Grand Valley Health Care Center

Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly by failing to ensure: 1. Two (2) of 2 black dumpsters (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) were completely closed while not actively being used. 2. There were no soiled gloves, masks, and a bag of trash on the floor area and surroundings of the facility's dumpster. 3. The dumpster designated for food and organic waste was not leaking fluid on the ground. These failures had potential to attract birds, flies, insects, pests, and possibly spread infection to 82 of 82 facility residents. Findings: During an observation on 12/30/2025 at 4:15 p.m., of the dumpster area with the Dietary Supervisor (DS), observed two (2) black dumpsters that were not completely closed and there was a bag of trash, soiled gloves, plastic, mask, and paper on the floor and the surroundings of the dumpster. During an observation on 12/30/2025 at 4:16 p.m., of the dumpster designated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: 1. An unopened box of expired lancets (tiny, sharp needles used to prick the skin to obtain a small blood sample for blood glucose [sugar] monitoring) found in one of one medication storage room was disposed of on the date of expiration This deficient practice had the potential to cause an infection if the expired lancets were used on a resident. 2. One of three sampled resident's (Resident 21) insulin pen (a device used to administer insulin [a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication]) tip was not cleaned with an alcohol pad prior to attaching the needle. This failure had the potential to increase Resident 21's risk of developing an infection at the site of the injection. Findings: a. During a concurrent observation and interview on [DATE] at 4:15 p.m., with Registered Nurse 1 (RN 1), observed inside the medication storage room, one unopened box of expired…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dead cockroach (a type of insect) was observed in the residents' refrigerator in the staff break room. This failure had the potential to result in 80 of 82 residents, who received food from the kitchen, acquiring food borne illnesses (illness caused by consuming contaminated foods or beverages) by consuming potentially contaminated food. Findings: During a concurrent observation and interview on 12/31/2025 at 11:28 a.m., with the Dietary Supervisor (DS), observed the residents' refrigerator in the staff break room. Observed there was a resident's food stored inside the refrigerator and one (1) dead cockroach inside the vegetable bin. The vegetable bin was difficult to remove because a bench chair and another refrigerator were blocking the refrigerator door from completely opening. The DS stated the brown insect looked like a dead cockroach. During a concurrent observation and interview on 12/31/2025 at 11:31 a.m., with the Housekeeping…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Licensed Vocational Nurse (LVN 5) knocked on a resident's door and requested permission before entering the room for one of two sampled resident (Resident 114) reviewed under the dignity care area. This deficient practice violated the resident`s rights to be treated with respect and dignity, which had the potential to affect the resident's sense of self-worth and self-esteem. Findings: During a review of Resident 114's admission Record, the admission Record indicated the facility admitted the resident on 12/17/2025 with diagnoses including muscle weakness and type 2 diabetes mellitus (a group of diseases that result in too much sugar in the blood). During a review of Resident 114's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 12/23/2025, the MDS indicated the resident`s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and sense) skills for daily decision making were intact. The MDS indicated that Resident 114…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) for one of three residents (Resident 11) reviewed under the accidents care area by failing to indicate in the care plan titled, Impaired Physical Mobility and Self-Care Deficit, dated 1/08/2025, the required level of assistance needed to safely transfer Resident 56 from the bed to the and from wheelchair back to the bed. This deficient practice had the potential to place Resident 11 at risk for injuries. Findings: During a review of Resident 11's admission Record (AR), the AR indicated that the facility initially admitted the resident on 6/21/2024 and readmitted the resident on 4/28/2025 with diagnoses including muscle weakness and presence of artificial knee joint. During a…

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

Based on observation, interview and record review, the facility failed to implement its policy and procedure titled Residents Who Present with Communication Barriers, by failing to provide a communication device or board (a tool that includes pictures that help residents communicate their healthcare and every-day needs to facility staff) in their preferred language for one of two sampled residents (Resident 55) reviewed under the communication-sensory care area. This deficient practice had the potential to prevent the resident from communicating with the staff and receiving care in a timely manner. Findings: During a review of Resident 55's admission Record, the admission Record indicated that the facility admitted the resident on 7/18/2025, with diagnoses including muscle weakness and dysphagia (difficulty swallowing). During a review of the Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 10/23/2025, the MDS indicated Resident 55`s preferred language is not English and needed an interpreter to communicate with a doctor or health care staff. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to draw a resident's hemoglobin (Hgb, is the iron-rich protein in red blood cells that carries oxygen) and hematocrit, (Hct, is the percentage of the total blood volume made up of red blood cells) as indicated in the physician's order for one (Resident 4) of five residents investigated for unnecessary medications. This had the potential for residents to suffer side effects from having low blood counts such as dizziness and syncope (fainting). Findings: During a review of Resident 4's admission Record (or Facesheet, the front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 4's Census (the document that indicates when a resident goes and returns from a general acute 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 maintain an environment free from potential accident hazards for one of three residents (Resident 21) observed during medication administration when Resident 21's medications were left unattended at the resident's bedside. This deficient practice had the potential to result in an unsafe medication administration to Resident 21. Findings: During a review of Resident 21's admission Record, the admission Record indicated the facility originally admitted the resident on 6/9/2022 and most recently readmitted the resident on 3/7/2025 with diagnoses including, but not limited to, urinary tract infection (UTI- an infection in the bladder/urinary tract), type 2 (chronic) diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and unspecified dementia (a progressive state of decline in mental abilities). During a review of Resident 21's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/18/2025, the MDS indicated the resident had…

