Vermont Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper urinary catheter care by maintaining the Foley catheter drainage bag below the bladder level during care for one of two sampled residents (Resident 37).This failure had the potential to cause urine backflow into the resident's bladder, increasing the risk for urinary tract infection (UTI- an infection in the bladder/urinary tract) and indwelling catheter-related complications.Findings:During a review of Resident 37's admission Record, the admission Record indicated Resident 37 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 37 with diagnoses including chronic respiratory failure (any condition that affects breathing function and result in lungs not functioning properly), benign prostatic hyperplasia (BPH, age-associated prostate gland enlargement that can cause urination difficulty) and retention of urine (difficulty emptying the bladder).During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure adequate hydration for one of three sampled residents (Resident 13), who was visually impaired (unable to see) and required assistance with fluid intake.This deficient practice resulted in Resident 13 becoming dehydrated placing the resident at risk for worsening urinary tract infection (UTI - an infection in the bladder/urinary tract), electrolyte imbalance (when the levels the blood become too high or too low), and potential hospitalization.Findings:During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing), glaucoma (a group of eye conditions that can cause vision loss or blindness), visual loss both eyed, and diabetes mellitus type 2 ( DM- a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 13's urine culture (a test that checks and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary care and services for one of two sampled residents (Resident 3) who are receiving enteral feeding (delivers liquid nutrition through a flexible tube that goes directly into the stomach or small intestine). The facility failed to:1.Ensure the tube feeding formula (liquid, specialized nutrition delivered directly to the stomach or small intestine to support health when eating by mouth is not possible or sufficient) was not administered more than 24 hours to Resident 3.This failure had the potential to cause Resident 3 to have intolerance to the tube feeding formula leading to diarrhea (loose stool), nausea, vomiting and inadequate nutrition. Findings:During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. The admission Record indicated Resident 3 with diagnoses including anoxic brain damage(brain oxygen…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record, review, the facility failed to ensure one of one sampled residents (Resident 8) received appropriate monitoring and labeling of an intravenous (IV- giving medicine, fluids, or nutrition directly into a person's vein using a small tube, allowing it to enter the bloodstream instantly) site who was on IV antibiotic (a medicine that fights infections caused by harmful bacteria) therapy.This failure had the potential to result in IV infiltration( when the IV catheter slips out of the vein, causing fluids or medication to leak into surrounding tissue), leading to pain, tissue injury, and increased risk of infection.Findings:During a review of Resident 8's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 8 with diagnoses including multiple sclerosis (a disease in which the immune system attacks the protective covering of the nerves causing nerve damage),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure respiratory care was provided according to physician's order and nasal cannula (NC-plastic tube to deliver supplemental oxygen) was dated according to the facility policy and procedure (P&P) for one of one sampled resident (Resident 150).This failure had the potential to result in residents receiving too much oxygen, delayed identification of tubing replacement, and increased the risk of infection. Findings:During a review of Resident 150's admission Record, the admission Record indicated Resident 150 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 150 with diagnoses including hydrocephalus (a condition where too much fluid builds up in the brain's fluid spaces), chronic respiratory failure (any condition that affects breathing function and result in lungs not functioning properly) and intracranial hemorrhage (a serious medical emergency where a blood vessel brakes and causes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that one of three sampled residents (Resident 44) with a physician order for fluid restriction ( a physician ordered limit on the total amount of liquids resident can consume in 24 hours to prevent fluid buildup in the body) received care and services consistent with the physician order and consistently monitor, implement, or enforce the prescribed fluid restriction. resulting in the resident receiving fluid amounts that exceeded the ordered limit.These failures resulted in Resident 44 receiving fluid amounts that exceeded the physician ordered limit, and placed Resident 44 at risk for adverse health outcomes and demonstrated a lack of adherence to Resident 44's individualized plan of care and physician orders.Findings:During a review of Resident 44's admission Record, the admission Record indicated Resident 44 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 44 with diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to act on recommendations from the consultant pharmacist (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) from 1/29/2026, 2/27/2026 and 3/29/2026 regarding clarifying Resident 10's diagnosis to support the use of Seroquel (generic name - quetiapine, a medication used to treat schizophrenia (a mental illness that is characterized by disturbances in thought), affecting one of five residents sampled for review of unnecessary medications (Resident 10). This deficient practice of failing to respond to recommendations from the consultant pharmacist resulted in Resident 10 receiving quetiapine for an unclear diagnosis and/or indication possibly resulting in medication side effects (a secondary, typically undesirable effect of a drug or medical treatment) leading to a decrease in physical, mental, or psychosocial well-being.Findings:During a review of Resident 10's admission Record, the admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 40) was free from unnecessary drugs. The facility failed to:1.Monitor Resident 40 for side effects (secondary effects of a medication that may be beneficial or harmful) and adverse reactions (undesirable, harmful effects) associated with opioid (class of drugs used to reduce moderate to severe pain and can affect brain areas controlling emotion and breathing) use. Resident 40 was receiving Oxycodone (strong, addictive opioid medication used to manage severe and ongoing pain) 15 milligrams (mg- unit of measurement) by mouth every six hours and 7.5 mg (half tablet) at bedtime, and Morphine Sulfate (prescription-only potent narcotic pain reliever) 15 mg by mouth every 12 hours, both of which are potent opioid medications used to manage severe and ongoing pain.This failure had the potential to result in Resident 40 experiencing an unrecognized and unidentified adverse side effect (undesirable harmful effect)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5 percent (%) during medication pass for two of six sampled residents (Residents 128 and 159) by failing to:1. Ensure Resident 128's Keppra ([generic name - levetiracetam] a medication used to treat seizures {a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness}) was administered within one hour before or after its scheduled time of administration, as per facility's policy and procedure (P&P) titled, Medication Timing of Administration Policy, dated 2024.2. Ensure Resident 159's gastrostomy tube ([g-tube] a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problem) was flushed with water before and after natural psyllium husk ( medication to treat constipation) was administered via g-tube, in accordance with physician…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent a significant medication error for one out of six sampled residents (Resident 128) during medication administration, by failing to administer Resident 128's Keppra ([generic name - levetiracetam] a medication used to treat seizures) within one hour before or after its scheduled time of administration, as per facility's policy and procedure (P&P) titled, Medication Timing of Administration Policy, dated 2024.This deficient practice failed to ensure Resident 128's Keppra was administered in accordance with physician's orders or professional standards of practice and had the potential to result in seizures and hospitalization.Findings:1. During a review of Resident 128's admission Record, the admission Record indicated, Resident 128 was originally admitted to facility on 2/9/2026 and readmitted on [DATE]. The admission Record indicated Resident 128 with diagnoses including but not limited to hemiplegia (total paralysis [loss of…

