California Healthcare And Rehabilitation Center

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 five (5) percent (%). Four (4) medication errors out of 26 total opportunities contributed to an overall medication error rate of 15.38% affecting three (3) of six (6) residents observed for medication administration (Resident 84, 87 and 201.) The medication errors were as follows: 1.Resident 84 did not receive sevelamer (a medication used for hyperphosphatemia [having high blood levels of phosphate, a mineral] for people on dialysis [treatment that removes waste and excess fluid from the blood,]) on 4/20/2026, as prescribed by Resident 84's physician. 2. Resident 87 did not receive oyster shell calcium (a medication used as a dietary supplement to provide support to bones), on 4/20/2026, as prescribed by Resident 87's physician. 3.Resident 201 did not receive menthol-methyl salicylate cream (a medication used for pain) and glipizide (a medication used to lower blood sugar levels,) 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 Findings: During an observation on 4/20/2026 at 10:10 a.m. in Medication Cart Station 3, Licensed Vocational Nurse (LVN) 2 was observed administering gabapentin (a medication used for neuropathy [nerve damage,]) and metformin (a medication used for high blood sugar level) orally to Resident 201. Resident 201 was observed swallowing the gabapentin and metformin tablets with a glass of water. LVN 2 was observed not administering glipizide (a medication used for high blood sugar levels) to Resident 201. During a concurrent interview and record review on 4/20/2026 at 2:25 p.m. with LVN 2, LVN 2 reviewed Resident 201's Medication Administration Record ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record]) for April 2026. LVN 2 stated that LVN 2 did not administer glipizide that day (4/20/2026) at 10:10 a.m. to Resident 201, as prescribed by Resident 201's physician, since glipizide was not available in Medication Cart Station 3 or in the facility.…

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

Based on observation, interview, and record review the facility failed to: 1.Remove and discard from use one (1) expired latanoprost (a medication used for glaucoma [a condition of increased pressure in the eyeball]) eye drop bottle for Resident 26, in accordance with manufacturers' requirements and facility policies, in one (1) of five (5) inspected medication carts (Medication Cart 2B). 2. Label one (1) levalbuterol (a medication used to treat and prevent shortness of breath) inhalation solution foil pouch (a package made of foil protecting the inhalation solution from light and degradation) with a date open for Resident 99, in accordance with the manufacturer's requirements in one (1) of five (5) Medication Carts (Medication Cart 1B.) These deficient practices increased the risk that Residents 26 and 99 could have received medications that had become ineffective or toxic due to improper storage or labeling, accidentally used due to improper labeling, possibly leading to health complications resulting in infections, hospitalization or death. Cross referenced to F880.Findings:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prepare food by methods that conserved appearance, flavor and temperature when: 1.Cold foods were not served cold and capri blend vegetables were squashed and brownish green in color for lunch meal on 4/20/2026.2. Foods not served at palatable temperatures for breakfast time on 4/22/2026.These failures had potential to result in 103 of 125 facility residents including Resident 76, Resident 130, and Resident 169 at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen. Findings: During a review of Resident 76's Face Sheet, the Face Sheet indicated the facility admitted Resident 76 on 4/18/2025 with diagnosis including, but not limited to, essential hypertension (HTN, high blood pressure), type two diabetes (increased of blood sugar due to insulin resistance), and dysphagia (difficulty swallowing). During a review of Resident 76's Minimum Data Sheet (MDS- a resident assessment tool) dated…

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

Based on observation, interview, and record review, the facility failed to prepare food in a form designed to meet individual needs when pureed capri blend vegetables looked flat and spread on the plate and puree spring fruit crip was watery and did not hold its shape. These failures had the potential to result in difficulty in swallowing, difficulty in eating, decrease in food and nutrient intake to 21 of 21 residents on puree diet (foods that are soft, pudding like consistency and hold its shape), resulting in unintended (not planned) weight loss and choking (when food gets stuck in your airway, blocking the flow of air to your lungs). Findings: During a review of the facility's cook spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled, Winter Menus, dated 1/12/2026, the spreadsheet indicated residents on puree diet/International Dysphagia Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) Level 4 would include the following foods on the tray: -Pureed baked hamburger 1/2 cup (c, a household measurement)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews, the facility failed to provide residents' meals at regular times scheduled in accordance with resident needs, preferences, and requests when lunch was served late on 4/22/2026.This deficient practice had the potential to result in hunger and frustration for 124 to 125 residents receiving meals from the kitchen, including Resident 76 and Resident 88. Findings:1. During a review of Resident 76's Face Sheet, the Face Sheet indicated the facility admitted Resident 76 on 4/18/2025 with diagnoses including, but not limited to, essential hypertension (HTN, high blood pressure), type two diabetes (increased of blood sugar due to insulin resistance), and dysphagia (difficulty swallowing).During a review of Resident 76's Minimum Data Sheet (MDS- a resident assessment tool) dated 10/21/2025, the MDS indicated Resident 76 understood others and make self-understood. The MDS indicated Resident 76 needed supervision or touching assistance (helper provides verbal cues and 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.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. A personal iced drink with a straw was stored in the pitcher storage area.2. Kitchen staff failed to perform handwashing when:a. Dietary Aide 1 (DA 1) sneezed and touched his hair, then proceeded to work on the trayline (an area where food is assembled from the steamtable [kitchen appliance that keeps food warm at a safe serving temperature] onto resident's plates) without washing his hands.b. DA 1 transitioned from handling dirty items to clean items in the pot sink area without washing his hands.c. [NAME] 2 touched the lid of the trash can and then handled a pan containing pureed sausages without washing her hands. 3. Refrigerator and freezer temperature monitoring was not consistently performed when: a. The refrigerator and freezer temperature log contained no documented temperature records for 4/13/2026 and 4/19/2026.b. The resident's freezer located by Station 1 did not contain a thermometer, and staff did not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dispose garbage and refuse properly when: 1.A garbage container by the preparation area was not completely closed or covered when not actively in use. 2.The dumpster (a movable waste container designed to be brought and taken away by special collection vehicle, or to a bin that a specially designed garbage truck lifts) surroundings had sticky black spills. These failures had potential to attract birds, flies, insects, pests and possibly spread infection to 125 of 125 facility residents. Findings: During an observation on 4/20/2026 at 8:49 a.m., of the trash can containing food scraps, paper and plastic trash, it was observed that the trash can was not actively being used and it was not covered. During a concurrent observation and interview on 4/20/2026 at 9:10 a.m., with the Dietary Supervisor (DS), the trash can by the preparation area was observed to uncovered. The DS stated that the trash should be kept closed with a lid to prevent cross-contamination. The DS stated none of the staff were using the trash…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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). Accurately document on the medical diagnoses and on the Physician Orders for Life-Sustaining Treatment (POLST-a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of-life) for one of 35 sampled residents (Resident 211).2). Accurately document the form titled Supportive and Safety Device/Restraint - Physical. The form indicated that informed consent (process in which the residents are given important information including possible risks and benefits, about a medical procedure or treatment) had been obtained for the use of lower bedside rails (adjustable metal or rigid plastic bars that attach to the bed ) however, the facility was unable to provide the required signed consent form for review for one of two sampled residents (Resident 19).3). Ensure the medication administration record (MAR - a record of all active physician orders 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 to offer the updated 2025/2026 influenza (flu, a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and lungs) vaccine (medications used to prevent diseases usually given by injection or by mouth) at the start of the respiratory illness season (typically from October through April in the U.S., peaking between December and February, characterized by increased circulation of respiratory illnesses including the fly and COVID-19 [an infectious respiratory illness caused by the SARS-CoV-2 virus]) when the vaccine became available for four of five sampled residents (Residents 1, 2, 13, and 20) investigated for immunizations (the process where a person is made resistant to a disease). This deficient practice increased the risk for Residents 1, 2, 13, 20 to experience complications from the flu virus including pneumonia (an infection/inflammation in the lungs), respiratory failure (when the lungs cannot release enough oxygen into…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a resident's dignity and respect for two of two sampled residents (Resident 212 and 94) reviewed under the dignity care area by: a. Failing to ensure the Infection Preventionist Nurse (IPN) knocked or requested permission before entering Resident 212's room. b. Failing to ensure Resident 94's indwelling urinary catheter (a flexible tube that is inserted into the bladder to help drain urine) collection bag (designed to collect urine drained from the bladder via catheter) was covered with a dignity bag (a bag used to cover and hold the catheter drainage/collection bag, so it is not visible). These deficient practices violated the residents' rights to be treated with respect and dignity and had the potential to negatively affect resident's sense of self-worth and self-esteem. Findings: a. During a review of Resident 212's Face Sheet, the Face Sheet indicated the facility admitted Resident 212 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.

