Terrace Post Acute

Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards and practices for two of two sampled residents (Resident 46 and 3) by failing to accurately document the insulin (hormone that regulates the amount of glucose [sugar] in the blood) administration injection site and blood sugar test (measures the glucose levels in your blood) result. This deficient practice placed the resident at risk of not receiving appropriate care due to inaccurate resident medical care information and the potential to result in confusion in the care and services for Resident 46 and 3.Findings: a. During a review of Resident 46's admission Record, the admission Record indicated the facility admitted the resident on 12/28/2025 with diagnoses including muscle weakness, chronic obstructive pulmonary disease (COPD-a lung disease that block airflow and make it difficult to breathe) and type two (2) diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]). 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 notify the physician of a resident's change of condition for one of one sampled resident (Resident 4) by failing to notify the physician when Resident 4 had signs and symptoms of bleeding and hypoglycemia (low blood sugar in the body). This deficient practice had the potential to result in a delay of care services resulting in serious health complications requiring hospitalization. Findings: During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 to the facility on 8/30/2023, and re-admitted the resident on 11/24/2024 with diagnoses including chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]) and gastrostomy tube (GT- a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration) infection. During review of Resident 4'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 interview and record review, the facility failed to: 1. Update a resident's comprehensive care plan (a document that summarizes a resident's needs, goals, and care/treatment) for one of one sampled resident (Resident 4) reviewed under the tube feeding care area by failing to update Resident 4's care plan with the most recent physician's order for enteral feeding (a way of delivering nutrition directly to the stomach or small intestine) This deficient practice had the potential to result in failure to deliver the necessary care and services to meet Resident 4's nutritional needs related to tube feeding. 2. Ensure the resident or the resident`s representative participated during the Interdisciplinary (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of the residents' care plan) care plan meeting for one of five sampled resident (Resident 7) reviewed under the care planning care area. This deficient practice had the potential to result in Resident 7 not receiving person centered care (person-centered care allows…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one sampled resident (Resident 93) received treatment and care in accordance with professional standards of practice by failing to: 1. Ensure licensed nurses clarify the order for digoxin with the physician and obtain an order to monitor the apical pulse (a pulse point on your chest that gives the most accurate heart rate) or set apical pulse parameters (a specific, pre-set guideline for when to temporarily stop a medication, such as a blood pressure drug, to prevent a patient's blood pressure or heart rate from falling too low) before administering digoxin (medication that slows the heart rate). 2. Ensure licensed nurses clarify the order for metoprolol (BP and heart rate lowering medication) and diltiazem (blood pressure [BP] medication that could lower the heart rate) and obtain physician-ordered heart rate parameters prior to administering both medications. This deficient practice had the potential cause hypotension (when the blood pressure [BP] is too low), fainting, falling and/or accidents for 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.

Based on observation, interview and record review, the facility failed to offer sufficient fluid intake to maintain proper hydration (the process of replacing water in the body) and health by failing to provide a pitcher of water and a cup at the bedside of one of three sampled residents (Resident 20) investigated under the hydration care area. This deficient practice placed Resident 20 at an increased risk for dehydration (a condition caused by the loss of too much fluid from the body).Findings: During a review of Resident 20's admission Record, the admission Record indicated the facility initially admitted Resident 20 on 6/3/2014 and readmitted her on 4/21/2023 with diagnoses that included peptic ulcer (an open sore or painful wound that develops on the lining of your stomach/digestive tract), dysphagia (difficulty swallowing) and gastro-esophageal reflux disease (long term condition when stomach acid frequently flows back up into the esophagus [food pipe], causing irritation. During a review of Resident 20's History and Physical (H&P), dated 10/27/2025, the H&P indicated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide two of three sampled residents (Resident 13 and Resident 42) reviewed under the respiratory care area, with necessary respiratory care services consistent with professional standards of practice by failing to: 1. Ensure Resident 13 and Resident 42 had a physician order for oxygen prior to administering oxygen to Resident 13 and 42. 2. Ensure Resident 42's nasal cannula and oxygen set-up was labeled with a date and changed weekly per facility policy. These deficient practices had the potential to place Resident 13 and Resident 42 at increased risk for infection and cause complications associated with oxygen therapy.Findings: 1. During a review of Resident 13's admission Record, the admission Record indicated the facility originally admitted Resident 13 on 11/25/2022, and re-admitted the resident on 5/5/2025 with diagnoses including chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make 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 interview and record review the facility failed to ensure one of three Certified Nursing Assistants (CNA 7) investigated for competency skills, possessed the competencies (a measurable pattern of knowledge, skills, abilities, behaviors that an individual needs to perform work roles successfully) necessary to perform their job roles. This deficient practice had the potential for staff to perform care incorrectly and not according to a resident's plan of care. Findings: During an interview and record review with the Director of Staff Development (DSD) on 1/14/2026 at 3:41 p.m., the DSD reviewed CNA 7's Competency Assessment. The assessment indicated CNA 7 was hired on 4/03/2024 and the competency assessment was completed on 8/09/2025. The DSD stated certified nursing assistants should have skills validation completely annually (every 12 months). The DSD stated that since CNA 7 started on 4/03/2024, the competency assessment should be done by 4/03/2025, not 8/09/2025. The DSD stated this is important to do every year to validate their performance skills, to ensure CNAs are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Diet Requisition Form was completed timely for one of five sampled residents (Resident 130) observed during breakfast. This resulted in the facility delivering Resident 130's breakfast tray two hours later than the other residents and only after the facility was informed of the resident`s complaint of not getting her breakfast. This deficient practice had the potential to result in decreased meal intake which could lead to weight loss and malnutrition (lack of sufficient nutrients in the body).Findings: During a review of Resident 130's admission Record, the admission Record indicated the facility admitted the resident on 1/11/2026 with diagnoses including muscle weakness and history of falling. During a review of Resident 130`s History and Physical dated 1/12/2026, indicated that the resident has the capacity to understand and make decisions. During a concurrent observation and interview on 1/12/2026 at 9:15 a.m., observed Resident 130 in bed and no breakfast tray. Resident 130 stated…

