The Orchard - Post Acute Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to report multiple, consecutive Restorative Nursing Aide (nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) treatments that was refused by one of seven sampled residents (Resident 43) to the physician. These failures resulted in Resident 43 not receiving services and interventions to improve ROM and address reasons for refusals, prevent contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness), and improve overall mobility and physical functioning. Findings: During a review of Resident 43's admission Record, the admission Record indicated the facility originally admitted Resident 43 on 2/18/2020 and re-admitted Resident 43 on 3/14/2025 with diagnoses including left-sided hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following a cerebral infarction…

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 communication tool or device that translate to a language the resident could understand for one of three residents (Resident 94) who does not speak the formal language in the facility. This deficient practice prevented Resident 94 from communicating the necessary needs with facility staff that could delay in the resident receiving appropriate care/treatment. A review of Resident 94's admission Record [AR] indicated Resident 94 was admitted to the facility on [DATE], with diagnoses that included prostate cancer (uncontrolled growth and spread of abnormal cells that can invade and damage healthy tissues) and anemia (lower-than-normal number of red blood cells). The AR indicated that Resident 94 primary language was Spanish. A review of Resident 94's History and Physical Examination (HPE, a comprehensive physician's note regarding the assessment of the Patient's health status) signed by the attending physician on 7/3/2025, the HPE…

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 seven sampled residents (Resident 81) who was assessed as being at risk for pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) was provided a pressure relieving barrier to be placed between Resident 81's overlapping, contracted (loss of motion of a joint associated with stiffness and joint deformity) toes of the left foot as indicated on the facility policy. This deficient practice had the potential to result in Resident 81 developing pressure ulcers on the left foot. Findings: During a review of Resident 81's admission Record, the admission Record indicated the facility admitted Resident 81 on 12/9/2014 with diagnoses including right-sided hemiplegia and hemiparesis following an unspecified cerebrovascular disease (group of conditions that impact the brain's blood vessels and blood flow) and apraxia (disorder of the brain and nervous system in which a person is unable to carry out…

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 care and services to one of three sampled residents (Resident 142) who was incontinent of bladder (loss of bladder control) and had recent history of urinary tract infection (UTI- an infection in the bladder/urinary tract) was not kept clean and dry. Resident 142's incontinent brief was soaked with urine when observed at 10:35 AM. Certified Nursing Assistant (CNA) 2 stated she changed Resident 142's incontinent brief around 7:45 AM and she was going to check if the resident need to be changed at 11:30 AM. This deficient practice had the potential to result Resident 142 to be at risk for recurrent UTI and skin breakdown. Findings: During a review of Resident 142's admission Record (AR), the AR indicated that the facility originally admitted Resident 142 on 6/17/2025 and readmitted her on 7/8/2025 with diagnoses including atherosclerosis (hardening of arteries) of coronary artery bypass graft(s) (known as bypass surgery-- a medical procedure to improve blood flow to the heart), UTI, and sepsis (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 implement the facility's policy and procedure for Nutrition Status Management to weigh one of four sampled residents (Resident 142) upon readmission for nutrition evaluation and management. Resident 142 was weighed six days after readmitted to the facility on [DATE]. The nutrition evaluation by the Registered Dietitian (RD- professionals who are experts in food and nutrition) review was not conducted and did not identify Resident 142's weight loss until six days later. This deficient practice had resulted in the delayed implementation of the intervention for Resident 142's weight maintenance and nutrition management to prevent further weight loss.Findings: During a review of Resident 142's admission Record (AR), the AR indicated that the facility originally admitted Resident 142 on 6/17/2025 and readmitted her on 7/8/2025 with diagnoses including atherosclerosis (hardening of arteries) of coronary artery bypass graft(s) (known as bypass…