Based on interview, and record review, the facility failed to implement its policy and procedure (P&P) titled Side Rails (adjustable metal or rigid plastic bars that attach to the bed ) for one of four residents (Resident 19) reviewed under the restraints care area by failing to obtain an informed consent (process in which the residents are given important information including possible risks and benefits, about a medical procedure or treatment) for the use of lower side rails. This deficient practice violated Resident 19's and/or the resident's representative the right to be informed of and to participate in the resident's treatment. Findings: During a review of Resident 19's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on 4/9/2014 and readmitted Resident 19 on 11/08/2025 with diagnoses including hypertension (high blood pressure), diabetes type two (high blood sugar), and Alzheimer's disease (a disease that affects memory, thinking and behavior). The Face Sheet indicated Resident 19 has a designated Power of Attorney (POA- legal authorization…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clarify wishes written on Resident 211's advanced directive (a legal document indicating resident preference on end-of-life treatment decisions) with the healthcare agent (a person legally authorized to make decisions on behalf of another individual when that person is unable to communicate r communicate their own decisions when one of four sampled resident's (Resident 211) orders did not match the advance directive. This failure had the potential to result in Resident 211 receiving unnecessary treatment and inappropriate care. Findings: During a review of Resident 211's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility admitted Resident 211 on [DATE] with diagnoses that included cerebral infarction (stroke - loss of blood flow to a part of the brain), nontraumatic subarachnoid hemorrhage (sudden bleeding in the brain that is not caused by head injury), 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 a safe homelike environment to two of two sampled residents (Resident 50 and Resident 13) investigated under environment task by failing to: a. Ensure Resident 50 had a trash bin to dispose of his trash in his room. This deficient practice caused Resident 50 to have to dispose his trash in the bin labeled urinal only and had the potential to affect the resident`s self-esteem and self- worth. b. Ensure Resident 13's floor mat (a cushioned floor pad designed to help prevent injury should a person fall) was in good condition and there was not trash on the floor and a dark red substance on the bottom of the bed frame. This deficient practice had the potential to violate the resident's right to living in a safe, comfortable, and homelike environment. Findings: a. During a review of Resident 50's Face Sheet, the Face Sheet indicated the facility admitted Resident 50 on 12/7/2023 and readmitted on [DATE] with diagnosis including emphysema…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 remove one of five sampled residents' (Residents 8) restraints reviewed under the Restraints care area, in accordance with the physician's order. This failure to remove the restraints as ordered had the potential to increase the risk of harm including decreased circulation, skin breakdown, and decline in mobility. Findings:During a review of Resident 8's Face Sheet, the Face Sheet indicated the facility admitted Resident 8 on 5/4/2024 and readmitted on [DATE] with diagnoses that included acute respiratory failure with hypoxia (a life-threatening, sudden-onset medical emergency where the lungs cannot properly oxygenate the blood), tracheostomy (a surgical procedure that creates an opening in the windpipe to establish a direct airway), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and traumatic subdural hemorrhage (bleeding in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete an admission comprehensive assessment within the required timeframe for when one of three sampled residents (Resident 211). This failure had the potential to result in Resident 211 not receiving the necessary treatment and appropriate care. Findings: During a review of Resident 211's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility admitted Resident 21 admitted on [DATE] with diagnoses that included cerebral infarction (stroke - loss of blood flow to a part of the brain), nontraumatic subarachnoid hemorrhage (sudden bleeding in the brain that is not caused by head injury), and hypertension (high blood pressure). During a review of Resident 211's Minimum Data Set (MDS-a resident assessment tool) dated 4/21/2026, the MDS indicated Resident 211 had severely impaired cognitive skills (mental abilities used to think, learn, remember, understand, and make…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) was transmitted timely to the Centers for Medicare and Medicaid Services (CMS, a U.S. federal agency that administers major healthcare programs such as Medicare [a federal health insurance program in the U.S. for people aged 65 or older] and Medicaid [a program in the U.S. that provides low-cost health coverage to millions of Americans with limited income]) for two (Resident 22 and Resident 166) of two sampled residents. This deficient practice had the potential to result in delayed services for Resident 22 and Resident 166. Findings: a. During a review of Resident 22's Face Sheet (the front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility originally admitted Resident 22 to the facility on 5/24/2023 and re-admitted on [DATE] with diagnoses that included diabetes mellitus (DM, a disorder characterized by difficulty 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 provide care and services in accordance with professional standards that will meet each resident's physical, mental and psychosocial needs for one of one sampled residents (Resident 94) when the facility: 1.Failed to notify physician of Resident 60's refusal of dermatologist recommendation for skin biopsy of right temple 2. Failed to obtain treatment orders for ongoing care of right temple skin wound. This deficient practice had the potential for the wound to worsen, resulting in delayed healing and increased risk for infection.Findings: During a review of Resident 94's Face Sheet (the front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility admitted Resident 94 to the facility on 9/10/2025 with diagnosis that included severe protein-calorie malnutrition (critical lack of food, specifically protein and calories, causing the body to waste away, lose muscle due to starvation or chronic disease), neuromuscular dysfunction of bladder…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 to ensure the low air loss mattress (a specialized mattress that continuously circulates air) was used correctly for two of six sampled residents (Resident 155 and 60) reviewed under pressure ulcer/injury when:1.Resident 155's LALM was set to 499 pounds instead of 160 pounds. 2. Resident 60's LALM was turned off. These failures had the potential to result in development or worsening of pressure ulcers (localized pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), slower healing, and increased skin breakdown. Findings: 1. During a review of Resident 155's Face Sheet (FS - front page of the chart that contains a summary of basic information about the resident), the FS indicated Resident 155 was admitted on [DATE] with diagnoses that included cerebral infarction (stroke – loss of blood flow to a part of the brain), tracheostomy (a surgical procedure that creates an opening in the windpipe to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for two out of five residents (Resident 105 and Resident 202) investigated for accidents by: a. Failing to ensure Resident 105's floor mat (a cushioned floor pad meant to prevent injury if a person falls) was placed next to Residents 105's bed. b. Failing to ensure medical equipment or waste container was not placed on top of Resident 105's floor mat. c. Failing to ensure a floor mat was placed on the right side of Resident 202's bed as ordered.These deficient practices placed the residents at increased risk of injury. Findings: a/b. During a review of Resident 105's Face Sheet (the front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility originally admitted Resident 105 on 3/3/2022, and re-admitted Resident 105 on 9/25/2025 with diagnoses that included epilepsy (a brain disorder that causes seizures),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 indwelling urinary catheter tubing (a hollow tube inserted into the bladder to drain or collect urine) did not have a dependent loop and urine did not backflow for one of two residents (Resident 212) investigated under urinary catheter. This deficient practice had the potential to negatively affect Resident 212 from receiving the proper care necessary to prevent urinary tract infection (UTI - an infection in the bladder/urinary tract). Findings: During a review of Resident 212's Face Sheet, the Face Sheet the facility admitted Resident 212 to the facility on 4/15/2026 with diagnoses including dementia (a progressive state of decline in mental abilities), tracheostomy (a surgical procedure that creates an opening in the neck leading directly into the trachea [windpipe]) and dependence on a ventilator (a medical machine that helps a patient breathe or completely takes over their breathing when they cannot do so on their own). During a review of Resident 212'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 flush the gastrostomy tube ([GT] - a tube inserted through the belly that delivers nutrition and medications directly to the stomach) with water prior to medication administration, for one (1) of six (6) residents observed for medication administration (Resident 87.) This deficient practice had the potential to cause Resident 87 to receive suboptimal (less than the highest standard or quality) care and have complications of the GT, including aspiration (when food or liquid comes back up from the stomach and enters the lungs [pair of organs situated within the rib cage responsible for breathing,]) and clogging requiring replacement of the GT. Findings: During an observation on 4/21/2026 at 9:45 a.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 was observed not flushing the GT with water, and LVN 4 grabbing the medication cup containing crushed (pressed very hard so that the shape is destroyed and turned into soft powder) medication for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the hemodialysis (also known as dialysis, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) center completed a pre and post-dialysis assessment (evaluation done after hemodialysis by the hemodialysis licensed nurses) by not ensuring the dialysis center recorded a resident's pre- and post-dialysis weights (the weight before and after fluid is removed during the dialysis treatment) on the Dialysis Communication Record (a record of a resident's vital signs and assessments the days he goes to a dialysis treatment) for one (Resident 18) of two residents in the facility investigated for dialysis. This deficient practice had the potential for Resident 18 to have unidentified complications after dialysis treatment such as abnormal vital signs (pulse rate, temperature, respiratory rate, and blood pressure). Findings: During a review of Resident 18's Face Sheet, the front page of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain consent and a physician's order for the use of four side rails for one of two sampled residents (Resident 116).This deficient practice had the potential to place the resident at risk for inappropriate use of bed rails and bed rail-related accidents, including the risk of a body part being caught between the rails which could lead to injury.Findings: During a review of Resident 116's Face Sheet (the front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 116 was admitted on [DATE] with diagnosis that included nontraumatic intracranial hemorrhage (spontaneous brain bleed), respiratory failure (when the lungs cannot get enough oxygen in the blood making it difficult to breath), and hypertensive emergency (blood pressure rises to extreme levels that cause damage to vital organs).During a review of Resident 116's MD Progress Notes, dated 7/9/2025, the progress notes…