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

Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly by failing to ensure there were no soiled gloves and masks on the floor area and surroundings of the facility's dumpster. This deficient failure had potential to attract birds, flies, insects, pests, and possibly spread infection to 120 of 120 facility residents. Findings: During a concurrent observation and interview on 1/13/2026 at 10:34 a.m., with the HKD, observed multiple used gloves and masks on the floor of the surrounding area of the dumpster bins. The HKD stated that the surrounding area of the dumpster should be clean due to infection control. During a concurrent observation and interview on 1/15/2026 at 12:27 p.m., with the IPN, observed the same multiple used gloves and masks on the floor of the surrounding area of the dumpster bins. The IPN stated that the facility should maintain cleanliness, without any trash on the floor due to high risk of infection. During a review of the facility's P&P titled, Infection Prevention and Control, reviewed on 1/16/2025, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain infection control measures by failing to: 1. Ensure Smoker Aid 1 (SA 1) performed hand hygiene (the practice of cleaning and disinfecting one's hands to remove dirt, germs, and bacteria) prior to scooping out ice and serving it to one of one sampled resident (Resident 13). 2. Ensure Housekeeper 2 (HK 2) 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) when cleaning a 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 antifungals] in nursing homes) 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 a resident on morphine sulfate (strong pain medication used to treat moderate to severe pain) was not administered the medication after it had expired for one of three sampled residents (Resident 1).This deficient practice resulted in Resident 1 receiving a medication after its expiration date and had the potential for the medication to be ineffective.During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on [DATE] with diagnoses that included quadriplegia (paralysis [complete or partial loss of muscle function] of all four limbs) and hypotension (low blood pressure- condition where the force of blood against the artery walls is lower than normal). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated [DATE], the MDS indicated Resident 1's cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) 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 interview and record review, the facility failed to ensure that a resident's physician assistant (PA - a licensed healthcare professional who practices medicine on a team with physicians) completed a comprehensive History and Physical (H&P - a formal comprehensive assessment by a healthcare professional that involves a resident interview, physical examination and documentation of findings. The H&P serves as the foundation for diagnosing a resident's condition, formulating a treatment plan, and guiding subsequent medical care.) Examination for one of three sampled residents (Resident 1) by failing to include an assessment of mental status (assessment of a resident's mental capacity which includes cognition, mood behavior and perceptions). This deficient practice resulted in an incomplete evaluation of the residents' overall condition, had the potential for inconsistent care coordination due to incomplete H&P and a delay in care and services.During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 8/7/2025 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.

Based on interview and record review, the facility failed to ensure accurate documentation of the administration of medications for one of three sampled residents (Resident 1), by failing to document the administration and refusal of Resident 1's medications on the Medication Administration Record (MAR - a report detailing the medications administered to a resident by the licensed nurse in the facility). This deficient practice had the potential to result in medication errors and/or drug diversion (illegal distribution or abuse of prescription drug). Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 2/26/2021 with diagnoses that included quadriplegia (paralysis [complete or partial loss of muscle function] of all four limbs), muscle wasting and atrophy (partial or complete wasting away of a body part), and anxiety disorder (mental health condition characterized by persistent and excessive worry, fear, and nervousness that can interfere with daily life). 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 to: 1. Ensure timely communication and management of a resident's pain for one of three sampled residents (Resident 3) when on 5/5/2025 at around 10:00 a.m. Certified Nurse Assistant 1 (CNA 1) failed to report Resident 3's complaint of headache to a licensed nurse. 2. Ensure a pain risk assessment was completed quarterly (12/2024 and 3/2025) for one of three sampled residents (Resident 3) as per facility policy. These deficient practices resulted in a delay in assessment and pain relief for Resident 3 and had the potential to result in Resident 3 experiencing unnecessary pain and discomfort. Findings: 1. During a review of Resident 3's admission Record, the admission Record indicated the facility originally admitted Resident 3 on 6/3/2014 and re-admitted on [DATE] with diagnoses that included chronic pain syndrome (persistent pain that lasts for months or longer and can significantly impact a person's daily life). During a review of Resident 3's Minimum Data Set…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Administering Medications for one of three sampled residents (Resident 1) by failing to document Resident 1's medication refusals (total of seven refusals on 4/22/2025) of Golytely (an oral solution indicated for bowel cleansing prior to colonoscopy [a diagnostic procedure used to examine the inner lining of the large intestine using a flexible, lighted tube]) and failing to ensure Resident 1's physician was made aware of Resident 1's refusals of the Golytely Oral Solution on 4/22/2025. This deficient practice may result in inadequate bowel cleansing making it hard to see the colon lining clearly during the colonoscopy which may lead to missed diagnosis such as inflammation and increased risk of procedure complications due to poor visibility. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 3/7/2025 and readmitted 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 interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who were unable to carry out activities of daily living (ADL-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) received the necessary services to maintain good personal hygiene. This deficient practiced resulted in Resident 1 having long facial hair and overgrown fingernails and had the potential to negatively impact Resident 1's quality of life. Findings: During a review of Resident 1 ' s admission record (facesheet) dated 2/5/2025, the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included pneumonia (an infection/inflammation in the lungs), type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), sepsis (a life-threatening blood infection), urinary (UTI-an infection in the bladder tract infection/urinary tract), and hypertension (HTN-high…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility's infection control policy by failing to ensure staff wore appropriate PPEs (Personal Protective Equipment- equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) while in an isolation room of a resident who tested positive for respiratory syncytial virus (a common respiratory virus that infects the nose, throat, and lungs) for one of two sampled residents (Resident 2) This deficient practice had the potential to result in the spread of infection placing residents, staff, and visitors at risk to be infected with respiratory syncytial virus (a common respiratory virus that infects the nose, throat, and lungs) and becoming seriously ill, leading to hospitalization and/or death. Findings: During a review of Resident 2's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including shortness of breath 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 label and date a resident's intravenous (IV-the infusion of liquid substances directly into a vein) antibiotic (medications used to treat infections) medication bag per the facility's policy for one of three sampled residents (Resident 1). This deficient practice had the potential for medication administration errors. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 2/26/2021 with diagnoses that included quadriplegia (paralysis [complete or partial loss of muscle function] of all four limbs), hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]), and muscle wasting (weakening, shrinking, and loss of muscle). During a review of Resident 1's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings) dated 10/1/2024, the H&P indicated Resident 1 had the capacity to 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.

Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 3) received laboratory services as ordered by the physician. This deficient practice had the potential for Resident 3 to have decreased quality of care, delay in care and services, and decreased quality of life. Findings: During a review of Resident 3's admission Record, the admission Record indicated the facility readmitted the resident on 3/1/2024 with diagnoses that included multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), type two (2) diabetes (a chronic condition that affects the way the body processes blood glucose [sugar]), and bipolar disorder (mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks). During a review of Resident 3's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings) dated 3/2/2024, the H&P indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to maintain medical records in accordance with accepted professional standards for one of three sampled residents (Resident 1) by failing to complete the admission assessment form titled, Nursing Documentation Evaluation (a form that is used by nursing staff to document the initial assessment of a resident) upon Resident 1's admission to the facility. This deficient practice had the potential to negatively affect the overall care provided to Resident 1. 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 including sepsis (a life-threatening blood infection), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), and morbid obesity (excessive overweight). 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.

