaluated to prevent further decline, Resident 26 not having vision evaluated for new glasses to allow Resident 26 to read the daily chronicles, and Resident 28 not having the annual vision evaluation to maintain and/or improve his vision. Findings: a) During a review of Resident 4's admission record, the admission record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including end stage renal disease (gradual loss of kidney function), seizures (uncontrolled electrical activity in the brain that causes temporary stiffness, twitching or limpness), hypoglycemia (low blood sugar), renal dialysis (blood purifying treatment given when kidney function is not optimal), legal blindness (minimal vision even with prescription…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the physician's orders for Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) to put on a right elbow splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) and right resting hand splint included safe parameters (fixed time limits) for splint wearing time for one out of 17 sampled residents (Resident 19). This deficient practice had the potential for Resident 19 to develop pain and skin breakdown due to wearing splints for longer than Resident 19 could tolerate. CROSS REFERENCE F657 Findings: During a review of Resident 19's admission Record, the admission record indicated Resident 19 initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following…

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

Based on observation, interview, and record review, the facility failed to provide sufficient space for storage of non-therapy nursing items in order to provide adequate space for rehabilitative therapy services provided in the rehabilitation gym. This deficient practice had the potential to minimize the usable treatment space of the rehabilitation gym and create a cluttered, crowded environment for residents receiving therapy services. Findings: During an observation of the rehabilitation gym on 10/24/23 at 10:14 am, there was a white cabinet full of boxes of At-Home Coronavirus Disease 2019 (COVID-19, a highly contagious viral infectious disease) test kits (fast and individual tests that can detect the presence of COVID-19 in an individual), a crate of cardboard boxes (at least 4 large boxes) of a type of tube feeding (medical device that provides nutrition to people who cannot eat by mouth) formula, another cabinet with at least five more boxes of tube feeding formula, and underneath the cabinet were more cardboard boxes of multiple brands of tube feeding formula. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to safe guard the personal clothing of two of two sampled residents(Resident 1 and 2). These deficient practices violated Residents 1 and 2's rights and caused Resident 1 to feel sad and Resident 2 to feel angry because their personal clothing were not available for use. Findings: a. During a review of Resident 1's admission Record , the admission record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including dementia (a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities), schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) and anxiety disorder (mental illness causing persistent fear and/or worry). During a review of Resident 1's History and Physical (H/P), dated 4/1/2023, the H/P indicated, Resident 1 had the capacity to make needs known but did not have the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident, who had a history of elopement ( when a resident who is not capable of protecting or caring from themselves leaves the facility unsupervised) on 1/5/2022 and wandering (a person that roams around and becomes lost or confused about their location) had adequate supervision and monitoring (staff that are immediately at hand to redirect a resident from dangerous situations) for one of one sampled residents (Resident 1). The facility failed to: 1. Ensure Resident 1 was monitored for elopement and wandering behavior when the facility's front door was remodeled, and the wander guard sensor ( alarm to signal if a resident at risk for elopement tries to exit the facility) was disabled on 9/19/2023. 2. Ensure Resident 1's Care Plan (CP) was revised to reflect interventions to prevent elopement and wandering after the facility's front door was remodeled and the wander guard sensor was disabled on September 19,2023. 3. Ensure staff followed 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 develop and implement a comprehensive care plan for two out of three sampled residents (Resident 1 and 2). The facility failed to A. Develop and implement a care plan for Resident 1 after the resident presented with a new onset left lower extremity weakness and inability to bear weight on the left leg on 7/24/2023. B. Develop and implement a care plan for Resident 2 addressing incontinence (lack of voluntary control over urination) and risk for pressure injury (PI -result of skin damage after prolonged periods of exposure to moisture and pressure). These deficient practices had the potential to negatively affect the delivery of necessary care and services for the residents. Findings: A. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis including subdural hematoma (a buildup of blood on the surface of the brain), muscle weakness and myocardial…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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), who presented with a new onset left lower extremity weakness and inability to stand, signs and symptoms (s/s) of a possible stroke (when something blocks supply to part of the brain or when a blood vessel in the brain bursts) was continuously monitored and transferred to a General Acute Care Hospital (GACH) in a timely manner. The facility failed to: 1. Monitor Resident 1's vital signs (measurements of the body's most basic functions), and continuously assess for s/s of a possible stroke for approximately five hours until Resident 1 was transferred to the GACH. 2. Immediately inform the physician (MD) of Resident 1's change of condition (COC) on 7/24/2023 at 12:33 p.m. This deficient practice resulted in Resident 1 being unmonitored for 5 hours and a delay in Resident 1's evaluation and treatment at GACH which potentially increased the risk of harm to the resident's well-being. Resident 1 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of one resident's (Resident 1) medical records reflected resident was turned and repositioned every two hours, as needed, and as tolerated. This deficient practice placed Resident 1 at risk for not receiving the appropriate care or services which could lead to a pressure injury (PI -result of skin damage after prolonged periods of exposure to moisture and pressure). Findings: A. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis including subdural hematoma (collection of blood on brain ' s surface), muscle weakness and myocardial infarction (MI- heart attack- lack of blood flow to the heart). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care-screening tool), dated 7/21/2023, the MDS indicated Resident 1's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience,…

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