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

Based on observation, interview, and record review the facility failed to ensure residents who were incontinent (lacks voluntary control over urination) of bladder (organ in the pelvis that stores urine) received appropriate treatment and services to prevent urinary tract infections (UTI, common infections that happen when bacteria infect the urinary tract) by failing to ensure the urinary catheter (a thin flexible tube that is inserted into the bladder to help drain urine) collection bag tubing was not looped or coiled to allow the urine to flow freely into the collection bag for one of two residents (Resident 79) reviewed under the urinary catheter care area. This failure had the potential to result in the backflow of urine into the resident's bladders, which can cause urinary tract infections (UTI- an infection in the bladder/urinary tract). Findings: During a review of Resident 79's admission record, the admission record indicated, the facility initially admitted Resident 79 to the facility on 1/2/2023 and readmitted the resident on 11/28/2025 with diagnoses including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the hemodialysis (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 multiple days from 9/4/2025 to 12/18/2025 for one (Resident 34) of two residents in the facility who received dialysis treatments. This deficient practice had the potential for Resident 34 to have unidentified complications after dialysis treatment such as abnormal vital signs (pulse rate, temperature, respiration rate, and blood pressure). Findings: During a review of Resident 34's admission Record, the admission Record indicated the document indicated the resident was admitted to the facility on [DATE] and re-admitted…

