The Care Center On Hazeltine, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents who receive apixaban (a medication that treats and helps prevents blood clots in the heart and blood vessels) were accurately monitored for side effects (an often harmful and unwanted effect) for one of six sampled residents (Resident 13). This deficient practice had the potential to result in Resident 13 experiencing adverse side effects (unwanted, uncomfortable, or dangerous effects that a drug may have) from the anticoagulant including unusual bruising (a mark on the skin that occurs when small, bleeding from the gums or nose, and having blood in the stool. Findings: During a review of Resident 13's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to, epilepsy (a brain disorder that causes seizures [sudden, uncontrolled electrical disturbances in the brain which can cause uncontrolled jerking, blank…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 was free from unnecessary psychotropic drugs (any drug that affects behavior, mood, thoughts, or perception in excessive dose, excessive duration, without adequate monitoring) for one of six sampled residents (Residents 10) by failing to ensure Resident 10 received the correct dose of duloxetine (medication that is used to treat depression [a persistent feeling of sadness or a lack of interest in outside stimuli]) as ordered by the physician. This deficient practice resulted in an administration of excessive dose of duloxetine to Resident 10 and had the potential to place the resident at risk for significant adverse consequence (unwanted, uncomfortable, or dangerous effects that a drug may have) from the use of unnecessary psychotropic drug, which could result to impairment (being weakened) or decline (gradually become less) in the resident's mental, physical condition, functional, and psychosocial status. Findings: 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident was free from significant medication error by failing to administer the correct dose of duloxetine (medication used to treat depression [a persistent feeling of sadness or a lack of interest in outside stimuli]) as ordered by the physician for one of three sample residents (Resident 10). This deficient practice resulted in an administration of excessive dose of duloxetine to Resident 10 and had the potential to place the resident at risk for significant adverse consequence (unwanted, uncomfortable, or dangerous effects that a drug may have) from the use of unnecessary psychotropic drug, which could result to impairment (being weakened) or decline (gradually become less) in the resident's mental, physical condition, functional, and psychosocial status. Cross reference F758 Findings: During a review of Resident 10's admission Record, the admission Record indicated the facility originally admitted the resident on 6/1/2020,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe and sanitary environment and food storage practices in the kitchen when: 1. A single sausage patty was observed exposed and unwrapped on top of an open box containing an unsealed bag of the same sausage patties in Freezer 1. 2. An undated bottle of Gatorade belonging to a staff member was stored in Refrigerator 2. 3. Shelves intended to hold clean trays were observed stained, with crumbs and dust. 4. Two plastic bins holding clean utensils were observed with reddish food residue and crumbs and placed on dusty shelves. These deficient practices had the potential to place the facility residents at risk for foodborne illness (illness caused by food contaminated with bacteria, viruses, and other toxins) and to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another). Findings: During an initial kitchen tour on 11/4/2024 at 7:45 a.m., with [NAME] 1, observed an unwrapped sausage patty on top of an open box containing an unsealed bag of the same…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain infection control practices when Licensed Vocational Nurse 1 (LVN 1) did not wash hands between administering medications via gastrostomy tube (also known as a G-Tube, is a flexible that is inserted through the abdominal wall and into the stomach to provide nutrition and fluids) and giving an insulin (a hormone that lowers the level of sugar in the body) injection to Resident 32. This deficient practice had the potential to cause Resident 32 to develop an infection. Findings: During a review of Resident 32's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to, anemia (a condition where the body does not have enough healthy red blood cells), colon cancer, and vascular dementia (a progressive state of decline in mental abilities that occurs when the blood supply to the brain is disrupted). During a…

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

Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) to meet the resident`s needs for one of five sampled residents (Resident 14) by failing to develop and implement a comprehensive person-centered care plan addressing Resident 14`s problem with communication. This deficient practice had the potential to result in Resident 14 not being able to communicate requests, needs or concerns which could lead to inadequate care of Resident 14. Findings: During a review of Resident 14's admission Record, the admission Record indicated the facility admitted the resident on 5/11/2023, with diagnoses including unspecified dementia (a progressive state of decline in mental abilities) , repeated falls, dysphagia (swallowing difficulties), and depression (a mood disorder that causes a persistent feeling of sadness…