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 pharmaceutical services to one of five sampled residents (Resident 157) as evidenced by: 1. Failing to administer Entresto (a medication to treat heart failure [a chronic condition in which the heart does not pump blood as well as it should]) to Resident 157 on 6/29/2025 at 9 AM, 6/30/2025 at 5 PM, 7/1/2025 at 5 PM and 7/16/2025 at 5 PM. 2. Failing to document the reason why Entresto was not administered on 6/30/2025 at 5 PM, 7/1/2025 at 5 PM and 7/16/2025 at 5 PM. 3. Failing to notify the physician and obtain an order when Resident 157 did not receive Entresto on 6/29/2025 at 9 AM, 6/30/2025 at 5 PM, 7/1/2025 at 5 PM, and 7/16/2025 at 5 PM due to unavailability of the medication at the scheduled time for administration. These deficient practices placed Resident 157 at risk for worsening of her heart condition and hypertension (high blood pressure). During a review of Resident 157's admission Record (AR), the AR indicated 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 promptly provide dental services for one of nine sampled residents (Resident 79) by failing to follow recommendations from the dentist for an oral surgery referral for bone spurs removal (a surgical procedure to remove a bone spur - small sharp pieces of bone that could sometimes detach after a tooth extraction or other oral surgery). This deficient practice resulted in Resident 79 having pain and resorting to eating oatmeal, soups, and pureed food that can potentially result lt in weight loss. During a review of Resident 79's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), gout (a type of arthritis [a condition that caused pain, swelling, and stiffness in one or more joints] that caused sudden, severe pain, swelling, and stiffness in one or more…

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 and interview and record review the facility failed to follow its policy and procedure on food storage, preparation, distribution and serving food in accordance with professional standards for food service safety by failing to ensure that the Dietary Aid (DA) 1 labeled individually packaged four (4) cups of cottage cheese, 12 cups of yogurt, and four (4) cups of puddings in the refrigerator with the date of Use By. This deficient practice had the potential to cause food unlabeled past safe storage time/ period, and place residents who consume this food at risk for foodborne illness (food poisoning or food illness due to pathogens [harmful organisms that cause illness such as bacteria, viruses, or parasites] and toxins that contaminate food). Findings: During an observation and concurrent interview on 8/5/2025 at 11:35 AM, a food tray with a total of 20 individually- wrapped food in dessert cups was observed in the refrigerator which includes four cups of cottage cheese, 12 cups of variety flavors of yogurt, and four cups of pudding. The tray and the 20…

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 immediately notify the resident's Physician for one of three sampled residents (Resident 2) reviewed for accidents, of a change in condition when Resident 2 had a fall and was currently receiving anticoagulant (a group of medications that decreased your blood's ability to clot) medications. This deficient practice had the potential for Resident 2 to have complications from the use of anticoagulant due to frequent falls and not to receive the necessary interventions and negatively affect the provision of care and services. During a review of Resident 2's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included history of falling, abnormalities of gait and mobility (a change to your walking pattern), and personal history of other diseases of the nervous system (a complex network of nerves and tissues that allowed us to think, feel, and move) and sense organs (parts of the body that helped us…

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 Minimum Data Set (MDS- a resident assessment tool), accurately reflected resident's vision status for one out of three sampled residents (Resident 2), who has visual impairment (a term describing any vision loss that cannot be fully corrected). Resident 2 was assessed having adequate vision (sees fine detail, such as regular print in newspapers/books). This deficient practice had the potential for Resident 2 to not receive care to address Resident 2's visual impairment. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included history of falling, abnormalities of gait and mobility (a change to your walking pattern), and personal history of other diseases of the nervous system (a complex network of nerves and tissues that allowed us to think, feel, and move) and sense organs (parts of the body that helped us perceive 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 develop a comprehensive person-centered plan of care for one out of three sampled residents (Resident 2) who was assessed to have visual impairment (a term describing any vision loss that cannot be fully corrected) did not have a care plan to address interventions for the resident's visual impairment. This deficient practice had the potential for Resident 2 not to receive care and services for visual impairment such as keeping the resident safe and to prevent accidents and falls. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included history of falling, abnormalities of gait and mobility (a change to your walking pattern), and personal history of other diseases of the nervous system (a complex network of nerves and tissues that allowed us to think, feel, and move) and sense organs (parts of the body that helped us perceive the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure fall prevention interventions were implemented for one out of three sampled residents (Resident 2), reviewed for accidents when Resident 2, who had history of multiple falls at the facility (5/24/2025, 5/25/2025, 6/7/2025, and 6/10/2025), did not have a floor mat in place when the resident was lying in bed, as indicated in the resident's care plan titled Actual Fall. This deficient practice had the potential for recurrent falls for Resident 2 and sustain major injuries as a result of a fall from the resident's bed. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included history of falling, abnormalities of gait and mobility (a change to your walking pattern), and personal history of other diseases of the nervous system (a complex network of nerves and tissues that allowed us to think, feel, and move) and sense organs (parts…