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

Based on interview and record review, the facility failed to implement its antibiotic stewardship (actions designed to use antibiotic [medications that fight bacterial infections] medications effectively while reducing the possibility of being prescribed an unnecessary medication) program by failing to conduct and complete an infection surveillance form before antibiotics were initiated for one of two sampled residents (Resident 15). This deficient practice had the potential for Resident 15 to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use for future infections.Findings: During a review of Resident 15's admission Record, the admission Record indicated the facility originally admitted the resident on 12/4/2025 with diagnoses including sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs) and urinary tract infection (UTI- infection in the urinary system). During a review of Resident 15'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 ensure one of three sampled residents (Resident 1) was treated with dignity and respect by not honoring Resident 1's request that Certified Nursing Assistant (CNA) 1, whom Resident 1 reported as being rough during care, not provide care to Resident 1 upon readmission to the facility.During a review of Resident 1's admission record, the admission Record indicated the facility admitted Resident 1 on 7/8/2025 and readmitted on [DATE] with diagnoses including fracture of the left femur (break of the long bone in the leg), osteoporosis (weak and brittle bones due to lack of calcium and vitamin D), rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), morbid obesity (severely overweight), and generalized anxiety disorder (a mental health condition characterized by excessive, uncontrollable worry about everyday events).During a review of Resident 1's History and Physical (H&P)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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' Notice of Proposed Transfer and Discharge were provided to the resident and/or resident representative at least 30 days prior to discharge or as soon as practicable for three of three sampled residents (Resident 1, Resident 2, and Resident 3).This deficient practice placed the residents at increased risk of an inappropriate discharge and denied the residents the right to file an appeal to the appropriate agency within 10 days of being notified of a proposed transfer and discharge.a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 6/13/2025 with diagnosis including chronic venous hypertension with ulcer (long-lasting skin sore on the leg, caused by poor blood flow in the veins) of left lower extremity and methicillin resistant staphylococcus aureus infection (a bacterial infection caused by a type of bacteria that has become resistant to many of the antibiotics used…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 actively involved in their discharge planning and had a safe discharge to a lower level of care.This deficient practice resulted in Resident 1 having to be admitted to the general acute care hospital (GACH) within 24 hours of discharge to a lower level of care and had the potential for decreased quality of care, decreased quality of life, and continuity of care.During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 6/13/2025 with diagnosis including chronic venous hypertension with ulcer (long-lasting skin sore on the leg, caused by poor blood flow in the veins) of left lower extremity and methicillin resistant staphylococcus aureus infection (a bacterial infection caused by a type of bacteria that has become resistant to many of the antibiotics used to treat ordinary infections).During a review of Resident 1's History & Physical (H&P)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident's low air loss mattress (a specialized mattress that alternates pressure to prevent skin breakdown) was in the correct setting for one (Resident 1) of three sampled residents.This deficient practice had the potential to place the resident at increased risk for discomfort and development of pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence).Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with the most recent admission on [DATE] with diagnoses including urinary tract infection (UTI-an infection in the blader/urinary tract), type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), morbid obesity (severely over weight), cerebral infarction (a condition where part of the brain dies due to lack of blood supply), 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 ensure one of three sampled residents (Resident 2) received care and services in accordance with professional standards of practice by failing to administer Resident 2's Norco (a medication used to relieve severe pain) as prescribed by the physician. This deficient practice had the potential for Resident 2 to experience untreated pain.Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted Resident 2 on 6/2/2022 and readmitted on [DATE] with diagnoses that included metabolic encephalopathy (a brain disorder caused by a chemical imbalance in the body due to an underlying illness or organ dysfunction), sepsis (a serious condition in which the body responds improperly to an infection), paraplegia (loss of movement and/or sensation, to some degree, of the legs), and chronic pain syndrome (a condition where pain persists for more than three to six months, beyond the expected healing time for an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure clinical records for one of four sampled residents (Resident 1) were maintained in accordance with accepted professional standards by failing to accurately document the administration of Resident 1's Oxycodone Hydrocholoride (a medication used to treat moderate to severe pain) on the Medication Administration Record (MAR- a report that serves as a legal record of the medications administered to a resident). This deficient practice placed Resident 1 at risk for medication errors, delayed pain relief and the potential for diversion (refers to redirection of prescription drugs from their intended use or disposal to unauthorized purposes) of a narcotic (a substance that dulled the senses and relieved pain) medication. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included fracture (broken bone) of lower end of right femur (thigh bone),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were provided necessary assistance with activities of daily living, specifically with mobility and getting out of bed for two of two sampled residents (Resident 3 and Resident 4). This deficient practice resulted in residents remaining in bed for prolonged periods and potentially compromise residents ' dignity, preferences and functional well-being. Findings: a. During a review of Resident 3 ' s admission Record, the admission Record indicated the facility originally admitted Resident 3 on 3/17/2025 and readmitted Resident 3 on 3/30/2025 with diagnoses that included traumatic subdural hemorrhage (bleeding in the area between the brain and the skull usually caused by a head injury) without loss of consciousness (state of being awake and aware of one ' s surroundings), pneumonia (lung infection) and epilepsy (a neurological disorder characterized by recurring seizure [a sudden burst of electrical activity in the brain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 oral care for one of three sampled residents (Resident 3). This deficient practice resulted in Resident 3 not being provided with oral care on 5/16/2025 which could lead to potential negative outcomes such as development of oral health issues (discomfort and pain) including tooth decay or gum disease. Findings: During a review of Resident 3 ' s admission Record, the admission Record indicated the facility originally admitted Resident 3 on 3/17/2025 and readmitted Resident 3 on 3/30/2025 with diagnoses that included traumatic subdural hemorrhage (bleeding in the area between the brain and the skull usually caused by a head injury) without loss of consciousness (state of being awake and aware of one ' s surroundings), pneumonia (lung infection) and epilepsy (a neurological disorder characterized by recurring seizure [a sudden burst of electrical activity in the brain causing changes in behavior, movement, feelings and level of consciousness]). During a review of Resident 3 ' 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 interview and record review, the facility failed to implement an effective bowel (tube-shaped organ in the abdomen that completes the process of digestion) and bladder (a hollow organ that stores urine) retraining program (B&B retraining program - aim to establish or regain control over bowel and bladder function) for two of three sampled residents (Resident 1 and Resident 3) by not ensuring that the resident ' s bowel and bladder assessment was re-assessed in a timely manner. This deficient practice had the potential to result in Resident 1 and Resident 3 not being accurately assessed as candidates for a B&B retraining program and may have limited their (Resident 1 and Resident 3) opportunity to regain bowel and bladder function. Findings a. During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 2/27/2025 with diagnoses that included osteoporosis (a bone disease that develops when the quality and structure of the bone changes) with current…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to inform and provide information for two of two sampled residents (Resident 2 and 3) in advance regarding deep cleaning of their rooms. This deficient practice had the potential to affect the residents' sense of self-worth, self-esteem, and the resident's right. Findings: a. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 1/29/2025 with diagnoses including right knee and right ankle fractures (broken bones) and hypothyroidism (condition in which the thyroid gland doesn't produce enough thyroid hormone). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 2/4/2025, the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was intact, and the resident needed moderate assistance from staff with toileting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of four sampled residents (Resident 1) when on 1/8/2025, Resident 2 punched Resident 1 in the face several times with a fist (a person's hand when the fingers are bent in toward the palm and held there tightly). This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. Resident 1 sustained a left periorbital (around the eye) discoloration (change in the color, texture or pigmentation of the skin), abrasion (when the surface layers of the skin have been broken) on the left eyebrow, skin tear (a wound that happens when the layers of skin separate or peel back) on the left forearm (part of the arm between the elbow and the wrist) and skin tear on left dorsal (back portion) hand that needed first aid (initial assistance and care given 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 ensure a resident received treatment and care in accordance with professional standards of practice for one of four sampled resident (Resident 2) by failing to follow-up with the physician to obtain an order to continue monitoring Resident 2's surgical wound with non-removable dressing. This deficient practice had the potential for Resident 2 to have a wound infection. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated the facility admitted the resident on 11/22/2024 with diagnoses including left hip fracture (broken bone) subsequent (following) encounter for orthopedic (relating to the orthopedics, the medical specialty that treats the bones, muscles, joints, and nerves) aftercare and dementia (a progressive state of decline in mental abilities). During a review of Resident 2 ' s Minimum Data Set (MDS - a resident assessment tool) dated 11/28/2024, the MDS indicated the resident ' s cognitive (the mental action or process of acquiring knowledge and understanding…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administration of a physician ordered eye drop was accurately documented in the Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications given to a resident) for one of four sampled residents (Resident 3). This deficient practice had the potential to result in confusion in the delivery of care and placed the resident at risk for not receiving the medication as ordered by the physician. Findings: During a review of Resident 3 ' s admission Record, the admission Record indicated the facility admitted the resident on 10/29/2024 with diagnoses that included glaucoma (eye diseases that can cause vision loss and blindness by damaging a nerve in the back of eyes). During a review of Resident 3 ' s Minimum Data Set (MDS - a resident assessment tool) dated 11/4/2024, the MDS indicated the resident ' s cognitive (the 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.