Based on interview and record review, the facility failed to ensure accurate documentation of the administration of medications for one of three sampled residents (Resident 1), by failing to document the refusal of Resident 1's medications on the Medication Administration Record (MAR, a report detailing the medications administered to a resident by the licensed nurse in the facility). These deficient practices had the potential to result in medication errors and/or drug diversion (illegal distribution or abuse of prescription drug). Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 2/26/2021 with diagnoses that included quadriplegia (paralysis [complete or partial loss of muscle function] of all four limbs), hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and muscle spasm (sudden, involuntary and painful contractions [tightening, shortening, or lengthening] 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 c. During a review of Resident 96's admission Record, the admission Record indicated the facility originally admitted the resident on 3/31/2024 and readmitted the resident on 7/12/2024 with diagnoses including acute pyelonephritis (occurs as a complication of an ascending urinary tract infection that spreads from the bladder to the kidneys), type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate). The admission Record indicated Resident 96's primary language is Hungarian. During a review of Resident 96's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 10/24/2024, the MDS indicated the resident had moderately impaired cognition (thought processes) and required maximal assistance from staff for most activities of daily living (ADLs - basic tasks that people do every day to survive and be well). On 11/18/2024 at…

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

Based on interview and record review, the facility failed to monitor a resident for side effects and behavioral episodes for the use of quetiapine (antipsychotic- a medication used to treat psychosis [a mental condition in which thought, and emotions are so affected that contact is lost with external reality]) for one of five sampled residents (Resident 86) investigated under the care area of unnecessary medications. This deficient practice had the potential to place the resident at increased risk of taking an unnecessary medication and experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention). Findings: During a review of Resident 86's admission Record, the record indicated the facility admitted the resident on 7/17/2024 with diagnoses including hemiplegia (one-sided paralysis [complete or partial loss of muscle function]). During a review of Resident 86's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings), dated 7/17/2024, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure residents were free from any significant medication errors for one (Resident 78) of five residents investigated for unnecessary medications by failing to follow the hold parameters (indications when to hold a blood pressure medication because the blood pressure is too low) for lisinopril (medication to treat high blood pressure) as ordered by the physician. This deficient practice had the potential to cause complications such as low blood pressure and syncope (fainting) and, possible requirement of hospitalization. Findings: During a review of Resident 78's Face Sheet, the Face Sheet indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included hypertension (HTN, high blood pressure). During a review of Resident 78' s Minimum Data Set (MDS, a resident assessment tool), dated 9/24/2024, the MDS indicated Resident 78 was severely impaired in cognition (the process of acquiring knowledge 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 proper food handling and storage practices by failing to: 1. Ensure a bin full of zucchini and a bin full of cantaloup found inside the walk-in refrigerator were labeled with the date they were received. 2. Ensure an open bag of dry pasta and an open bag of tostadas found inside the dry storage room were labeled with the date they were opened. These deficient practices had the potential to place 114 out of 116 residents who receive food from the facility kitchen at risk for foodborne illness (illness caused by the ingestion of contaminated food or beverages). Findings: During a concurrent observation and interview on 11/18/2024 at 7:51 a.m., with [NAME] 1, observed the facility's walk-in refrigerator. Observed a plastic bin full of zucchini with no label of when it was received. Observed a plastic bin full of cantaloup with no label of when it was received. [NAME] 1 verified by stating that neither bin had a label on it and stated they should have been labeled with the date they were received. Observed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Licensed Vocational Nurse 9 (LVN 9) removed gloves and performed hand hygiene in between cleaning a resident's eyes and after cleaning a resident's eye and opening a new package of supplies and ensure LVN 9 removed gloves and performed hand hygiene in between administering eye drops to both eyes for one of five sampled residents (Resident 72) investigated under the care area of infection control. These deficient practices had the potential to cause cross contamination (unintentional transfer of bacteria/germs or other contaminants from one surface to another) between Resident 72's eyes and from Resident 72 to other residents. 2. Ensure a trash bin used for Personal Protective Equipment (equipment designed to protect the wearer from injury or the spread of illness or infection such as gloves and gowns) was provided to two of 23 residents who were on Enhance Barrier Precaution (EBP- a method of using PPE to reduce the spread of…

