Clara Baldwin Stocker Home For Women

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise the Care Plan (CP, a form where one can summarize a person's health conditions, specific care need, and current treatments) related to gastrostomy tube (G-tube, a small flexible tube placed through the skin of the abdomen directly into the stomach) and nutrition for one of one sampled resident (Resident 6) after Resident 6's g-tube was removed.This failure had the potential for Resident 6 not to receive necessary care or services related to the removal of the g-tube. Findings: Based on interview and record review, the facility failed to revise Resident 6's CP related to G-tube and nutrition after Resident 6's g-tube was removed.During a review of Resident 6's admission Record (AR), the AR indicated Resident 6 was admitted to the facility on [DATE] with multiple diagnoses including dysphagia, oropharyngeal phase (a swallowing disorder affecting the mouth and throat) and heart failure (the inability of the heart to pump blood effectively.)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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to justify a diagnosis of bipolar disorder (BPD, an illness in which the patient goes back and forth between opposite extremes such as high and low levels of mood) for one of one sampled Resident (Resident 64) based on a comprehensive assessment Resident 64 as indicated in the facility's policy and procedure (P&P) titled, Antipsychotic [a class of psychiatric medications primarily used to manage psychosis symptoms] Medication Use.This failure had the potential for Resident 64 to receive unnecessary treatment and/or services and the potential to result in a physical decline to Resident 64.Findings:During a review of Resident 64's admission Record (AR), the AR indicated Resident 64 was admitted to the facility on [DATE] with multiple diagnoses including Alzheimer's disease (a condition that occurs later in life and worsens with time in which brain cells degenerate; it is accompanied by memory loss, physical decline, and confusion), dementia (a gradual…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident's low air loss (LAL - composed of multiple inflatable air tubes that alternately inflate and deflate, mimicking the movement of a patient shifting in bed or being rotated by a caregiver, never leaving the patient in one position for any extended length of time) mattress was set to the correct setting for one of one sample resident (Resident 5).This deficient practice placed Resident 5 at risk for discomfort and the potential for developing pressure ulcers.During a review of Resident 5's admission Record (AR), the AR indicated Resident 5 was originally admitted to the facility on [DATE] with diagnoses that included encounter for palliative care (a specialized medical care for people living with a serious illness, focused on relieving symptoms, pain, and stress to improve quality of life for both the patient and their families), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administer a zinc ointment (a medication that helps protect and heal the skin) per the physician's order for a pressure ulcer (PU - injury to the skin and underlying tissue caused by constant long term pressure) to the sacral area (the bottom of the back right above the tail bone) for one of three sample residents (Resident 3). This failure has the potential to effect the healing of Resident 3's pressure ulcer. Findings: During review of Resident 3's face sheet, the face sheet indicated Resident 3 was admitted to the facility on [DATE] with diagnosis including but not limited to: arthritis (pain, swelling and stiffness of the joints), right knee infection, muscle weakness, and morbid obesity. A review of Resident 3's Minimum Data Assessment (MDS-standardized assessment screening tool), dated 12/11/2025, the MDS indicated Resident 3 required partial assistance from the nursing staff with bathing, dressing, and using the toilet. 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 observation, interview, and record review, the facility failed to ensure the resident did not store medications in their room for one of three residents (Resident 3). This failure had the potential to place Resident 3 at risk for unsafe self-administration of medication, which could result in skin irritation, systemic absorption (the process by which medication is absorbed into the bloodstream) and contamination. Findings: During review of Resident 3's face sheet, the face sheet indicated Resident 3 was admitted to the facility on [DATE] with diagnosis including but not limited to: arthritis (pain, swelling and stiffness of the joints), right knee infection, muscle weakness, and morbid obesity. During a review of Resident 3's Minimum Data Assessment (MDS-standardized assessment screening tool), dated 12/11/2025, the MDS indicated Resident 3 required partial assistance from the nursing staff with bathing, dressing, and using the toilet. During a concurrent observation and interview on 1/28/2026 at 12:15…

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

F627INTENT These regulations and guidance address inappropriate discharges and:Ensure a facility does not transfer or discharge a resident in an unsafe manner, such as a locationthat does not meet the resident's needs, does not provide needed support and resources, or does notmeet the resident's preferences and, therefore, should nothave occurred. F627Based on observation, interview and record review, the facility failed to ensure Resident 1's discharge location met Resident 1's needs for family support and resources. This deficient practices led to an inappropriate discharge.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 9/19/2025, with diagnoses that included pneumonia (lung infection) and history of falling.During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/26/2025, the MDS indicated Resident 1 had intact cognition. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds or supports…