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

Based on interview and record review, the facility failed to ensure adequate monitoring and documentation of potential side effects for apixaban, an anticoagulant (blood thinner) used to prevent blood clots, for one of five sample residents (Resident 191) during review of unnecessary medications.This deficient practice had the potential to result in Resident 191 experiencing adverse effects, including signs and symptoms of bleeding. Without proper monitoring, staff may fail to recognize bruising or internal bleeding, resulting in delayed care, significant blood loss, and potentially life-threatening outcomes.Findings: During a review of Resident 191's Face Sheet(admission record), the Face Sheet indicated the facility originally admitted Resident 191 on 10/23/2016 and re-admitted the resident on 2/20/2026, with diagnoses including hypertension(high blood pressure), chronic respiratory failure (long-term condition where the lungs cannot adequately exchange oxygen and carbon dioxide, leading to low oxygen, and functional quadriplegia (complete loss of ability to move all four…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Binding Arbitration Agreement (a binding agreement in which parties agree to submit certain disputes to arbitration rather than court litigation) was explained in a manner understandable to the resident for one of three sampled residents (Resident 183), despite the resident having the capacity to make his own decisions. This deficient practice had the potential to result in the residents signing an agreement without fully understanding its terms and could compromise the resident's rights. Findings: During a review of Resident 183's Face Sheet (the front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the resident was admitted to the facility from a General Acute Care Hospital (GACH, or simply hospital on 4/21/2026 with diagnoses that included osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D).During a review of Resident 183'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 Based on observation, interview, and record review, the facility failed to maintain infection control measures by failing to: 1. Ensure trash was not placed with a resident's urinal in the URINAL ONLY bin belonging to one of one sampled resident (Resident 50). This deficient practice placed residents and staff at risk of exposure and possibly contracting infectious microorganisms. 2. Ensure a visitor wore an isolation gown (type of personal protective equipment [PPE- specialized clothing or equipment worn by an employee for protection against infectious materials] used in healthcare settings to protect healthcare personnel from the spread of infection or illness, particularly from contact with blood and body fluids) and gloves when inside a shared resident's room who was on enhanced barrier precautions (EBP -a set of infection control practices that use PPE to reduce exposure to reduce the spread of multidrug-resistant organisms [MDROs -microorganisms that are resistant to multiple classes of antibiotics 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 a resident specific care plan was developed for one of two sampled residents (Resident 1), when Resident 1 intermittently refused a physician order for Restorative Nursing Assistant (RNA - are Certified Nursing Assistants [CNAs] with specialized training in rehabilitation techniques, focusing on helping residents regain independence in daily activities) sit-to-stand treatment requiring a two-person assist, scheduled five times per week.This deficient practice had the potential to result in a decline in Resident 1's functional status, including reduced mobility, diminished strength and decreased ability to perform Activities of Daily Living (ADL - essential, routine self-care tasks such as bathing, dressing, eating, transferring, and toileting that residents perform daily). During a review of Resident 1's Face Sheet, the Face Sheet indicated the facility admitted Resident 1 on 3/12/2026, with diagnoses that included but not limited to acute kidney failure with tubular necrosis (when the kidneys suddenly…

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

Based on interview, and record review, the facility failed to ensure one of five sampled residents (Resident 5) confidential personal information was protected by copying Resident 5's facility records onto an unencrypted (not converted into a code that would prevent unauthorized access) Universal Serial Bus drive (USB-also known as a flash drive, thumb drive, or memory stick - a small, portable, plug-and-play device used for storing and transferring files between computers) and mailing it to Family Member 1 (FM 1). The envelope that contained the unencrypted USB drive with Resident 5's PHI (Patient Health Information - any individually identifiable health information-including demographic data, medical history, test results, and insurance details-created or received by covered entities like healthcare providers) was returned to the facility with torn open and a sticker on the envelope indicating Return to Sender and no longer contained the USB drive. This deficient practice had the potential to result in the unauthorized exposure of Resident 5's confidential information.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 interview and record review, the facility failed to develop a facility policy and procedure (P&P) for sending Protected Health Information (PHI) via Universal Serial Bus (USB-also known as a flash drive, thumb drive, or memory stick - a small, portable, plug-and-play device used for storing and transferring files between computers) drive.This deficient practice resulted in an unencrypted (not converted into a code that would prevent unauthorized access) USB drive with a resident's PHI to be lost in the mail, potentially exposing a resident's confidential information.During a review of an email sent to the facility by FM 1 dated 1/26/2026, the email indicated FM 1 was Resident 5's authorized representative and was requesting copies of the complete medical records for Resident 5.During a review of an email sent by the facility's Medical Records Director (MRD) to FM 1 dated 1/28/2026, the email indicated all the medical records that FM 1 requested would be put on a USB drive and mailed to the address FM 1 had provided. During a review of a facility letter sent to FM 1 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.

Based on interview and record review the facility failed to provide referrals to local agencies and support services that can assist residents' representatives with discharge planning and failed to notify a resident's representative of a denial of admission by the facility preferred by the resident's representative for the resident's discharge, in accordance with the facility's policy titled, Discharge Summary and Plan, for one of four sampled residents (Resident 1). This deficient practice had the potential to delay Resident 1's return to the community and placed the resident at risk for not receiving the necessary care and services related to the resident's discharge goals and needs.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/6/2025 with diagnoses including malignant neoplasm (an abnormal growth of cells that grows uncontrollably, invades nearby healthy tissues, and can spread to other parts of the body, making it serious and potentially life-threatening) of ribs sternum (breastbone), 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 maintain accurate clinical records in accordance with accepted professional standards and practices for one of four sampled residents (Resident 1) by failing to ensure the Activity Director (AD) or activity assistant document the activities provided to Resident 1 from 11/6/2025 to 1/5/2026. This deficient practice placed the resident at risk of not receiving appropriate care due to inaccurate medical documentation.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/6/2025 with diagnoses including malignant neoplasm (an abnormal growth of cells that grows uncontrollably, invades nearby healthy tissues, and can spread to other parts of the body, making it serious and potentially life-threatening) of ribs sternum (breastbone), and clavicle (collarbone), muscle weakness, and difficulty walking. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to accurately identify and assess the stage of a pressure ulcer (PU - a localized injury to skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) for one of ten sampled residents (Resident 3) and did not implement appropriate interventions when on 9/15/2025 Licensed Vocational Nurse 1 (LVN 1) documented Resident 3's pressure ulcer located in the sacrum (a large, triangular bone located at the base of the spine) area as a Deep Tissue Injury (DTI- a pressure injury with damage to underlying soft tissue which may present as a purple or maroon area of discolored intact skin or a blood-filled blister [fluid-filled sac on the skin]) instead of Unstageable (a PU with full thickness tissue loss where the base is completely covered by slough [a type of non-viable, dead tissue that is typically yellowish, soft, and stringy, or creamy in texture] or eschar [a hard, dry, leathery,…