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

Based on interview and record review, the facility failed to keep a copy of a resident's Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions) in the medical record for one (Resident 4) out of 29 sampled residents. This deficient practice had the potential to create confusion, which could lead to conflict with the resident's wishes regarding his/her health care. Findings: During a review of Resident 4's admission Record, the record indicated the facility originally admitted the resident on 4/4/2013 and readmitted the resident on 11/2/2022 with diagnoses including Parkinsonism (a general term for a group of conditions that cause similar motor symptoms, such as tremors, rigidity, and slow movement), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), schizophrenia (a mental illness that is characterized by disturbances in thought),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (a type of abuse that uses language) for one of three sampled residents (Resident 89) when on 11/01/2024, Resident 88 screamed at Resident 89 I will kill you. This deficient practice resulted in Resident 89 being subjected to verbal abuse while under the care of the facility. Residents who are subjected to verbal abuse are at increased risk for low self-esteem (when someone lacks confidence in themselves and their abilities), anxiety (a feeling of fear, dread, and uneasiness), depression (mood disorder that causes a persistent feeling of sadness and loss of interest in activities for long periods of time) and social isolation (when someone has few or no social connections or support and lacks relationships with others). Findings: During a review of Resident 89's admission Record, the admission Record indicated the facility initially admitted Resident 89 on 7/28/2023 and readmitted the resident on 3/14/2024 with diagnoses including quadriplegia (a form of paralysis…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of two sampled residents (Resident 69 and 12) were invited and participated in Interdisciplinary Team (IDT - a group of professionals with different areas of expertise who work together to achieve a common goal for the resident) care plan meetings (a written document that summarizes a resident's needs, goals, and care/treatment) investigated under the care area of care planning. These deficient practices violated the residents' right to be included in developing a resident-centered care plan and a missed opportunity in obtaining the cooperation of the resident which had the potential to result in failure in the delivery of necessary care and services. Findings: a. During a review of Resident 69's admission Record, the admission Record indicated the facility originally admitted the resident on 1/23/2023 and readmitted the resident on 7/7/2023, with diagnoses that included but not limited to, gastroesophageal reflux disease (stomach contents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 meet the professional standards of care for one (Resident 72) out of 29 sampled residents by failing to check the resident's respiration rate (a number of breaths a person takes per minute) before administering Gabapentin (medication used to control seizures and for neuropathic pain [a pain caused by damage to the nervous system]) as ordered by the physician. This deficient practice had the potential to result in Resident 72 having unintended complications related to the administration of Gabapentin, such as respiratory depression (condition when breathing is too slow or too shallow). Findings: During a review of Resident 72's admission Record, the admission Record indicated the facility initially admitted Resident 72 on 9/5/2021 and readmitted the resident on 3/24/2023 with diagnoses including cerebrovascular disease (a condition that affect blood flow to your brain), epileptic seizures (a sudden electrical storm in the brain that causes temporary disruptions in a person's body functions, like 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to clarify (contacting the physician to obtain additional details about an existing order) fingerstick (a way to check the blood sugar by inserting a small needle into a finger) orders with the physician which indicated the resident was to receive a fingerstick seven times a day instead of the usually prescribed four times a day. This deficient practice had the potential to result in pain from excessive finger sticks. Findings: During a review of Resident 78's Face Sheet, the Face Sheet indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included diabetes mellitus (high blood sugar). During a review of Resident 78' s Minimum Data Set (MDS, a resident assessment tool), dated 9/24/2024, the MDS indicated Resident 78 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure a resident's bed was in low position per physician's orders for one of five sampled residents (Resident 32) investigated under the care area of accidents. 2. Provide a resident who was at high risk for falls with a tab alarm (a safety device used primarily in healthcare settings to alert caregivers when a patient attempts to get out of bed or chair without assistance) and floor mats (a cushioned floor pad designed to help prevent injury should a person fall) as ordered by the physician for one of five sampled residents (Resident 51) investigated under the care area of accidents. These deficient practices had the potential to place the residents at increased risk of sustaining a fall with injuries. Findings: a. During a review of Resident 32's admission Record, the admission Record indicated that the facility admitted the resident on 9/16/2024 with diagnoses that included type two (2) diabetes mellitus (a chronic condition 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 ensure that residents who needed respiratory treatment (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 84) when Resident 84's nebulizer (a small machine that turns liquid medicine into mist that can be easily inhaled) tubing was not labeled with the date it was last changed. This deficient practice had the potential to cause respiratory infection to Resident 84 Findings: During a review of Resident 84's admission Record, the admission Record indicated that the facility initially admitted Resident 84 on 11/25/2022 and readmitted the resident on 7/30/2024 with diagnoses including acute respiratory failure (a condition in which your blood doesn't have enough oxygen causing shortness of breath and difficulty breathing, often caused by a disease or 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.

Based on observation, interview, and record review the facility failed to implement and maintain an infection control program for one out of six sampled residents (Resident 3) by failing to label the urinal bottle (a container used to collect urine and is made for either male or female anatomy) with the name and room number of Resident 3. This deficient practice had the potential for cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another) and to spread infection among residents. Findings: During a review of Resident 3's admission Record, the admission Record indicated the facility originally admitted the resident on 12/28/2023 with diagnoses that included atherosclerotic heart disease (hardening of the arteries [blood vessels that carry away blood away from the heart]) of native (natural or original) coronary (heart) artery without angina pectoris (chest pain), anemia (when red blood cells is lower than normal), and hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is 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 observation, interview, and record review the facility failed to reorder, refill and administer one of three sampled residents (Resident 3) Lidoderm Patch (medication applied to the skin used to treat pain) timely. This deficient practice resulted in delay in the delivery of medication for Resident 3. Resident 3 did not receive the Lidoderm Patch as ordered by the physician which had the potential for Resident 3 to have increased level of pain, discomfort, and decreased quality of life. Findings: During a review of Resident 3's admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included hypertension (HTN- high blood pressure), epilepsy (brain disorder that causes episodes of abnormal electrical activity in the brain that can cause temporary changes in behavior, consciousness [the state of being awake and aware of one's surroundings ], movement, or sensations), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 laboratory results were communicated with the physician timely for one of three sampled residents (Resident 4). This deficient practice had the potential to delay necessary care and services for the resident. Findings: During a review of Resident 4's admission record, the document indicated the facility readmitted the resident on 9/16/2024 with diagnoses that included paroxysmal atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), cardiomyopathy (condition makes it hard for the heart to deliver blood to the body), and sepsis (a life-threatening complication of an infection) due to Escherichia coli (E. coli - a type of bacteria that normally lives in your intestines). During a review of Resident 4's Minimum Data Set (MDS-a standardized assessment and screening tool) dated 9/23/2024, the document indicated the resident's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. 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.

Based on interview and record review, the facility failed to ensure the Medication Administration Record (MAR, a report detailing the medications administered to a resident by the licensed nurses) coincided with the Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) and entries were accurately documented per facility policy for one of three sampled residents (Resident 1). This deficient practice had the potential to result in medication error and/or drug diversion (illegal distribution or abuse of prescription drug). Findings: During a review of Resident 1's admission Record, the document indicated the facility originally admitted the resident on 2/26/2021 with diagnoses that included quadriplegia (paralysis [complete or partial loss of muscle function] of all four limbs), polyneuropathy (when multiple peripheral nerves [a network of nerves that run throughout the head, neck, and body] become damaged), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and pain in left knee.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 call lights (a device used by a resident to signal his/her need for assistance from staff) were within residents' reach while in bed for two of three sampled residents (Resident 2 and Resident 3). This deficient practice had the potential to delay the provision of services and the residents' needs not being met. Findings: a. During a review of Resident 2's admission Record, the document indicated the facility admitted the resident on 9/6/2024 with diagnoses that included dysphagia (difficulty swallowing), muscle weakness, and difficulty in walking. During an observation on 9/17/2024 at 7:55 a.m., observed Resident 2 in bed and yelling in Spanish. Observed Resident 2's call light not within reach and on the floor. During a concurrent observation and interview on 9/17/2024 at 7:57 a.m., with Certified Nursing Assistant 3 (CNA 3) in Resident 2's room, observed Resident 2 in bed. Observed Resident 2's call light not within reach and on the floor. Observed CNA 3 pickup Resident 2's call light from the floor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1) who is at risk of developing a pressure ulcer/injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin) was repositioned. This deficient practice had the potential to place Resident 1 at risk of developing a pressure ulcer/injury. Findings: During a review of Resident 1's admission Record, the document indicated the facility originally admitted the resident on 2/26/2021 with diagnoses that included quadriplegia (paralysis [complete or partial loss of muscle function] of all four limbs), polyneuropathy (when multiple peripheral nerves [a network of nerves that run throughout the head, neck, and body] become damaged), and pain in left knee. During a review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 6/1/2024, the document indicated Resident 1's cognitive skills (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) 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.