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

Based on interview and record review, the facility failed to implement its Policy and Procedure (P&P) titled, Abuse Prevention Policy for one of three sampled residents (Resident 1) when the facility did not report a staff to resident abuse allegation (a claim that abuse has occurred) to the State Agency (SA-the state health inspection team that ensures healthcare providers are following federal laws) within two hours.This failure had the potential to result in Resident 1 experiencing abuse and to affect Resident 1's psychosocial (the emotional and social requirements that individuals must have to feel safe, supported, and capable of functioning well in their environment) wellbeing.Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted the resident on 1/12/2024 with diagnoses including hypertensive heart disease (a heart problem resulting in high blood pressure) with heart failure (condition in which the heart cannot pump enough blood to all parts of the body) and rheumatoid arthritis (a disease affecting the joints…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow its policy and procedure (P&P) titled N95 Fit Testing, (N95 respirator, a device designed to protect the wearer from hazardous particles in the air such as fumes gases and viruses) by failing to ensure one of four sample staff [Certified Nurse Assistant 4 (CNA 4)] was fit tested for an N95 respirator mask upon hire. This failure had the potential to result in the spread of Coronavirus 2019 (COVID-2019, a severe respiratory illness caused by a virus and spread from person to person) and other airborne diseases to the residents, staff, and visitors. Findings: During an interview on 2/25/25 at 12:30 pm with CNA 4, CNA 4 stated, CNA 4 began working at the facility on 2/3/25 and CNA 4 has not been fit tested for the N95 mask. During a concurrent interview and record review on 2/25/25 at 12:45 pm with the Director of Staff Development (DSD), the facility's P&P titled, N95 Fit Testing, was reviewed. The P&P indicated All employees to the facility must be in accordance with the provisions of Occupational Safety and Health…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide reasonable accommodation to meet residents needs for two of two sampled residents (Residents 21 and 25) by failing to ensure that the call light was within reach for both residents. These deficient practices resulted in delayed provision of services and had the potential to negatively impact the psychosocial well-being of Residents 21 and 25. Findings: a. During a review of Resident 21's admission Record (AR), the AR indicated the facility admitted Resident 21 on 8/7/2024, with diagnoses including anxiety disorder, and failure to thrive (when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal). During a review of Resident 21's Minimum Data Set (MDS, a resident assessment tool), dated 11/13/2024, the MDS indicated Resident 21 had severe cognitive (the ability to think and process information) impairment. The MDS indicated Resident 21 required substantial/maximal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for three of three sampled residents (Residents 15, 23, and 38) by failing to: A. Ensure Resident 15 had padded side rails to prevent injury from potential seizures, per physician's orders. B. Ensure and monitor that hospice staff were signing in and out during visits for Resident 23. C. Ensure Resident 38 physician's orders to obtain a STAT (right now, immediate) chest x-ray (images of inside the body) were followed. These deficient practices resulted in the failure to the delivery of necessary care and services for Residents 12, 23 and 24. Findings A. During a review of Resident 15's admission Record (AR), the AR indicated the facility admitted Resident 15 on 6/25/2019, and re-admitted on [DATE], with diagnoses including seizures (a temporary episode of abnormal electrical activity in the brain that causes a person to experience changes in…

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

Based on observation, interview and record review, the facility failed to ensure personal beverages for employees were not stored in one of two kitchen refrigerators (Refrigerator 1). This deficient practice had the potential for cross contamination and placed the residents at risk for foodborne illness (illness caused by the ingestion of contaminated food or beverages). Findings: During a concurrent observation and interview on 11/25/2024 at 9:35 AM with the Dietary Supervisor (DS) two Starbucks beverages with plastic open tops were observed in the refrigerator next to resident food items. The DS stated the two beverages belonged to employees and they should not be stored in the refrigerator due to the potential for cross contamination. During a review of the facility's policy and procedure (P&P) titled, Employee Meals, dated 2018, the P&P indicated food brought by employees from outside the facility shall not be kept in the facility's refrigerator in the kitchen.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain its infection prevention and control program for 5 of 5 sampled residents (Residents 11, 23, 34, 241 and 242) by failing to ensure: A. The urinals were stored in shared restrooms for Residents 23, 34, 241 and 242 were properly labeled. B. Licensed Vocational Nurse (LVN) 2 disinfected (to thoroughly clean something by using a special chemical solution that kills germs like bacteria and viruses on a surface) the pill counting tray before and after use for Resident 11. C. Ensure the facility had sufficient hand hygiene supply and resources in the laundry area. D. Housekeeping Supervisor (HS) performed hand hygiene after touching the dumpster. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection to Residents 11, 23, 34, 241 and 242 and other residents and staff in the facility. Findings: A1. During a review of Resident 23's admission Record (AR), the AR 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY CROSS REFERENCE - F656 and F676 Based on interview and record review, the facility failed to develop a comprehensive communication assessment for Resident 2 who primarily spoke Arabic, as indicated in the facility's policy and procedure. This deficient practice had the potential to result in Resident 2 being unable to communicate the residents needs and wants and not receive individualized care to meet the resident's medical, nursing, and mental and psychosocial needs that would have been identified in the language assessment. Findings: During a review of the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnosis that included hemiplegia and hemiparesis (cause weakness or paralysis on one side of the body), dysphagia (difficulty swallowing), psychosis (loss of contact with society) and hearing loss. During a review of the Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 8/23/2024, the MDS indicated Resident 2 needed or wanted an interpreter to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop or implement an individualized person-centered care plan for one of one sampled resident (Resident 2) who only spoke and understood Arabic (language of the Arabs) as indicated in the facility's policy. This failure had the potential to result in unmet individual needs and not receiving the necessary care and services for Resident 2 to achieve an optimal level of function and had the potential to affect the resident's physical well-being. CROSS REFERENCE - F636 and F676 Findings: During a review of the admission Record of Resident 2, the admission record indicated Resident 2 was admitted to the facility on [DATE] with diagnosis that included hemiplegia and hemiparesis (cause weakness or paralysis on one side of the body), dysphagia (difficulty swallowing), psychosis (loss of contact with society) and hearing loss. During a review of the Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 8/23/2024, indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 2) was provided a communication tool or resources to effectively communicate his needs. Resident 2 who spoke Arabic (language of the Arabs), was not provided a communication tool. These deficient practices had the potential to result in the resident's care needs not being effectively conveyed to the staff which could lead to a decline in the resident's quality of life. Cross reference with F636 and F656 Findings: During a review of the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnosis that included hemiplegia and hemiparesis (cause weakness or paralysis on one side of the body), dysphagia (difficulty swallowing), psychosis (loss of contact with society) and hearing loss. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment and care-screening tool), the MDS dated [DATE], indicated Resident 2 needed or wanted an interpreter to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 191) who received hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) had been provided with an emergency kit at the resident's bedside. This deficient practice had the potential to delay treatment to Resident 191 when needed during an emergency. Findings: During a review of Resident 191's admission Record, (AR) , the AR indicated Resident 191 was admitted on [DATE] with diagnoses that included end stage renal disease (ESRD, irreversible kidney failure) dependence on hemodialysis and type 2 diabetes mellitus (disorder characterized by difficulty in blood sugar control and poor wound healing) During a review of Resident 191's History and Physical, (H&P) dated 11/23/2024, the H&P indicated Resident 191 did not have decision making capacity. The H&P, indicated Resident 191 could independently bathe, feed, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide, restore, or improve normal bladder function for one of two sampled residents (Resident 92) whose urinary indwelling foley catheter (a tube that removes urine from the bladder to a collection bag) was observed with the presence of sediments (cells, debris and other solid matter in urine). This deficient practice had the potential to result in catheter related complications such as urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, bladder, or urethra). Findings: During a review of Resident 92's admission Record (AR), the admission record indicated the resident was admitted to the facility on [DATE] with diagnosis that included Alzheimer's Disease (disease causing memory loss and other mental functions), psychosis (abnormal condition of the mind that involves a loss of contact with reality), and hypertension (elevated blood pressure). During a review of Resident 92's Second 90 Day Physician…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 191) who received hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) had been provided with an emergency kit at the resident's bedside. This deficient practice had the potential to delay treatment to Resident 191 when needed during an emergency. Findings: During a review of Resident 191's admission Record, (AR), the AR indicated Resident 191 was admitted on [DATE] with diagnoses that included end stage renal disease (ESRD, irreversible kidney failure) dependence on hemodialysis and type 2 diabetes mellitus (disorder characterized by difficulty in blood sugar control and poor wound healing) During a review of Resident 191's History and Physical, (H&P) dated 11/23/2024, the H&P indicated Resident 191 did not have decision making capacity. The H&P, indicated Resident 191 could independently bathe, feed, and dress…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Resident 20's fluoxetine (medication used to treat depression) had clinical justification as to why gradual dose reduction (GDR) was contraindicated and adequately define the indication for fluoxetine. This deficient practice had the potential to overmedicate Resident 20 with unnecessary medication. Findings: During a review of Resident 