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

Based on interview and record review, the facility failed to ensure a licensed nurse documented on the resident's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) after administering an antibiotic (medication that kills or inhibits the growth of bacteria) for one of four sampled residents (Resident 1).This deficient practice had the potential to result in medication errors and Resident 1 to receive duplicate medication therapy, which could cause harm to the resident. During a review of Resident 1's admission Record, the admission Record indicated that the facility admitted the resident on 4/21/2025 with diagnoses that included hypokalemia (a condition where there is abnormally low level of potassium in the bloodstream), rhabdomyolysis (a condition where damaged muscle tissue breaks down and releases its contents into the bloodstream, potentially harming the kidneys ) and peripheral vascular disease (PVD- a slow progressive narrowing of the blood flow to the arms and legs).During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and interview, the facility failed to ensure the call light above the resident ' s door is functioning for one out of four sampled residents (Resident 3) to alert staff the call light is on. This deficient practice had the potential to result in a delay in care, and Resident 3`s inability to ask for assistance. Findings: During a review of Resident 3 ' s admission Record, the admission Record indicated that Resident 3 was admitted to the facility on [DATE], with diagnoses including Parkinson ' s Disease (brain disorder that causes unintended or uncontrollable movements such as shaking, stiffness, and difficulty with balance and coordination), spinal stenosis (a condition where the spaces in the spine become narrower, putting pressure on the nerves and spinal cord), and elevated white blood cell (responsible for protecting your body from infection). During a review of Resident 3 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/8/2025, the MDS indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. During a review of Resident 27's admission record, the admission record indicated the facility admitted the resident on 9/20/2023, with diagnoses including multiple sclerosis (a chronic disease that damaged the central nervous system), type two(2) diabetes mellitus (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly) and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 27's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/4/2024, the MDS indicated the resident was totally dependent on staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The resident had severe cognitive impairment (problems with the ability to think, learn, remember, use judgement, and make decisions). During a review of Resident 27's Care Plan (a document that…

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

Based on observation, interview, and record review the facility failed to ensure residents were free from any physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for two of three sampled residents (Resident 149 and Resident 183) by failing to: 1. Perform a bed rail/side rail (a safety device that can be installed on the side of a bed to help people get in and out of bed, turn in bed, and prevent falls) assessment prior to putting up the residents' lower side rails. 2. Obtain a physician's order on the use of bed rail/side rail. This deficient practicse had the potential to result in the restriction of residents' freedom of movement and physical harm from entrapment. Findings: a. During a review of Resident 149's admission Record, the admission Record indicated that the facility admitted Resident 149 on 1/14/2025 with diagnoses including but not limited to metabolic encephalopathy (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 b. During a review of Resident 163's admission Record, the admission Record indicated that the facility admitted the resident on 7/20/2024 with a diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 163's MDS, dated [DATE], the MDS indicated that the resident was in a persistent vegetative state with no discernible consciousness and was dependent on staff for all activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). On 5/7/2025 at 12:40 p.m., during a concurrent interview and record review, reviewed Resident 163's MDS records with the Minimum Data Set Coordinator (MDSC). A review of the admission MDS, dated [DATE], Section I - Active Diagnoses indicated that the resident did not have an active diagnosis of schizophrenia. A review of the Quarterly MDS, dated [DATE], Section I - Active Diagnoses indicated that the resident did have an active diagnosis of schizophrenia. A review 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.

b. During a review of Resident 59's admission Record, the admission Record indicated that the facility admitted the resident on 2/20/2025 with diagnoses including type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), generalized muscle weakness, and reduced mobility. During a review of Resident 59's Minimum Data Set (MDS - a resident assessment tool), dated 3/4/2025, the MDS indicated that the resident had moderately impaired cognition (thought processes) and was dependent on staff for most activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). The MDS also indicated that the resident was at risk of developing pressure ulcers/injuries and had one or more unhealed pressure ulcers/injuries. During a review of Resident 59's admission Reassessment, dated 2/21/2025, the reassessment indicated that the resident had a stage II pressure ulcer/injury on the sacrococcyx. During a review of Resident 59's physician's order, dated 4/23/2025, the order indicated to cleanse the…

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

Based on observation, interview and record review the facility failed to ensure residents receive treatment and assistive devices to maintain hearing abilities for one of one resident (Resident 5) reviewed under the communication/sensory care area when Resident 5 was not provided with an audiology consultation for his impaired hearing. This failure prevented Resident 5 from receiving the services and equipment needed to improve his hearing ability. Findings: During a review of Resident 5's admission Record, the admission Record indicated the facility admitted Resident 5 on 2/28/2024 with diagnoses including type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), heart failure (a condition where the heart muscle is weakened and cannot pump blood effectively enough to meet the body's need), acute kidney failure (a sudden and significant loss of kidney [organ that filters blood] function), and depression (persistent feelings of sadness, hopelessness, and loss of interest in activities previously enjoyed). During a review of…

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

1.b. During a review of Resident 36's admission Record, the admission Record indicated that the facility originally admitted the resident on 7/6/2014 and readmitted the resident on 4/29/2025 with diagnoses including metabolic encephalopathy (a condition where brain dysfunction results from a problem with the body's metabolism, causing a change in brain function), legal blindness, and a history of falling. During a review of Resident 36's Minimum Data Set (MDS - a resident assessment tool), dated 3/3/2025, the MDS indicated that the resident had intact cognition (thought processes) and was dependent on staff for most activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 36's Fall Risk Assessment, dated 3/4/2025, the Fall Risk Assessment indicated that the resident was at high risk for falls. During a review of Resident 36's physician's order, dated 5/1/2025, the order indicated to provide the resident with a floor mat to decrease potential injury every shift. On 5/7/2025 at 2:41 p.m., during an…

