West Haven Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of one sampled resident's (Resident 50), Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment was accurately coded regarding the use of insulin (a hormone that removes excess sugar from the blood). This failure had the potential to result in delays of necessary care and services and inaccurate plan of care and interventions for Resident 50. Findings: During a review of Resident 50's admission Record (AR), the AR indicated the facility re-admitted Resident 50 on 8/18/2024 with diagnoses including cellulitis (a skin infection that causes swelling and redness) of the abdominal wall, severe sepsis (a life-threatening blood infection), and Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control) with other specified complication. During a review of Resident 50's History & Physical (H&P) dated 8/6/2025, the H&P indicated the resident had the capacity to understand and make decisions.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care and services to prevent a fall (unintentional coming to the ground) for one of four sampled residents (Resident 2) by failing to ensure Certified Nursing Assistant 5 (CNA 5) provided two-person physical assistance (help from two persons) when turning Resident 2 in bed while changing Resident 2's adult brief. This deficient practice resulted in Resident 2's fall on 11/24/2025 and Resident 2 sustained a right femur fracture (broken thigh bone).Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 2/13/2024 and readmitted on [DATE] with diagnoses including unspecified fracture of the lower end of the right femur, morbid (severe) obesity (excessive body fat that poses a risk of severe health complications), and muscle weakness (a reduced ability to exert force). During a review of Resident 2's Care Plan (CP) for at risk for falls related to bowel/bladder incontinence (loss 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 staff failed to elevate the resident's head of the bed (HOB) while receiving formula through the gastrostomy tube (GT - a tube inserted through the abdomen that delivers nutrition directly to the stomach) in accordance with the resident's care plan and physician's order for one of two sampled residents (Resident 11). This deficient practice had the potential to result in aspiration (inhalation of foreign materials) and pneumonia (a lung infection) for Resident 11. Findings: During a review of Resident 11's admission Record, the AR indicated the facility initially admitted Resident 11 on 10/3/2023 and readmitted on [DATE] with diagnoses including gastroesophageal reflux disease (GERD- the stomach acid or contents leak back into the esophagus) without esophagitis (irritation or inflammation of the esophagus [tube that carries food from throat to the stomach]) and dementia (long term and often gradual decrease in the ability to think and remember…

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

Based on observation, interview, and record review, the facility failed to implement its Policy and Procedure (P&P) titled, Foods Brought in by Visitors, by failing to label outside food for Resident 88 and ensure outside food adhered to Resident 88's prescribed diet. This deficient practice had the potential to result in food-borne illnesses (food poisoning) for Resident 88 that could lead to serious medical complications and hospitalization. Findings: During a review of Resident 88's admission Record (AR), the AR indicated the facility admitted Resident 88 on 3/3/2026 with diagnoses including pneumonia (an infection in the lungs) and diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 88's Care Plan (CP) dated 3/3/2026, the CP indicated Resident 88 was at risk for aspiration. The CP intervention indicated for the staff to educate the resident and family about the importance of adhering to the prescribed diet and the risks of eating food outside of the prescribed diet. During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement care plans (CP- a personalized document that outlines a resident's medical and social care needs and the actions required to address them) for four of seven sampled residents (Residents 1, 2, 6, and 7) according to the facility's policy and procedure (P&P) titled, Care Planning, by failing to: 1. Ensure Residents 1 and 6 had CPs developed for the administration of intravenous (IV- soft, flexible tube placed inside a vein to administer fluids and medication directly to the bloodstream) antibiotics (abx- medication that inhibits the growth of or destroys bacteria in the body). 2. Ensure Resident 7 had a CP developed and implemented for the use of peripherally inserted central venous catheter (PICC- a thin, flexible tube inserted into a vein in the upper arm and threaded into a larger vein near the heart). 3. Ensure Resident 2's CP for IV indicated the location of the IV. These failures resulted in Residents 1, 2, 6, and 7 not having…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clear, complete and signed intravenous (IV- soft, flexible tube placed inside a vein to administer fluids and medication directly to the bloodstream) medication orders, and IV flush (to insert normal saline [NS- a sterile solution of water and sodium chloride (table salt)]) orders according to the facility's policies and procedures (P&P) titled, Medication Orders, Peripheral Catheter (IV) Flushing, and, Continuous Infusion of Medications and Solutions, for seven of seven sampled residents (Residents 1, 2, 3, 4, 5, 6, and 7) by failing to: 1. Ensure Resident 1's Physician Order for Infusion (IV) Therapy (POFIT) dated 6/30/2025, and IV medication administration record (MAR- a report that serves as a legal record of the medications administered to a resident) dated 6/2025 to 7/2025 indicated peripheral (away from the heart) IV flush orders and that licensed nurses (LN) Resident 1's IV was being flushed with 10 milliliters (mL- unit of measurement)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide concise and clear documentation for six of seven sampled residents (Residents 2, 3, 4, 5, 6, and 7) according to the facility's policy and procedure (P&P) titled, Documentation- Nursing, by failing to ensure: 1. Ensure Resident 2's intravenous (IV- soft, flexible tube placed inside a vein to administer fluids and medication directly to the bloodstream flush (to insert normal saline [NS- a sterile solution of water and sodium chloride (table salt)]) in the IV Therapy medication administration record (MAR- a report that serves as a legal record of the medications administered to a resident) (IV MAR) were legible (able to clearly read). 2. Ensure Resident 3's medication name and diagnosis in the IVMAR were legible. Ensure Resident 3's medication dose and diagnosis were on the Physician Order for Infusion (IV) Therapy (POFIT) were legible. 3. Ensure Resident 4's allergies, medication dose, and flush times were legible in the IV MAR. 4. Ensure…