Based on interview and record review the facility failed to implement the facility's policy on pain as evidenced by failing to ensure a pain risk assessment was completed quarterly (every three months) and for new onset of pain on 9/4/2024 for one of three sampled residents. (Resident 1) This deficient practice had the potential to result in Resident 1 not maintaining Resident 1's highest possible level of comfort. Findings: During a review of Resident 1's admission Record indicated the facility originally admitted the resident on 2/26/2021 with diagnoses that included quadriplegia (paralysis [complete or partial loss of muscle function] of all four limbs), polyneuropathy (when multiple peripheral nerves [a network of nerves that run throughout the head, neck, and body] become damaged), and pain in left knee. During a review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 6/1/2024, indicated Resident 1's cognitive skills (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) 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 accurately assess one of three sampled residents (Resident 1) for elopement (leaving the facility without notice or permission) risk, when on 8/31/2024, Resident 1 left the facility's premises without staff supervision. This deficient practice had the potential for Resident 1 not to be monitored for elopement and may result in harm, injury and or death. Findings: During a review of Resident 1's admission Record indicated the facility originally admitted Resident 1 on 8/31/2012 and readmitted on [DATE] with diagnoses that included Parkinsonism disease (disorder of the central nervous system [made up of the brain and spinal cord] that affects movement, often including tremors), dysphagia (difficulty in swallowing), difficulty in walking, bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels and concentration), and hypertension (elevated blood pressure). During a review of Resident 1's Minimum Data Set…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain complete and accurate medical records for one of five sampled residents (Resident 2) by failing to follow the documentation instructions for the monitoring of side effects from Buspar (medication indicated to treat anxiety [feelings of worry, or fear that are strong enough to interfere with one's daily activities]). This deficient practice resulted in Resident 2's Medication Administration Record (MAR - a report detailing the medications administered to a resident) for 7/2024 being inaccurate and had the potential to result in confusion regarding Resident 2's condition. Findings: During a review of Resident 2's admission Record, the admission Record indicated that the facility admitted Resident 2 on 12/23/2023 with diagnoses that included major depressive disorder (persistent feeling of sadness) and Alzheimer's disease (affects memory, thinking, and behavior, symptoms eventually grow severe enough to interfere with daily tasks). During a review of Resident 2's Minimum Data Set (MDS- a standardized assessment and…

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

Based on observation, interview, and record review, the facility failed to administer medications in a safe manner for one of six sampled residents (Resident 1), by administering an eye drop medication beyond the use date or opened date. This deficient practice had the potential to result in eye infection and cause irritation to the eye due to the administration of eye drop medication beyond the use date or opened date. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 5/13/2024 with diagnoses that included respiratory failure (a serious condition that makes it difficult to breathe on your own), type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), and chronic bronchitis (inflammation [swelling] and irritation of the bronchial tubes [airways that carry air to and from the air sacs in the lungs]). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care planning tool), dated 5/24/2024, indicated Resident 1 had severely impaired…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 notify one of three sampled residents (Resident 1) physician, when on 5/19/2024, Resident 1's blood pressure (BP - pressure of circulating blood against the walls of blood vessels, normal range less than 120/80 millimeters of mercury [mmHg - unit of measure]) was low and Licensed Vocational Nurse 1 (LVN 1) failed to administer Atenolol (a medication used to treat hypertension [high blood pressure]) due to parameters (specific measurements or factors used such as to hold medications if out of range) being out of range. These deficient practices had the potential to cause a delay of obtaining appropriate medical treatment and interventions for which could have resulted in a negative impact to Resident 1's well-being. Findings: A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 5/3/2024 with diagnoses that included hypertension and atrial fibrillation (an irregular, rapid heart rhythm). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-planning 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.

Based on interview and record review, the facility failed to maintain complete and accurate medical records for one of three sampled residents (Resident 1) by failing to ensure licensed nurses did signed the Medication Administration Record (MAR - a report detailing the drugs administered to a resident by a healthcare professional) for Resident 1 on 5/1/2024 during the 3:00 p.m. to 11:00 p.m. shift. This deficient practice resulted in Resident 1's medical records being inaccurate and had the potential to result in confusion regarding Resident 1's condition and what care and services were provided to Resident 1. Findings: A review of Residents 1' admission Record indicated the facility admitted Resident 1 on 2/26/2021 with diagnoses that included quadriplegia (paralysis [inability to move] of all four limbs [arms and legs] or of the entire body below the neck), polyneuropathy (a disease of the nerves [cables that carry electrical impulses between your brain and the rest of your body]), muscle spasm ( a sudden, involuntary movement in one or more muscles), hypertension (high blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident call system (a tool that allows residents to communicate with nurses that they are in of need assistance)was functioning for five of seven sampled residents (Resident 1, 3, 5, 6, and 7). This deficient practice placed the resident at risk of inability to summon health care workers as needed to receive assistance that may include urgent care. Findings: 1. A review of Resident 1 ' s admission Record indicated the facility originally admitted Resident 1 on 3/26/2024 and readmitted Resident 1 on 4/8/2024 with diagnoses that included epilepsy (a common condition that affects the brain and causes frequent seizures [a sudden and temporary change in the electrical and chemical activity in the brain which leads to a change a person ' s movement, behavior, and level of awareness]) and diabetes mellitus (DM - a group of diseases that affect how the body uses blood sugar). A review of Resident 1 ' 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 protect the resident ' s right to be free from verbal abuse (harsh and insulting language directed at a person) for one of four sampled residents (Resident 1), when on 5/4/2024, Resident 2 verbally abused and threatened Resident 1. This deficient practice resulted in Resident 1 being subjected to verbal abuse by Resident 2 while under the care of the facility and had the potential to result in Resident 1 ' s emotional distress and restlessness (inability to rest or relax). Findings: A review of Resident 1 ' s admission Record indicated the facility originally admitted Resident 1 on 3/26/2024 and readmitted Resident 1 on 4/8/2024 with diagnoses that included epilepsy (a common condition that affects the brain and causes frequent seizures [a sudden and temporary change in the electrical and chemical activity in the brain which leads to a change a person ' s movement, behavior, and level of awareness]) and diabetes mellitus (a group of diseases 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 1.c. A review of Resident 27's admission Record indicated the facility admitted the resident on 9/9/2012 and readmitted the resident on 6/9/2023 with diagnoses that included diabetes mellitus, end stage renal disease (a medical condition in which a person's kidneys stop functioning on a permanent basis), and hemiplegia and hemiparesis (mild to severe loss of strength or paralysis on one side of the body) following cerebral infarction (stroke, when blood flow to the brain is blocked or there is sudden bleeding in the brain). A review of Resident 27's MDS dated [DATE], indicated the resident had the ability to make herself understood and had the ability to understand others. During a concurrent interview and record review on 11/29/2023 at 11:05 a.m., with the Social Services Designee (SSD), reviewed Resident 27's Advance Directive Acknowledgement form dated 12/8/2022. The SSD stated the AD Acknowledgement form is completed when it is discussed at admission to indicate if the resident has or does not have an AD.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents received medications in accordance with professional standards of practice by failing to ensure the medications a resident received before going to a general acute care hospital (GACH, or simply hospital) would also be received upon returning from the GACH for two of 21 sampled residents (Resident 169 and Resident 111). 2. Ensure a resident received the prescribed 9 a.m. scheduled application of Refresh Eye Ointment (an eye medication to keep the eyes from becoming dry) during the medication pass observation on 11/28/2023 for one of five sampled residents (Resident 45). These deficient practices resulted in the omission of medications which could have resulted in severe health complications. 3. Ensure the Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Records (MAR) for three of five sampled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 of unnecessary medication for one of five sampled residents (Residents 82) investigated for Unnecessary Medications by failing to ensure carvedilol (medication to treat high blood pressure [the force of the blood pushing on the blood vessel walls is too high]) and midodrine (medication to treat low blood pressure [the force of the blood pushing on the blood vessel walls is too low]) were not scheduled to be administered at the same time. This deficient practice had the potential to result in the resident receiving unnecessary medication potentially causing too low or too high blood pressure and injury to the resident. Findings: A review of Resident 12's admission Record indicated the facility admitted the resident on 7/4/2018 and readmitted the resident on 5/18/2023 with diagnoses that included multiple sclerosis (a chronic and progressive disorder that impacts the brain, spinal cord, and optic nerves [a nerve at the back of your eye that connects to your brain]), 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.