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

Based on observation, interview, and record review the facility failed to practice standard hygienic practices in the kitchen when two staff members failed to wear beard restraints (coverings designed to cover facial hair including beards, mustaches, and goatees in the food service) during food preparation. This deficient practice had the potential to result in harmful bacterial growth that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or toxins) in 136 of 166 medically compromised residents receiving meals from the kitchen.Findings:During an observation on 4/22/ 2026, at 10:00 a.m., kitchen staff (AM Cook) was observed standing at the food preparation table with an uncovered beard approximately two to three inches in length around the chin while seasoning chicken on a baking sheet, without wearing a beard net or restraint. After placing the chicken in the oven, the AM [NAME] returned to the preparation table and began chopping fresh zucchini for the lunch meal. During the concurrent observation, the Assistant Dietary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 clinical weight records were complete and accurate, and failed to identify and verify the weight loss documented in the medical record for one of six sampled residents (Resident 4) reviewed for nutritional status. This failure placed the resident at risk for not receiving timely clinical evaluation and intervention.Findings:During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE], and readmitted on [DATE]. The admission Record indicated Resident 4 with diagnoses including chronic respiratory failure (any condition that affects breathing function and result in lungs not functioning properly), dependence on respirator (ventilator- a machine for artificial breathing), and atrial fibrillation (irregular heart rate that can cause poor blood flow).During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool), dated 2/9/2026, the MDS indicated Resident 4's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review, the facility failed to ensure one of five sampled residents, Resident 1 was provided with a dignity bag (a bag covering Foley catheter [soft, thin, and [NAME] tube that helps a person go to the bathroom when they can't do it on their own] ) for the Foley catheter while seated in wheelchair in the hallway.This failure has the potential to compromise the resident's dignity. During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted on [DATE] to the facility with the diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side (total paralysis of the arm, leg, and trunk the left side of the body following a stroke), difficulty in walking, anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 11/24/2025, the MDS indicated the resident had the ability to make…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure the Interdisciplinary Team (IDT-a team composed of members from different departments working collaboratively to set goals and make decisions that ensure residents receive optimal care) initiated a care conference for one of two sampled residents (Resident 2) following an alleged resident-to-resident altercation (an incident involving two residents fighting or mistreating each other). This failure had the potential to delay addressing Resident 2's care needs, resulting in a delay in necessary interventions.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including unspecified dementia ( a progressive state of decline in mental abilities) generalized anxiety disorder( mental health condition marked by persistent, excessive and uncontrollable worry about everyday things), unspecified psychosis,(a severe mental condition in which thought, 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 resided at the facility and was transferred to a General Acute Care Hospital (GACH) 2 on 6/23/2025 for evaluation and treatment and was readmitted to the facility on [DATE] after Resident 1 was treated and stabilized at the GACH 1. This deficient practice resulted in Resident 1 remaining at GACH 1 for 3 days after Resident 1 was deemed appropriate to go back to the facility on 7/28/2025. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (medical condition where a part of the brain is damaged or dies due to a lack of blood supply) affecting left dominant side,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to assist one of three residents (Resident 2) to shower at least twice a week.This deficient practice had the potential to result in poor hygiene for Resident 2 which can lead to poor self-image and discomfort. Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including muscle weakness, difficulty in walking, and history of traumatic brain injury (type of brain injury that occurs when an external force causes damage to the brain).During a review of Resident 2's Minimum Data Set (MDS), a resident assessment tool, dated 5/23/2025, the MDS indicated Resident 2's cognition was severely impaired. The MDS indicated Resident 2 needed partial assist (helper does less than half the effort to complete the task) with showring and toileting hygiene, and supervision with oral and personal hygiene.During a review of Resident 2's Care Plan report, the care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medication was not left on one of three resident's (Resident 1) bedside table.This deficient practice had the potential to result in visitors, residents, and staff unauthorized access and use of Resident 1's medication and could result in a medication error.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (condition characterized by weakness or partial paralysis affecting one side of the body) affecting left dominant side, type 2 diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), and low back pain. During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 6/21/2025, the MDS indicated Resident 1's cognitive skills (ability to think and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement care plan interventions for one of one resident (Resident 1) by failing to ensure visual checks were done and documented to prevent falls.This deficient practice resulted in Resident 1 having an unwitnessed fall that resulted in a bilateral (both sides) inferior pubic ramus (bony structure that forms part of the pelvis [bones between the lower stomach and upper thighs that connect the spine to the leg]) and right superior ramus (branch of the pelvic bone that make up part of the pelvis) fracture that required hospitalization at the General Acute Care Hospital (GACH). Findings:During a review of Resident 1's admission Record (Face Sheet), the admission Record indicated Resident 1 was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses including fracture of right ischium (paired bone forming the lower and back part of the hip bone), fracture of right pubis, (lower and front part of each side of the hip bone), wedge…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 physician for one of three sampled residents (Resident 1) was notified when Resident 1 had scant bleeding to her tracheostomy stoma (an opening surgically created through the neck into the trachea [windpipe] to allow air to fill the lungs) site, and complaints of pain, following the change of the tracheostomy tube. This deficient practice resulted in Resident 1's physician being unaware of Resident 1's change of condition (COC) and the inability of the physician to give instructions for Resident 1's care. This deficient practice placed Resident 1 at risk for continued bleeding and pain. Findings: During a review of Resident 1' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses including cerebral infarction ([stroke] brain tissue death caused by a lack of blood flow, often due to a blocked blood vessel), tracheotomy status (an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a change of condition (CIC/COC- noticeable shift or alteration in a patient's physical, mental, or functional stated, requiring attention and potentially promoting further medical evaluation or intervention) evaluation for three out of five residents when Resident 2, Resident 3, and Resident 5 were exposed to Coronavirus disease ([COVID 19] an infectious disease caused by the SARS-SoV-2 virus). This failure has the potential to result in missing identification of potential symptoms or complications, risking the health and safety of the residents. Findings: a. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 12/27/2024 with diagnosis including Hemophilus influenzae (a type of bacteria that can cause various infections, especially in children, ranging from mild ear infections to serious illnesses like meningitis) During a review of Resident 2's Minimum Data Set (MDS- a 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 wear proper personal protective equipment ([PPE] specialized clothing and equipment like gloves, gown, masks, and eye protection, used to create a barrier between healthcare workers and potential sources of infection) prior to entering the rooms of three out of five sampled residents (Resident 6, Resident 7 and Resident 8), which were designated as Novel Respiratory Precaution room. a. Housekeeping (HK) 1, Certified Nurse Aid (CNA) 1 entered Resident 6 and Resident 7's room without proper PPE. b. one Charge Nurse (CN) 1 entered Resident 8's room without proper PPE. These failures have the potential to result in an increased number of transmitted diseases in the facility, adding to the total accumulation of Coronavirus disease ([COVID 19] an infectious disease caused by the SARS-SoV-2 virus) cases among resident 28 and staff 25 over the previous two weeks. Findings: a. During a review of Resident 6's admission Record, the admission 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: 1.Failed to ensure morning medication administrations were done on time in the subacute unit (SAU, a nursing unit that provides a level of medical care that is less intensive than acute care but more specialized than typical skilled nursing care) for seven (7) of 26 residents on 3/12/25 and 4 of 25 SAU residents on 3/13/25. 2.Failed to ensure medications were checked for accuracy upon delivery receipt and before administration. As a result, the Zosyn (piperacillin sodium and tazobactam sodium, an antibiotic combination that treat certain infections) intravenous (IV, into the vein) medications for 2 of 2 sampled residents (Residents 22 and 44) were not administered in accordance with the physician orders. The facility pharmacy failed to communicate the changes in physician's order with the facility and the prescriber. 3.Failed to ensure the emergency drug usage log was complete with details. These failures had the potentials of medication errors and/or adverse effects. Findings: 1. During an interview on 3/12/25 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure two of three reviewed residents were free of significant medication errors as evident by: 1.The facility administered intravenous (into the vein) antibiotic (medication to treat infection) not in accordance with physician's order for two (2) of 2 sampled (Resident 22 received 30 of 36 doses in total and Resident 44 received 19 of 22 doses). These deficient practices had the potentials of worsening residents' health conditions. 2.Failing to administer Resident 361's Liothyronine (a medication used to treat hypothyroidism {when the thyroid gland doesn't make enough thyroid hormones to meet your body's needs}). This failure of failing to administer medications in accordance with the physician orders increased the risk for Resident 361 to potentially experience hypothyroidism symptoms such as constipation (problem with passing stools), feeling weak, and weight gain. Findings: 1.During a review Resident 22's admission Record, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a Change of Condition (COC) and notify physician for two of three residents (Resident 48 and Resident 362) when Resident 48 verbalized he wanted to die, and when Resident 362 missed a scheduled thyroid (a small gland in your neck) medication. This failure resulted in the lack of necessary care and treatment and had the potential to result in Resident 48 harming himself and Resident 362 developing hypothyroidism (when the thyroid gland doesn't make enough thyroid hormones to meet your body's needs). Findings: During a review of Resident 48's admission Record, the admission Record indicated Resident 48 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including paranoid schizophrenia (a mental illness that is characterized by disturbances in thought with intense paranoia, leading to false beliefs), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) 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 provide services to five of 11 reviewed residents (Resident 62, 109, 112, 40, and 121) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) by failing to: 1.Provide Resident 62 with passive range of motion ([PROM] movement of a joint through the ROM with no effort from person) to both arms in accordance with the Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Discharge summary, dated [DATE]. 2.Provide Resident 62 with active assistive range of motion ([AAROM] use of muscles surrounding the joint to perform the exercise but requires some help from a person or equipment) exercises to both legs, five times per week, from 9/2024 to 3/2025 in accordance with Resident 62's physician orders. 3.Provide Resident 109 with PROM to both arms and legs, five times per week, 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 observation, interview, and record review, the facility failed to: 1.Ensure there was sufficient Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) staff to provide treatment to five of 11 reviewed residents (Resident 62, 109, 112, 40, and 121) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move). This failure had the potential for Resident 62, 109, 11, 40, and 121 and other residents with physician orders for RNA to experience a decline in range of motion [ROM, full movement potential of a joint (where two bones meet)] and mobility (ability to move). 2.Ensure there was sufficient licensed nurses in the subacute unit (SAU, a nursing unit that provides a level of medical care that is less intensive than acute care but more specialized than typical skilled nursing care). This failure resulted in late administration of medication for seven (7) of 26 residents in SAU…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that medication error rate was less than five percent (%). Two medication errors out of 32 total opportunities contributed to an overall medication error rate of 6.25 % for two residents (Resident 134, and 22) observed during medication administration (MedPass). This deficient practice of medication administration error rate of 6.25 percent (%) exceeded the five (5) percent (%) threshold and had the potential of adversely affecting residents' health condition. Findings: 1. During a medication administration observation on 3/13/25 at 8:59 a.m., outside Resident 134's room, the Licensed Vocational Nurse (LVN 2) was preparing Resident 134's medications. In total, LVN 2 administered eight (8) medications to Resident 134. One of those 8 medications was Mucinex DM (brand name for guaifenesin and dextromethorphan, a combination medication to treat cough and chest congestion) 600/30 milligrams (mg- unit to measure mass) extended-release…