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. Ensure Licensed Vocational Nurse 2 (LVN 2) perform hand hygiene (HH – the practice of cleaning hands to prevent the spread of germs and infections) after checking a resident ' s blood pressure with bare hands for one of four sampled residents (Resident 3). 2. Ensure Treatment Nurse 1 (TN 1) perform hand hygiene between glove changes while providing wound treatment to one of four sampled residents (Resident 4). These deficient practices had the potential to result in the spread of germs placing residents, staff, and visitors at risk for infection. Findings: 1. During a review of Resident 3 ' s admission Record, the admission Record indicated the facility admitted the resident on 10/29/2024 with diagnoses including glaucoma (eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye). During a review of Resident 3 ' 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 ensure residents' low air loss mattresses (LALM, a mattress designed to distribute the resident's body weight over a broad surface area and help prevent skin breakdown) were set at the correct setting for three of 23 sampled residents (Residents 88, 11, and 196). This deficient practice had the potential to place the resident at risk for discomfort and development of pressure ulcers/injuries (an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure). Findings: a. During a review of Resident 88's admission Record, the admission Record indicated the facility admitted Resident 88 on 2/28/2023 and readmitted the resident on 10/2/2024 with diagnoses including fracture (broken bone) of the left femur (the thigh bone), fracture of the left pubic bone (a broken bone in the front part of left hip), fracture of the left ulna (a broken bone in the left forearm), and diabetes type two (2) (a chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure leftover food brought from outside by resident's family and visitors were labeled with a resident identifier and use-by date for three of four residents (Resident 76, 83, and 192). This deficient practice had the potential to result in foodborne illness (also called food poisoning, illness caused by eating contaminated food) for the residents. Findings: a. During a review of Resident 76's admission Record, the admission Record indicated the facility admitted the resident on 7/30/2024 with diagnoses that included hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]) and morbid obesity (is when you weigh more than 80 to100 pounds above your ideal body weight). During a review of Resident 76's Minimum Data Set (MDS - a resident assessment tool), dated 8/05/2024, the MDS indicated the resident's cognitive (the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. During a review of Resident 30's admission Record, the admission Record indicated that the facility initially admitted Resident 30 on 2/22/2024 and readmitted the resident on 8/30/2024 with diagnoses including acute embolism and thrombosis of deep veins of the right lower extremity (a clinical condition in which blood clots [a gel-like clump of blood] are forming and affecting the veins and arteries in the right lower extremity), degenerative disease of nervous system (a condition where the nerves or brain gradually break down or stop working properly over time), and repeated falls. During a review of Resident 30's H&P, dated 2/23/2024, the H&P indicated that the resident did not have the capacity to understand and make decisions. During a review of Resident 30's MDS dated [DATE], the MDS indicated that the resident had severely impaired cognition. The MDS further indicated that Resident 30 was dependent on the assistance of two or more helpers for showering, required maximal assistance for toileting 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 reasonable services and accommodations for two of three sampled residents (Resident 16 and Resident 28) by failing to: 1. Ensure Resident 16's call light (a device used by a resident to signal his/her need for assistance from staff) was within reach while in bed. 2. Ensure Resident 28 was provided a call light that was adaptive to the resident's needs. These deficient practices had the potential to delay the provision of services and residents' needs not being met. Findings: 1. During a review of Resident 16's admission Record, the admission Record indicated the facility admitted the resident on 5/20/2024, with diagnoses including, but not limited to chronic obstructive pulmonary disease (COPD - a chronic lung disease that makes it difficult to breathe), dysphagia (difficulty swallowing) following cerebral infarction (a type of stroke that occurs when blood flow to the brain is blocked) and hypertension (high blood pressure [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 that an advance directive (AD-written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) was discussed and written information was provided to the resident and/or responsible parties for one of two sampled resident (Resident 6). This deficient practice violated the resident's and/or the representative's right to be fully informed of the option to formulate an advanced directive and had the potential to cause conflict with health care wishes. Findings: During a review of Resident 6's admission Record, the admission Record indicated the facility admitted the resident on 9/11/2024 with diagnoses including chronic obstructive pulmonary disease (a group of lung diseases that make it difficult to breathe) and muscle weakness. During a review of Resident 6's Minimum Data Set (MDS- a resident assessment tool) dated 9/17/2024, the MDS indicated the resident had the ability to make self-understood and the ability…