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 accurately document in the Fall Risk Evaluation (FRE) on 6/10/2025 and accurately document in the Minimum Data Set (MDS, a federally mandated resident assessment tool) that one of three samples residents (Resident 2) had visual impairment (a term describing any vision loss that cannot be fully corrected) and was at high risk for accidents and fall due to blindness. This deficient practice had the potential for Resident 2 not to receive care to address Resident 2's visual impairment that could lead to a lack of or delay in delivery of necessary care or services to Resident 2 such as monitoring and supervision to prevent recurrent accidents and falls.Findings: During a review of Resident 2's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included history of falling, abnormalities of gait and mobility (a change to your walking pattern), and personal history of other diseases of…

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

Based on observation, interview, and record review, the facility failed implement the facility's policy and procedure for infection control by failing to: 1. Store food in a sanitary manner to prevent growth of microorganisms that causes food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins) for residents in the facility by not checking the boxes of fruit and vegetables that was rotten and spoiled items. 2. Ensure the dietary aid to follow hand washing practices consistent with accepted standard of practice after touching trash bin prior to returning to work. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for a wide spread of infection (a process when a microorganism, such as bacteria, fungi, or a virus, enters a person's body and causes harm) and developing foodborne illness (also called food poisoning, caused by eating contaminated food or eating food not kept at appropriate…

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 implement the facility's policy and procedure on infection control to prevent spread of infection for four (4) out of seven (7) sampled residents (Resident 102, 25, 108, and 454) by failing to: 1. Ensure the nasal cannula (NC-a device used to deliver supplemental oxygen to people) tubing was changed at least every 7 days for Resident 102. 2. Ensure the NC was stored properly and not reused after it was observed touching the trashcan and the floor for Resident 25. 3. Ensure the G-tube (A tube inserted through the wall of the abdomen directly into the stomach) formula bottle tubing was dated for Resident 108. 4. Ensure the peripheral intravenous (a thin, flexible tube that is inserted into a vein, it is used to give intravenous fluids, blood transfusions, chemotherapy, and other drugs) (PIV) dressing was dated for Resident 454. These deficient practices had the potential to result in the residents' infection (a process when a microorganism,…

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 safe, sanitary, and hazard free environment for two (2) out of six (6) residents (Resident 255, and 64) by failing to: 1. Ensure the footrest (a base of support and elevates the legs) of a wheelchair was not placed in the doorway, blocking the residents and staffs from leaving and entering Resident 255 room. This failure had the potential for residents and staffs to be at risk for accident by tripping onto the footrest and result in a major injury. 2. Ensure the facility's staff timely empty two used urinals filled with the resident's urine for Resident 64. This failure resulted in Resident 64's complaint of foul urine odor, feeling unsanitary and uncomfortable with the smell. Findings: 1. During a review of Resident 255's admission Record, indicated Resident 255 was admitted to the facility on [DATE] with diagnoses that included muscle weakness and anemia (a condition in which the blood does not have enough healthy red blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 21) were provided dignity and/or privacy during a medication pass. Licensed Vocational Nurse (LVN) 2 did not close Resident 21's door and/or pull the resident's privacy curtain during administration of medication via injection (medication adminitered using needle into the skin or muscle) into the resident's abdomen, while the resident's roommate was sitting across the room in Resident 21. This failure resulted the violation of Resident 21's right for privacy and dignity. Findings: During a review of Resident 21's admission Record, indicated Resident 21 was admitted to the facility on [DATE] with diagnoses that included muscle weakness and type 2 diabetes mellitus (DM- a disease that occurs when the blood sugar is too high). During a review of Resident 21's History and Physical Examination (H&P) dated 2/7/2024, indicated Resident 21 did not have 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 observation, interview and record review, the facility failed to accommodate the needs of one of one sampled resident (Resident 108) in accordance with the facility ' s policy and procedure by failing to ensure the call light (a device used by residents to signal his or her needs for assistance) was within reach. This deficient practice had the potential for Resident 108 not able to call the facility staff to ask for help or assistance especially during emergency. Findings: During a review of Resident 108's admission Record, indicated the facility originally admitted Resident 108 on 12/19/2021 and readmitted on [DATE] with diagnoses that included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), dysarthria (difficulty speaking because the muscles use for speech are weak), and hemiplegia ( paralysis that affects only one side of your body) hemiparesis (weakness or the inability to move on one side of the body) affecting right dominant side. During a review of…