20's admission Record, (AR), the AR indicated Resident 20 was admitted on [DATE] and readmitted on [DATE] with diagnoses included dementia (a progressive state of decline of mental abilities) with behavioral disturbance and mild, recurrent major depressive disorder (persistent feeling of sadness and loss of interest). During a review of Resident 20's Care Plan (CP, document that summarizes a resident's health conditions, specific care needs and current treatments) titled Resident is resistive to care and refusing care related to Dementia, dated 12/26/2023 the CP indicated interventions to give clear explanations…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that all drugs/medications used in the facility were labeled properly and/or discarded in accordance with professional standards of practice for one of two sampled medication carts (Med Cart 2). This deficient practice had the potential for residents to be administered (the act of giving a treatment, such as a drug, to a patient) with ineffective medications and potentially compromise the health, safety, and well-being of the residents. Findings: During a concurrent observation and interview on 11/26/24 at 11:02 a.m. with Licensed Vocational Nurse (LVN) 2 Med Cart 2 had the following stored: 1. Multiple opened house supply (over the counter) medications marked with an opened date (date medication was opened and used) stored in the first drawer except for an opened bottle of a Geri Care (brand name) Stool Softener 100 mg (milligrams, a unit of measurement) 200 Softgels with a manufacturer's expiration (exp) date of 2026/02 that was…

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

Based on observation, interview, and record review, the facility failed to ensure unauthorized person/s did not enter the facility undetected when: 1. The facility back door remained unlocked to the outside of the facility after dark. 2. Licensed Vocational Nurses (LVNs) 1, 2, 3, and 4 did not know how to lock the facility doors. These failures had the potential to compromise the safety of 37 of 37 residents in the facility and placed the residents at risk for accident hazards and harm. Findings: During an observation on 9/30/24 at 4:25 am, the facility's gate to the staff parking area located in the back of the facility was wide open and allowed entry to the staff parking area and access to the facility back door. There was no one in the staff parking area and the area was not well-lighted. The small gate located just before the facility back door was wide open and allowed easy access to the facility back door which was unlocked. The facility back door easily pulled open and allowed entry to the facility. During an interview on 9/30/24 at 4:31 am with LVN 1, LVN 1 stated 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 implement its policy and procedure (P&P) titled, Isolation (separation of residents with an infection from residents without an infection) - Categories of Transmission-Based Precautions, when two of two residents (Residents 5 and 6) diagnosed with clostridium difficile (C. diff- a highly contagious bacteria that causes severe diarrhea) infection did not have their own package of incontinent wipes (disposable washcloths or wipes used to cleanse the skin and manage urine and/or stool) inside the isolation room during the night shift (11 pm to 7 am) on 9/30/24. This failure had the potential to spread infection to residents and staff. Findings: 1. During a review of Resident 5's admission Record (AR), the AR indicated Resident 5 was admitted to the facility on [DATE], with diagnoses which included C. diff infection. During a review of Resident 5's Clinical Physician Orders (PO), dated 9/27/24, the PO indicated an order to place Resident 5 on contact…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 readmit one of two sampled residents (Resident 1) to the first available bed at the Skilled Nursing Facility (SNF) as indicated in the facility policy. This deficient practice resulted in the violation of Resident 1's rights to resume residency at the facility. Findings: During a review of the admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with the diagnoses that included Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), hyperlipidemia (elevated level of lipids-like cholesterol and triglycerides in blood). During a review of Resident 1's History and Present Illness (H&P- the most formal and complete assessment of the patient and the problem), dated 3/25/2023, the H&P indicated Resident 1 does not have decision making capacities. During a review of the Minimum Data Set (MDS- a comprehensive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 oxygen tubing was labeled for one of one sampled resident (Resident 2) who was receiving respiratory therapy by a nasal cannula (N/C, a tube used to deliver oxygen to help with breathing). This deficient practice had the potential to result in Resident 2's oxygen tubing not being changed and could have resulted in infection to Resident 2. Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included chronic diastolic (congestive) heart failure (heart doesn't pump blood as well as it should), chronic respiratory failure (condition making it difficult to breath on your own), and dependence on supplemental oxygen (not enough oxygen in your bloodstream to supply organs and tissues). During a review of Resident 2's History & Physical (H&P), dated 2/14/24, the H&P indicated Resident 2 had decision making capacities. During a review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure proper pain management interventions were in place for one of one sampled resident (Resident 3). Resident 3 had penile fungal dermatitis (inflammation of the skin) and the facility put on an adult brief (diaper) on Resident 3 despite Resident 3 having diagnoses of unuria (lack of urine) and oliguria (low urine output) and being continent (ability to control bowel movement) of bowel. This failure resulted in