Based on observation, interview, and record review, the facility failed to ensure residents were free from any significant medication errors for one of five sampled residents (Residents 82) investigated for Unnecessary Medications by: 1.Failing to ensure carvedilol (medication to treat high blood pressure [the force of the blood pushing on the blood vessel walls is too high]) was administered in accordance with the physician's order to hold (do not give) for a systolic blood pressure (SBP, measures the pressure in your arteries [pathway that carries blood away from the heart]) less than 110 millimeters of mercury (mmHg, u unit of measurement). 2. Failing to ensure midodrine (medication to treat low blood pressure [the force of the blood pushing on the blood vessel walls is too low]) was administered in accordance with the physician's order to hold for a SBP greater than 110 mmHg. This deficient practice had the potential to result in the resident receiving unnecessary medication potentially causing too low or too high blood pressure and injury to the resident. Findings: 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medication and biologicals were stored with currently accepted professional standards for two of six medication carts (Medication Cart 1 and Medication Cart 2) investigated during the Medication Storage task by failing to: 1.Ensure six unopened insulin (a medication to treat diabetes mellitus [a chronic condition that affects the way the body processes blood sugar]) pens (an injection device with a needle that delivers insulin) were not stored in Medication Cart 2 for four of four sampled residents (Resident 27, 36, 86, and 93). 2. Ensure one opened tube of muscle rub (a medication used on the skin to treat minor aches and pains) and one opened bottle of Aspercreme Lidocaine (a medication used on the skin to stop itching and pain) were labeled with a resident identifier, and two opened bottles of glucometer (medical device for determining the approximate concentration of glucose in the blood) Assure Control Solution (solutions 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 draw (obtain) laboratory (lab) tests in a timely manner as ordered by the physician for two of two sampled residents (Resident 60 and Resident 269) by failing to: 1. Ensure Resident 60's order for a complete metabolic panel (CMP, a group of labs that indicate how the body is functioning including an indication of the nutritive status), was drawn when ordered. The CMP was not drawn until 15 days after it was ordered by the resident's physician. 2. Ensure Resident 269's order for complete blood count (CBC, a test that counts the cells that make up your blood), CMP, Urinalysis (UA-urine test) and urine culture and sensitivity (C&S-test to diagnose an infection), hemoglobin A1C, prostate-specific antigen (PSA-blood test to screen for prostate cancer), Brain Natriuretic Peptide (BNP- test used to detect heart failure [(heart is not pumping as well as it should be]), and ammonia level (test to diagnose and monitor the liver) were drawn when ordered. The CBC,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and safe food handling practices by failing to: 1. Ensure food items not in their original containers were labeled and dated. 2. Ensure personal belongs of kitchen staff, including bags and food items, were not kept in the kitchen area. These deficient practices had the potential to place 104 out of 109 residents living in the facility at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). Findings: During a kitchen inspection on 11/27/23 at 7:59 a.m., with Dietary Aide 1 (DA1), observed in the dry storage room one plastic bag of hamburger buns partly used and one plastic bag of hotdog buns partly used with no delivery dates, no open dates, and no use by dates. Also in the storage room was a plastic container containing cornflakes with no label and no use by date. During a concurrent observation and interview on 11/27/2023 at 8:48 a.m., with the Dietary Supervisor (DS), the DS was shown the partly used hamburger buns, the partly used hotdog…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 c. A review of Resident 15's admission Record indicated the facility admitted the resident on 7/13/2022 and readmitted the resident on 6/21/2023 with diagnoses that included urinary tract infection (UTI, an infection in the urinary system), major depressive disorder (persistent feelings of sadness and loss of interest that can interfere with daily living), and heart failure (a condition in which the heart cannot pump enough blood to meet the body's needs). A review of Resident 15's MDS dated [DATE], indicated the resident had the ability to make himself understood and had the ability to understand others. The MDS further indicated the resident required moderate assistance with toileting, bathing, dressing, and transferring from chair to bed. A review of Resident 15's physician's order dated 7/5/2023, indicated an order for oxygen via nasal cannula (NC, device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) at two (2) liters per minute (LPM, a unit of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to promote resident`s dignity by failing to ensure resident`s fingernails are trimmed and not dirty for one (Resident 106) of one sampled resident investigated under the Care Area- Dignity. This deficient practice had the potential to affect the resident's sense of self-worth and self-esteem. Findings: A review of Resident 106's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included chronic kidney disease (gradual loss of kidney function), type two diabetes mellitus (a group of diseases that result in too much sugar in the blood), and hypertension (high blood pressure [when the force of blood flowing through your blood vessels, is consistently too high]). A review of Resident 106's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/1/2023, indicated the resident's cognitive (the mental action or process of acquiring…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 its policy and procedure by failing to notify the physician immediately on 11/28/2023 regarding one of three sampled residents (Resident 269) continued right eye discharge. This deficient practice had the potential to negatively affect the delivery of care and services to Resident 269. Findings: A review of Resident 269's admission Record indicated the facility admitted the resident on 11/13/2023 with diagnoses including congestive heart failure (CHF-chronic condition in which the heart doesn't pump blood as well as it should), anemia (low number of red blood cells), and kidney failure (a medical condition in which the kidneys lose the ability to remove waste and balance fluids). A review of Resident 269's Minimum Data Set (MDS-a standardized assessment and screening tool) dated 11/23/2023, indicated the resident had intact cognition (ability to think and make decisions). A review of Resident 269's physician's order dated 11/20/2023, indicated the resident had an order for ciprofloxacin hydrochloride…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) for two of seven sampled residents (Resident 15 and 73) by failing to: 1. Develop a comprehensive care plan for Resident 15's oxygen use. 2. Develop a comprehensive care plan for Resident 73's hypertension (high blood pressure [when the force of blood flowing through your blood vessels, is consistently too high]) diagnosis. These deficient practices had the potential to result in a delay in or lack of delivery of care and services and miscommunication among the care team regarding the residents' needs. Findings: a. A review of Resident 15's admission Record indicated the facility admitted the resident on 7/13/2022 and readmitted the resident on 6/21/2023 with diagnoses that included urinary tract infection (UTI, an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a visually impaired resident was seen by an ophthalmologist (eye care specialist who is a doctor of medicine) as per the optometry (specialized health care profession that involves examining the eyes and relate structures for defects or abnormalities) consult done on 10/4/2023 for one of one sampled resident (Resident 106) reviewed under the care area Communication and Sensory. This deficient practice resulted in a delay in the provision of necessary care and services for Resident 106. Findings: A review of Resident 106's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included chronic kidney disease (gradual loss of kidney function), type two diabetes mellitus (a group of diseases that result in too much sugar in the blood), and hypertension (high blood pressure [when the force of blood flowing through your blood vessels, is consistently 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 observation, interview, and record review, the facility failed to ensure a resident who required assistance with nail trimming was provided care and services to maintain good personal hygiene for one of one sampled resident (Resident 106) investigated under activities of daily living (ADL- activities related to personal care). This deficient practice had the potential to result in a negative impact on the resident's self- esteem due to an unkempt appearance. Findings: A review of Resident 106's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included chronic kidney disease (gradual loss of kidney function), type two diabetes mellitus (a group of diseases that result in too much sugar in the blood), and hypertension (high blood pressure [when the force of blood flowing through your blood vessels, is consistently too high]). A review of Resident 106's Minimum Data Set (MDS - a standardized assessment and care screening…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure two of three sampled residents (Resident 112 and 269) received foot care and treatment. This deficient practice placed residents at risk to acquire a foot infection when toenails were not properly assessed and treated by licensed nurses and podiatrist (a person who treat disorders of the foot, ankle, and related structure of the leg). Findings: a. A review of Resident 112's admission Record indicated the facility admitted the resident on 10/14/2023 with diagnoses including acute and chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood), pneumonitis (inflammation of the lungs), and atrial fibrillation (irregular heartbeat). A review of Resident 112's Minimum Data Set (MDS-a standardized assessment and screening tool) dated 10/20/2023, indicated the resident had intact cognition (ability to think and make decisions). The MDS indicated that resident needed moderate assistance 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.