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

Based on observation, interview, and record review, the facility failed to develop a resident specific comprehensive care plan in the management of dysuria (pain or discomfort when urinating) for one out of thirty sampled residents (Resident 101). This deficient practice had the potential to result in Resident 101 to experience recurrent dysuria and urinary tract infection (UTI, an illness in any part of urinary tract, the system of organs that makes urine). Findings: During a review of Resident 101's admission Record, indicated the facility originally admitted Resident 101 on 12/13/22 and readmitted Resident 101 on 5/24/23 with diagnoses that include UTI and hemiplegia (paralysis of one side of the body). During a review of a Minimum Data Set (MDS, a standardized assessment and care planning screening tool), dated 5/20/24, indicated Resident 101 had severely impaired cognitive (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 101 required setup or clean-up assistance with eating and oral hygiene, supervision with personal…

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 necessary care and services to residents who was dependent with the staff to carry out activities of daily living (ADL), maintain grooming, and good personal hygiene for one of two sampled residents (Resident 454) by not shaving his facial hairs after a bed bath. This deficient practice had the potential to negatively affect Resident 454's physical appearance, dignity, and quality of life. Findings: During a review of Resident 454's admission Record, indicated the facility admitted Resident 454 on 7/9/2024 with diagnoses that included congestive heart failure (CHF) (the heart doesn't pump enough blood for your body's needs), muscle weakness, and abnormalities of gait and mobility. During a review of Resident 454's History and Physical Examination, dated 7/10/2024, indicated Resident 454 had the capacity to understand and make decisions. During a review of Resident 454 's Care Plan (CP) for ADL (Activities of Daily Living) Self-care performance Deficit related to diagnoses shortness of breath, CHF, 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 necessary respiratory care and services for one of four sampled residents (Resident 90) by failing to label with the date and time when first used and replacing the oral suctioning (a procedure involves inserting a small plastic tube attached to a suction machine into the mouth to remove saliva or secretion) canister (a container used in medical settings to collect waste material during suction procedure) of Resident 90. This deficient practice placed Resident 90 at risk for respiratory infection (any infectious disease of the parts of the body involved in breathing). Findings: During a review of Resident 90's admission Record, indicated the facility originally admitted Resident 90 on 1/6/21 and readmitted on [DATE] with diagnoses that include hemiplegia (paralysis of one side of the body) and dysphagia (difficulty swallowing). During a review of a Minimum Data Set (MDS, a standardized assessment and care planning screening tool),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the facility policy and procedure titled Resident Care - Recognition and Management of Pain, dated 1/2021, for two (2) out of two (2) sampled residents (Resident 25, and 604) by failing to: 1. Ensure Certified Nurse Assistant (CNA) 6 immediately report to Licensed Vocational Nurse (LVN) 8, Resident 25's complaint of pain to ensure LVN 8 reassess the resident for the pain medication's effectiveness, and reassess Resident 25 ---was observed experiencing pain in his left leg's stump [the basal portion of a bodily part (as a limb) remaining after the rest is removed] on 7/23/2024 at 10:17 AM. 2. Ensure Resident 604 with pain in the shoulder, clavicle (the collar bone/the bone that connects the breastbone to the shoulder blade) and ribs due to fracture (broken bone) was provide pain medication timely to control pain. These deficient practices resulted in Resident 25 experiencing pain on 7/23/2024, and Resident 604 experiencing…