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

Based on interview and record review, the facility failed to ensure licensed vocational nurses (LVNs) and certified nurse assistants (CNAs) had the competency (the capability to apply or use the knowledge, skills, and abilities required to successfully perform tasks in the work setting) to understand different infection types in the healthcare setting by failing to: 1. Ensure the Infection Prevention Nurse (IPN), Director of Staffing Development (DSD), LVN 3, LVN 4, CNA 4, CNA 5 and Restorative Nurse Assistant/CNA (RNA) 1 were aware that Group A Streptococcus (GAS- bacteria that enters the body and causes an illness and affects the skin and throat) were bacteria (organism that enters the body and cause illness) that could cause infections through respiratory droplets (respiratory particles created when coughing, sneezing, or talking) or direct contact. 2. Ensure CNA 4 and RNA 1 were aware the facility had an active outbreak (OB- sudden rise in the incidence of a disease) of GAS. These failures had the potential to result in widespread infection in the facility. Findings: 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 standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and/or diseases in the healthcare setting) were followed in accordance with the facility ' s policies and procedures (P&P) titled, Hand Hygiene (procedures that included the use of alcohol-based hand rubs [containing 60%–95% alcohol] and hand washing with soap and water), and Enhanced Barrier Precautions (EBP- set of infection control measures that use personal protective equipment [PPE- equipment worn to minimize exposure to a variety of hazards] to reduce the spread of multidrug-resistant organisms [MDRO- organism that is resistant to most antibiotics] by wearing a gown and gloves), and Resident Isolation- Categories of Transmission-Based Precautions (TBP- set of infection control measures that use PPE to reduce the spread of different organisms) for four of four sampled residents by failing to: 1. Ensure the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a clean, safe, sanitary, and homelike environment for two of two resident shower rooms (Shower room [ROOM NUMBER] and Shower room [ROOM NUMBER]). These deficient practices had the potential to expose residents to mold and injury from broken tile and cracked grout when receiving care in Shower rooms [ROOM NUMBERS]. Findings: During an observation on 1/22/25 at 2:30 p.m. in Resident Shower room [ROOM NUMBER], along the corners where the tile wall meets the tile floor, there were multiple areas of a black color substance on grout lines. The other areas of the shower room had cracked/missing/unsealed grout lines and cracked/broken and missing tiles. During a concurrent observation and interview on 1/23/25 at 10:30 a.m. with Housekeeping Staff 1 (HK 1), in Resident Shower room [ROOM NUMBER], HK 1 stated Housekeeping cleans the resident showers. HK 1 stated the shower is not clean and HK 1 reports any broken or repair work for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete and transmit the quarterly Minimum Data Set (MDS - a resident assessment tool) in a timely manner for three of three sampled residents (Resident 13, Resident 44 and Resident 50) as indicated in the Centers for Medicare & Medicaid Services (CMS - a federal agency that manages health care programs in the United States) Resident Assessment Instrument (RAI, a tool used by nursing homes to assess the needs, strengths, and preferences of residents) manual. a. For Resident 13, the quarterly MDS was not transmitted within 14 days after the quarterly assessment. b. For Resident 44, the MDS was not transmitted within 14 days after the quarterly assessment. c. For Resident 50, the MDS was not transmitted within 14 days after being admitted to the facility. These deficient practices resulted to a late completion and transmission of MDS assessment to CMS Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 41) received treatment and care in accordance with the physician's order for the administration of Chlorpromazine/Risperidone (antipsychotic medications) by failing to ensure Resident 41 was monitored for orthostatic hypotension with two blood pressure readings 5 to 10 mins apart and observed for adverse side effects. This deficient practice had the potential to cause Resident 41's blood pressure to decrease ( hypotension, blood pressure that is too low) with dizziness and fainting that could lead to falls and injuries. Findings: During a review of Resident 41's admission Record (AR), the AR indicated, Resident 41 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), epilepsy (a brain disorder that causes repeated seizures due to…