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

Based on observation, interview, and record review the facility failed to: 1. Reconcile (the process of comparing transactions and activity to supporting documentation) one (1) medication emergency kit (eKIT-contains certain medications that could be taken if needed immediately) containing controlled medications (CM- medications which have a potential for abuse and may also lead to physical or psychological dependence) for 5/2025, in one (1) of two (2) inspected medication rooms (Medication Room Station 1). 2. Reconcile one (1) medication eKIT containing CMs for 5/2025, in one (1) of five (5) inspected medication carts (Medication Cart Station 2B.) These deficient practices increased the opportunity for CM diversion (the transfer of a controlled medication or other medication from a lawful to an unlawful channel of distribution or use). Findings: During a concurrent observation and interview on 5/5/2025 at 12:50 p.m., with Registered Nurse 1 (RN 1) and in the presence of the Director of Nursing (DON) in Medication Room Station 1, observed one (1) medication eKIT in the refrigerator…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 five (5) percent (%). Two (2) medication errors out of 34 total opportunities contributed to an overall medication error rate of 8.82% affecting two (2) of six (6) residents observed for medication administration (Resident 151 and 183.) The medication errors were as follows: 1. Resident 151 received carvedilol (a medication used to for hypertension [HTN - a condition in which the blood vessels have persistently raised pressure]) at a different time than ordered by Resident 151 ' s physician. 2. Resident 183: a. did not receive docusate (a medication used to soften stool) as ordered by Resident 183 ' s physician b. received a form of multivitamin (a medication used as a dietary supplement to provide essential vitamins, minerals, and other nutritional elements) that was different than the one ordered by Resident 183 ' s physician These failures had the potential to result in Resident 151…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Remove and discard from use one expired insulin (medication used to regulate blood sugar levels) Aspart (short-acting insulin) Flexpen (an injection device containing insulin) for Resident 6, in accordance with manufacturer ' s requirements and facility policy and procedures in one (1) of two (2) inspected medication rooms (Medication Room Station 1.) 2. Label one (1) insulin Humulin R (long-acting insulin) vial for Resident 12, in accordance with manufacturer's requirements and facility policy and procedures in one (1) of two (2) inspected medication rooms (Medication Room Subacute.) 3. Remove and discard from use one (1) Procrit (brand name medication for epogen used to treat anemia [having low red blood cells) vial for Resident 14, in accordance with manufacturer 's requirements and facility policy and procedures in one (1) of two (2) inspected medication rooms (Medication Room Subacute.) These deficient practices increased the risk…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prepare food by methods that conserved temperature, flavor and appearance when the temperature of the food were as follows: -Zest spinach 121 degrees Fahrenheit (°F, a scale of temperature) -Chocolate cake 60°F, -Milk 47°F and 49°F -Puree chocolate cake 57°F. This deficient practice placed 138 of 199 facility residents on regular, therapeutic diets (a meal plan that controls the intake of certain food and nutrients) and puree diets (food with soft pudding like consistency) at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen. Findings: During a review of the facility'' daily spreadsheet (a list of food, amount of food that each diet would receive) titled Spring Cycle Menus, dated 5/6/2025, the spreadsheet indicated residents on Regular and therapeutic diet t would include the following foods on the tray: -Meat balls with gravy 2 pieces 1-2 ounces (oz, a unit of measurement) -Gravy 1 oz -Penne with garlic and herbs ½ cup (c., household measurement -Zesty spinach ½…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prepare foods in a form designed to meet individual needs when puree (foods that are smooth with pudding like consistency) when puree pasta was sticky pasta and not smooth pudding like consistency. These failures had the potential to result in difficulty in swallowing, chewing, decreased in food intake and nutrient intake to 18 of 18 residents on puree diet, resulting in unintended (not planned) weight loss and chocking (when food gets stuck in your airway, blocking the flow of air to your lungs). Findings: During a review of the facility's menu spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled Spring Cycle Menus, dated 5/6/2025, the spreadsheet indicated residents on puree diet would include the following foods on the tray: -Puree meatballs 2- number 16 scoops (1/2 c total) -Gravy 1 oz -Puree penne with garlic and herbs ½ c. -Puree zesty spinach 1/3 c. -Puree fresh green salad with dressing 1/3 c. -Puree chocolate cake 1/3 c. -Milk 4 fluid oz. During a concurrent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 food storage and food preparation practices in the kitchen when: 1. Opened plastic bags of frozen pancakes and frozen pie crust in the freezer were not labeled and dated. 2. Kitchen equipment and kitchen areas were not cleaned and sanitized. a. The reach-in refrigerator's ceiling had dust and dirt debris. b. The two drawers by the preparation area were dirty to touch and had dust buildup. c. Plate warmer's internal part where the clean plates were stored had food and white dirt debris. d. The two push carts where clean resident's trays, bases and domes were stored had dirt, food and hair debris. e. Condiment containers contain loose sugar, pepper, sweetener particles and dirt residues. 3. Kitchen equipment and utensils were not maintained in their proper condition, smooth and easy to clean. a. Seven (7) of 7 green shelves in the Walk-in Refrigerators 1 and 2 had cracks, chips, and rust with amber discoloration. b. The green chopping board had black and brown stains and scratches. c.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dispose garbage and refuse properly when there were soiled gloves, empty plastic bottles, plastic and other trash on the floor and surrounding areas of the dumpster bin (a movable waste container designed to be brought and taken away by a special collection vehicle, or to a bin that a specially designed garbage truck lifts). This failure had potential to attract birds, flies, insects, pests, and possibly spread infection to 138 of 199 facility residents. Findings: During a concurrent observation and interview on 5/7/2025 at 3:10 p.m. of the dumpster with the Dietary Supervisor (DS), observed soiled gloves, empty bottles, plastic and other trash on the ground. The DS stated it was not okay to have trash around the dumpster surroundings because it could attract pests, and could spread sickness to the residents. The DS stated he did not know who maintains the trash area. During an interview on 5/7/2025 at 4:11 p.m. with the Maintenance Director (MD), the MD stated he maintains the dumpster and trash area and it…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) records for one of seven sampled residents (Resident 690) with limitation in range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) indicated the provision of passive range of motion ([PROM] movement of a joint through the ROM with no effort from person) to both legs from 4/22/2025 to 5/5/2025 in accordance with the physician's order, dated 4/22/2025. This failure resulted in the inaccurate provision of care recorded in Resident 690's medical records. Findings: During a review of Resident 690's admission Record, the admission Record indicated the facility admitted Resident 690 on 4/18/2025 with diagnoses including neoplasm (abnormal tissue growth) of meninges (three protective layers of connective tissue that surround the brain and spinal cord), nontraumatic intracerebral hemorrhage (bleeding in brain tissue),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection control practices by failing to: 1. Implement Enhanced Barrier Precautions ([EBP] an infection control intervention in nursing homes designed to reduce transmission of bacteria and other microorganisms that have developed resistance to antibiotics making infections hard to treat) with Resident 130 and 151 in the therapy gym during high contact activities. This deficient practice had the potential to increase the risk of spreading infection to other residents. 2. 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 151 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). This deficient practice had the potential for cross contamination and placed the residents at risk…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 therapy gym had adequate space and equipment to provide therapy services by failing to ensure: 1. One of two therapy mats functioned properly and was accessible for resident care. 2. One of eight hand weights was well-maintained for residents' use. 3. One of one oxygen concentrators (medical device used for delivering oxygen) was serviced. 4. One of one containers of ultrasound (imaging test that uses high-energy sound waves to look at tissues and organs inside the body) gel was not expired. These failures had the potential to place residents receiving therapy services from safe and optimal use of the therapy equipment. Findings: During an observation on [DATE] at 9:43 a.m., in the therapy gym, one combination ultrasound and electrical stimulation (use of mild electrical pulses through the skin to help stimulate injured muscles or manipulate nerves to reduce pain) machine was in the therapy gym. During a concurrent observation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to complete a comprehensive Minimum Data Set ([MDS] a federally mandated resident assessment tool) for one of 38 sampled residents (Resident 690) after admission on [DATE]. This failure had the potential to prevent Resident 690 from receiving services to achieve Resident 690's goal of walking with a single point cane ([SPC] walking device with a curved or bent handle at the top and long shaft that ends in a single tip used to provide support while walking) to return home. Findings: During a review of Resident 690's admission Record, the admission Record indicated the facility admitted Resident 690 on 4/18/2025 with diagnoses including neoplasm (abnormal tissue growth) of meninges (three protective layers of connective tissue that surround the brain and spinal cord), nontraumatic intracerebral hemorrhage (bleeding in brain tissue), lack of coordination, muscle weakness, foot drop (condition where the individual experiences difficulty 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 Minimum Data Set (MDS - a standardized assessment and screening tool) was transmitted timely to the Centers for Medicare and Medicaid Services (CMS) system for one (1) out of one (1) sampled residents (Resident 35). This deficient practice had the potential to result in delayed services for Resident 35. Findings: During a review of the admission record , the admission record indicated Resident 35 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including type 2diabetes (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly), urinary tract infection (infection in any part of the urinary system), and essential hypertension (high blood pressure that is not due to another medical condition). During a review of Resident 35's Record of Death dated [DATE], the record of death indicated that the body of Resident 35 was released 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 interview and record review, the facility failed to develop a complete baseline care plan within 48 hours of a resident`s admission to the facility by failing to address the resident`s indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine) for one of one sampled resident (Resident 99) reviewed under catheter care area. This deficient practice had the potential of Resident 99 to not receive appropriate care and treatment in the facility. Findings: During a review of Resident 99's admission Record (face sheet), the admission Record indicated that the facility originally admitted the resident on 9/15/2020 and readmitted on [DATE], with diagnoses including type two (2) diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), obstructive uropathy (a blockage in the urinary tract that prevents urine from draining normally), and reflux uropathy (when urine flows backward into the kidneys). During a review of Resident 99'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.