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

Based on observation, interview, and record review, the facility failed to maintain a safe and comfortable temperature level for one of four sampled residents (Resident 30). This deficient practice had the potential to result in loss of body heat and risk of hypothermia (dangerously low body temperature) for Resident 30. Findings: During a review of Resident 30's admission Record, the admission Record indicated that the facility initially admitted Resident 30 on 2/22/2024 and readmitted the resident on 8/30/2024 with diagnoses including acute embolism and thrombosis of deep veins of the right lower extremity (a clinical condition in which blood clots [a gel-like clump of blood] are forming and affecting the veins and arteries in the right lower extremity), degenerative disease of nervous system (a condition where the nerves or brain gradually break down or stop working properly over time), and repeated falls. During a review of Resident 30's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a person-centered care plan (a written document that summarizes a resident's needs, goals, and care/treatment) for two of three sampled residents (Resident 28 and 50) by failing to: 1. Develop a care plan addressing Resident 28's range of motion (ROM - the amount of movement that a particular joint or series of joints can achieve in a specific direction) limitations. 2. Develop a care plan addressing Resident 50's bowel and bladder incontinence (a problem holding in urine or stool). These deficient practices had the potential to result in failure to deliver the necessary care and services. Findings: a. During a review of Resident 28's admission Record, the admission Record indicated the facility re-admitted the resident on 7/26/2024, with diagnoses including, but not limited to osteomyelitis (a serious bone infection that causes inflammation and swelling in the bone) of vertebra (bones in the spine), type two (2) diabetes mellitus…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 30's admission Record, the admission Record indicated that the facility initially admitted Resident 30 on 2/22/2024 and readmitted the resident on 8/30/2024 with diagnoses including acute embolism and thrombosis of the deep veins of the right lower extremity (a clinical conditions in which blood clots [a clump of blood that has changed from liquid to gel-like state, which can block blood flow] is forming and affecting the veins and arteries in the right lower extremity), degenerative disease of the nervous system (a condition where the nerves or brain gradually break down or stop working properly over time), and repeated falls. During a review of Resident 30's History and Physical, (H&P) dated 2/23/2024, the H&P indicated that the resident did not have the capacity to understand and make decisions. During a review of Resident 30's Minimum Data Set (MDS - a resident assessment tool), dated 10/17/2024, the MDS indicated that the resident had severely impaired cognition (a severely…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comprehensively assess the limited mobility and range of motion (ROM - the amount of movement that a particular joint or series of joints can achieve in a specific direction) for one of two residents (Resident 28) when the resident was readmitted on [DATE]. This deficient practice resulted in Resident 28 not having the appropriate equipment to maintain their maximum practicable independence and had the potential to cause further decline in functional mobility, ROM, and quality of life. Findings: During a review of Resident 28's admission Record, the admission Record indicated the facility re-admitted the resident on 7/26/2024, with diagnoses including, but not limited to osteomyelitis (a serious bone infection that causes inflammation and swelling in the bone) of vertebra (bones in the spine), type two (2) diabetes mellitus (when sugar level is too high in the blood) with diabetic neuropathy (a nerve problem that causes pain, numbness, tingling,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a fall risk evaluation was completed after a fall on 8/29/2024 and ensure the fall risk evaluation completed on 9/6/2024 was accurate for one of four sampled resident (Resident 30). This deficient practice had the potential to negatively affect Resident 30's plan of care and the delivery of necessary care and services. 2. Ensure Licensed Vocational Nurse 5 (LVN 5), who was administering medications to a resident, did not leave the prepared medications unattended at the resident's bedside for one of 23 sampled residents (Resident 197). This deficient practice had the potential to result in unauthorized personnel or residents having access to the resident's medications. Findings: 1. During a review of Resident 30's admission Record, the admission Record indicated that the facility initially admitted Resident 30 on 2/22/2024 and readmitted the resident on 8/30/2024 with diagnoses including acute embolism and thrombosis of deep…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Licensed Vocation Nurse 1 (LVN 1) failed to ensure that residents who needed respiratory care (the health care discipline that specializes in the promotion of optimum cardiopulmonary function and health and wellness) were provided such care, consistent with professional standards of practice to one out of three sampled residents (Residents 242) by failing to: 1. Ensure that the suction catheter (a flexible hallow tube used to remove secretions from a patient's airway) was covered with a sleeve when not in use. 2. Administer oxygen (a colorless, odorless, and tasteless gas, that support life) to Resident 242 according to the physician order. 3. Label Resident 242's suction tubing with the date for when it was last changed. These deficient practices had the potential to cause respiratory infection to Resident 242. Findings: During a review of Resident 242's admission Record, the admission Record indicated that the facility initially admitted Resident 242 on 10/4/2024 and readmitted the resident on 10/11/2024 with diagnoses including malignant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administer pain medication as prescribed by the physician for one of sampled resident (Resident 6). This deficient practice had the potential to result in adverse consequences (undesired harmful effect resulting from a medication or other intervention). Findings: During a review of Resident 6's admission Record, the admission Record indicated the facility admitted the resident on 9/11/2024 with diagnoses including chronic obstructive pulmonary disease (a group of lung diseases that make it difficult to breathe) and muscle weakness. During a review of Resident 6's Minimum Data Set (MDS- a resident assessment tool) dated 9/17/2024, the MDS indicated the resident had the ability to make self-understood and the ability to understand others. During a review of Resident 6's physician's orders, the physician's orders indicated an order for hydrocodone-acetaminophen (Norco- brand name; used to relieve moderate to severe pain) oral tablet 10-325 milligram (mg- unit of measurement) one tablet by mouth every four (4) hours as needed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete a post-dialysis (the removing of waste and excess fluid to prevent build up in the body for residents who have loss of kidney [organs that remove waste products from the blood and produce urine] function) assessment for one of one sampled resident (Resident 13). This deficient practice placed Resident 13 at risk for complications of dialysis such as redness at the dialysis access site (way to reach the blood for hemodialysis), edema (too much fluid trapped in the body's tissues), excessive bleeding, and a change in vital signs (clinical measurements that indicate the state of a patient's essential body functions). Findings: During a review of Resident 13's admission Record, the admission Record indicated the facility admitted the resident on 7/18/2024 with diagnoses including, but not limited to end stage renal disease (when the kidneys can no longer filter blood properly), dependence on renal (kidney) dialysis. A review of Resident 13's History and Physical (H&P- a formal assessment by a healthcare provider 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its policy and procedure for an allegation of financial abuse for one of three sampled residents (Resident 1) by failing to: 1. conduct a thorough investigation of the alleged financial abuse. 2. provide documented evidence that a Situation, Background, Assessment and Recommendation (SBAR - a communication tool that helps provide essential, concise information about the condition of a resident) Form was completed. 3. ensure Resident 1 was monitored every shift for 72 hours for emotional distress or negative outcome as a result of the alleged financial abuse. These deficient practices had the potential to place Resident 1 at risk for further abuse and could have resulted in Resident 1 needing care or emotional support which was not provided. Findings: During a review of Resident 1's admission Record indicated Resident 1 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included hydrocephalus (a condition where too…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act by failing to ensure the results of the abuse investigation for the allegation of financial abuse that occurred on 10/3/2024 was reported to the State Survey Agency (SSA) within five (5) working days for one (1) of three (3) sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 at risk for further abuse. Findings: During a review of Resident 1's admission Record indicated Resident 1 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included hydrocephalus (a condition where too much cerebrospinal fluid [CSF- a clear, colorless, watery fluid that flows in and around your brain and spinal cord to help cushion the brain and spinal cord from injury and provide nutrients] builds up in the brain), and Alzheimer's Disease (a brain disorder that slowly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 written course of action that helps a resident achieve outcomes that improve their quality of life) for one of three sampled residents (Resident 1), who was involved in an allegation of financial abuse. This deficient practice had the potential to negatively affect the delivery of care and services to Resident 1. Findings: During a review of Resident 1's admission Record indicated Resident 1 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included hydrocephalus (a condition where too much cerebrospinal fluid [CSF- a clear, colorless, watery fluid that flows in and around your brain and spinal cord to help cushion the brain and spinal cord from injury and provide nutrients] builds up in the brain), and Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). Resident 1'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.

