Upland Rehabilitation and Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the provision of care and services for dialysis (a treatment to cleanse the blood of waste and extra fluids through a machine when the kidney(s) have failed) when a bandage was left on the dialysis site for more than four hours for one of two sampled residents (Resident 49). This had the potential to prevent appropriate monitoring for complications including potential for infection and malfunction of Resident 49's dialysis access site . Findings: During a review of Resident 49's admission Record (AR), the AR indicated Resident 49 was admitted on [DATE], with diagnoses that included end stage renal disease (irreversible kidney failure) among others. During a review of Resident 49's Order Listing Report (OLR), dated May 6, 2025, the OLR indicated Resident 49 had an active order for dialysis every Monday, Wednesday, and Friday. During a concurrent observation and interview on May 6, 2025, at 8:39 AM, with Licensed Vocational Nurse 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the side rail (also called bedrail) assessment was accurate and side rail use was indicated to meet the needs of one of 37 final sampled residents (Resident 66), who was unable to use the side rails due to functional limitations in both upper extremities. This failure had the potential for injury related to improper use of side rails for Resident 66. Findings: A review of Resident 66's admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 66's physician's order, dated February 8, 2023, indicated an order for half (1/2) side rails up in bed to aid in bed mobility. A review of Resident 66's Minimum Data Set (MDS, a standardized assessment tool), dated June 13, 2024, indicated Resident 66 had impaired range of motion in both upper extremities. A review of Resident 66's OT [Occupational Therapy] Evaluation and Plan of Treatment, dated July 9 to August 5, 2024, indicated Resident 66 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure safe and effective pharmaceutical services when an order was not clarified before a medication was held for one of five residents (Resident 112). This failure had the potential to result in preventable medication errors resulting from incomplete or unclear orders for Resident 112. Findings: During a review of Resident 112's facesheet (demographics), the facesheet indicated the resident was readmitted on [DATE], and had diagnoses of dependence on renal (kidney) dialysis (procedure for filtering blood when kidneys stop working) and hypertension (high blood pressure). During a review of Resident 112's SNF [Skilled Nursing Facility] H&P [History & Physical], the H&P indicated Resident 112 was diagnosed with chronic (persistent) congestive heart failure (CHF- when the heart does not pump blood normally). During a review of Resident 112's medical record, an order dated April 28, 2025, indicated a medication order for furosemide (diuretic - water pill)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications were stored at an appropriate temperature range, in accordance with drug manufacturers' requirements, in one of three medication rooms (Station 2 Med Room). This failure had the potential for residents to be given deteriorated (reduced quality) medications which could result in suboptimal treatment. Findings: During a review of the Station 2 Daily Record of Medication Room Temperature, the log indicated the Station 2 Medication Room temperature was recorded as 78 degrees Fahrenheit (F - a temperature scale) on May 4, 2025, and May 5, 2025. During a concurrent observation and interview on May 5, 2025, at 9:41 AM, with the Assistant Director of Nursing (ADON), an inspection of the Station 2 Medication Room was conducted. When the medication room cabinet was opened, multiple medications were observed stored inside. The ADON acknowledged the product labeling for the following six (6) drug products indicated to store the medications at a maximum of 77 degrees F. a. Three (3) bottles of Extra…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete and accurate documentation for one of 37 final sampled residents (Resident 151), when Restorative Nursing Assistant (RNA) services were not documented. This failure had the potential for Resident 151's care needs to go unmet due to inaccurate information in the record. Findings: A review of Resident 151's admission Record, indicated Resident 151 was admitted to the facility on [DATE], with diagnoses including osteoarthritis (a disease where joint tissue breaks down) to both knees and history of stroke (brain damage due to an interruption in blood flow). A review of Resident 151's Physician Orders, dated October 14, 2024, indicated RNA services daily five times a week for ambulation (walking) with front wheel walker, as tolerated, to be conducted every Monday, Tuesday, Wednesday, Thursday, and Friday. A review of the Point of Care Audit Report for March 2025, indicated four RNA entries in Resident 151's medical record for March. A review…

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