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

Based on observation, interview, and record review, the facility failed to ensure the intravenous (IV, into the vein) antibiotic (medicines that fight bacterial infections) medications had labels in accordance with the physician orders for two (2) of 2 sampled residents (Residents 22 and 44). This failure had the potential of medication error. Findings: During a concurrent observation, interview and record review on 3/13/25 at 11:19 a.m., Registered Nurse Supervisor (RNS 4) was in Resident 22's room at bedside and Resident 22 was receiving an IV medication. The surveyor asked to see the label of the Resident 22's IV medication. RNS 4 stated the label on Resident 22 IV medication read piperacillin sodium and tazobactam sodium (antibiotic combination that treat certain infections, also known as Zosyn) 3.375 gram (gm, unit to measure mass) in 100 milliliter (ml, unit to measure volume) of 0.9% sodium solution (normal saline, NS, a mixture of water and salt, or sodium chloride, with a salt concentration of 0.9%; it is a form of IV fluids used for fluid replenishment and compound with IV…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure the ice machine had an air gap for back flow (the unwanted reverse flow of contaminated water) prevention. This failure had the potential to expose residents to food-borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites) and put residents at risk for cross contamination (unintentional transfer of harmful bacteria from one object to another). Findings: During an observation on 3/11/25 at 8:14 am in the kitchen. The ice machine pipe leading to the drain had black grime and dirt on it and there was no air gap between pipe and ice machine drain. During a concurrent observation and interview on 3/14/2025, at 7:26 a.m. with Assistant Dietary Supervisor (ADS) in the kitchen ice machine room. The ADS stated there was black dirt on the pipe leading to the drain. The ADS stated he was not aware of the air gap Food Drug Administration (FDA) FDA Food Code 5-202.13. During a concurrent observation and interview on 3/14/2025, at 7:26 a.m. with the Registered Dietician (RD)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 did not provide accurate documentation for five of 11 reviewed residents (Resident 62, 40, 112, 133, and 109) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) by failing to: 1.Ensure Resident 62's Documentation Survey Report (record of nursing assistant tasks) from 3/2024 to 3/2025 (one year) included a task for the Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) to perform active assistive range of motion ([AAROM] use of muscles surrounding the joint to perform the exercise but requires some help from a person or equipment) exercises to the right leg in accordance with the physician's order. 2.Ensure Resident 40's Documentation Survey Report from 7/2024 to 11/2024 (5 months) included a task for the RNA to perform left arm passive range of motion ([PROM] movement of a joint through the ROM with no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain and observe infection control practices by: 1.Failing to maintain an appropriate and recommended temperature of one of three linen dryers. 2.Failing to perform hand hygiene between residents. 3. Failed to handle clean linens in a safe and sanitary manner in the laundry room. 4.Failing to clean two of two cloth gait belts (assistive device placed around a person's waist to assist with safe transferring between surfaces or while walking) used with Resident 134, 143, and 16 in accordance with the manufacturer's recommendations for disinfecting wipes (pre-moistened towelettes that contain a sanitizing or disinfecting formula that kill or reduce germs on surfaces). These failures had a potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and place residents at risk for spread of infection. Findings: 1.During a concurrent observation and interview on…