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 an accessible-hemodialysis (a process of removing toxins and excess fluid in the blood by insering a plastic catheter or tube into the body using a machine ) emergency kit (kit used in the event bleeding was observed in the hemodialysis site) for one of three sample residents (Resident 138) who received hemodialysis. This deficient practice had the potential to delay or unable to immediately provide interventions in an event of emergency to Resident 138 for complications such as trauma, and bleeding on the dialysis access site (a surgically created vein used to remove and return blood to the body during hemodialysis) that could lead to a significant blood loss and decline in the resident's wellbeing. Findings: During a review of Resident 138's admission Record, indicated the facility admitted Resident 138 on 3/14/24 with diagnoses that include acute kidney failure (failure of the kidney to filter waste/toxins and excess fluids in the blood) and hypertension (high blood pressure). During a review of 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 provide pharmaceutical (medication related) services to prevent consequences of medication-related adverse events (undesired effects) for two (2) out of three (3) sampled residents (Resident 21 and Resident 22) by failing to: 1. Administer PreserVision (medication used for dry eye) with food per physician's order for Resident 21. This failure had the potential to cause Resident 21 to have stomach irritation such as stomach pain, nausea, and vomiting. 2. Administer Metformin Hydrochloride (medication given to lower the blood sugar level) was administered with meals as ordered by the physician for Resident 22. This failure had the potential to result in Resident 22 to develop adverse reaction to the medication such as significant drop in blood sugar level. Findings: 1. During a review of Resident 21's admission Record, indicated Resident 21 was admitted to the facility on [DATE] with diagnoses that included muscle weakness and type 2…

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 food served for one of two sampled residents (Residents 354) was palatable and hot food were served hot and/or above 120 degrees °F (°F-a measurement of temperature) as indicated in the facility's policy and procedure titled, Meal Service, dated 2023. This deficient practice had the potential to affect palatability of the food to the residents and to have poor meal intake that could lead to weight loss. Findings: During a review of Resident 354's admission Record indicated Resident 354 was admitted to the facility on [DATE] with diagnosis that included iron deficiency anemia (low blood count), protein-calorie malnutrition (inadequate intake of food as a source of protein, calories, and other essential nutrients), hyperlipidemia (an abnormally high concentration of fat particles in the blood). During a review of Resident 354's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 7/13/2024, 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.

Based on observation, interview, and record review, the facility failed to ensure that one of two sampled residents ' diagnostic tests were completed as ordered by Resident 1 ' s physician to confirm the diagnosis of dementia (a progressive condition marked by the development of multiple cognitive deficits). This deficient practice had the potential to result in Resident 1 not receiving the adequate dementia care and being able to achieve her highest level of functioning. Findings: During an observation on 9/28/23, Resident 1 was observed sitting in a wheel chair in her room watching television. A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 9/07/2022, with diagnoses that included metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction), unspecified dementia without behavioral disturbances, psychotic disturbances, mood disturbances and anxiety. A review of Resident 1 ' s History and Physical Examination (HPE) signed and dated by the attending physician on 9/10/2022, indicated the resident did not have the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that assistance with resident's call lights were provided for 4 of 5 residents (Residents 2, 3, 4 and 5) within a timely manner and according to the resident's assessed needs, ADL (Activities for Daily Living) care plans, and facility policy on Nursing Clinical - Responding to call light. These deficient practices had the potential to result in ADL decline, unavoidable falls, and loss of dignity for Residents 2, 3, 4, and 5 which all stated that facility staff takes a long time to respond to residents when call lights are activated for help or staff assistance. Findings: 1. A review of Resident 2's admission Record, indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the following diagnosis including hemiplegia (muscle weakness on one side of the body that can affect the arms, legs and facial muscles), hemiparesis (weakness or the inability to move on one side of the body) 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 follow its policy and procedure to have one of two sampled residents (Resident 1) Physician Orders for Life Sustaining Treatment (POLST) signed by the physician. This deficient practice has resulted in confusion and a delay in the necessary care/services for Resident1 during an emergency on [DATE]. Findings: A review of Resident 1's admission Record indicated the resident was admitted on [DATE] with the following diagnoses of muscle weakness and abnormalities of gait and mobility. A review of Resident 1's History and Physical (H&P), dated [DATE], indicated the resident had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS; a standardized assessment and care screening tool) dated [DATE], indicated the resident was severely impaired of cognition (thought process). The MDS indicated Resident 1 was assessed requiring one-person limited assistance (resident highly involved in activity; staff provide guided…