Based on interview and record review, the facility failed to update and revise a resident's care plan (a document that summarizes a resident's needs, goals, and care/treatment) after the resident's restraint freedom splint (multipurpose soft splints that help restrict elbow and knee movement) was discontinued, for one of two sampled residents (Resident 63). This deficient practice had the potential to result in confusion in the delivery of care and service. Findings: During a review of Resident 63's admission Record, the admission Record indicated that the facility admitted the resident on 2/14/2018 and readmitted the resident on 6/17/2024 with diagnoses including acute respiratory failure (a condition in which your blood doesn't have enough oxygen causing shortness of breath and difficulty breathing), encephalopathy (brain disease, damage, or malfunction of brain), chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood) with hypoxia (a condition where there is an inadequate supply of oxygen to the body's tissues), and quadriplegia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 156) was provided a communication device or board (a tool that includes pictures that help residents communicate their healthcare and every-day needs to facility staff) in her preferred language in order to effectively communicate with staff. This deficient practice prevented Resident 156 from communicating with the staff and receiving care in a timely manner. Findings: During a review of Resident 156's admission Record (face sheet), the admission Record indicated that the facility admitted the resident on 3/26/2024, with diagnoses including dysphagia (difficulty swallowing), essential hypertension (HTN-high blood pressure), and need for assistance with personal care. The admission Record further indicated that Resident 156`s primary language was Chinese. During a review of Resident 156's Minimum Data Set (MDS - a resident assessment tool) dated 4/8/2025, the MDS indicated that the resident`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.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 540) was provided a toileting program and/or bowel and bladder training (when facility staff assist a resident to the restroom at specific timed intervals) to restore as much bladder function as possible. This deficient practice had the potential to result in continued urinary incontinence (the involuntary leakage or loss of bladder control, resulting in unintended urination), development of urinary tract infection (UTI- an infection in any part of the urinary system), and potential to not achieve or restore normal bowel and bladder function. Findings: During a review of Resident 540's admission Record, the admission Record indicated the facility originally admitted the resident on 4/6/2025 with diagnoses including acute and chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood), acute kidney failure (a condition in which the kidneys are damaged and cannot filter blood well), and type two (2) diabetes mellitus (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 that one of one sampled resident (Resident 15), who was receiving nutrition by gastrostomy tube (GT-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), received appropriate care and services to prevent complications of enteral feeding (tube feeding, a way of delivering nutrition directly to your stomach or small intestine). This deficient practice had the potential to lead to the inadequate care of Resident 15 and place the resident at an increased risk for complications such as infection. Findings: During a review of Resident 15's admission Record (face sheet), the admission record indicated that the facility originally admitted the resident on 11/21/2024 and readmitted on [DATE], with diagnoses including tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs), gastrostomy, 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 1. Ensure that a resident received oxygen as ordered by the physician for one of two sampled residents (Resident 107) reviewed under Respiratory Care area. 2. Ensure that Resident 107`s oxygen tubing had a label indicating the date and time of when it was last changed. 3. Ensure that Resident 107`s oxygen humidifier (a medical device used to add moisture to supplemental oxygen, making it easier and more comfortable to breathe, especially for patients using oxygen therapy for extended periods ) was full. These deficient practices had the potential to place Resident 107 at an increased risk of infection and cause complications associated with oxygen therapy. Findings: During a review of Resident 107's admission Record (face sheet), the admission Record indicated that the facility originally admitted the resident on 4/19/2021 and readmitted on [DATE], with diagnoses including acute (appear rapidly) and chronic (a condition that lasts longer…

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

Based on interview and record review, the facility failed to ensure non-pharmacological interventions (treatments or therapies that do not involve the use of medications) were attempted prior to administering as needed oxycodone (a drug used to treat moderate to severe pain) for one of two sampled residents (Resident 100). This deficient practice placed Resident 100 at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention) from oxycodone such as drowsiness, increased risk of falling, or loss of appetite. Findings: During a review of Resident 100's admission Record, the admission Record indicated the facility originally admitted the resident on 9/19/2020 and readmitted the resident on 3/29/2025 with diagnoses including but not limited to sarcoma (a group of cancers which start in the bones and connective tissue), pain in the right knee, and aftercare following surgery for a neoplasm (abnormal and excessive growth of tissue). During a review of Resident 100's Minimum Data Set (MDS - a resident assessment tool),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who received dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) received treatment in accordance with standards of practice for one of four sampled residents reviewed under the dialysis care area (Resident 160) by: 1. Failing to assess the resident`s right upper chest quinton catheter (non-tunneled central line catheters, which are often used as temporary access for hemodialysis) dialysis access site. 2. Failing to implement the physician's order for fluid restriction (limiting the amount of liquid a person consumes daily, often prescribed to manage kidney disease) limited to no water pitcher at the resident`s bedside. These deficient practices had the potential to place Resident 160 at risk for fluid overload (a condition where you have too much fluid volume in your body) and infection. Findings: During a review of Resident 160's 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.

Deficiency Text Not Available

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its Patient Assessment, policy and procedure for one sampled resident (Resident 18) reviewed under dementia care by failing to conduct a quarterly social service assessment . This deficient practice had the potential for Resident 18 to not attain or maintain the highest practicable physical, mental and psychosocial health. Findings: During a review of Resident 18's admission Record, the admission Record indicated that the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including pneumonia (is an infection that inflames the air sacs [thin-walled structures composed of simple squamous epithelium] in one or both lungs), Parkinsonism (a clinical syndrome characterized by a group of motor symptoms, including bradykinesia[ slowed movement], rigidity[stiffness], and tremor, and often associated with impaired posture and gait), and schizophrenia (a serious mental illness that affects how a person thinks, feels,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation to one of seven sampled residents (Resident 690) with range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) concerns in accordance with the physician's order, dated 5/1/2025. This deficient practice prevented Resident 690 from receiving a PT Evaluation to assess the possibility of receiving additional therapy to achieve Resident 690's goal of walking with a single point cane ([SPC] walking device with a curved or bent handle at the top and long shaft that ends in a single tip used to provide support while walking) to return home. Findings: During a review of Resident 690's admission Record, the admission Record indicated the facility admitted Resident 690 on 4/18/2025 with diagnoses including neoplasm (abnormal tissue growth) of meninges (three…

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

Based on interview and record review, the facility failed to provide appropriate hospice services (a program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease) to one of one sampled resident (Resident 61) reviewed under Hospice and End of Life care area by failing to: 1. Designate a member of the facility's interdisciplinary team to coordinate care provided to the residents by the facility and the hospice company in their Hospice Program, policy. 2. Honor Resident 61`s Responsible Party 2`s (RP 2) wish to end the resident`s hospice services. These deficient practices had the potential to negatively affect Resident 61`s physical comfort and psychosocial well-being. Findings: During a review of Resident 61's admission Record (face sheet), the admission Record indicated that the facility admitted the resident on 4/22/2024, with diagnoses including history of falling, muscle weakness, cerebrovascular disease (conditions that affect blood flow to your brain), seizure (a sudden, uncontrolled electrical disturbance 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 maintain sanitary conditions in the food services department when one (1) fly (a type of insect) was observed in the kitchen. This failure had the potential to result in 138 of 199 residents, who received food from the kitchen, to acquire food borne illnesses (illness caused by consuming contaminated foods or beverages) by consuming potentially contaminated food. Findings: During an observation on 5/6/2025 at 11:06 a.m. one (1) fly was flying around the preparation area and landed on the dessert rack. During an observation on 5/6/2025 at 11:13 a.m. one fly was flying around the trayline area (an area where foods were assembled from the steamtable to resident's plate). During an interview on 5/6/2025 at 12:52 p.m. with the Dietary Supervisor (DS), the DS stated the pest control vendor came in the beginning of 4/2025. The DS stated a fly landing on the food rack is not okay as it could transmit diseases through food contact of the residents. During a review of facility's policies and procedures (P&P) titled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents at risk for developing pressure ulcers localized damage to the skin and/or underlying tissue usually over a bony prominence) had their skin assessed and documented on a weekly basis per the facility policy and procedure (P&P) for two of three sampled residents (Resident 1 and Resident 2). This deficient practice had the potential to delay necessary treatments and services and to increase the residents' risk of skin breakdown. Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 to the facility on 7/13/2018 and readmitted the resident on 12/05/2018 with diagnoses including diabetes mellitus (DM- a chronic condition that affects the way the body processes blood glucose [sugar]) and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to review and update a care plan (a document outlining a detailed approach to care customized to an individual resident's need) after a resident`s Change of Condition (COC-an improvement or worsening of a patient`s condition which was not anticipated) for one of two sampled residents (Resident 1 ). This deficient practice had the potential to result in Resident 1 receiving inadequate care and supervision to prevent falls. Findings: During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted the resident on 4/9/2014, and readmitted on [DATE], with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), need for assistance with personal care, history of falling, and fracture of left femur (thigh bone). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 10/12/2024, the MDS indicated that the resident`s cognitive skills (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 follow the facility's policy and procedure titled Assessing Falls and Their Causes, for one of two sampled residents (Resident 1) by failing to complete a fall risk assessment after the resident`s fall on 12/25/2024. This deficient practice placed Resident 1 at increased risk for recurrent falls and injuries. Findings: During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted the resident on 4/9/2014, and readmitted on [DATE], with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), need for assistance with personal care, history of falling and fracture of left femur (thigh bone). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 10/12/2024, the MDS indicated the resident`s cognitive skills (the brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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), was treated with dignity by not communicating with Resident 1 his (Resident 1's) preferred time to receive activities of daily living (ADL-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) care. This deficient practiced had the potential to decrease the resident's sense of well-being, level of satisfaction with life and feelings of self-worth and self-esteem. Findings: During a review of Resident 1's admission Record dated 10/25/2024, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included sepsis (a serious condition in which the body responds improperly to an infection), heart failure (a heart condition in which the heart is unable to pump blood efficiently), pneumonia (an infection of one or both of the lungs caused by bacteria or viruses), anemia (a condition where the body does not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 permit one of four sampled residents (Resident 1) to return to the facility after hospitalization. This deficient practice subjected Resident 1 to an unnecessary prolonged hospitalization. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted the resident on 5/29/2024 with diagnoses that included intracranial (within the skull) injury with loss of consciousness (when a person is neither awake nor aware of the external environment) of unspecified duration, traumatic subdural (space between the skull and the brain) hemorrhage (excessive bleeding) with loss of consciousness of 30 minutes or less, and acute (sudden) respiratory failure (condition in which not enough oxygen passes from your lungs into your blood). During a review of Resident 1's Minimum Data Set (MDS -a resident assessment tool), dated 6/5/2024, the MDS indicated that Resident 1 was cognitively (the mental action 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.