Based on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse (harsh and insulting language directed at a person) by Certified Nursing Assistant 1 (CNA 1) towards one of five sampled residents (Resident 1). On 9/7/2024, CNA 1 hurled (to utter) an obscene word (a curse word that is a socially offensive use of language) at Resident 1. This deficient practice resulted in Resident 1 being subjected to verbal abuse while under the care of the facility and had the potential to cause emotional harm which could result to a feeling of low self-esteem and self-worth. Findings: During a review of Resident 1's admission Record indicated that the facility admitted the resident on 7/20/2024 with diagnoses including, but not limited to, osteomyelitis (bone infection) of the ankle and foot and type two diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) with foot ulcer (an open wound or sore that can be difficult to heal). During a review of Resident 1's History and Physical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that the primary care physician (Primary Medical Doctor 1 [PMD 1]) for one of four sampled residents (Resident 1), who had a history of hypothyroidism (a condition where the thyroid gland doesn't release enough thyroid hormone [plays a role in regulating weight, energy levels, growth and metabolism] into the bloodstream), reviewed Resident 1's General Acute Care Hospital 1 (GACH 1) progress notes, including medications essential to Resident 1's medical treatment. PMD 1 failed to prescribed Resident 1 her (Resident 1) routine medication (medication taken regularly) of Levothyroxine (a medication used to treat an underactive thyroid gland [a gland that makes and stores hormones that help regulate the heart rate, blood pressure, body temperature, growth development and energy) upon admission to the facility on 5/26/2024. This deficient practice resulted in Resident 1 not receiving 30 doses of Levothyroxine from 5/26/2024 to 6/25/2024. Subsequently,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 four sampled resident ' s (Resident 2) urinary drainage bag (bag that collects a resident ' s urine) was not placed above the resident ' s bladder (organ inside the body that stores urine). This deficient practice had the potential to result in urine flowing back into the resident ' s bladder which would then increase the risk for a urinary tract infection (an infection in any part of the urinary system) that can cause serious health problems such as sepsis (a serious condition in which the body responds improperly to an infection and a potentially life-threatening complication). Findings: A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 1/28/2024 with diagnoses including chronic kidney disease (CKD - a condition in which the kidneys are damaged and cannot filter blood as well as they should), and dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). 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 ensure the hemodialysis (also known as dialysis, the process of removing waste products and excess fluid from the body because the kidneys no longer function) center documented the pre (before) and post (after) dialysis weight of one of two sampled resident (Resident 279). This deficient practice placed the resident at risk for potential unidentified complications after dialysis treatment. Findings: A review of Resident 279' s Face Sheet (admission Record) indicated the facility admitted the resident on 9/25/2023 with diagnoses that included end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis) and dependence on renal (kidney) dialysis. A review of Resident 279's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 10/09/2023, indicated Resident 279 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure: 1. Licensed nurses signed one of three sampled resident's (Resident 14) Medication Administration Record (MAR- a report detailing the medications administered to a resident by a healthcare professional) after administering Hydrocodone-Acetaminophen (Norco- a medication used to treat pain) to the resident on six separate occasions. 2. Licensed nurses signed one of three sampled resident's (Resident 34) MAR after administering Norco to the resident on 10/4/2023. 3. Licensed nurses signed one of three sampled resident's (Resident 24) MAR after administering Acetaminophen-Codeine Number 3 (Tylenol #3 - a medication used to treat pain) to the resident on 10/22/2023 and 10/29/2023. 4. Physician`s order to check for blood sugar and to administer Insulin Lispro (a medication used to control high blood sugar) are implemented on 10/24/2023 for one of one resident (Resident 40) investigated under quality of care. 5. Licensed nurses immediately signed one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure: 1. Licensed nurses monitored the behavior of angry outburst for a resident on Olanzapine (a medication used to treat schizophrenia [a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior] and bipolar disorder [a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration]) for one of five sampled residents (Resident 74) investigated for unnecessary medications. 2. Licensed nurses were monitoring specific behaviors of one of two sampled residents (Resident 54) for the use of Abilify (a medication used to treat schizophrenia and bipolar disorder by regulating mood, behavior, and thoughts), Lithium Carbonate (a mood stabilizing medicine used to treat bipolar disorder), Depakote (used to treat bipolar disorder). This deficient practice had the potential to result in adverse reaction or impairment in the resident's mental or physical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow proper sanitation and food handling practices by: 1. Failing to ensure a red sanitation bucket (contains sanitizing solutions with a recommended concentration of a chemical sanitizer, usually quaternary [Quat, potent chemical disinfectant] ammonium [an ingredient in many household cleaning products] compounds or chlorine [a type of sanitizing solution]), located in the dish washing area of the kitchen, for the quaternary solution registered at the required 200 parts per million (ppm- unit of measure, 200 ppm indicates the sanitizing solution is effective) as per facility policy. 