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

Based on observation, interview, and record review, the facility failed to ensure laundry washers were maintained in operational condition for 160 of 160 residents by failing to ensure the washer temperature gauges were functioning properly. This failure had the potential to affect the resident's health and place the residents at risk for the spread of infection. Findings: During a concurrent observation and interview on 3/13/2025 on 7:36 a.m., in the laundry room with the Maintenance Supervisor (MS), it was observed three of three washer temperature gauges were not functioning properly. The MS stated the temperature gauges so not always work and he uses a thermometer to check the sink water temperature to monitor the washer temperatures. The MS demonstrated how he checked the temperatures by taking the thermometer, turned on the sink across from the washers, sticking the thermometer under the water, and recorded the reading on the boiler temperature log. The MS stated the washer temperature gauges are not accurate and that is why he uses the sink water temperatures stating they 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 failed to ensure a preadmission screening resident review (PASARR) level II was completed for one of two sampled residents (Resident 22). This deficient practice had the potential to result in an inappropriate placement and delay of needed services for Resident's 22. Findings: During a review of Resident 22's admission Record, dated 3/14/2025 Resident 22's admission record indicated Resident 22 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including major depressive disorder (depressed mood causing significant impairment in daily life) schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) . During a review of Resident 22's Minimum Data Set ({MDS}- a resident assessment ) the MDS dated [DATE], indicated Resident 22 has moderate cognitive impairment (difficulty with thinking, remembering, making decisions, and understanding things). The MDS also indicated Resident 22 was taking a antipsychotic 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 implement a care plan for one of three sampled residents (Resident 48). This failure had the potential to place Resident 48 at risk for a delay of care and treatment. Findings: During a review of Resident 48's admission Record, the admission Record indicated Resident 48 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including paranoid schizophrenia (a mental illness that is characterized by disturbances in thought with intense paranoia, leading to false beliefs), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and cerebral infarction (loss of blood flow to the brain). During a review of Resident 48's Minimum Data Set ({MDS}- a resident assessment tool), dated 1/23/2025, the MDS indicated Resident 48 was moderately cognitively (ability to think, understand, learn, and remember) impaired and required substantial assistance with showering/bathing, dressing, 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 four reviewed residents (Resident 218) had a Interdisciplinary Team (a group of healthcare professionals from different disciplines who collaborate to provide comprehensive and coordinated patient care) meeting scheduled within 72 hours after Resident 218 was admitted to the facility on [DATE] to discuss Resident 218's plan of care. This failure resulted in Resident 218 not aware of his plan of care and not being involved and unable to participate his plan of his care. Findings: During a review of Resident 218's admission Record, the admission Record indicated Resident 218 was admitted to the facility on [DATE] with diagnoses including motor-vehicle accident, right humerus upper arm bone) fracture (broken bone) , left tibia lower leg bone) fracture, and scalp (skin covered area on the top of the head) contusion (also known as a bruise, occurs when blood vessels break under the skin, causing blood to leak and become trapped). 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 ensure one of five sampled residents (Resident 154) who was dependent with activities of daily living ([ADL's]- activities such as bathing, dressing and toileting a person performs daily) received the necessary care and services to maintain good grooming, and personal hygiene. These deficient practices resulted in Resident 154 to experience pressure injury (is damage to the skin and underlying tissues caused by prolonged pressure, friction, or moisture, often leading to open sores or wounds) and had the potential to delay wound healing. Findings: During a review of Resident 154's admission Record, the admission Record indicated Resident 154 was admitted to the facility on [DATE], with diagnoses including Stage 4 (wound that penetrate all layers of skin exposing muscles, tendons [tissue that unites a muscle with a bone] cartilage {tissue that lines a joint}, and bones caused by prolonged pressure on the skin) pressure injury on her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assist resident who receive proper assistive devices to maintain hearing abilities for one of three sample residents (Resident 20). This failure resulted in a delay in services and Resident 20 not being able to hear adequately during a conversation. Findings: During a review of Resident 20's admission Record, the admission Record indicated Resident 20 was admitted to the facility 12/27/2024 with diagnoses including hyperlipidemia (high cholesterol) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 20's Minimum Data Set ({MDS}- a resident assessment tool) dated 1/3/2025, the MDS indicated Resident 20's cognition (ability to think, understand, learn, and remember) was intact and was dependent (helper does all the effort) with toileting and bathing. During a review of Resident 20's care plan initiated 12/26/2024, the care plan indicated Resident 20 has a communication deficit, hearing impaired with goals that included. During a review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure one of two sampled residents, Residents 22 intravenous catheter (IV - a flexible tube that's inserted into vein to deliver fluids or medications) was rotated when Resident 22's IV site was not changed for nine days. This deficient practice had the potential to cause an infection at the insertion site. Findings: During a review of Resident 22's admission Record, dated 3/14/2025 Resident 22's admission record indicated Resident 22 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including major depressive disorder (depressed mood causing significant impairment in daily life) schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) . During a review of Resident 22's ({MDS}- a resident assessment tool) the MDS dated [DATE], indicated Resident 22 has moderate cognitive impairment (difficulty with thinking, remembering, making decisions, and understanding things). The MDS also…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident who were receiving hemodialysis (clinical purification of blood as a substitute for the normal function of the kidney) treatments was provided with an emergency dialysis kit at bedside, in order to respond to a potential medical complication for one of two sampled residents (Resident 5). This deficient practice had the potential to cause a delay in treatment in case of an emergency. Findings: During a review of Resident 5's admission Record, dated 3/14/2025 Resident 5's admission record indicated Resident 5 was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses including end stage renal disease ( ESRD (End Stage Renal Disease-irreversible kidney failure) dependent on renal dialysis, type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing. During a review of Resident 5's ({MDS}- a resident assessment tool) the MDS dated [DATE], indicated…