Based on observation, interview, and record review, the facility failed to implement infection control and prevention measures when: 1. One single-dose container of acetic acid (solution to prevent blockage in tubes connected to the resident's body) was not discarded after being opened. This failure had the potential for cross contamination (unintentional transfer of germs) to residents or residents to be treated with deteriorated treatments which could negatively impact their clinical condition. 2. One non-laundry staff entered the restricted clean area of the laundry department and obtained items from a linen cart. This failure had the potential for cross contamination and spread of infection which could adversely affect the health and wellbeing of residents and staff. Findings: 1. During a concurrent observation and interview on May 5, 2025, at 12:08 PM, an inspection of Treatment Cart 1 near Nursing Station 1 was conducted with Licensed Vocational Nurse 5 (LVN 5). LVN 5 stated she was the Treatment Nurse (nurse specializing in wound care). When Treatment Cart 1 was opened, one…

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

Based on observation, interview, and record review, the facility failed to ensure one of three residents, (Resident 1) received treatment and care in accordance with professional standards of practice, when: 1. A Certified Nursing Assistant (CNA 1) left Resident 1 in bed naked and uncovered with the curtain halfway open. 2. A CNA (CNA 2) took a long time in attending to Resident 1 for a change. These failures had the potential to cause Resident 1 a psychological effect for maintaining respect and dignity. Findings: During a review of Resident 1 ' admission Record (general demographics) on September 11, 2024, the document indicated Resident 1 was admitted to the facility on November August 29, 2024, with diagnoses internal right hip prosthesis (a condition with hip replacement), heart failure (a condition that develops when your heart does not pump enough blood for the body needs), and hypertension (a condition with a high blood pressure). A review of Resident 1 ' s care plan dated, August 29, 2024, indicated, Focus: ADL (Activities of daily living) self-care performance deficit r/t…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review and interview, the facility failed to provide a resident and or representative a copy of medical records following a written request for 1 of 3 residents reviewed for resident rights (Resident 1). This failure could potentially violate Resident 1 (R1) rights to access her medical records. Findings: During a review of Residents 1 ' s (R1) admission Record (general demographics), the document indicated R1 was admitted to the facility on [DATE] , with diagnosis to include sepsis, (complication of an infection), urinary tract infection ( bladder infection), generalized muscle weakness ( decreased strength in muscle ), type 2 diabetes mellitus ( a long term condition in which the body has trouble controlling blood sugar and using it for energy ), dementia (is a condition that can be caused by a number of diseases which destroy nerve cells and damage the brain). During an interview with Medical Record Director (MRD) on September 16,2024 at 2:04 PM. MRD denies getting a fax request or e-mail…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 treat a resident in a dignified manner with respect and value for one of three sampled residents (Resident 2) when a staff entered Resident 2 ' s room and removed her oxygen tubing (a plastic tube that carries oxygen from a tank or machine to a person, connecting to a nasal cannula [a tube that goes in the nose] or mask) without requesting permission from Resident 2 on August 19, 2024. This failure compromised Resident 2 ' s dignity, violated her right to respect, and affected her well-being and ability to make choices, which had the potential to cause psychosocial harm (mental distress and suffering) and lead to feelings of upset. Findings: A review of Resident 2's admission Record (a document containing clinical and demographic data), indicated Resident 2 was admitted to the facility on [DATE], with a diagnosis which included heart failure (a condition in which the heart is unable to pump blood effectively to meet the body's needs),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 proper care was provided to prevent a pressure ulcer/injury (injury to skin/tissue from prolonged pressure on the skin) for one of three sampled residents (Resident 1). This failure placed a clinically compromised Residents (Resident 1) health and safety at risk, when a facility acquired unstageable pressure ulcer to coccyx left buttocks (lower back/spine) developed while in the facility. Findings: During review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included metabolic encephalopathy (problem in brain caused by chemical imbalance in blood), acute respiratory failure with hypoxia (not enough oxygen), tracheostomy (opening in trachea to help air and oxygen reach lungs), acute kidney failure (kidney cant filter waste from blood). During a concurrent interview and record review of Resident 1's Medical Record with the Director of Nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reasonable accommodation of resident needs and preferences was provided when one resident of four sampled residents (Resident 1) was not provided a bedside commode and not assisted to the bathroom for toileting. This failure had the potential to cause Resident 1 a psychological effect for maintaining respect and dignity. Findings: During a review of Resident 1' admission Record (general demographics) on June 27, 2023, the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that include cardia arrest (a condition that occurs when the heart stops beating suddenly) pericardial effusion (a condition that occurs when there is a buildup of extra fluid in the space around the heart). A review of Resident 1's care plan dated, November 8, 2023, indicated, Focus: ADL (Activities