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

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 14) was provided a communication device or board (a tool that includes pictures that help residents communicate their healthcare and every-day needs to facility staff) in his preferred language. This deficient practice had the potential to prevent the resident from communicating with the staff and receiving care in a timely manner. Cross reference F656 Findings: During a review of Resident 14's admission Record, the admission Record indicated the facility admitted the resident on 5/11/2023, with diagnoses including unspecified dementia (a progressive state of decline in mental abilities) , repeated falls, dysphagia (swallowing difficulties), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities of living). During a review of Resident 14's Minimum Data Set (MDS -a federally mandated resident assessment tool) dated 8/8/2024, the MDS indicated the resident`s cognitive skills…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 discard a medicated ointment belonging to Resident 8 from one of one inspected treatment carts after the resident had been discharged . This deficient practice resulted in the facility staff still being able to access a discharged resident's medication. Findings: During a review of Resident 8's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and dementia (a progressive state of decline in mental abilities). The admission Record indicated Resident 8 was discharged on 10/26/2024. During a review of Resident 8's History and Physical (H&P), dated 7/30/2024, the H&P indicated Resident 8 does not have the capacity to understand and make decisions. During a review of Resident 8's physician's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to meet the nutritional needs for one of three sampled residents (Resident 12) by failing to provide a fortified diet (a food that has extra nutrients [important substances you get from food that help your body survive and grow] added to it) as ordered by the physician. This deficient practice had the potential to result in Resident 12's decreased nutritional intake and weight loss. Findings: During a review of Resident 12's admission Record, the admission Record indicated that the facility originally admitted the resident on 8/25/2014, and readmitted on [DATE], with diagnoses including dysphasia (swallowing difficulties), anorexia (an eating disorder that causes people to weigh less than is considered healthy for their age and height), unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and schizophrenia (a disorder that affects a person's ability to think, feel, 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 ensure there was an adequate indication for the use of permethrin cream (a medication used to treat scabies [a condition caused by tiny insects called mites] that infest and irritate a person's skin) and ivermectin (a medication that treats infections caused by roundworms, threadworms, and other parasites [organism that lives on or in a host organism and gets its food from or at the expense of its host]) for one of three sampled residents (Resident 1). This deficient practice had the potential to result in the use of unnecessary medication and cause adverse side effects (an undesired harmful effect resulting from a medication or other intervention) such as burning, itching, numbness, rash, redness, stinging, swelling of the skin, weakness, uncontrollable shaking of a part of the body, and chest discomfort. Findings: A review of Resident 1's admission Record indicated the facility readmitted Resident 1 on 3/22/2023 with diagnoses that included chronic obstructive pulmonary disease (refers to a group of diseases that cause…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY c. A review of Resident 49's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses that included seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations or states of awareness), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning). A review of Resident 49's MDS dated [DATE], indicated that Resident 49's cognitive skills for daily decision making was severely impaired. The MDS also indicated that Resident 49 required extensive assistance with bed mobility, dressing, and personal hygiene. A review of Resident 49's Care Plan titled, ADL: Resident 49 requires assistance in personal hygiene indicated an intervention to assist with maintaining good personal hygiene every shift and as needed. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure the attending physician assess and documented in the resident`s medical record the rationale for extending Ativan (medication is used to treat anxiety [(intense, excessive, and persistent worry and fear about everyday situations]) for 30 additional days for one of two sampled residents (Resident 47) reviewed for Unnecessary Medications. 2. Provide non-pharmacological interventions (health interventions that are not primarily based on medication) to Resident 11 prior to administering as needed (prn) Ativan on multiple dates for one (Resident 11) of five sampled residents investigated for unnecessary medications. These deficient practices had the potential to result in unnecessary medications and had the potential to result in adverse reaction or impairment in the resident's mental or physical condition. Findings: 1. A review of Resident 47's admission Record indicated the facility admitted the resident on 10/20/2023, with diagnoses that…