Resident 3 to experience pain and had the potential to result in psychosocial and physical declines to Resident 3. Findings: During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included Type 2 diabetes mellitus (body has trouble controlling blood sugar and using it for energy), end stage renal disease (kidneys cease functioning on a permanent basis), and anuria and oliguria. During a review of the GACH 1 (general acute care hospital)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 conduct an N95 mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) fit testing (the use of a protocol to evaluate the fit of a respirator on an individual) for two of four sampled staff (Licensed Vocational Nurse 1 [LVN 1] and Certified Nurse Assistant 1 [CNA 1]) upon hire during a Coronavirus (COVID-19, a mild to severe respiratory illness that spread from person to person) outbreak (a sudden increase in occurrences of a disease when cases are in excess of normal expectancy for the location or season) in accordance with the Department of Public Health's (DPH) guidelines and the facility's policy and procedure titled, Fit testing Policy for N95. This deficient practice had the potential to result in the transmission of COVID-19 to the residents, staff, and visitors. Findings: During an interview on 12/6/2023 at 2:50 pm with LVN 1, LVN 1 stated she was not fit tested with the N95 mask when she got hired on 9/9/2023. LVN 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ten of ten sampled residents (Residents 20, 182, 183, 184, 185, 6, 12,15, 22, and 82) were provided information regarding the right to formulate an advance directive (AD, legal documents that provide instructions for medical care and only go into effect if you cannot communicate your own wishes). This failure had the potential to result in Residents 20, 182, 183, 184, 185, 6, 12,15, 22, and 82 to receive unwanted care and treatment or unnecessary life-sustaining treatment. Findings: a.During a review of Resident 20's admission Record (AR) indicated, Resident 20 was originally admitted on [DATE] and readmitted on [DATE] with multiple diagnoses including type 2 diabetes mellitus (an adult-onset disease that occurs when your blood glucose, also called blood sugar, is too high), essential (primary) hypertension (high blood pressure) and heart failure, unspecified. During a review of Resident 20's History of Present Illness (H&P) dated 10/6/23,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive care plan (CP) for three of three sampled residents (Residents 12, 15, and 10). a-b. For Residents 12 and 15, the facility did not include interventions (left blank) in the care plans (CP), titled, Imbalance Nutrition. c. For Resident 10, who was prescribed medication for her depression, the facility did not create a care plan for depression. This failure had the potential to result in no individualized care and a physical decline to Resident 12 and Resident 15. Findings: a.During a review of Resident 12's admission Record (AR), the AR indicated Resident 12 was readmitted to the facility on [DATE] with diagnoses that included urinary tract infection (an infection in any part of the urinary system) and altered mental status (change in behavior). During a review of Resident 12's Weights/Vitals in the Electronic Health Record (EHR), dated 5/2/23, 10/3/23, and 11/1/23, the EHR indicated Resident 12's weights were 160 lbs., on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility's interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of the resident) failed to reassess fall prevention interventions for one of one sampled resident (Resident 8), according to the facility's policies and procedures (P&P). This failure had the potential to result in injury and a physical decline to Resident 8. Findings: During a review of Resident 8's admission Record (AR), the AR indicated Resident 8 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), essential hypertension (high blood pressure), and unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning). During a review of Resident 8'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent (%, unit of measurement). During a medication administration observation, two of 32 medications were not administered in accordance with pharmacy instructions resulting in a medication error rate of 6.25%. 1.For Resident 4, Licensed Vocational Nurse 1 (LVN 1) crushed potassium chloride extended release (K+ER, medication used to treat low levels of potassium [mineral that the body needs] in the blood) and almost administered the medication to Resident 4. The pharmacy instructions indicated to not crush the medication prior to administration. 2.For Resident 4, LVN 1 removed the contents out of a medication capsule, Amitiza (medication to treat chronic [long standing] constipation) and almost administered the medication to Resident 4. The pharmacy instructions indicated to swallow the medication whole. These failures resulted in an increased risk for adverse effects (unwanted,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 food safety requirements were followed when, a. two frozen pies located in the freezer and 23 refrigerated blocks of margarine located in the refrigerator were undated in one of one food storage room (Food Storage room [ROOM NUMBER]) according to the facility's policy and procedure (P&P). b. Pureed eggs that were held on one of one steam table (Steam Table 1) had a temperature of 120 degrees Fahrenheit (F, a unit of measurement) and the pureed hash browns that were held on Steam Table 1 had a temperature of 122 degrees F. The facility failed to ensure the temperatures were greater than 140 F. These failures had the potential to result in food-borne illnesses (illness cause by food contaminated with infectious organisms) and a physical decline to all residents residing at the facility. Findings: a.During a concurrent observation and interview on 11/13/23 at 8:35 a.m. with the Dietary Supervisor (DS) in Food Storage room [ROOM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infection control practices were followed in one of one laundry room (Laundry room [ROOM NUMBER]) by not ensuring proper temperatures were used when processing resident soiled laundry as indicated in the facility's policy and procedure (P&P), titled Departmental (Environmental Services) - Laundry and Linen. This failure had the potential to result in the spread of infections throughout the facility and negatively impact the health of all residents residing at the facility. Findings: During an observation and concurrent interview of Laundry room [ROOM NUMBER] with Laundry Supervisor (LS), on 11/15/23 at 2:01 pm., the facility's washing machine had non-functioning temperature gauge. The LS stated the LS did not know if the facility's washing machine was a low temperature or a high temperature washer. The LS stated the water temperature for a high temperature wash should be 160 degrees Fahrenheit (F, unit of temperature) but the gauge…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the antibiotic stewardship program (promotes the appropriate use of antibiotics) for one of four sampled residents (Resident 183). Resident 183 was administered Vancomycin (type of antibiotic) for eight consecutive days and the antibiotic administration did not meet the McGreer's criteria (infection surveillance checklist to determine appropriate antibiotic use). This failure resulted in unnecessary administration of Vancomycin to Resident 183 and had the potential to result in Resident 183 to develop resistance to the antibiotic. Findings: During a review of Resident 183's admission Record (AR), the AR indicated Resident 183 was re-admitted to the facility on [DATE] with diagnoses that included pancytopenia (low levels of all three blood cell types: red blood cells, white blood cells and platelets) and generalized weakness. During a review of Resident 183's Minimum Data Set (MDS, a resident assessment and care-screening tool), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 183) had a baseline care plan (CP provides direction on the type of nursing care an individual needs that include goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to meet an objective] and an evaluation plan) developed and implemented within forty-eight hours of admission. This failure could result in the impediment of continuity of care and lack of communication among staff which could lead to decrease resident safety and safeguard against adverse events that could most likely occur right after admission for Resident 183. Findings: During a review of Resident 183's admission Record indicated, Resident 183 was originally admitted on [DATE] and readmitted on [DATE] with multiple diagnoses including Ogilvie syndrome (a sudden and unexplained paralysis of your colon), malignant neoplasm of prostate (a disease in which cancer cells form in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 184) was provided an environment that promoted Resident 184's well-being by failing to provide Resident 184 with a properly working television (TV) remote control. This failure resulted in a tension between Resident 184 and her roommate and preventing Resident 184 from watching TV that helped distract her from her pain. Findings: During a review of Resident 184's admission Record indicated, Resident 184 was originally admitted on [DATE] and readmitted on [DATE] with multiple diagnoses including neuralgia (pain caused by damaged or irritated nerves) and neuritis (inflammation of a peripheral nerve or nerves, usually causing pain and loss of function), spinal stenosis (narrowing of the spine causing pain) and low back pain. During a review of Resident 184's History of Present Illness dated 11/4/23, indicated, Resident 184 had decision making capacities. During a review of Resident 184's Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow a physician's order that indicated Restorative Nursing Aide (RNA, nursing aide program that helps residents to maintain their function and joint mobility) services for one of two sampled residents (Resident 15). This failure had the potential to result in contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and tightness of the joints) and a physical decline to Resident 15. Cross Reference F688 Findings: During a review of Resident 15's admission Record (AR), the AR indicated Resident 15 was readmitted to the facility on [DATE] with diagnoses that included Type 2 diabetes mellitus (chronic condition affecting the way the body processes blood sugar), acute osteomyelitis (infection of the bones), and immunodeficiency (failure or absence of elements of the immune system). During a review of Resident 15's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 10/20/23, 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 observation, interview, and record review, the facility failed to provide wound care services and treatment in accordance with the facility's policy and procedures for one of two sampled residents with pressure ulcers (Resident 183) by failing to ensure Resident 183's low air loss mattress (LAL, special type of mattress used for both the prevention and treatment of pressure ulcer, a localized damage to the skin and underlying soft tissue usually over a bony prominence from prolonged pressure on the skin) was set correctly. This failure could impede in preventing the development of new pressure ulcers or result in reoccurrence of the pressure ulcers for Resident 183. Findings: During a review of Resident 183's admission Record indicated, Resident 183 was originally admitted on [DATE] and readmitted on [DATE] with multiple diagnoses including Ogilvie syndrome (a sudden and unexplained paralysis of your colon), malignant neoplasm of prostate (a disease in which cancer cells form in the tissues of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide necessary care & services for one of two sampled residents (Resident 