Based on observation, interview, and record review, the facility failed to ensure residents received adequate assistance devices and monitoring to prevent accidents for one of four sampled residents (Resident 17) investigated for Accidents, by failing to ensure the floor mats (thick, soft material designed to reduce the impact of a fall) were in place. This deficient practice had the potential to result in injuries from a fall to Resident 17. Findings: A review of Resident 17's admission Record indicated the facility admitted the resident on 1/20/2021 and readmitted the resident on 9/15/2022 with diagnoses that included Parkinsonism (a term to describe a collection of movement symptoms including stiffness, walking difficulties, balance problems, and tremors), dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and epilepsy (chronic disorder that causes recurrent seizures [abnormal electrical activity in the brain]). A review of Resident 17's Minimum Data Set (MDS - an assessment and…

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

Based on observation, interview and record review, the facility failed to administer parenteral fluids (medical technique that administers fluids, medications, and nutrients directly into a person's vein) for one of three sampled residents (Resident 271), consistent with professional standards of practice and in accordance with the facility's policy and procedure. This deficient practice had the potential to place Resident 271 at risk for complications and a central line-associated blood stream infection (CLABSI- a serious infection that occurs when germs enter the bloodstream through the central line). Findings: A review of Resident 271's admission Record indicated the facility admitted the resident on 11/10/2023 with diagnoses including diverticulitis (inflammation of the intestine), urinary tract infection (UTI- infection of the urinary system), and extended spectrum beta lactamase (ESBL- enzymes [proteins that help speed up metabolism] produced by bacteria that make them resistance to antibiotic) resistance. A review of Resident 271'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 provide respiratory care services consistent with professional standards of practice for one of three sampled residents (Resident 15) investigated for Respiratory Care by failing to ensure Resident 15 was monitored for as needed (PRN) oxygen use. These deficient practices had the potential to cause a delay in or lack of delivery of care and services including the treatment of disease processes causing shortness of breath. Findings: A review of Resident 15's admission Record indicated the facility admitted the resident on 7/13/2022 and readmitted the resident on 6/21/2023 with diagnoses that included urinary tract infection (UTI, an infection in the urinary system), major depressive disorder (persistent feelings of sadness and loss of interest that can interfere with daily living), and heart failure (a condition in which the heart cannot pump enough blood to meet the body's needs). A review of Resident 15's Minimum Data Set (MDS - an assessment and screening too) dated 10/8/2023, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident's food preferences are considered and accommodated for one of two sampled residents (Resident 58). This deficient practice placed the resident at risk for decreased meal intake which could result in weight loss or malnutrition (lack of sufficient nutrients in the body). Findings: A review of Resident 58's admission Record indicated the facility originally admitted the resident on 9/20/2018 and readmitted on [DATE], with diagnoses that included chronic kidney disease (gradual loss of kidney function), hypotension (low blood pressure), and history of falling. A review of Resident 58's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/27/2023, 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 required limited assistance for dressing, eating,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 left over food brought from outside was stored in the refrigerator or discarded for one of one sampled resident (Resident 73). This deficient practice had the potential to result in foodborne illness (also called food poisoning, illness caused by eating contaminated food) for Resident 73. Findings: A review of Resident 73's admission Record indicated the facility originally admitted the resident on 3/15/2023 and readmitted on [DATE], with diagnoses that included chronic kidney disease (gradual loss of kidney [organ that removes waste products from the blood and produces urine] function), type two (2) diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]), and hypertension. A review of Resident 73's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/12/2023, indicated the resident's cognitive (the mental action or process of acquiring knowledge and…