Based on observation, interview, and record review, the facility failed to ensure that facility staff (Certified Nurse Assistant 2 [CNA2]) documented blisters (small bubble-like raised bumps [raised area of the skin] on the skin) on the left posterior hand for one of three sampled residents (Resident 2) on the resident's Daily Body Check Report form. This deficient practice had the potential for Resident 2 to not to receive the care and services needed to treat Resident 2's worsening bump on the left posterior hand. Findings: During a review of Resident 2's admission Record, the document indicated the facility readmitted the resident on 9/5/2024 with diagnosis of hemiplegia (paralysis of one side of the body), head injury, and brain damage. During a review of Resident 2's History and Physical dated 3/15/2024, the document indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS- a care screening tool) dated 9/20/2024, the document indicated Resident 2 was dependent (helper does all of the effort, resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of five sampled residents (Resident 3) was provided with a left-hand splint (a device that supports and protects the hand and wrist, and keeps them positioned correctly) to reduce further contractures (a permanent tightening of the muscles, skin, and nearby tissues that causes the joints to shorten and become very stiff) of Resident 3 ' s left hand. This deficient practice placed Resident 3 at increased risk for worsening and further development of contractures. Findings: During a review of Resident 3 ' s admission Record indicated the facility admitted the resident originally on 11/9/2022 and readmitted on [DATE] with diagnoses that included cerebral infarction (a type of stroke that occurs when blood flow to the brain is blocked, causing brain tissue to die), right hand contracture, left hand contracture, tracheostomy (a surgical procedure to create an opening through the neck into the trachea [windpipe]), and gastrostomy (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 that the resident`s fingernails of two of five sampled residents (Resident 2 and 3) were not dirty as evidence by black substances under the tip of the nails. This deficient practice resulted in Resident 2 and 3 having dirty fingernails that had the potential to result in a negative impact on the resident's self-esteem and self-worth. Findings: 1. During a review of Resident 2 ' s admission Record, the admission Record indicated that the facility admitted Resident 2 on 5/20/2024 and readmitted Resident 2 on 7/29/2024 with diagnoses that included dementia (a decline in mental function that affects a person's ability to think, remember, and reason), tracheostomy(a surgical procedure to create an opening through the neck into the trachea [windpipe]), and gastrostomy tube (g-tube: a tube inserted through the belly that brings nutrition directly to the stomach). During a review of Resident 2 ' s Minimum Data Set (MDS- a standardized…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 practices by failing to ensure two of 11 sampled staff (Certified Occupational Therapy Assistant 1 [COTA 1] and Physical Therapy Assistant 1 (PTA 1) wore isolation gowns (protective apparel, used to protect the wearer from the spread of infection or illness if the wearer comes in contact with potentially infectious liquid and solid material) while providing therapy services to Resident 4, in Resident 4 ' s room which was placed on enhanced standard precautions (ESP - a set of infection control measures that involve wearing gowns and gloves during high-contact resident care activities for residents at increased risk of Multidrug- Resistant Organisms [MDROs - bacteria that have become resistant to certain antibiotics [a medicine that fights bacterial infections] such as residents with wounds or indwelling medical devices [a medical device that is left inside the body for variety of reasons including to administer food or medications]). These deficient practices had the potential to…

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

Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for one of five sampled residents (Resident 1). This deficient practice had the potential to result in a delay with resident care, possible injury to residents when unable to obtain the needed care and services and residents not receiving assistance with activities of daily living (ADL- tasks of everyday life such as eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet). Findings: During a review of Resident 1's admission Record indicated the facility admitted the resident on 4/22/2024 with diagnoses that included cerebrovascular disease (conditions that affect blood flow to the brain), skull (the bony framework of the head) fracture (broken bone), and seizure (a sudden, uncontrolled burst of electrical activity in the brain causing changes in behavior, movements,…

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

Based on observation, interview, and record review the facility failed to provide care and services to maintain good grooming and personal hygiene for one of five sampled residents (Resident 1). This deficient practice resulted in Resident 1 having dirty fingernails that had the potential to result in a negative impact on the resident's self-esteem and self-worth. Findings: During a review of Resident 1's admission Record indicated the facility admitted the resident on 4/22/2024 with diagnoses that included cerebrovascular disease (conditions that affect blood flow to the brain), skull (the bony framework of the head) fracture (broken bone), and seizure (a sudden, uncontrolled burst of electrical activity in the brain causing changes in behavior, movements, feelings and levels of consciousness [the state of being aware of and responsive to one's surroundings]). During a review of Resident 1's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 5/2/2024, indicated Resident 1's cognition (mental action or process of acquiring knowledge and understanding through…

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

Based on interview and record review, the facility failed to ensure that the Physician Progress Notes (record that documents the physician's role in the assessment, evaluation, and care of residents) were completed as required for one of five sampled residents (Resident 1). This deficient practice had the potential for inconsistent care coordination due to incomplete records and placed Resident 1 at risk for poor continuity of care and care needs. Findings: During a review of Resident 1's admission Record indicated the facility admitted the resident on 4/22/2024 with diagnoses that included cerebrovascular disease (conditions that affect blood flow to the brain), skull (the bony framework of the head) fracture (broken bone), and seizure (a sudden, uncontrolled burst of electrical activity in the brain causing changes in behavior, movements, feelings and levels of consciousness [the state of being aware of and responsive to one's surroundings]). During a review of Resident 1's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 5/2/2024, indicated Resident 1's…

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

2. A review of Resident 179's admission Record indicated the facility admitted the resident on 3/9/2024 and readmitted the resident on 4/1/2024 with diagnoses of fracture (broken bone) of right femur (thighbone), fracture of left tibia (two bones between the knee and ankle), and fracture of right lower leg. A review of Resident 179's History and Physical (H&P - a formal assessment of a patient and their problem), dated 4/1/2024, indicated the resident had the capacity to understand and make decisions. A review of Resident 179's Order Summary Report, dated 4/1/2024, indicated to give oxycodone hydrochloride (medication used to treat moderate to severe pain) tablet 7.5 milligram (mg- a unit of measurement) by mouth three times a day for severe pain. A review of Resident 179's Medication Administration Record (MAR- the report that serves as a legal record of the drugs administered to a resident of a facility by a health care professional) dated 5/2024, indicated Resident 179 did not receive her prescribed oxycodone 7.5 mg on the following dates and times: - 5/13/2024 at 10:00 a.m.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure licensed nurses attempted non-pharmacological interventions (any type of healthcare intervention which is not primarily based on medication) prior to administering as needed lorazepam (medication used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations]) to two of 37 sampled residents (Residents 11 and 166). This deficient practice had the potential to place the residents at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention). Findings: a. A review of Resident 11's admission Record indicated the facility originally admitted the resident on 9/27/2017 and readmitted the resident on 12/28/2023 with diagnoses including anxiety disorder. A review of Resident 11's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/18/2024, indicated the resident had intact cognition (thought processes) and was…

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

Based on observation, interview, and record review, the facility failed to ensure the window screen was affixed to the frame and did not have gaps or openings from top to bottom for one of 18 resident's room (Room A) investigated under physical environment. This deficient practice had the potential to result in insect infestation that could pose harm to the residents. Findings: During the initial facility tour and room observation on 5/28/2024 at 11:37 a.m., observed Room A occupied by three residents. Upon closer observation of the room environment, observed one panel of the window screen was not affixed on the window frame creating a gap or opening from top to bottom measuring half an inch. During a concurrent observation and interview on 5/29/2024 at 11:46 a.m., with the Assistant Director of Nursing (ADON), the ADON verified the observation by stating there was a gap on the window screen of Room A. The ADON stated staff frequently conduct room inspections to ensure the environment is safe for the residents. The ADON stated that they make sure rooms are clutter free and free 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.