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

Based on observation, interview, and record review, the facility failed to store food in accordance with the facility's Policy and Procedure (P&P) for two of two boxes of potato (hash browns). This failure had the potential to cause food-borne illnesses. Findings: During a concurrent observation and interview on 1/21/2025 at 9:42 am with the Dietary Supervisor (DS) inside the dry food storage area of the facility's kitchen, there were two boxes of unopened, dehydrated, and seasoned potato (hash browns) with received date of 11/19/2024 and used by date of 1/19/2025. The DS stated food products needed to be use before the used by date to make sure food served to the residents were safe and of good quality. During an interview on 1/23/2025 at 4:17 pm with the Director of Nursing (DON), the DON stated, food items that had a used by date should be use within the specified used by date to make sure that food served were at its highest quality and to prevent food-borne illnesses. During a review of the undated list of dry goods storage guidelines, the list indicated unopened potato 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 interview and record review, the facility failed to ensure its binding arbitration agreements included a selection of a neutral arbitrator and a venue convenient to both the facility and resident/resident responsible party for two of four sampled residents (Residents 15 and 65). These failures placed Residents 15 and 65 at risk for unjust arbitration and delayed arbitration hearing in an event of an arbitration dispute. Findings: a. During a review of Resident 15's admission Record (AR), the AR indicated, Resident 15 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular accident (CVA, stroke, loss of blood flow to a part of the brain), dementia (a progressive state of decline in mental illness) and anxiety (intense, excessive, and persistent worry and fear about everyday situations). During a review of Resident 15's Minimum Data Set (MDS, a resident assessment tool), dated 11/21/2024, the MDS indicated, Resident 15 had severely impaired cognition (ability to understand).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assist the resident meal at eye level for one of one sample resident (Resident 38). This failure had the potential to result in the Resident 38's dignity was not maintained. Findings: During a review of Resident 38's admission Record (AR), the AR indicated the facility admitted Resident 38 on 6/29/2023, with diagnoses that included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 38's Minimum Data Set (MDS, a resident assessment and screening tool), dated 12/25/2024, indicated Resident 38 had clear speech, understood others, and made self-understood. Resident 38 required partial/moderate assistance (helper dose less than half the effort) for upper body dressing and chair/bed-to-chair transfer. During an observation on 1/21/2025 at 10:12 am, in Resident 38's room, Resident 38 was sitting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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) on Advance Directives (AD, a legal document indicating resident preference on end-of-life treatment decisions) for two of eight sampled residents (Residents 185 and 19) by failing to ensure Advance Directive Acknowledge (ADA) Forms were completed on admission for Residents 19 and 185. These failures had the potential risk for facility staff to provide medical treatment and services against the will of Residents 19 and 185. Findings: a. During a review of Resident 185's admission Record (AR), the AR indicated the facility admitted Resident 185 on 1/15/2025, with diagnoses that included hypertension (high blood pressure) and Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 