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

Based on interview and record review, the facility failed to implement its antibiotic stewardship program (a coordinated program that promotes the appropriate use of drugs used to treat infections, including antibiotics [a medicine that inhibits the growth of or destroys bacteria or germs]) by failing to conduct infection surveillance (a systematic collection of data to track infection which is collected when a resident has certain signs and symptoms that could be a bacterial infection) and complete the infection control reporting form once signs and symptoms of infection were identified and antibiotics were initiated for one of five sampled residents (Resident 271). This deficient practice had the potential for Resident 271 to develop antibiotic resistance from unnecessary or inappropriate antibiotic use for future infections. Findings: A review of Resident 271's admission Record indicated the facility admitted the resident on 11/10/2023 with diagnoses that included urinary tract infection (UTI, an infection in any part of the urinary system) and extended spectrum beta lactamase…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 their facility's medication administration policy by failing to ensure: 1. Registered Nurse 1 (RN 1) administered the medication Midodrine (a medication that works by constricting the blood vessels and increasing blood pressure [BP]) as ordered, for one of three sampled residents (Resident 1). 2. Registered Nurse 3 (RN 3) signed the Medication Administration Record (MAR- a report detailing the medications administered to a resident by a healthcare professional) after administering Midodrine to one of three sampled residents (Resident 1) on 11/7/2023. These deficient practices had the potential to result in medication errors and had the potential to result in confusion on the delivery of care and services. Findings: 1. A review of Resident 1's admission Record indicated the facility admitted the resident on 2/26/2021 with diagnoses that included quadriplegia (paralysis [complete or partial loss of muscle function] of all four limbs [arms and legs]) and hypotension (low blood pressure). A review of Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) for one of three sampled residents (Resident 5) by: 1. failing to ensure a care plan was developed for Resident 5 ' s noncompliance with the usage of the physician ordered bi-level positive airway pressure (BiPAP, a device that helps with breathing, it delivers air and added oxygen through a mask on the face; the device helps open the lungs with air pressure, it uses a lower pressure when exhaling than when inhaling) machine at night for obstructive sleep apnea (OSA - a disorder in which a person frequently stops breathing due to collapse of the upper airway during sleep). 2. failing to ensure Resident 5 ' s person-centered care plan was resident specific and included interventions such as checking the resident ' s oxygen saturation (O2 sat- the amount of oxygen in the blood, normal range is 95 percent [%-unit of measure]to 100%)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the attending physician when one of three sampled residents (Resident 5) was non-compliant with the use of the ordered oxygen (O2) therapy with a bi-level positive airway pressure (BiPAP, a device that helps with breathing, it delivers air and added oxygen through a mask on the face; the device helps open the lungs with air pressure, it uses a lower pressure when exhaling than when inhaling) machine for obstructive sleep apnea (OSA - a disorder in which a person frequently stops breathing due to collapse of the upper airway during sleep). This deficient practice had the potential for the physician not knowing about the resident's unused BiPAP at night and could have potentially delayed necessary interventions. Findings: A review of Resident 5 ' s admission Record indicated the facility originally admitted Resident 5 on 3/7/2019 and re-admitted Resident 5 on 7/11/2023 with diagnoses that included OSA, nocturnal (at night time) dependence on…

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

Based on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 4) received prescribed medications (tizanidine-used to treat muscle spasms) as ordered by the physician and the medication was readily available. This deficient practice had the potential to result in Resident 4 experiencing side effects (undesirable effect of a drug) such as increased muscle spasms, and a delay in care and services. Findings: A review of Resident 4's admission Record indicated the facility admitted the resident on 2/26/2021 with diagnoses that included quadriplegia (paralysis [complete or partial loss of muscle function] of all four limbs), other muscle spasm (involuntary contractions of a muscle, typically harmless and temporary, but can be painful), and anxiety disorder (feelings of worry or fear that are strong enough to interfere with one's daily activities). A review of Resident 4's Minimum Data Set (MDS - standardized assessment and care planning tool) dated 6/5/2023, indicated Resident 4's cognitive (refers to conscious mental activities…

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

Based on observation, interview, and record review, the facility failed to implement infection control policy and procedures by failing to: 1. Ensure appropriate signages were placed outside resident rooms that were under isolation for one of four sampled residents (Resident 4). 2. Ensure a staff member donned (put on) a gown and gloves prior to entering an isolation room for one of four sampled residents (Resident 4). This deficient practice has the potential to spread infection and cross contamination among other residents. Findings: A review of Resident 4's admission Record indicated the facility admitted the resident on 2/26/2021 with diagnoses that included quadriplegia (paralysis [complete or partial loss of muscle function] of all four limbs), other muscle spasm (involuntary contractions of a muscle, typically harmless and temporary, but can be painful), and anxiety disorder (feelings of worry or fear that are strong enough to interfere with one's daily activities). A review of Resident 4's Minimum Data Set (MDS- an assessment and care screening tool), dated 6/5/2023,…

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 interview and record review, the facility failed to provide one of three sampled residents (Resident 3) with a copy of a tuberculosis (TB - a bacterial disease that usually attacks the lungs) test result upon request. This deficient practice violated Resident 3 ' s rights to obtain copies of clinical records when requested. Findings: A review of Resident 3 ' s admission Record indicated; the facility admitted the resident on 5/13/2022 with diagnoses including hypertension (high blood pressure). A review of Resident 3 ' s History and Physical dated 9/29/2022, indicated that the resident had the capacity to understand and make decisions. A review of Resident 3 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 5/20/2023, indicated that the resident is able to understand others and is able to be understood by others. The MDS further indicated that Resident 3 required extensive assistance from staff with bed mobility, transfer, dressing, and toilet use. A review of Resident 3 ' s Immunization Reports indicated that Resident 3 had two TB tests.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 3) received a two (2)-step tuberculin Skin Test (TST- a test to determine if a resident is infected with tuberculosis [TB - a bacterial disease that usually attacks the lungs]; a two-step is defined as two TST done within one month of each other) as ordered by the physician. This deficient practice had the potential to spread infection among staff and other residents. Findings: A review of Resident 3 ' s admission Record indicated; the facility admitted the resident on 5/13/2022 with diagnoses including hypertension (high blood pressure). A review of Resident 3 ' s History and Physical dated 9/29/2022, indicated that the resident had the capacity to understand and make decisions. A review of Resident 3 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 5/20/2023, indicated that the resident is able to understand others and is able to be understood by others. The MDS further indicated that Resident 3 required extensive assistance from staff…

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