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

Based interview, and record review the facility failed to ensure staffing information was accurate and current on 1/13/25,2/12/25, 3/9/25 and 3/10/25. This deficient practice had the potential to affect the care of all the residents in the facility and for resident needs to go unmet. Findings: During a concurrent interview and record review on 3/14/25 at 10:24 a.m. with the Director of Staff Development (DSD), the facility's Sub Acute Unit Census ( count of the number of people (patients, residents, etc.) who are currently under the care or in residence at a specific facility at a given time) and Nursing Staffing Assignment and Sign-In Sheet ( a document used in healthcare facilities to track and verify nursing staff assignments, ensuring accurate documentation of hours worked and verification of presence and duties performed) dated 1/13/25, 2/12/25, 3/9/25 and 3/10/25 were reviewed. The DSD stated she was responsible for the staffing at the facility and ensuring that the daily census was accurate and reflects the Nursing Staffing Assignment and Sign-In Sheets reflect the current…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 residents (Resident 78) was provided necessary behavioral health care and services for the treatment of the residents emotional and mental condition by ensuring: 1.Resident 78 who verbalized feelings of wanting to die was assessed, monitored, and provided interventions to address Resident 78's feelings of wanting to die. 2.Physician, psychiatrist (a physician who specializes in psychiatry, the branch of medicine devoted to the diagnosis, prevention, study, and treatment of mental disorders), psychiatrist nurse practitioner, and interdisciplinary team ([IDT]-comprises professionals from various disciplines who work in collaboration to address a patient with multiple physical and psychological [mental and emotional) needs) were notified when Resident 48 verbalized wanting to die. These failures resulted in Resident 78 not receiving the necessary care, services, and interventions to address Resident 78's emotional,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 112) is free of unnecessary psychotropic medicine(any drug that affects brain activities associated with mental processes and behavior) by failing to: 1.Ensure Resident 112 had a gradual dose reduction(GDR-tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the medication can be discontinued altogether) assessment by the facility or documentation by the physician the dose reduction was not recommended. Resident 112 was on Zoloft(medicine that treat depression) since 11/2/2023. 2.Ensure Resident 112 was seen and evaluated by a psychiatrist when Resident 112 was placed on Zoloft on 11/3/2023 and diagnosed with depression on 1/15/2024. These failures had the potential to place Resident 112 at risk for using psychotropic medicine for excessive duration and without adequate monitoring which could lead to development of adverse effects from the medicine 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 Resident 10 was provided with lower dentures. This deficient practice had the potential to result in weight loss because of inability to effectively chew foods for Resident 10. Findings: During a review of Resident 10's admission Record, dated 3/14/2025 Resident 10's admission record indicated Resident 10 was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses including protein calorie malnutrition, muscle weakness, dementia (a progressive state of decline in mental abilities), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing. During a review of Resident 10's ({MDS}- a resident assessment tool) the MDS dated [DATE], indicated Resident 10 is cognitively intact. The MDS also indicated, Resident 10 needs substantial assistance (helper does more than half the work) with activities of daily living (ADL's - activities such as toileting, bathing 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's Quality Assessment and Assurance Committee ([QAA] develop and implement appropriate plans of action to correct identified quality deficiencies) failed to ensure effective oversight of the facility and implementation of the facility's plan of correction (POC) of the deficient practices identified during the previous recertification survey. This failure resulted in the facility having repeat deficiencies in the areas of activities of daily living care provided for dependent residents, increase and prevent the decrease in range of motion and mobility, pharmacy services, procedures and pharmacist records, free of medication error rates five percent or more, and labeling and storage of drugs and biologicals. Findings: During a review of the facility's Statement of Deficiencies for the 2024 Recertification survey indicated the following repeat deficiencies: activities of daily living care provided for dependent residents, increase and prevent the decrease in range of motion and mobility, pharmacy services, procedures and pharmacist…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its protocol for antibiotic stewardship program (coordinated program that promotes the appropriate use of antibiotics by clinicians) on one of four sampled residents ( Resident 91) by failing to monitor and address antibiotic use for Resident 91. This failure had the potential to put Resident 91 at risk for antibiotic resistance (ability of bacteria and other microorganisms to withstand the effects of antibiotics, rendering them ineffective) or inappropriate use of antibiotic. Findings: During a review of Resident 91's admission Record, the admission Record indicated the resident was admitted on [DATE] to the facility with diagnoses that included atrial fibrillation(abnormal, and irregular heartbeat), retention of urine(when the bladder does not empty completely) benign prostatic hyperplasia (BPH- enlarged prostate gland) and obstructive and reflux uropathy ( condition where urine flow is blocked in the urinary tract causing damage to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain a functional call light ( device or button that the residents can press to signal staff for assistance) for one of four sampled residents (Resident 139) by failing to follow facility's policy and procedure regarding call light system. This failure had the potential to result in a delay in meeting Resident 139's needs for assistance which could lead to falls and accidents if assistance is not provided in a timely manner. Findings: During a review of Resident 139's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included repeated falls, muscle weakness, unspecified dementia (a progressive stated of decline in mental abilities),and legal blindness(having very poor eyesight even with glasses or contacts or a severely limited field of vision). During a review of Resident 130's Minimum Data Set (MDS- a resident assessment tool) dated 12/20/2024,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure accurate picture of the resident ' s status on the Minimum Data Set (MDS- a resident assessment tool) related to fall on one of three sampled residents (Resident 4) to reflect Resident 1 ' s fall on 1/4/2024. This failure had the potential to negatively affect Resident 4 ' s plan of care and delivery of necessary care and services. Findings: During a review of Resident 4 ' s admission Record, the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including fracture of unspecified neck of right femur, right humeral fracture, history of falling, muscle weakness and bilateral primary osteoarthritis of the hip (a condition that occurs when the cartilage that lines your joints is worn down ). During a review of Resident 4 ' s Minimum Data Set (MDS-resident assessment tool) dated 2/23/2024, the MDS Section J ( section dedicated to assessing resident ' s health condition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to observe infection control measures on one of three sampled residents (Resident 1) by failing to ensure a visitor was wearing personal protective equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) prior to entering Resident 1 ' s room who was on droplet precautions( a set of infection control measures used to prevent the spread of respiratory illnesses through droplets that are generated by a resident who is coughing, sneezing or talking). This failure had a potential to place residents and staff members at risk for the spread of infectious diseases. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the resident was admitted on [DATE] to the facility with diagnoses that included hemiplegia and hemiparesis following a cerebral infection affecting the right dominant side ( weakness or paralysis on the right side of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure medical records were complete, legible, organized, and were readily available for one of three sampled residents (Resident 1) according to the facility ' s policy and procedure (P&P) titled Health Information Record Manual – Chapter III Legal Health Record. This deficient practice had the potential to cause miscommunication and confusion amongst the health care team due to illegible and/or missing documentation of Resident 1 ' s records which could result in Resident 1 to incur medication errors, a delay in care, and inability for Resident 1 to live at her highest practicable level. Findings: During a review of Resident 2 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 2 was readmitted to the facility on [DATE] with diagnoses including pressure-induced deep tissue damage (deep layers of muscle and connective tissues), epilepsy (seizures), hemiplegia (loss of strength) and hemiparesis (paralysis) following a cerebral…