185's Minimum Data Set (MDS, a resident assessment and screening tool), dated 1/20/2025, the MDS indicated Resident 185 had clear speech, understood others,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure the bed grab bar foam pads for seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) precaution was in good condition for one of two sampled residents (Resident 9). This failure had the potential to put Resident 9 at risk for injury. Findings: During a review of Resident 9's admission Record (AR), the AR indicated the facility admitted Resident 9 on 1/7/2020, with diagnoses that included epilepsy (a chronic neurological condition characterized by recurrent, unprovoked seizures-involuntary movement) and Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 9's Minimum Data Set (MDS, a resident assessment and screening tool)), dated 12/25/2024, indicated Resident 9 had clear speech, understood others, and made self-understood. Resident 9 required partial/moderate assistance (helper dose less than half the effort) for upper body…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 set-up assistance (helper sets up, resident completes the activity) during lunch time for one of one sampled resident (Resident 15). This failure had the potential for Resident 15 to lose weight due to decrease meals/fluid intake, dehydration and electrolyte imbalance. Findings: During a review of Resident 15's admission Record (AR), the AR indicated, Resident 15 was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), hyperlipidemia (elevated level of lipids like cholesterol and triglycerides), and chronic kidney disease (presence of kidney damage or decreased kidney function). During a review of Resident 15's Minimum Data Set (MDS, a resident assessment tool), dated 11/21/2024, the MDS indicated, Resident 15 had severely impaired cognition (ability to understand). The MDS indicated Resident 15 required set up or clean-up assistance with eating, substantial/maximal assistance (helper…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 necessary care and services for gastrostomy tube (GT, a tube inserted through the wall of the abdomen directly into the stomach) site as ordered by the physician and as indicated in the plan of care for one of one sampled resident (Resident 234). This failure had the potential for complications related to tube feeding for Resident 234. Findings: During a review of Resident 234's admission Record (AR), the AR indicated, Resident 234 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common foe people with swallowing problems). During a review of Resident 234's Order Summary Report (OSR), dated 12/25/2024, the OSR indicated, Resident 234 had an order for GT site treatment to cleanse with normal saline (NS, a saltwater solution), pat…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement its Policy and Procedure (P&P) on the use of grab bars (bars installed on the side of the bed)/bed rails/side rails (adjustable metal or rigid plastic bars attached to the bed) for one of one sampled resident (Resident 237) by failing to: a. Ensure appropriate alternative interventions were attempted and did not meet the needs of Resident 237 before the installation of grab bars. b. Ensure to obtain an informed consent to review the risks and benefits before the installation of grab bars. c. Ensure to develop an individualized person-centered care plan on the use of grab bars to meet the resident's specific needs. These failures placed Resident 237 at risk for entrapment (an event in which resident was caught, trapped, or entangled in the tight spaces around the bed), and injury from the use of grab bars. Findings: During a review of Resident 237's admission Records (AR), the AR indicated, Resident 237 was admitted to the…