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 safety measures by assisting, and monitoring to prevent falls and injury for one of five sampled residents (Resident 1) by failing to: 1. Ensure Resident 1, who was assessed at high risk for falls was free from falls and injury when the resident fell hitting her forehead on the floor in her room on [DATE] and on [DATE], when Resident 1 slipped on her feces on the floor and fell. 2. Ensure facility staff immediately assisted Resident 1 when the resident activated the call light (communication system that link facility staff to the needs of residents) on [DATE] as indicated in the facility's policy on Responding to Call lights, and Resident 1's care plan for Risk for Falls and Actual Fall. Resident 3, (Resident 1's roommate) reported Resident 1 activated the call light and facility staff did not come in the room to assist immediately on [DATE]. These deficient practices resulted in Resident 1 losing her balance, hitting the wall, and falling onto…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive and person-centered care plan that included measurable objectives and time frames for three residents (Residents 96, 98, and 113). Residents 96, 98, and 113 did not have care plans with measurable objectives and time frames. This deficient practice had the potential to negatively affect the delivery of care and services for the residents. Findings: a. A review of Resident 96's admission Record indicated the resident admitted to the facility on [DATE] with diagnoses that included dementia (a group of thinking and social symptoms that interferes with daily functioning.), depression (disorder characterized by persistent sadness), and anxiety disorder (disorder characterized by persistent nervousness or anxiousness). A review of Resident 96's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 10/27/21, indicated the resident had severe impairment in cognitive skills (ability to make daily…

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 treatments and services to prevent and/or limit decline in range of motion (ROM) and mobility for five of 28 sampled residents (Residents 30, 36, 52, 91, and 116) who were receiving restorative nursing aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) services. The facility failed to ensure: a. For Resident 30, RNA treatments for both upper extremities (BUE, shoulder, elbow, wrist, hand) passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises five times a week and RNA treatments for sit to stand (moving from a sitting position to standing position) five times a week were provided since 1/13/21, when the order for RNA program was written. b. RNA services were provided to Resident 52 for active assistive range of motion (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another…

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 interventions were implemented for the prevention of avoidable accidents for five out of nine sampled residents (Residents 116, 438, 4, 455, and 56). 1. Staff tilted a shower chair backwards onto the two rear wheels while transferring Resident 116 with a Hoyer lift (a mechanical lift that allows a person to be transferred from one surface to another). 2. Residents 438, 4, and 455 did not have a functioning bed and wheelchair alarm (sensor pad connected to an alarm monitor that can be placed on the bed and wheelchair seat. The alarm is triggered and signals the staff if the resident is attempting to get out of bed or wheelchair) to alert the staff if the residents attempted to get out of the beds or wheelchairs. 3. Resident 56, who had a diagnosis of epilepsy (a brain disorder that causes people to have recurring seizures), did not have padded (cushioned) side rails (barriers attached to the side of a bed). These deficient practices…

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 review of documents, the facility failed to ensure safe disposition of medications. 1. During an inspection of one of four medication carts (Medication Cart 4C), the Narcotic and Hypnotic Record for tramadol (a controlled substance medication used to treat moderate to severe pain) was not disposed of with two licensed nurses as witnesses as indicated in the facility's policy and procedure. 2. During an inspection of Medication Cart 2, three unknown oral medications were observed in a sharps container (a puncture-resistant and leak-proof container with a one-way top used to dispose of sharps) . These deficient practices had the potential for diversion of controlled substance drugs and accidental use of the wrong medication. Findings: 1. During an inspection of a Medication Cart 4C and record review with Licensed Vocational Nurses 4 and 5 (LVN 4 and LVN 5), on 12/8/21 at 7:16 AM, the facility's Narcotic and Hypnotic Record indicated tramadol was wasted (discarded and/or not…