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

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 3) had tracheostomy (an opening surgically created through the neck into the trachea (windpipe) to allow direct access to the breathing tube) care that included changing the tracheostomy tie (a device made of cloth and Velcro used to help stabilize and keep the tracheal cannula secure and in place) and applying a tracheostomy dressing (a covering that protects the area around a tracheostomy and absorbs secretions from the tracheostomy site) after showering. This failure resulted in Resident 3 ' s tracheostomy tie and tracheostomy dressing becoming wet after showering on 9/13/2024 and had the potential for Resident 3 to develop skin breakdown or infection due to a wet tracheostomy tie and tracheostomy dressing. 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 acute respiratory…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 responsible party of change of condition, when it was discovered that a resident was noted to have a skin tear on her left forearm for one out of three sampled residents, Resident 1. This deficient practice had violated the resident ' s responsible party right to be informed of the care services provided. Findings: During a review of Resident 1 ' s admission record, Resident 1 was admitted on [DATE]. Diagnosis included unspecified dementia with psychotic disturbance (a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities and includes delusions or hallucinations), unspecified schizophrenia (a mental disorder that affects a person ' s ability to think, feel, and behave clearly), unspecified psychosis not due to a substance or physiological condition (inadequate information to make the diagnosis of a specific psychotic disorder), and unspecified glaucoma (a disease…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to re-admit one of three sampled residents (Resident 1), who was transferred to a General Acute Care Hospital (GACH) due to unresponsiveness for evaluation and treatment and not allowed readmission when the GACH wanted to transfer Resident 1 back to the facility. This deficient practice resulted in Resident 1 remaining at the GACH for 16 days after being cleared by the GACH to return to the facility. 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]. Resident 1's diagnoses included acute (sudden or severe) and chronic (having an illness persisting for a long time or constantly recurring) respiratory failure (when the lungs cannot provide enough oxygen or can't remove enough carbon dioxide [a colorless odorless gas that is a waste product in the human body] from the body) tracheostomy (an opening surgically created through the neck into 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 implement Enhanced Standard Precautions (ESP), precautions utilized to prevent the spread of multidrug resistant organisms ([MDROs]- Bacteria that resist treatment with more than one antibiotic [medication that treat bacterial infections]) for three of three sampled residents ( Resident 1, 3, and 4) , who had a gastrostomy tube (Gtube- tube inserted in belly that allows to administration of nutrition and medication) and tracheostomy (surgical opening in the neck where a tube is placed to allow for air to enter lungs). The facility failed to 1) Ensure LVN 1 and LVN 2 had the proper understanding of ESP. 2) Ensure proper signage on the door of residents requiring ESP. 3) Ensure licensed vocational nurse (LVN) 1 and 2 used an isolation gown when providing high contact resident care such as dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, device care (gastrostomy tube)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 free from abuse by facility staff, for one of three sampled residents (Resident 1), as evidenced by: 1.Certified Nursing Assistant (CNA) slapped Resident 1's left forearm. 2. Registered Nurse Supervisor (RNS) did not separate Resident 1 from CNA 3 after the incident. These deficient practices had the potential to subject Resident 1 for further abuse and had the potential to cause feelings of intimidation, neglect and not feeling safe in the facility. Findings: During a review of Resident 1's Face Sheet (admission record), the Face Sheet indicated Resident 1was originally admitted to the facility on [DATE] with diagnoses that included unspecified dementia (impaired ability to remember, think, or make decisions that interferes with everyday activities) , unspecified severity, without behavioral disturbance ( a persistent and repetitive pattern of behavior that can create distress in others at risk), mood disturbance ( a condition that causes…

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

Based on interview and record review, the facility failed to document, for one of three sampled resident's (Resident 1), records accurately and completely when Resident 1 had a change of condition. This failure has the potential to result in an inaccurate depiction of care and services rendered for Resident 1. Findings: During a review of Resident 1's Face Sheet (admission record), the Face Sheet indicated Resident 1 original admission date was 2/15/2024 with diagnoses that included unspecified dementia (impaired ability to remember, think, or make decisions that interferes with everyday activities), mood disturbance (a condition that causes extreme happiness or sadness for a long period of time), and anxiety (a pervasive feeling of worry that affects daily life). During a review of Resident 1's Minimum Data Set (MDS), a standardize assessment tool, dated 2/22/2024, the MDS indicated Resident 1 has severe cognitively impairment (when someone has difficulty learning, remembering, concentrating, making decisions, or understanding the meaning of something) and required substantial…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect one of three sampled residents (Resident 1), right to be free from physical abuse by Resident 2. Facility failed to: 1. Separate Resident 1 and Resident 2 when CNA 1 witnessed Resident 2 hit Resident 1 on the face on 4/13/2024. 2. Separate Resident 1 and Resident 2 when Resident Representative ([RR] for Resident 1 (resident ' s legal guardian acting on behalf of the resident with the written consent of the resident, or a surrogate) reported the allegation of physical abuse to Registered Nurse (RN) 1 on 4/15/2024. These deficient practices placed Resident 1 at risk for further abuse and had the potential to cause feelings of intimidation, neglect and not feeling safe in the facility which was considered their home. Findings: During a review of Resident 1 ' s admission Record, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including major depressive disorder (a mental health disorder characterized by persistently…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 an allegation of abuse were reported to the state agency (Department of Public Health (DPH) or the police department within two hours of the occurrence of incident and no later than 24 hours for one of three sampled residents (Resident 1). This deficient practice had the potential to result in unidentified abuse in the facility and had the potential for Resident 1 to experience further abuse from Resident 2. Findings: During a review of Resident 1 ' s admission Record, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), transient ischemic attack ([TIA] a short period of symptoms similar to those of a stroke), and heart failure ( a lifelong condition in which the heart muscle can't pump enough blood to meet the body's needs). 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 interview and record review the facility failed to ensure Licensed Vocational Nurse (LVN) 1 had training on preventing all forms of abuse, and procedures for reporting incidents of abuse. This deficient practice had a potential to place the residents at risk for elder abuse, neglect and exploitation or misappropriation of resident property and inappropriate dementia management. Findings: During a review of Resident 1 ' s admission Record, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), transient ischemic attack ([TIA] a short period of symptoms similar to those of a stroke), and heart failure ( a lifelong condition in which the heart muscle can't pump enough blood to meet the body's needs). During a review of Resident 1 ' s History and Physical (H&P), dated 12/13/2023, the H&P 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.