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

Based on interview and record review, the facility failed to attempt a gradual dose reduction for one of 5 sampled residents (Resident 11). This deficient practice put Resident 11 at risk of receiving unnecessary medication. Findings: During a review of Resident 11's admission Record (AR), the AR indicated the facility admitted Resident 11 on 5/5/2009 and readmitted Resident 11 on 12/13/2024 with diagnoses that included cellulitis (bacterial skin infection), sepsis (a life-threatening complication of an infection), and major depressive disorder (persistent feelings of sadness, loss of interest that interfere with daily life). During a record review of Resident 19's Physician Orders (PO), dated 2/13/2024, the PO indicated Lexapro (Escitalopram Oxalate, medication used to treat depression), oral Tablet 5 milligrams (mg) give one tablet by mouth one time a day related to major depressive disorder, recurrent, manifested by (m/b) persistent crying related (r/t) unable to do things she used to do. During a review of Resident 11's monthly Medication Regimen Review (MRR), dated 8/21/2024,…

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

Based on observation, interview, and record review the facility failed to follow infection prevention guidelines for an Enhanced Barrier Precaution room (EBP, infection control measure that involve wearing gloves and gowns during high contact patient care to prevent the spread of bacteria) for one of one sampled resident (Resident 78) when the private care giver (PC) was inside Resident 78's room helping other staff member giving Resident 78 a bed bath without wearing a gown. This failure had the potential to result in spreading infections from Residents 78 to the PC, staff members and other residents in the facility. Findings: During a review of Resident 78's admission Record (AR), the AC indicated the facility admitted Resident 78 on 12/24/2024, with diagnoses that included hypertension (high blood pressure) and pressure Ulcer/injury stage 3 (Full-thickness loss of skin. Dead and black tissue may be visible). During a review of Resident 78's Minimum Data Set (MDS, a resident assessment and screening tool), dated 12/28/2024, the MDS indicated Resident 78 had clear speech, usually…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 keep an electric fan (a powered machine used to create a flow of air to cool and ventilate rooms and control humidity) in a safe, operating, and sanitary condition for one of one sampled resident (Resident 19). This failure had the potential to affect Resident's 19 quality of life and overall health. Findings: During a review of Resident 19's admission Record (AR), the AR indicated, Resident 19 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing) and myocardial infarction (heart attack). During a review of Resident 19's Minimum Data Set (MDS, a resident assessment tool), dated 11/29/2024, the MDS indicated, Resident 19 had an intact cognition (ability to understand). The MDS indicated Resident 19 required partial/moderate assistance (helper did less than half the effort) with oral hygiene…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care and services, for one of three sampled residents (Resident 1), by failing to: Follow the facility's Policy and Procedure (P&P) to implement interventions to promote the prevention of pressure ulcer/pressure sore (localized damage to the skin and/or underlying tissue usually over a bony prominence (areas where bones are close to the surface) development for Resident 1, who was on a low air loss mattress (LAL, mattress designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) and was at high risk for developing a pressure ulcer. This deficient practice had the potential to result in Resident 1 developing a pressure ulcer and/or worsening of Resident 1's existing pressure ulcers. Findings: During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the facility's policy and procedures (P&P) on controlled medication storage for one of two sampled Medication Storage (MS) Rooms (MS room [ROOM NUMBER]) when: 1. Two licensed nurses were not present when checking the Controlled Substance Two (II) Emergency Kit (CS II E-kit, emergency medications that require authorization if a medication is not in stock in the facility's pharmacy or medication cart. Substance II medications have a high potential for abuse, potentially leading to severe physical dependence) in MS room [ROOM NUMBER] when five tablets' of 10/325 milligrams (mg, unit of measurement) of Percocet (prescribed controlled medication used to treat moderate to severe pain) and two tablets of 5/325 mg of Percocet were reported missing from the CS II E-kit on [DATE]. 2. A discrepancy on Cart 1 Controlled Drug Reconciliation (CDR, process of comparing number of controlled medications on paper to the physical number of controlled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care and services to prevent a fall (unintentionally coming to rest on a lower-level surface) for two of three sampled residents (Residents 2 and 3) by failing to: 1. Ensure Certified Nurse Assistant (CNA) 5 kept Resident 2's bedside tray, water pitcher and cup within reach of Resident 2 while in bed. 2. Ensure LVN 1 and CNA 4 provided Resident 3 with adequate supervision while Resident 3 was in the restroom unassisted. 3. Ensure Residents 2 and 3 had a red star emblem placed on/and or located the head of bed, assistive devices such as wheelchairs, outside Residents 2 and 3's room on the name sign and a wrist band indicating Residents 2 and 3 were fall risks, based on the facility's policy and procedure (PP) titled. Fall Prevention Program. As a result of these failures, on 2/24/2024 at 2:05 pm, Resident 2 fell out of bed while reaching for the water pitcher, that was not within reach. Resident 2 suffered a head laceration (deep…