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 it was free of a medication error rate of five percent or greater, as evidenced by the identification of three medication errors out of 25 opportunities for error, to yield a cumulative error rate of 12 percent for two of four sampled residents (Residents 18 and 59). During medication pass observations, the following were observed: 1. Licensed Vocational Nurse 3 (LVN 3) failed to provide food as indicated on the physician`s order for the administration of Sevelamer [medication used to lower the amount of phosphorus (a mineral found in the bones and needed to build strong healthy bones) in the blood for residents receiving kidney dialysis (machine used to remove waste and extra fluid from the body)] for Resident 59. 2a. LVN 3 failed to provide food as indicated on the physician`s order for the administration of Ferrous Sulfate [medication used to treat or prevent low blood level of iron (needed to make healthy red blood cells] for…

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

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety by failing to discard expired food items. During an inspection of the dried food storage, the following items were observed expired: 1. Hamburger buns with a best before date of 11/23/21. 2. Hotdog buns with best before date of 12/1/21. 3. Hotdog buns with best before date of 12/6/21. This deficient practice had the potential to result in foodborne illness to residents. Findings: During an inspection of the dried food storage area, on 12/6/21 at 8:26 AM, the following expired items were found: 1. Hamburger buns with a best before date of 11/23/21. 2. Hotdog buns with best before date of 12/1/21. 3. Hotdog buns with best before date of 12/6/21. During an interview on 12/6/21 at 8:50 AM, he Assistant Kitchen Supervisor (AKS) stated that the bread (buns) was no good and should not have been stored in the dry food storage area because the facility could serve it to the residents and the residents could get sick. The AKS stated that he…

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 collaborate with the hospice the development, implement, and revision of the hospice visits calendar and provide documentation of the resident's hospice plan of care for two of two residents (Residents 96 and 98). This deficient practice had the potential to negatively affect the delivery of care and services related to the end-of-life status for hospice residents. Findings: a. A review of Resident 96's admission Record indicated the resident admitted to the facility on [DATE] with diagnoses that included dementia (a group of thinking and social symptoms that interferes with daily functioning.), depression (disorder characterized by persistent sadness), and anxiety disorder (disorder characterized by persistent nervousness or anxiousness). A review Resident 96's Hospice Face Sheet indicated that the resident was admitted to hospice care on 11/29/19. A review of Resident 96's Minimum Data Set (MDS, a standardized assessment and care-screening tool),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement recommended practices to prevent the spread of Covid-19 (Coronavirus disease, a severe respiratory illness caused by a virus and spread from person to person) and to implement their Infection Prevention and Control Policy and Procedure and Centers for Disease Control and Prevention (CDC) guidelines for three of 12 sampled residents (Residents 4, 62, and 13) in the [NAME] Zone (Non-Covid-19 area) when: 1. Staff failed to instruct Resident 4 to wear a face mask to cover the nose and mouth and replace a face mask when soiled. 2. Residents 62 and 13 were not provided hand washing prior to eating lunch. These deficient practices had the potential to spread infection to residents, staff, and visitors in the facility. Findings: 1. A review of Resident 4 's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included epilepsy (an electrical brain disorder marked by episodes of 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 interview and record review, the facility failed to complete routine surveillance Coronavirus Disease 2019 (COVID-19, a new infectious viral disease that can cause respiratory illness) testing for three of three unvaccinated staff [Certified Nursing Assistants (CNAs) 3, 4, and 5] according to the local state Department of Public Health requirements when: a) CNA 3 did not test 48 hours prior to the start of the shift on 11/29/21. b) CNA 4 did not test 48 hours prior to the start of the shift on 12/6/21. c) CNA 5 worked more than one shift and did not test twice during the week of 11/22/21 to 11/28/21. These deficient practices had the potential to spread COVID-19 to the facility staff, residents, and/or visitors. Findings: During an interview and record review on 12/9/21 at 10:53 AM, the Director of Staff Development (DSD) who also served part-time as the Infection Preventionist Nurse (IPN) stated that CNAs 3, 4, and 5 were three of three unvaccinated staff members with religious exemptions. DSD stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident's medical records were updated to show documentation that advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed and written information were provided to the residents and/or responsible parties for one of the seven sampled residents (Resident 30). This deficient practice violated the resident's and/or the representatives' right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding health care. Findings: A review of Resident 30's admission Record indicated the resident initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included aphasia (loss of ability to understand or express speech, caused by brain damage) following cerebral infarction (a result of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the residents were provided with a safe, clean, comfortable, and homelike environment for one of seven sampled residents (Resident 62). Resident 62's wheelchair was observed with a worn right arm rest, the left arm rest had no cushion, and the chair back and seat had torn spots. This deficient practice had the potential to make the resident feel like they were not in a comfortable homelike environment. Findings: During an observation on 12/06/21 at 11:20 AM, Resident 62 was sitting in his wheelchair in his room. Resident 62's right arm rest cushion was worn, cracked with cushion exposed, left arm rest had no cushion at all, and the chair back and seat had torn spots. During an interview on 12/08/21 at 10:25 AM, Maintenance 1 (M1) stated if the arm rest was broken, the facility could replace it. M1 stated that the nurses could also let maintenance staff know if any wheelchairs were broken and the facility would fix right away.…