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

Based on observation, interview, and record review, the facility: 1. Failed to document temperatures for the medication refrigerator. 2. Failed to ensure a bottle of Bismuth Subsalicylate (medication used to treat diarrhea [loose, watery and possibly more-frequent bowel movements]) that was labeled open on 11/17/2020 (approximately three years ago) was discarded. 3. Failed to ensure a bottle of Milk of Magnesia (medication to treat an upset stomach) was labeled with its open date (the date at which a new medication is first opened). These deficient practices had the potential to compromise the therapeutic effectiveness medication. Findings: 1. During a concurrent interview and record review on 11/17/2023 at 5:53 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 reviewed the facility's Medication Refrigerator temperature log for 10/2023 and 11/2023. LVN 1 stated that facility staff should document the temperature of the refrigerator at the start and the end of each shift. LVN 1 reviewed the Medication Refrigerator temperature log for 10/2023 and 11/2023 and stated that there was…

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

Based on observation, interview, and record review, the facility failed to implement infection control practices by: 1. Failing to ensure one of three sampled staff (Maintenance Assistant [MA]) did not wear gloves while walking in the facility's hallway. 2. Failing to ensure one of three sampled staff (Certified Nursing Assistant 2 [CNA 2]) removed their used gloves prior to exiting a resident room and failing to ensure CNA 2 performed hand hygiene (washing of hands) after removing a set of gloves. 3. Failing to ensure the facility's Infection Preventionist (IP) was able to articulate the facility's water management process to reduce the risk of Legionnaire's disease (a severe form of pneumonia [lung inflammation usually caused by infection]). 4. Facility failed to ensure the water management program was reviewed by the Infection Control Committee on an annual basis. These deficient practices had the potential to spread infection and cross contamination (the physical movement or transfer of harmful bacteria [germs] from one person, object, or place to another) among staff and other…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 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 ensure the facility's monthly surveillance monitoring report was completed for 9/2023 and 10/2023. This deficient practice had the potential for residents to develop antibiotic resistance from unnecessary or inappropriate antibiotic use for future infections. Findings: During a concurrent interview and record review on 11/17/2023 at 7:29 p.m., with the Infection Preventionist (IP), the IP stated that the antibiotic stewardship program is a program that monitors the antibiotics used in the facility to ensure residents are appropriately prescribed antibiotics. The IP stated when the facility receives a physician's order for antibiotics for a resident, the licensed nurse will then fill out a surveillance date collection form (a systematic collection of data to track…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 promote one of three sampled resident's (Resident 4) dignity by failing to ensure Certified Nursing Assistant (CNA 1) was not standing over Resident 4 while assisting the resident with feeding. This deficient practice had the potential to affect the resident's sense of self-worth and self-esteem. Findings: A review of Resident 4's admission Record indicated the facility admitted the resident on 5/8/2023 with diagnoses including toxic encephalopathy (a disturbance of normal brain function) and dysphagia (difficulty swallowing). A review of Resident 4's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/12/2023, indicated the resident had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and was totally dependent on staff for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. During a concurrent observation and interview on 11/18/2023 at 12:31 p.m., 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 interview and record review, the facility failed to ensure there was documented evidence that education about an advanced directive (written document that indicated a person's wishes regarding medical treatment if that person is no longer able to communicate) was provided for one of three residents (Resident 17) investigated under the Advance Directives care area. This deficient practice violated Resident 17's and/or their representatives' right to be fully informed of the option to formulate an advance directive and had the potential to cause conflict due to lack of communication regarding Residents 17's wishes about their medical treatment. Findings: A review of Resident 17's admission Record indicated the resident was admitted on [DATE] with diagnosis the included fibromyalgia (a chronic [long-lasting] disorder that causes pain and tenderness throughout the body), encounter to palliative care (specialized medical care for people TV living with a serious illness), muscle weakness, and moderate calorie…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a safe, clean comfortable and homelike environment for one of one sampled resident (Resident 35) by failing to repair peeling paint in the restroom door and failing to ensure that there was no hole in the drywall above Resident 35's bed. This deficient practice had the potential to negatively affect the residents' comfort and well-being. Findings: A review of the Resident 35's admission Record indicated the facility admitted the resident on 11/19/2022 with diagnoses that included muscle weakness (a decrease in muscle strength), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and dehydration (an abnormal loss of water from the body). A review of Resident 35's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 8/26/2023 indicated the resident had clear speech, usually makes self-understood, and usually understand others. The MDS indicated that the resident required extensive assistance with bed mobility, dressing, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a written course of action that helps a patient achieve outcomes that improve their quality of life) with measurable goals and objectives including person-centered interventions addressing a resident's hearing loss problem for one of one sampled resident (Resident 44) investigated under the care area Communication-Sensory. This deficient practice had the potential to negatively affect the delivery of care and services to Resident 44. Findings: A review of Resident 44's admission Record indicated the facility admitted the resident on 6/10/2022, with diagnoses that included hypertension (high blood pressure), muscle weakness, and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 44's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 6/15/2023, indicated the…