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

Based on interview and record review the facility failed to obtain written informed consent for two of three sampled residents (Residents 16 and 71) for the use of psychotropic (any medication capable of affecting the mind, emotions, and behavior) medication. a. For Resident 16, there was no consent obtained for the use of Clonazepam (medication to treat acute panic disorder) Clozapine (medication to treat psychosis [severe mental disorder in which thought, and emotions are so impaired that contact is lost with external reality]), Divalproex Sodium (medication to treat bipolar disorder [mental disorder with periods of depression and periods of elevated mood]) and Bupropion (medication to treat depressive disorder [a feeling of severe sadness or hopelessness]). b. For Resident 71, there was no consent obtained for the use of Remeron (medication used to treat depression). These deficient practices violated the resident's right to be informed and make medical decisions. Findings: a. During a review of Resident 16's admission record, the admission record indicated the facility admitted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs for four of four sampled residents (Residents 4, 43, 30 and 3) who were at risk for fall, by failing to ensure the residents' call light was within reach as indicated in the facility's Policy and Procedure, titled Call Light and the residents' plan of care. These deficient practices had the potential for the residents not to receive or received delayed care to meet the residents' needs and placed the residents at risk for fall or injury. Findings: a. During a review of Resident 4's admission Record (AR), the AR indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included generalized muscle weakness (lack of strength in the muscles) and dementia (loss of cognitive functioning, thinking, remembering, and reasoning). During a review of Resident 4's untitled Care Plan (CP), dated 2/8/2023, the CP indicated Resident 4 had impaired activities of daily living (ADL, 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 observation, interview, and record review, the facility failed to provide necessary care and services for gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition directly to the stomach) site and feedings as ordered by the physician and as indicated in the facility's Policy and Procedure (P&P) and plan of care for two of two sampled residents (Resident 181 and Resident 25). a. The GT site for Resident 181 did not have a drain sponge (pre-cut T-slit sponge dressing that provides a snug fit around catheters, tubes, and tracheotomies) or silicon foam dressing (a soft dressing that forms a seal between the dressing and the wound) as ordered by the physician. b. The GT site for Resident 25 did not have a drain sponge or silicon foam dressing as ordered by the physician. c. Resident 25 did not receive the desired amount of gastrostomy tube feeding formula as recommended by the registered dietitian and as ordered by the physician. These failures had the potential for complications…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 its binding arbitration agreement included the selection of a venue that is convenient to both facility and resident/responsible party for three of three sampled residents (Residents 36, 51 and 58) who signed the arbitration binding agreements upon admission to the facility. This deficient practice placed Residents 36, 51 and 58 at risk for delayed arbitration hearing in an event of an arbitration dispute. Findings: a. During a review of Resident 51's admission Record (AR), the AR indicated the facility admitted Resident 51 on 12/01/23, with diagnoses that included chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing related problems) and hypertension (high blood pressure). During a concurrent interview and record review on 1/18/24 at 10:57 a.m. with the Director of Nursing (DON), the binding arbitration agreement for Resident 51 was reviewed. The facility's arbitration agreement form titled, Resident-Facility Arbitration Agreement, indicated…

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

Based on interview and record review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN, provides information to residents/beneficiaries so they can decide if they wish to continue receiving skilled services that may not be paid for by Medicare and assume financial responsibility) for two of two sampled residents (Residents 38 and 42) who were discharged from Medicare Part A skilled services and continue to reside in the facility. This deficient practice placed Residents 38 and 42 at risk for paying out-of-pocket costs for non-coverage services while in the facility. Findings: a. During a review of Resident 38's admission Record (AR), the AR indicated the facility admitted Resident 38 on 6/19/23, with diagnoses that included chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing related problems) and diabetes mellitus (high blood sugar level). During a concurrent interview and record review on 1/19/24 at 11:18 a.m. with the Administrator, the SNF Beneficiary Notification for Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a bed in good condition for two of two residents (Residents 41 and 229.) This deficient practice had the potential to pose a safety risk for Residents 41 and 229. Findings: During a review of Resident 41's admission Record, the admission record indicated the facility admitted the resident on 6/17/2020 with diagnoses that included epilepsy (brain disorder in which a person has repeated seizures (convulsions) over time. During a review of Resident 41's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 12/10/2023, the MDS indicated the resident had severe cognitive impairment. The MDS indicated Resident 41 was dependent with toileting, personal hygiene and oral hygiene and required partial/moderate assistance (helper does less than half the effort) with eating. During a review of Resident 229's admission Record, the admission record indicated the facility readmitted the resident on 1/5/2024 with…