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 an ongoing program of activities designed to meet the needs for one of three residents (Resident 113). The facility did not provide regular in room visits for Resident 113 as indicated on the residents's care plan. This deficient practice had the potential to negatively affect the overall well-being of the resident. Findings: A review of Resident 113's admission Record indicated the resident initially admitted to the facility on [DATE] with diagnoses that included generalized muscle weakness, hypertension (high blood pressure), and dementia (name for a group of symptoms caused by disorders that affect the brain). A review of Resident 113's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 11/3/21, indicated the resident had severe impairment in cognitive skills. The MDS indicated the resident required extensive assistance from staff for transferring, dressing, toileting, and personal hygiene. 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 observation, interview, and record review, the facility failed to effectively manage a resident's pain for one of two sampled residents (Resident 455) for three days (from 12/6/21 to 12/8/21). The facility failed to reassess the resident's pain and notify the resident's physician that Resident 455's ordered pain medications did not alleviate the pain. This deficient practice resulted in the resident experiencing unnecessary pain which affected the resident's daily activity and ability to sleep well. Findings: A review of Resident 455's admission Record indicated that the resident admitted to the facility on [DATE] with diagnoses that included repeated falls, multiple right rib fractures (a complete or partial break in the rib bone), and difficulty walking. A review of Resident 455's History and Physical, dated 12/7/21, indicated that the resident had fluctuating capacity to understand and make medical decisions. A review of Resident 455's Pain Management Review, dated 12/4/21, indicated that Resident…

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

Based on observation, interview, and record review, the facility failed to label one opened medication packet of multidose vials with an opened date. During an inspection of a medication cart 2, an opened packet of Ipratropium Bromide/Albuterol Sulfate (used to prevent and treat wheezing and shortness of breath caused by breathing problems) did not have a label of when it was opened. There were four of five doses remaining in the package. This deficient practice had the potential for use of expired medications which could adversely affect the residents. Findings: On 12/8/21 at 1:02 PM, during an inspection of medication cart 2, an opened packet (with four of five doses remaining) of Ipratropium Bromide 0.5 milligram (mg, a unit of measurement)/Albuterol Sulfate 3 mg inhalation solution had no open date labeled on the medication packet. On 12/8/21 at 1:02 PM, during an interview, a Licensed Vocational Nurse 2 (LVN 2) stated that she did not know when it was opened. LVN 2 stated it may have been opened last night. On 12/8/21 at 1:14 PM, during an interview, the Director of Nursing…

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.