Based on interview and record review, the facility failed to ensure a resident had a comprehensive care plan (a written document that summarizes a patient's needs, goals, and care/treatment) addressing the use of insulin (a hormone that lowers the level of glucose [sugar] in the blood) for one of one sampled resident (Resident 57) investigated for insulin use. This deficient practice had the potential to result in failure to deliver the necessary care and services. Findings: A review of Resident 57's admission Record indicated the facility initially admitted the resident on 10/27/2014 and readmitted the resident on 3/5/2024 with diagnoses that included muscle weakness, type two (2) diabetes mellitus (DM- a chronic condition that affects the way the body processes blood glucose [sugar]), and gastro-esophageal reflux disease (stomach contents flow backward, up into the esophagus, the tube that carries food from your throat into stomach). A review of Resident 57's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 4/14/2024, indicated the resident had the…

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

Based on interview and record review, the facility failed to ensure Licensed Vocational Nurse 4 (LVN 4) was competent in taking orthostatic blood pressure (taking a blood pressure [BP] lying down flat, sitting up, and standing up to ensure a resident does not have orthostatic hypotension [a form of low blood pressure that happens when standing after sitting or lying down which can cause dizziness or lightheadedness and possibly fainting]) measurements for one of 37 sampled residents (Resident 158). This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention) of hypotension (low blood pressure). Findings: A review of Resident 158's admission Record indicated the facility admitted the resident on 5/4/2023 with diagnoses including schizophrenia (a serious mental health condition that can cause people to have abnormal interpretations of reality). A review of Resident 158's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated…

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

Based on interview and record review, the facility failed to ensure the Controlled Drug Record form (CDR- accountability record of medications that are considered to have a strong potential for abuse) reflected what was on the Medication Administration Record (MAR - report that serves as a legal record of the drugs administered to a resident by a health care professional) for one of three sampled residents (Residents 492). These deficient practices resulted in inaccurate reconciliation of the controlled medication and placed the facility at potential for inability to readily identify loss and drug diversion (illegal distribution of abuse of prescription drugs or their use for unintended purposes) of controlled medications. Findings: A review of Resident 492's admission Record indicated the facility admitted the resident on 5/8/2024 with diagnoses including respiratory failure (condition in which not enough oxygen passes from your lungs into your blood). A review of Resident 492's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/21/2024, 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 on interview and record review the facility failed to ensure one of three sampled residents (Resident 187) did not exceed more than 3,000 milligrams (mg, unit of measure) of acetaminophen (Tylenol, a medication used to treat pain and fever) per day per physician order. This deficient practice had the potential to cause toxic levels of acetaminophen to build up in the blood which can lead to nausea, vomiting, abdominal pain, and/or liver failure. Findings: A review of Resident 187's admission Record Face Sheet indicated the facility admitted the resident on 4/25/2024 with diagnoses including fracture (broken bone) of shaft of left tibia (lower leg) and multiple fractured ribs. A review of Resident 187's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/5/2024, indicated the resident is dependent on staff for toileting, bathing, and dressing. A review of Resident 187's History and Physical (H&P - a formal assessment of a patient and their problem), dated 5/14/2024, indicated the resident had the capacity to understand and make decisions. 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 properly store six boxes of Santyl ointment (medication used for removing damaged tissue or burned skin to allow for wound healing and growth of healthy skin) in the medication's room discontinued medication cabinet for one of three residents (Resident 57) when it was discontinued by the physician on 5/22/2024. The deficient practice had the potential to cause unintentional medication administration and a loss of control against drug loss, diversion, or theft. Findings: A review of Resident 57's admission Record indicated the facility admitted the resident on 3/5/2024 with diagnoses that included respiratory failure (condition in which not enough oxygen passes from your lungs into your blood), tracheostomy (procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck), and cervical (the first seven bones of the spine composing the neck) spinal cord injury. A review of Resident 57's Minimum Data Set (MDS, a standardized resident assessment and care…

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

Based on observation, interview, and record review, the facility failed to ensure an eight-ounce glass of milk was not left at the resident's bedside for more than four (4) hours for one of three sampled residents (Resident 94). This deficient practice had the potential to result in food borne illness (when contaminated food is consumed which causes an infection resulting illness) upon ingestion of a spoiled milk. Findings: A review of Resident 94's admission Record indicated the facility originally admitted the resident on 9/3/2020 and readmitted the resident on 10/29/2023, with diagnoses including gastro-esophageal reflux disease (stomach contents flow backward, up into the esophagus, the tube that carries food from your throat into stomach), shortness of breath, and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 94's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 4/4/2024, indicated that the resident's cognitive (thought processes) skills for daily decision making…

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

b. A review of Resident 179's admission Record indicated the facility admitted the resident on 3/9/2024 and readmitted the resident on 4/1/2024 with diagnoses of fracture (broken bone) of right femur (thighbone), fracture of left tibia (two bones between the knee and ankle), and fracture of right lower leg. A review of Resident 179's History and Physical (H&P - a formal assessment of a patient and their problem), dated 4/1/2024, indicated the resident had the capacity to understand and make decisions. A review of Resident 179's Order Summary Report, dated 4/25/2024, indicated an order for vancomycin (used to treat and prevent various bacterial infections) 1.25 gram (gm, a unit of measurement) intravenously (entering by way of a vein) every 12 hours for surgical infection. During a concurrent interview and record review on 5/30/2024 at 3:32 p.m., with the Director of Staff Development (DSD), reviewed the infection surveillance forms for the month of 4/2024. The DSD stated that the infection surveillance forms must be collected before starting an antibiotic. The DSD stated this is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) for one of six sampled residents (Resident 1), who sustained a fall on 5/8/2024. This deficient practice placed Resident 1 at risk for further falls and injuries. Findings: A review of Resident 1's admission Record indicated the facility originally admitted the resident on 9/27/2017 and readmitted on [DATE] with diagnoses that included osteoporosis (a health condition that weakens bones), dementia (the loss of cognitive [thinking, remembering and reasoning] functioning that it interferes with a person's daily life and activities), and respiratory failure (a condition that makes it difficult to breathe on your own) dependent on ventilator (a machine that helps you breathe). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 2/18/2024, indicated Resident 1's cognition…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 update the Physician Order for Life- Sustaining Treatment (POLST - a written medical that helps give residents with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) for one of five sampled residents (Resident 1), when Resident 1 ' s code status (describes the type of resuscitation procedures [ the process of treating the lack of breathing or heartbeat of a seriously ill resident]), if any; a resident would like the health care team to conduct if a resident ' s heart stopped beating and/or stopped breathing) was changed from Do Not attempt Resuscitation (DNR-instructs health care providers to not to do cardiopulmonary resuscitation [CPR- an emergency lifesaving procedure performed when the heart stops beating] if a patient's breathing stops or if the patient's heart stops beating) to Full Code (if a resident ' s heart stopped beating and/or they stopped…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 update a comprehensive person-centered care plan (a plan for an individual ' s specific health needs and desired health outcomes) for one of five sampled residents (Resident 1), who had their code status (describes the type of resuscitation procedures [ the process of treating the lack of breathing or heartbeat of a seriously ill resident]) changed from Do Not attempt Resuscitation (DNR-instructs health care providers to not to do cardiopulmonary resuscitation [CPR- an emergency lifesaving procedure performed when the heart stops beating] if a patient's breathing stops or if the patient's heart stops beating) to Full Code (if a resident ' s heart stopped beating and/or they stopped breathing, all resuscitation procedures including CPR will be provided to keep the resident alive). This deficient practice had a potential for a resident and or resident ' s representative ' s wishes for medical treatment to be violated in case of an emergency, and or cause…

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