2. Failing to ensure kitchen staff completely submerged (to cover and overflow with water) frozen food items in a deep pot and failed to ensure the food in the deep pot was under running water with a temperature of 70 degrees Fahrenheit (° F- unit of measure) while thawing (frozen food becoming liquid or soft because of warming) the frozen food. These deficient practices had the potential to place 78 of 91 residents living 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 interview, and record review, the facility failed implement the facility's hospice (care designed to give supportive care to a resident in the final phase of a terminal illness [illness that cannot be cured] and focus on comfort and quality of life) policy and procedure for one of one sample residents (Resident 133) by failing to ensure Resident 133's hospice binder (the binder that contains the hospice services calendar, plan of care including interventions, nursing notes for a resident who is on hospice services) was in the facility to ensure communication between the hospice and the facility, and to ensure continuity of care for the hospice resident. This deficient practice had the potential to delay coordination and delivery of hospice services. Findings: A review of Resident 133's Face Sheet (admission Record) indicated the facility admitted the resident on 10/12/2023, with diagnoses that included malignant neoplasm of the brain (brain cancer). A review of Resident 133's Minimum Data Set (MDS - an assessment and care screening tool), dated 10/18/2023, indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its antibiotic stewardship(the effort to measure and improve how antibiotics [a medication used to treat or prevent infections] are prescribed and used by residents) program by failing to conduct infection surveillance (a tool to monitor the health of the residents) and complete the infection control reporting form once signs and symptoms of infection were identified and antibiotics were initiated for four (Resident 9, Resident 74, Resident 130, and Resident 132) of five sampled residents. This deficient practice had the potential for Resident 9, Resident 74, Resident 130 and Resident 132 to develop antibiotic resistance (when germs like bacteria change over time and no longer respond to medicines) from unnecessary or inappropriate antibiotic use for future infections. Findings: a. A review of Resident 9's Face Sheet (admission Record) indicated the facility admitted the resident on 12/16/2022 and re-admitted on [DATE] with diagnoses 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to promote the resident's right to be informed of by the physician of the risks and benefits of the proposed plan for the administration of a psychotropic medication (medication that affects brain activities to control behavior or treat disordered thought processes) Olanzapine (a medication used to treat schizophrenia [a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior] and bipolar disorder [a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration]) for one of two sampled residents (Resident 62). This deficient practice had the potential for the resident and / or the resident 's representative (RR) not to be well-informed of the medications and the potential risks and side effects (undesirable effect of a medication or treatment). This also had the potential to place the resident and the RR to miss the opportunity to decide whether to proceed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 low air loss mattress (LAL- mattress designed to prevent and treat pressure wounds [injury to skin and underlying tissue resulting from prolonged pressure on the skin]) was on the needed setting per manufacturer's guidelines for one of two sampled residents (Resident 34). This failure had the potential to place Resident 34 at risk for developing or worsening pressure wounds. Findings: A review of Resident 34's admission Record indicated the facility admitted the resident on 9/16/2023 with diagnosis that included sepsis (a serious condition in which the body responds improperly to an infection), urinary tract infection (infection in any part of the urinary system), and pneumonia (infection that affects one or both lungs). A review of Resident 34's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 9/23/2023, indicated Resident 34's cognition (a mental process of acquiring knowledge and understanding) was intact. A review of Resident 34's Physician's Order dated 9/18/2023…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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's physician's orders were followed by failing to flush a resident's gastrostomy tube (G-Tube - a tube inserted through the abdomen that brings nutrition and medications directly to the stomach) with water in between each medication administration for one of two sampled residents (Resident 41) observed during the medication administration task. This failure had the potential for drug interaction with unknown side effects and for the G-tube to become clogged. Findings: A review of Resident 41's Face Sheet (admission record) indicated the facility admitted the resident on 9/02/2023 with diagnoses that included hypertension (HTN - high blood pressure, normal reference range is 120/80 millimeters of Mercury [mmHg - unit of measure]), cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it; stroke), and benign prostatic hyperplasia (BPH- enlarged prostate [gland found in males]), A review of Resident 41' 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 interview and record review, the facility failed to ensure the facility's Pharmacy Consultant (PC) conduct a Drug Regimen Review (DRR- a review of the drug regimen of a resident to identify and, if possible, prevent clinically significant medication issues) for the month of October 2023 for one of two sampled residents (Resident 9) investigated under unnecessary medications review. This deficient practice has the potential to miss the identification of any medication irregularities which could lead to the resident receiving an unnecessary medication with adverse side effects (unwanted undesirable effects that are possibly related to a drug). Findings: A review of Resident 9`s Face Sheet (admission Record) indicated the facility originally admitted the resident on 12/16/2022 and readmitted the resident on 06/17/2023, with diagnoses including chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe) and diabetes mellitus (the body's inability to regulate the amount of sugar). A review of Resident 9's Minimum Data…