During observation, interview, and record review the facility failed to ensure Dietary Aide (DA) 1 had the appropriate training on how to operate the dishwasher machine. This deficient practice had the potential to result in unsanitized dishes that could lead to foodborne illness (infectious organisms or their toxins are the most common causes of food poisoning with symptoms that may include cramping, nausea, vomiting (throwing up) or diarrhea (loose stool) including death) of 152 residents who received food from the facility kitchen. Findings: During a concurrent observation and interview on 3/5/24 at 9:00 a.m. with Dietary Aide (DA) 1 in the kitchen, DA 1 was observed unable to locate thermometer for dishwasher. DA 1 stated he did not know where the thermometer was located and that he did not receive training on how to operate the dishwasher upon hire. DA 1 stated, it was his responsibility to know how to operate the dishwasher and check the temperature. DA 1 stated it was important to ensure the temperature was the correct range to kill bacteria on the dishes so that 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 implement and maintain infection control measures by: 1.Failing to practice hand hygiene (a way of cleaning hands that substantially reduces potential pathogens (harmful microorganisms) on the hands) during provision of care to Resident 98. 2.Failing to ensure dirty linen was not laying on the landing pad (floor mats designed to provide a cushioned and reduce the likelihood of injury to fall risk resident.) on the floor of Resident 98. 3.Failing to monitor washer and dryer temperature. These failures had the potential to spread transmissible diseases to residents, staff members and visitors. Findings: 1.During a review of Resident 98's admission Record, the admission Record indicated Resident 98 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) following cerebral infarction( weakness 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 provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of their individuality by: A. Failing to place the call light within reach for Resident 109 and 55. This deficient practice resulted in Resident 109 and 55 not being able to call facility staff for help when needed and felt helpless. B. Failing provide shower/bed bath to Resident 99 when Resident 99 was observed wearing dirty hospital gown with food crumbs resting on neck folds and chest for two days. C.Failing to provide privacy to Resident 99 during a bed bath, when Certified Nursing Assistant (CNA) 1 left Resident 99 half-naked and did not cover the resident while CNA 1 was getting some clothing from Resident 99's closet. These deficient practices resulted in Resident 99 feeling embarrassed, cold and exposed and had the potential to lower Resident 99's self-esteem. Findings: A. During a review of Resident 109's admission Record, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide activities of daily living ( activities related to personal care including bathing,showering,dressing dressing, getting in and out of bed or a chair, walking, using the toilet, and eating ) to two of 13 sampled residents ( Resident 47 and 99) when: A.Resident 47 fingernails were not trimmed, cut short and cleaned. This deficient practice in Resident 47 feeling embarrassed and had the potential to cause injury and infection. B. Resident 99 where not provided shower or bath and was observed wearing dirty hospital gown with food crumbs for two consecutive days. This deficient practice had the potential for unpleasant body odor, which can affect Resident 99's self esteem, and social interactions. Findings: During a review of Resident 47's admission Record, the admission Record indicated, Resident 47 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hydrocephalus (a build-up of fluid in…

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

Based on observation, interview, and record review, the facility failed to ensure the emergency kit ([E-kit], a small quantity of medications kit that can be dispensed when pharmacy services are not available) of C1 was replaced in the medication storage room after E-Kit was opened on 3/6/2024. This deficient practice had the potential for medication dispensing errors, theft, or diversion and placed residents at risk for not receiving medication due to unavailability in E-kit. Findings: During an observation on 03/08/2024 at 11:18 a.m. of the medication storage room, it was observed that the E-kit of PO (the medication is taken by mouth or orally) and IV (intravenous) was sealed with yellow tags. During a concurrent interview and record review on 03/08/2024, at 11:18 a.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated, when E-kit is sealed with yellow tags, it meant it has been opened and some medications were dispensed. RNS 1 reviewed the Emergency Kit Pharmacy Log, and stated, on 3/06/2024, Keflex (This medication is used to treat a wide variety of bacterial infections)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than 5 percent (%) due to 2 errors observed out of 34 total opportunities (error rate of 5.88 %). The medication errors were as follows: 1. Resident 6 and Resident 253 did not receive metformin (medication to lower blood sugar level) with meals as ordered by the physician. This failure had the potential to result in Resident 6 and 253 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have). Findings: During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including muscle spasm, diabetes mellitus (high blood sugar), hypertension (high blood pressure) and cerebral infarction (damage to the brain caused by interruption of its blood supply). During a review of Resident 6's Minimum Data Set ([MDS] standardized assessment and…