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

Based on interview and record review, the facility failed to obtain information from prior employers for one of five randomly selected employees (Licensed Vocational Nurse 2[LVN2]) before hiring, in accordance with the facility's policy and procedure, titled Abuse and Neglect Prohibition. This deficient practice had the potential for the facility to hire employees with history of abuse, neglect or mistreatment of residents which could lead to possible harm and abuse of residents. Findings: During a concurrent interview with the Assistant Director of Staff Development (ADSD) and review of LVN 2's employee file on 1/18/2024 at 11:51 am, the ADSD stated LVN 2 was hired on 2/1/2023. The ADSD stated she forgot to indicate in the LVN 2's file that she called LVN 2's previous employer prior to hire. The ADSD stated, there was no other documented evidence that LVN 2's previous employment reference was checked prior to hire. The ADSD stated, employee reference verification was needed prior to determine if the employee have abuse records in their previous employment which could lead 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 staff failed to provide assistance with oral hygiene to one of one sampled resident (Resident 229). This deficient practice had the potential to affect Resident 229's sense of well-being. Findings: During a review of Resident 229's admission Record, the admission record indicated the facility readmitted the resident on 1/5/2024, with diagnoses that included lack of coordination and age -related osteoporosis (a condition wherein the bones lose strength and density). During a review of Resident 229's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 1/11/2024, the MDS indicated the resident had no cognitive impairment. The MDS indicated Resident 229 required substantial/maximal assistance (helper does more than half the effort) with oral hygiene, toileting hygiene, and personal hygiene.) During an interview on 1/16/2024 at 11:19 am, Resident 229 stated he did not have a toothbrush and toothpaste and asked the staff to…

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

Based on observation, interview, and record review, the facility failed to develop a care plan with interventions to address the resident's refusal to turn and reposition to help prevent the recurrence (re-open) of a healed pressure ulcer and prevent the development of a Stage 2 pressure ulcer (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer; the wound bed is viable, pink, or red, moist) on the coccyx (tailbone) for one of three sampled residents (Resident 71). This deficient practice placed Resident 71 at risk for developing new pressure ulcer and recurring Stage 3 pressure ulcer (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole [rolled wound edges] are often present). Findings: During a review of Resident 71's admission Record (AR), the AR indicated the facility readmitted the Resident 71 on 11/11/2023, with diagnoses that included Stage 3 pressure ulcer of right and left buttocks. During a review of Resident 71's Minimum Data Set (MDS - a standardized assessment and care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to label and date the intravenous catheter (IVC, a thin plastic tube inserted into a vein using a needle allowing for the administration of medications, fluids, and/or blood products) for one of one sampled resident (Resident 18). This failure had the potential to result in infection to Resident 18 and worsen the resident's health condition. Findings: During a review of Resident 18's admission Record (AR), the AR indicated, Resident 18 was readmitted to the facility on [DATE] with diagnoses that included COVID-19 (an infectious disease caused by the SARS-CoV 2 virus) and pneumonia (infection that affects one or both lungs). During a review of Resident 18's Order Summary Report (OSR), dated 1/15/2024, the OSR indicated Resident 18 had an order of Rocephin (an antibiotic used to treat bacterial infection) 1 gram (gm, a metric unit) intravenous every 24 hours for 5 days for pneumonia. During a review of Resident 18's untitled Care Plan (CP),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 oxygen therapy (treatment that provides supplemental oxygen) for two of three sampled residents (Resident 65 and Resident 180) according to standards of clinical practice and the facility's Policy and Procedure titled, Oxygen Therapy. a. Resident 65's nasal cannula (tube which on one end splits into two prongs which are placed in the nostrils to deliver oxygen) while not in used, was not stored in a clean plastic bag, and left hanging on resident's bed with nasal prongs touching the residents head of bed. b. Resident 180's oxygen tubing was left hanging on a portable oxygen tank while not being used. The oxygen tubing was not labeled with the resident's name and not dated when it was changed. These deficient practices placed Residents 65 and 180 at risk for respiratory complications and infection. Findings: a. During a review of Resident 65's admission Record, the admission record indicated the facility admitted Resident 65 on…

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

Based on observation, interview, and record review, the facility failed to ensure the nurse staffing information posted on 1/15/2024 accurately reflected the actual hours worked and the total number of staff, as indicated in the facility Policy and Procedure titled Staff Posting Requirements. This deficient practice had the potential to result in misinformation to the residents and the public of the facility's nursing staffing data. Findings: During an observation on 1/16/2024 at 9:11 am, the daily nurse staffing information was posted in front of Nursing Station 1. During a concurrent record review and interview on 1/18/2024, at 11:26 am with the Director of Staff Development (DSD 1), the nurse staffing information and the actual staffing sign in sheet for the staff who worked, reflected the following: On 1/15/2024 for the 11 pm to 7 am shift, there were two Licensed Vocational Nurses (LVNs) on the nurse staffing information posted while the sign in sheet indicated one LVN. On 1/15/2024 for the 11 pm to 7 am shift, there were seven Certified Nurse Assistants (CNAs) on the nurse…