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

Based on observation, interview, and record review, the facility failed to label and store drugs (medications) and biologicals (a therapeutic substance such as drugs that target specific parts of your immune system to treat disease) in accordance with accepted professional principles as evidenced by: 1. Failure to ensure a bottle of Valproic Acid Oral Solution (a medication used to treat bipolar disorder [a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration] or to prevent one from having a seizure [sudden, uncontrolled burst of electrical activity in brain that can cause changes in behavior, movements, feelings and levels of consciousness]) had the date it was opened documented on the bottle. 2. Failing to ensure a bottle of Iron (an important mineral that the body needs to produce red blood cells [delivers oxygen to tissues in your body] and keep an individual in good health) supplement was left in the medication cart past its expiration date of 1/2023. These deficient practices had the potential for residents to receive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the peripheral intravenous (IV, a medical technique that administers fluids and medications directly into a person's vein) access (the insertion of a flexible and sterile thin plastic tube, or catheter, into a blood vessel to provide medication) dressing was labeled with the insertion date for one of three sampled residents (Resident 132) observed with IV access. 2. Implement infection control practices for one of two sampled residents (Resident 179) by failing to ensure the resident's nasal cannula (a medical device that delivers extra oxygen through a tube and into your nose) tubing was dated to indicate the date it was last changed and that the tubing was not touching the floor. These deficient practices had the potential to transmit infectious microorganisms (germs that have the potential to cause disease) and placed the resident at risk for infection. Findings: 1. A review of Resident 132's Face Sheet (admission Record)…

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

Based on observation, interview and record review, the facility failed to ensure that two of two facility freezers (Freezer 1 and Freezer 2) were being maintained to good working conditions that provide a safe environment for the residents. This deficient practice had the potential to compromise the integrity of the food and placed 83 of 90 residents who received food from the kitchen at risk for foodborne illnesses (illness caused by the ingestion of contaminated food or beverages). Findings: During a concurrent observation and interview with Dietary Supervisor (DS) on 7/28/2023 at 3:57 p.m., in the kitchen, Freezer 1 internal temperature was at 18 degrees (°- unit of measure) Fahrenheit (F- unit of measure) and Freezer 2 temperature was at 14.9°F. During a concurrent observation and interview with Dietary Staff 2 (DS 2) on 7/29/2023 at 1:28 p.m., Freezer 1 internal temperature was at 12°F and Freezer 2 internal temperature was 15.3°F. During an interview with the Maintenance Supervisor (MS) on 7/29/2023 at 2:06 p.m., he stated that on 7/28/2023, there was an issue with keeping 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.