of daily living) self care performance deficit r/t (related to) limited mobility. Goal: Will safely perform bed mobility, transfers,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy and procedure to ensure call lights were answered in timely manner to provide care and services for two of three sampled residents (Resident 1 and 2). This failure had the potential to place a clinically compromised Residents (Resident 1 and 2) safety at risk. When residents were left soiled, and their activities of daily living were not met in timely manner. Findings: During interview and Records Reviewed with (Resident 1 and 2) indicates as followed: During review of Residents 1 ' s admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnosis to include atherosclerosis of aorta ( fat and calcium built up in the inside wall of a large blood vessel), hypertension ( high blood pressure), Hyperlipidemia(high levels of fat particles in the blood), Major depressive disorder ( depressed mood, loss of interest), overactive bladder ( a problem with bladder function…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the call lights were answered in a timely manner to provide nursing care and services for two of three residents (Resident 1 and 2). This failure had the potential to place two clinically compromised Residents (Resident 1 and 2) health and safety at risk when their activities of daily living were not met within a reasonable time. Findings: 1. During a review of Resident 1's clinical record, the face sheet (contains demographic and medical information), indicated Resident 1 was admitted on [DATE], with diagnoses which included: muscle weakness, chronic respiratory failure (lungs cannot get enough oxygen into the blood), tracheostomy (incision in the throat to help you breathe), dependence on respirator (apparatus used to induce artificial breathing) and depression. During a review of the clinical record for Resident 1, the Brief Interview for Mental Status (BIMS- screening tool to identify and monitor cognitive decline), dated May 22,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe and sanitary practices were maintained in the kitchen when: 1. Three (3) of three (3) ice machines had a black unknown substance in the ice chute (area between where ice is formed and where it enters the ice bin) which put 133 residents, who used or ingested ice from this machine, at risk for foodborne illness (illness acquired from ingesting contaminated food). 2. Three (3) sinks in the kitchen and one of three (3) ice machines (ice machine 1) did not have an air gap (which had the potential for back flow from the sewer to enter the ice machine and the sinks). These failures had the potential for food-borne illness (food poisoning) to a population of 133 immuno-compromised (having an impaired ability to fight disease) residents who receive food from the kitchen. Findings: 1. An inspection of facility's three ice machines was conducted with the Maintenance Supervisor (MS) and the Housekeeping/Laundry Supervisor (HKS) on May 3, 2022. The following were observed: a) At 10:30 AM- The ice machine near…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident's change of condition was assessed, monitored, and documented in accordance with the facility's policy and procedure for one resident (Resident 76) reviewed for change of condition. This failure had the potential to result in an unidentified complication and/or worsening condition due to a delay in assessment and treatment, placing Resident 76 at risk for further injuries. Findings: During a concurrent observation and interview on May 4, 2022, at 8:30 AM, in Resident 76's room, Resident 76 was sitting upright in a wheelchair. Resident 76 had a purplish skin discoloration on her left mid-upper arm. Resident 76 stated the injury occurred from an exercise machine that she used while in the gym a week ago. She further stated it was a little too tight on her arm. During a review of Resident 76's clinical record, the admission Record (contains demographic and medical information) indicated Resident 76 was admitted on [DATE],…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 supervision was provided for one of three residents (Resident 73) reviewed for accidents when Resident 73's bed had an 11-inch gap between the mattress and the footboard. This failure place Resident 73 at risk for entrapment, falls, and injuries. Findings: A review of Resident 73's admission Records (contains demographic and medical), it indicated, Resident 73 was admitted on [DATE], with the diagnoses of abnormal posture (rigid body positions), muscle weakness, osteoarthritis (loss of protective tissue at the end of bones). During a review of Resident 73's Care plan for falls, initiated May 25, 2022, indicated, Focus: At risk for falls related to decrease safety awareness ., Goal: Will be free of serious injury from falls ., Interventions: .monitor number of episodes resident get out of bed unassisted every shift. During an observation on May 3, 2022, at 10:50 AM, inside Resident 73's room, Resident 73 was lying down on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two residents (Resident 80) reviewed for tube feeding (enteral feeding- liquid nutrition administered via a feeding tube inserted into the stomach) receieved enteral nutrition services inaccordance with the facility's policy and procedure. This failure had the potential to impact Resident 80's health as a result of receiving less enteral nutrition than was recommended by the RD which may have resulted in sub-optimal (less than ideal) nutritional status for the resident. Findings: During an observation on May 3, 2022, at 11:53 AM, Resident 80 was lying in bed in an upright position. There was a feeding pump (pump which administers enteral nutrition) at his bedside. A bag of enteral nutrition was connected to the pump. The bag was labeled with the date, May 3, 2022, the current date of when it was hung, and the rate of administration was at 50 milliliters per hour (50 mls/hr). During a review of Resident 80's clinical 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain infection control practices when: 1. A Certified Nursing Assistant (CNA 1) did not perform COVID-19 (a highly contagious illness caused by a virus) screening upon entry into the facility on May 4, 2022, in accordance with the facility's policy and procedure. 