15). Resident 15 did not receive Restorative Nursing Aide (RNA, nursing aide program that helps residents to maintain their function and joint mobility) services due to Resident 15 being on Coronavirus-19 (COVID-19, highly contagious virus that can affect lungs and airways and spreads form person to person) isolation (staying away/kept away from others). This failure had the potential to result contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and tightness of the joints) and a physical decline to Resident 15. Cross Reference F684 Findings: During a review of Resident 15's admission Record (AR), the AR indicated Resident 15 was readmitted to the facility on [DATE] with diagnoses that included Type 2 diabetes mellitus (chronic condition affecting the way the body processes blood sugar), acute osteomyelitis (infection of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to secure an indwelling catheter (urinary catheter, a tubing inserted through the urethra and into the bladder to drain urine) tube to the leg for one of three sampled resident (Resident 232) in accordance with the facilities policy and procedure (P&P). This failure had the potential to result in a urinary tract infection (UTI, an infection of any part of the urinary system, kidneys, bladder, or urethra) to Resident 232. Findings: During a review of Resident 232's admission Record (AR), the AR indicated Resident 232 was admitted to the facility on [DATE] and readmitted on [DATE] with acute respiratory failure (when the lungs can't get enough oxygen into the blood), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and heart failure (condition in which the heart cannot pump enough blood to all parts of the body). During a review of Resident 232'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Registered Dietitian (RD) evaluated and monitored weight loss for two of two sampled residents (Resident 12 and Resident 15). In addition, the facility failed to ensure Interdisciplinary Team (IDT, a team of health care professions who work together to establish plans of care for residents) meetings were held to address weight loss for one of two sampled residents (Resident 12). These failures had the potential to result in further weight loss and physical declines to Residents 12 and Resident 15. Findings: a. During a review of Resident 12's admission Record (AR), the AR indicated Resident 12 was readmitted to the facility on [DATE] with diagnoses that included urinary tract infection (an infection in any part of the urinary system) and altered mental status (change in behavior). During a review of Resident 12's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 10/3/23, indicated Resident 12 was severely…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Residents 232 and 183) were provided with appropriate care and services for oxygen treatment when: a. Resident 232 received 5 L (L, unit of measurement) of oxygen instead of 2-3 L of oxygen by a nasal cannula (a tube used to deliver oxygen to help with breathing) and as indicated by the physician's order. b. Resident 183's oxygen humidifier (a medical device used to humidify supplemental oxygen to prevent the resident's airway from becoming dry) and nasal cannula tubing were not labeled with the date they were changed. These failures had the potential to result in Resident 232 to receive too much oxygen and Resident 183 to develope a respiratory infection. Findings: a.During a review of Resident 232's admission Record (AR), the AR indicated Resident232 was admitted to the facility on [DATE], and readmitted on [DATE] with acute respiratory failure (when the lungs can't get enough oxygen into the 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.

Based on observation, interview, and record review, the facility failed to post the number of hours worked by licensed nursing and Certified Nursing Assistant (CNA) staff directly responsible for resident care within two hours of the start of each shift, in one of two Nursing Stations (Nursing Station 1), as indicated in the facility's policy and procedure (P&P), titled, Posting Direct Care Daily Staffing Number. This failure resulted in inaccurate nursing hours posted by the facility and had the potential to result in residents and family members obtaining misleading information posted. Findings: During an observation and concurrent interview with the Director of Staff Development (DSD) on 11/14/23 at 2:27 pm., the facility's Daily Nursing Staff Posting, dated 11/14/23, was posted on the wall of Nursing Station 1 and indicated projected (estimated and based on the nursing schedule) nursing hours. The DSD stated projected nursing hours were posted every morning. The DSD stated, only projected hours are [were] posted. During an interview and concurrent record review on 11/14/23 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents remined free from significant medication errors for one of two sampled residents (Resident 4). This failure had the potential to result in an increased risk for adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) to Resident 4 and had the potential to result in a negative impact to Resident 4's health and physical well-being. Cross Reference F759 Findings: During a review of an admission Record (AR), the AR indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included Dementia (a decline in mental ability severe enough to interfere with daily life), hemiplegia (muscle weakness or partial paralysis to one side of the body), and diabetes (elevated blood sugar). A review of a Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 10/31/23, the MDS indicated Resident 4 had severe impaired cognition (ability to understand and process…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents with a nourishing, palatable, well-balanced diet when, one of one Kitchen Staff (the Kitchen Staff) served residents, who were on pureed diets (foods with a soft, pudding-like consistency), 3 ¼ ounce (oz., unit of