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

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 62) on psychotropic drugs (any drug that affects brain activities associated with mood, emotions, and behavior) was free from unnecessary medication by failing to ensure staff attempted a gradual dose reduction (GDR, the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) of Resident 62's Seroquel (antipsychotic drug [use to treat symptoms of psychosis or disconnection from reality) 50 milligrams (mg, unit of measurement) since ordered on 8/16/22. This deficient practice placed Resident 62 at risk for adverse drug reaction (a harmful and unintended response to a medicine). Findings: During a review of Resident 62's admission Record (AR), the AR indicated the facility admitted Resident 62 on 2/17/21, with diagnoses that included hemiplegia (paralysis on one side of the body) following cerebral infarction (also known as a stroke refers to damage to tissues in the…

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

Based on observation, interview, and record review, the facility failed to ensure one of one resident (Resident 40) was provided with carbohydrate-controlled (diet that restricts carbohydrates, such as those found in pasta, bread, and sugary foods) diet per physician's order. This deficient practice had the potential to result in high blood sugar for Resident 40. Findings: During a review of Resident 40's admission Record (AR), the AR indicated the facility admitted Resident 40 on 8/3/2022, with diagnoses that included type 2 diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in elevated levels of glucose/sugar in the blood and urine) and dependence on renal dialysis (a treatment that helps the body remove extra fluid and waste products from the blood when the kidneys are not able to). During a review of the Minimum Data Set (MDS - a standardized assessment and care planning tool), dated 11/5/2023, the MDS indicated Resident 40 had no cognitive (process of thinking and reasoning) impairment. The MDS indicated…

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

During an observation, interview, and record review, the facility failed to ensure food delivered were within temperature range and within the food temperature preferred for one of two sampled residents (Resident 57). This deficient practice had the potential for decreased appetite and food intake for Resident 57 and placed the resident at risk for weight loss. Findings: During a review of Resident 57's admission Record, the admission record indicated the facility admitted the resident on 8/11/2023, with diagnoses that included type 2 diabetes mellitus (elevated blood sugar level). During a review of Resident 57's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 11/17/2023, the MDS indicated Resident 57 had no cognitive impairment. The MDS indicated Resident 57 was dependent with toileting, shower and bath and required set- up or clean-up assistance with eating and oral hygiene. During an interview on 1/16/2024 at 3:05 pm, Resident 57 stated the food served to her was cold. Resident 57 stated when the vegetables were cold, she would not eat it. During…

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

Based on observation, interview, and record review, the facility failed to coordinate care with the hospice care (focuses on the care, comfort, and quality of life of a person with a serious illness who is approaching the end of life) provider for one of one sampled resident (Resident 23) by failing to ensure hospice services were provided as scheduled. This deficient practice placed Resident 23 at risk of not receiving appropriate hospice care in a timely manner. Findings: During a review of Resident 23's admission Record (AR), the AR indicated the facility admitted Resident 23 on 3/5/23, with diagnoses that included cerebral infarction (also known as a stroke refers to damage to tissues in the brain due to loss of oxygen to the area), hypertension (high blood pressure), and dementia (a group of conditions characterized by impairment of memory and judgment). During a review of Resident 23's Physician Order Sheet (POS) dated 3/5/23, the POS indicated Resident 23 was admitted to hospice care for diagnosis of end stage stroke. During a review of Resident 23's Minimum Data Set (MDS, a…

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

Based on observation, interview and record review, the facility failed to implement interventions to prevent and control the spread of Corona Virus 19 (COVID 19, a mild to severe respiratory illness that spread from person to person) by failing to ensure Certified Nurse Assistant 5 (CNA 5) performed hand hygiene ( way of cleaning one's hands that substantially reduces pathogens [harmful microorganisms] on the hands) and don (to put on) gown and gloves before entering Resident 17's room, which was located in the Red Zone (an area dedicated for residents who are COVID 19 positive) in accordance with the local Public Health guidelines and facility's Policy and Procedure on Transmission Based Standard. This deficient practice had the potential to result in the transmission of COVID 19 to the residents, staff, and visitors. Findings: During a review of Resident 17's admission Record, the admission record indicated the facility admitted Resident 17 on 4/6/2005 with diagnoses that included hypertension (high blood pressure) and type 2 diabetes mellitus (DM - a chronic condition that…

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