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

Based on observation, interview and record review, the facility failed to ensure refrigerator temperature readings were in a correct range of 36 to 46 degrees Fahrenheit (°F- unit of temperature) maintain proper temperature of their medication refrigerator. This deficient practice had the potential for harm to residents due to potential undetected temperature excursions, the potential loss of strength of the medications, and the potential for the residents to receive ineffective medication dosages. Findings: During a concurrent observation and interview on 3/6/2024, at 4:10 p.m. with Registered Nurse (RN) 3, observed ice buildup on the freezer of medication refrigerator and temperature s reading was 52 °F. RN 3 stated the thermometer inside the medication refrigerator read at 52 °F and should be reading 36 °F to 46 °F. RN 3 stated it was the responsibility of RN to check and ensure the temperature of the medication refrigerator was between 36 °F to 46°F. RN 3 stated if the temperature was not within the proper range of 36 °F to 46 °F, the efficacy of the stored medicines would be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 30) had a completed acknowledgement of advance directives (legal documents that provide instructions for medical care and only go into effect if you cannot communicate your own wishes). This failure had the potential for inadvertently missed health care wishes and decision of the resident during changes in condition or emergency. Findings: During a review of Resident 30's admission Record, the admission Record indicated, Resident 30 was admitted to the facility on [DATE] with diagnoses including dementia (impaired ability to remember, think or make decisions that interferes with doing everyday activities), hypothyroidism(thyroid gland can't make enough thyroid hormone to keep the body running normally), hearing loss, and glaucoma (a group of eye diseases that can cause vision loss and blindness). During a review of Resident 30's History and Physical (H&P), dated 2/28/2024, the H&P indicated Resident 30 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 observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 62) was free of physical restraint ( any manual method , physical or mechanical device, equipment or material that is attached or adjacent to resident's body, cannot be removed easily by resident and restricts the freedom of movement) by : 1.Failing to ensure the positioning wedges were not placed under the bed sheet and on both sides of Resident 62's lower body. This failure had the potential to result into unnecessary restraint and placed Resident 62 at risk for physical or psychosocial harm . Findings: During a record review of Resident 62's admission Record, the admission Record indicated Resident 62 was initially admitted on [DATE] and was readmitted on [DATE] to the facility with diagnoses including dementia(loss of cognitive functioning such as thinking, remembering and reasoning which can affect and interfere with daily life and activities), acquired absence of eye( post procedural 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 interview and record review the facility failed to ensure the licensed nurses completed one of 25 sampled residents (Resident 39) Change of Condition ([COC] a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) form to alert the resident's physician and interdisciplinary (IDT-a group of healthcare professionals with various areas of expertise who work together toward the goals of the residents) team of Resident 39's significant change in condition and the need to alter the resident's medical treatment significantly in accordance with the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status revised 2/2014. This deficient practice resulted in Resident 39 urine culture results on 2/25/2024 and 2/26/2024 not communicated to Resident 39's physician,and IDT resulting in delay of treatment. On 2/28/2024 Resident 39 experienced a low blood pressure, lethargy (a general state of fatigue that involves a lack…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 assess and follow through with the Preadmission Screening and Resident Review ([PASARR ]- a comprehensive evaluation that ensures people who have been diagnosed with serious mental illness, intellectual, and/or developmental disabilities are able to live in the most independent settings while receiving the recommended care and interventions to improve their quality of life) Level I and Level II evaluation for one of three sampled residents (Resident 109) to determine the facility's ability to provide the special need of the resident. This deficient practice placed Resident 109 at risk of not receiving necessary care and services needed. Findings: During a review of Resident 109's admission Record, the admission Record indicated, Resident 109 was admitted to the facility on [DATE] with diagnoses including epilepsy (a brain disease where nerve cells don't signal properly, which causes a sudden, uncontrolled burst of electrical activity in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY During observation, interview, and record review the facility failed to ensure one of 31 sampled residents (Resident 137) received Restorative Nursing Assistant ([RNA] assist the patient in performing tasks that restore or maintain physical function as directed by the established care plan) services to maintain or improve her ability to carry out her activities of daily living daily five times a week as ordered by Resident 137 physician. This deficient practice had the potential to result in Resident 137 developing contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and decrease mobility. Findings: During a review of Resident 137's admission Record indicated Resident 137 was admitted to the facility on [DATE], with diagnoses including, hypertension (high blood pressure), difficulty walking, and syncope (temporary loss of consciousness caused by a fall in blood pressure). During a review of Resident 137's Minimum Data Set (MDS- a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY During observation, interview, and record review the facility failed to provide personal care and implement fall precaution intervention (bed alarm [device applied on the surface of the bed that beeps when resident tries to get up]) for one of six sampled resident (Resident 17) who was assessed as high risk for fall when Resident 17 tried to get out of bed unassisted. These failures resulted in Resident 17 falling out of bed and sustained a hematoma (collection or pooling of blood and usually caused by a broken blood vessel that was damaged by an injury) on the right side of Resident 17 forehead. Findings: During a record review of Resident 17's admission Record, the admission Record indicated Resident 17 was admitted to the facility on [DATE] with diagnoses including history of falling, retention of urine (difficulty urinating and completely emptying of bladder), dementia (loss of cognitive functioning - thinking, remembering, reasoning to such extent that it interferes with person's daily and activities),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 an effective pain management on one of six sampled residents (Resident 6) by failing to: 1.Ensure Resident 6's pain level was assessed before administering pain medication. 2.Ensure appropriate pain medication was provided according to pain assessment. These failures placed Resident 6 at risk for inadequate pain relief and delay of care. Findings: During a record review of Resident 6's admission Record, the admission Record indicated Resident 6 was initially admitted to the facility on [DATE] and was readmitted to on 12/20/2023 y with diagnoses including muscle spasm, difficulty in walking, and thrombophilia ( blood form clots easily ). During a record review of Resident 6's Minimum Data Set ([MDS] standardized assessment and care screening tool) dated 12/27/2023, the MDS indicated the Resident 6 had an intact cognition (ability to think, learn, remember, use judgment, and make decisions) and was dependent on staff with bed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 109) was free from unnecessary medication (the use of medications when there is no valid medical indication or when multiple drug products are being used for a condition that could be more appropriately treated with a single drug or non-drug approaches). Resident 109 was on Seroquel (a medication that treats several kinds of mental health conditions including [schizophrenia- a serious mental disorder in which people interpret reality abnormally] and [bipolar disorder- a mental health condition that causes extreme mood swings]) without proper diagnosis and facility failed to provide psychological evaluation (assess the resident's functioning in areas associated with learning, behavior, social skills, mood and anxiety, and cognitive processing) as per indicated in Resident 109's Care plan dated 2/28/2024. These failures had the potential to result in Resident 109 receiving unnecessary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow up on necessary dental services for one of five sampled residents (Resident 61). This deficient practice had the potential to cause a delay in dental treatment and place Resident 61 at risk for pain, infection, and degraded self-esteem. Findings: During a review of Resident 61's admission Record, the admission Record indicated, Resident 61 was admitted to the facility on [DATE] with diagnoses including nontraumatic subarachnoid hemorrhage (bleeding in the space that surrounds the brain), atrial fibrillation (irregular, and often very rapid heart rhythm), type 2 diabetes mellitus (a disease in which your blood glucose, or blood sugar levels are too high), and hypothyroidism (condition when the thyroid gland doesn't make enough thyroid hormone). During a review of Resident 61's History and Physical (H&P) dated 12/5/2023, the H&P indicated Resident 61 had the capacity to understand and make decisions. During a review of Resident 61'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 initiate a care plan for fall risk for one of three sampled residents ( Resident 1. This deficient practice placed Resident 1 at risk of not having goals and planning interventions to meet their needs and had the potential to negatively affect the residents ' well-being. Findings: During a review of Resident 1 ' s admission records the admission record indicated Resident 1 was originally admitted on [DATE] and readmitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus (impaired ability to with other specified complications (a chronic condition that affects the way the body processes blood sugar), difficulty in walking, and hyperlipidemia( too much fat in the blood) . During a review of the Resident 1 ' s Minimum Data Set (MDS- a comprehensive assessment and care planning tool) dated 10/10/2023, the MDS indicated Resident 1 had intact cognition (has sufficient judgment . Resident 136 required partial moderate assistance (helper…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 re-admit one of two sampled residents (Resident 1), when Resident 1 was transferred to a General Acute Care Hospital (GACH) for evaluation of uncontrolled behavior, and the GACH cleared Resident 1 to return to the facility on 9/29/2023. This deficient practice resulted in the inappropriate and potentially unsafe discharge of Resident 1 to Resident 1's Responsible Party's (RP) home without giving Resident 1 and/or Resident 1's RP timely notice of transfer. This deficient practice had the potential for Resident 1's care needs to go unmet. 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 the diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and a mood disorder (illness that affects a way a person thinks and feels). During a review of Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY nterview, and record review, the facility failed to: A. Prevent Resident 2 from being slap on his right thigh by Resident 1 who had a history of striking out. B. Follow Resident 1 ' s care plan (CP) that Resident 1 will have no further episode of aggression that will harm staff and other residents. This deficient practice resulted in Resident 2 physically harmed and placed other 128 residents of the facility at risk for abuse. Findings: During a record review of Resident 1 ' s admission Record (AR) indicated the facility admitted Resident 1 originally on 6/13/2013 and readmitted on [DATE] with diagnoses including major depressive disorder (mood disorder that causes a persistent feeling of sadness), anxiety disorder (persistent and excessive worry that interferes with daily activities), and dementia (loss of thinking, remembering, and reasoning that interfere with daily life) with other behavioral disturbance. During a record review of Resident 1 ' s History and Physical (HP) indicated Resident 1 does not have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services to maintain or improve Resident 1 ' s ability to communicate with facility staff by failing to provide language line (a service provided by a vendor who offers accurate and reliable telephone on-line interpretation services) for one of two sampled residents (Resident 1). This deficient practice had the potential to result in a negative impact on Residents 1's quality of life and self- esteem and unable to communicate her needs to staff. Findings: During a review of Resident 1 ' s admission Record (face sheet), indicated Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including anxiety disorder (mental illness causing persistent fear and/or worry), chronic kidney disease (lasting damage to the kidneys), and glaucoma (a group of eye conditions that can cause vision loss or blindness). During a review of Resident 1 ' s History and Physical (H&P), dated…

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