measurement) of purred eggs and pureed hashbrowns versus a serving of 4 oz. This failure had the potential to result in unmet nutritional needs for residents that required pureed diets. Findings: During a concurrent observation and interview on 11/15/23 at 7:15 a.m. with the DS, the Kitchen Staff served purred eggs and hashbrowns to resident plates using the green handled scoop. The DS stated the green handled scoop provided 3 ¼ oz of food per serving. During an interview and record review on 11/15/23 at 12:57 p.m. with the DS, the facility's Cooks Spreadsheets, undated, was reviewed. The Cooks Spreadsheets indicated the regular serving size for pureed eggs and hashbrowns was 4 oz. The DS stated the kitchen staff used the wrong size scoop when serving the pureed eggs 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 interviews and record review, the facility failed to ensure a one-to-one sitter (1:1 sitter, a staff member designated to provide constant observation) was assigned to one of five sampled residents (Resident 3) as ordered by the physician due to Resident 3 being at high risk for falls on dates 10/14/2023 to 10/15/2023 (2 days). This failure had the potential to increase Resident 3's risks for injury and/or death. Cross Reference with F725 Findings: During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on 10/8/2023. During a review of Resident 3's Situation-Background-Assessment-Recommendations (SBAR, communication tool used by healthcare workers) Communication Form and Progress Note, dated 10/8/2023, the SBAR indicated Resident 3 had a witnessed fall while walking from the bathroom to his bed with a Certified Nursing Assistant (CNA, unnamed). During a review of Resident 3's physician notes, dated 10/9/2023, the physician notes indicated Resident 3 had worsening Alzheimer's dementia (decline in memory, thinking, behavior,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews and record review, the facility failed to ensure sufficient qualified nursing staff were assigned and providing nursing care to two of five sampled residents (Residents 3 & 4) in accordance with the facility's policies and procedures and the Facility Assessment by failing to: A. Ensure call lights were answered and addressed in a timely manner with Resident 4's needs. B. Ensure a one-to-one sitter (1:1 sitter, a staff member designated to provide constant observation) was assigned to Resident 3 as ordered by the physician on dates 10/14/2023 to 10/15/2023. These failures had the potential to result in a decline in the Resident 3 & 4's physical and psychosocial well-being due to poor quality of care and staff burnout. Cross Reference with F689 and F558 Findings: A. During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted resident on 3/24/2019 and was readmitted on [DATE] with multiple diagnoses including heart failure, severe chronic kidney disease…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews and record review, the facility failed to ensure the needs of one of five sampled residents (Resident 4) was accommodated by answering Resident 4's call light and addressing the reason for her call. This failure had the potential to negatively affect Resident 4's physical and psychosocial well-being due to the delay of provision of services. Cross Reference with F725 Findings: During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted resident on 3/24/2019 and was readmitted on [DATE] with multiple diagnoses including heart failure, severe chronic kidney disease (condition in which the kidneys are damaged and cannot filter blood as well as they should), and fluid overload (too much fluid in your body). During a review of Resident 4's Minimum Data Set (MDS, a standardized resident assessment and care-planning tool), dated 10/16/2023 the MDS indicated Resident 4 did not have an impairment in cognition (ability to understand and process information). 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 observation, interview and record review, the facility failed to treat one of four sampled residents (Resident 1) lower denture with respect. This deficient practice resulted in the loss of Resident 1's lower denture and in addition, becoming a chocking hazard for Resident 1 who did not have her lower denture to chew her food and affect Resident 1's nutritional (food necessary for health and growth) status. Findings: During a review of Resident 1 ' s admission Records indicated Resident 1 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that interferes with daily life) and colitis (swelling of the colon). During a review of Resident 1 ' s Physician Telephone Orders, dated 6/9/2023, indicated Resident 1 was admitted under respite care (a short-term relief for the primary caregiver) for five days. During a review of Resident 1 ' s Physician Telephone Orders dated 6/9/2023,…

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 manage the pain (pain on the abdomen [belly]) for one of three sampled residents (Resident 1) who had intellectual disabilities (ID, a condition that limits intelligence and disrupts abilities necessary for living independently) by failing to: 1. Ensure licensed nurses (in general) assessed, implemented pain management strategies, documented, and monitored Resident 1 ' s abdominal pain as indicated in the facility's undated policy and procedure (P&P) titled Pain Assessment and Management. This deficient practice resulted for Resident 1 to experience abdominal pain without interventions. (Cross reference F684) Findings: During a review of Resident 1 ' s admission Record, indicated the facility admitted Resident 1 on 5/20/2023 with diagnoses that included intestinal obstruction (blockage of the intestine where food and stools [feces] may not be able to move freely), constipation (occurs when the bowel movements become less frequent and stools become difficult to pass), and bladder (an organ inside the body that stores urine)…

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