2. A Licensed Vocational Nurse (LVN 2) did not perform hand hygiene or hand washing during a wound care treatment for Resident 150. These failures had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi or parasites) to a highly vulnerable population of 179. Findings: During an observation on May 4, 2022, at 7:01 AM, a Certified Nursing Assistant (CNA 1) arrived at the facility and walked directly to the nurse's station [nurse's station 1]. CNA 1 was not wearing a face cover. She did not perform COVID-19 screening (screen individuals for COVID-19 symptoms prior to enter into the facility) at the kiosk located in the lobby area. 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.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program when: 1. One live spider was observed in Resident 57's room. This failure resulted in Resident 57's dissatisfaction in the condition of his room, which could negatively impact his psychological wellbeing. 2. Three live spiders were observed in the conference room. This failure had the potential to result residents, staff, and visitors to be bitten by a spider, placing their health and safety at risk. Findings: 1. During a concurrent observation and interview with Occupational Therapist (OT 1), on May 3, 2022, at 12:31 PM, in Resident 57's room, Resident 57 was sitting up on a wheelchair close to his bed. A dark greyish-black spider, with a leg span (distance between the tips of the legs of a spider furthest from each other) approximately the size of a nickel, was on the wall near the head of Resident 57's bed. OT 1 confirmed there was a spider on the wall. During an interview with Resident 57, on May 6, 2022, at 12:00 PM, Resident 57 stated he remembered seeing 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.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary storage practices in the kitchen when 24 plastic water pitchers, 28 plastic water cups and 54 small plastic water trays which are used at resident bedsides were found stacked wet and ready for use. This failure had the potential to lead to harmful bacterial growth and cross contamination that could lead to waterborne illness for a medically compromised population of 130 residents who received drinking pitchers, cups and trays from the kitchen. According to the FDA Food Code 2017, Items must be allowed to drain and air-dry before stacked and stored. Stacking wet items, such as pans, prevents them from drying and may allow an environment where microorganisms can begin to grow. Findings: During an observation and interview on August 05, 2019, at 09:27 AM, with the Dietary Services Supervisor (DSS), 24 plastic water pitchers, 28 plastic water cups, and 54 small plastic water trays were stacked wet and ready for use. The DSS verbally confirmed these findings at this time, and stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to safeguard residents property when the staff did not complete an inventory list to include all jewelry for one of one sampled Resident (Resident 36) when her initial and updated personal Inventory lists only included one gold and silver watch. This failure had the potential for Resident 36's personnel belongings to be unaccounted for, lost or stolen. Findings: During an observation on August 5, 2019, at 10:27 AM, Resident 36 was awake sitting on her wheelchair. There were 3 jewelry boxes located on the shelf displayed on the wall near her bed containing jewelry. In addition, two plastic containers contained jewelry, which were on an open shelf near her bed. Hanging below the wall shelf, were multiple necklaces of various styles. During an interview with a Certified Nurse Assistant (CNA 1), on August 7, 2019, at 8:21 AM, she stated, If a resident is admitted we have an inventory list with everything they come in with. If later they decide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 35 sampled residents' (Resident 75) PASRR (Preadmission Screening and Resident Review (PASRR- is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) Form was filled out correctly for the diagnosis of dementia. This failure had the potential to result in an inappropriate level of care for Resident 75. Findings: During a review of Resident 75's clinical record, the admission Record (Face Sheet) indicated the resident had diagnoses which included; dysphagia (difficulty swallowing) with a gastrostomy tube (G-tube- a tube inserted through abdominal wall through which nourishment and medications can be administered) in place, hypertension (elevated blood pressure), type 2 diabetes mellitus (body does not use insulin properly), depression, psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), and dementia…

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