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

Based on interview and record review, the facility failed to ensure one of one sampled (Resident 44) resident investigated under the care area communication and sensory was provided a medical hearing consult promptly (the resident had been waiting approximately two months) after the resident was assessed to have a hearing loss problem. This deficient practice resulted in a delay in delivering the necessary care and services to maintain the resident`s ability to communicate. Findings: A review of Resident 44's admission Record indicated the facility admitted the resident on 06/10/2022 with diagnoses that included hypertension (high blood pressure), muscle weakness, and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 44`s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 06/15/2023, 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 were…

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

Based on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 11) had on bilateral (both sides) heel protectors (device that can help prevent and treat heel pressure sores), as ordered by the physician, investigated for pressure ulcer/injury (a skin injury that occurs when an area of skin is under constant or prolonged pressure). This deficient practice placed the resident at risk of discomfort and development of new pressure ulcers. Findings: A review of Resident 11's admission Record indicated the facility originally admitted the resident on 7/31/2015 and readmitted the resident on 2/7/2021 with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 11's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/12/2023, indicated the resident had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, 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 the facility's pneumococcal vaccine (prevents infection from pneumonia [infection that infects one of both lungs]) policy by failing to ensure one of five sampled residents (Resident 36) was provided education regarding the pneumococcal vaccine. This deficient practice had the potential for Resident 36 to not be aware of the risks and benefits of the pneumococcal vaccine. Findings: A review of Resident 36's admission Record indicated the facility readmitted the resident on 4/15/2021 with diagnoses that included encounter for attention to gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), type two diabetes mellitus (a condition that affects the way the body processes blood sugar) with hyperglycemia (high blood sugar), and dysphagia (difficulty swallowing). A review of Resident 36's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 9/19/2023, indicated Resident 36 had intact 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to protect resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) by Resident 1 for three of five sampled residents (Resident 2, Resident 3, and Resident 4). On 8/1/2023, facility staff witnessed Resident 1 hit Resident 2, Resident 3, and Resident 4. This deficient practice resulted in Resident 2, Resident 3, and Resident 4 being subjected to physical abuse by Resident 1 while under the case of the facility and had the potential to cause emotion harm which could result to a feeling of low self-esteem and self-worth. Findings: 1. A review of Resident 1's admission Record indicated the facility admitted the resident on 7/6/2023 with diagnoses that included schizoaffective disorder (mental health condition with symptoms of schizophrenia [a mental condition in which one sees or hears people or things that do not exist] and a mood disorder [mental health condition that mainly affects your…

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