Motion Picture And T.v. Hosp D/P SNF

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs by failing to: 1. Ensure the antibiotic medications had monitoring for adverse effect (unwanted undesirable effects that are possibly related to a drug) for two of three sampled residents (Residents 21 and 4) reviewed for antibiotic use. 2. Ensure the antiplatelet (medications that prevent blood clots from forming) had monitoring for adverse effect for one of three sampled residents (Resident 338) reviewed for anticoagulant (a substance that is used to prevent and treat blood clots in blood vessels and the heart) use. This deficient practice placed the residents at risk for unnecessary medication and undetected adverse/side effects. Findings: 1. During a review of Resident 21's Face Sheet, the Face Sheet indicated the facility admitted the resident on 11/30/2023. During a review of Resident 21's History and Physical (H&P), dated 11/24/2024, the H&P indicated the resident was awake,…

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 its medication error rate was less than five percent, when seven (7) medication errors out of 28 opportunities contributed to an overall medication error rate of 25%. The medication error rate are as follows: 1. For Residents 66 and 19, Licensed Vocational Nurse (LVN) 1 failed to administer 9 a.m. scheduled medications at the scheduled time. 2. For Resident 86, LVN 1 failed to flush the resident's gastrostomy tube (g-tube- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach for people with swallowing problems) with water in between medications when LVN 1 administered the resident's g-tube medications. These deficient practices had the potential to result in Resident 86 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and the potential to result in Residents 66 and 19's health and well-being to be negatively…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medications errors for one (1) of 1 sampled resident (Resident 10) reviewed for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) use and for three of five sampled residents (Resident 66, 19, and 86) reviewed under Medication Administration facility task, by: 1. Failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites for Resident 10. This deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). 2. Failing to ensure Residents 66 and 19's scheduled medications were administered as ordered at 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 safe and sanitary food storage and food preparation practices in the kitchen when: 1. One disposable cup of coffee belonging to a kitchen staff was placed on top of a metal cart outside the dry food storage area. 2. One and a half boxes of open box of dried noodles and not labeled with an open date was stored in the dry storage area 3. One open bottle of instant coffee and not labeled with an open date was stored in the dry storage area. 4. One open box of wonton chips inside an unsealed plastic bag as not labeled with an open date. 5. One container had a label peas, black eyed dried but observed brown colored short grain inside the container. 6. Observed red potatoes inside a bin that was wet. These deficient practices had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (transfer of bacteria from one object to another) in 88 of 89 residents who receive food from the kitchen.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain timely and accurate resident medical records for two of 21 sampled residents (Residents 4 and 86) when: a. For Resident 4, the Physical Therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) Discharge Summary (DC) and Occupational Therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Discharge Summary was not completed after PT treatment and OT treatments were completed in 1/2025. b. For Resident 86, the PT Discharge Summary was not completed after PT treatment was completed on 3/26/2025. These deficient practices had the potential for inaccurate medical documentation and cause a delay in provision of appropriate interventions for Residents 4 and 86. Findings: a. During a review of Resident 4's Face Sheet (FS), the FS indicated Resident 4 admitted to the facility on [DATE] with diagnoses…

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 2. During a review of Resident 86's Face Sheet (FS), the FS indicated Resident 86 admitted to the facility on [DATE] with diagnoses including but not limited to anoxic brain damage (damage to brain due to lack of oxygen supply to the brain), hemiplegia (weakness to one side of the body) affecting right dominant side, monoplegia (paralysis of one side of the body) of upper limb affecting left nondominant side, and aphagia (a disorder that makes it difficult to speak). During a review of Resident 86's Minimum Data Set (MDS, a resident assessment tool) dated 3/11/2025, the MDS indicated was severely impaired in cognitive skills for daily decision making. The MDS indicated Resident 86 was dependent on staff for oral hygiene, toileting, bathing, dressing, and bed to chair transfers. During a review of Resident 86's Care Plan (CP) dated 3/5/2025, the CP indicated Resident 86 was on EBP related to gastronomy tube (g-tube, a tube placed directly into the stomach for long-term feeding), wear appropriate PPE 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 interview and record review, the facility failed to ensure the physician or medical provider and resident's responsible party (RP) were notified for one (1) of 1 sampled resident (Resident 20) reviewed under change of condition when Resident 20 had an episode of hypoxia (low level of oxygen [O2 - a colorless and odorless gas that the body needs to work properly] in the body). This deficient practice violated Resident 20's right (including RP) to be informed and a had the potential to result in the delay of care, services and further decline of Resident 20 by failing to notify the provider. Findings: During a review of Resident 20's Face Sheet, the Face Sheet indicated the facility admitted the resident on 9/6/2023. During a review of Resident 20's Clinical Record Abstract, the Clinical Record Abstract indicated Resident 20's diagnoses including dementia (a type of progressive dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and Parkinson's disease (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 ensure resident received care consistent with professional standards of practice to prevent pressure injury (PI - localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) for one (1) of 1 sampled resident (Resident 9) reviewed for pressure injury by failing to perform an accurate assessment of Resident 9's PI on the right buttock. This deficient practice placed Resident 9 at risk for developing pressure injuries and worsening of the current PI. Findings: During a review of Resident 9's Face Sheet, the Face Sheet indicated the facility admitted the resident on 3/30/2022. During a review of Resident 9's Clinical Record Abstract printed on 4/11/2025, the Clinical Record Abstract indicated Resident 39's diagnoses including dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and…

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

Based on observation, interview, and record review, the facility failed to ensure a residents with a urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) received appropriate care and services to prevent urinary tract infections (UTI, an infection in the bladder/urinary tract) for one (1) of 1 sampled resident (Resident 40) reviewed for urinary catheter or UTI by failing to ensure Resident 40's urinary catheter tubing was anchored to the statlock (a device that secures the catheter in place preventing it from being pulled out or moving around). This deficient practice had the potential for the resident's urinary catheter to be pulled out or move around which may lead to pain, trauma, and catheter blockage. Findings: During a review of Resident 40's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on 9/27/2023 and readmitted the resident on 2/4/2024. During a review of Resident 40's Clinical Record Abstract, the Clinical Record Abstract indicated Resident 40's diagnoses including unspecified dementia (a progressive…

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 medication and biologicals were stored with currently accepted professional standards for one of three sampled residents (Resident 39) reviewed during the Pressure Ulcer / Injury (PI - localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) care area by failing to ensure mupirocin (a topical medication that treats skin infections caused by bacteria) was removed from the One [NAME] Treatment Cart when the medication was discontinued on 2/12/2025. This deficient practice resulted in Licensed Vocational Nurse (LVN) 1 administering the discontinued mupirocin to Resident 39 potentially resulting in a delay or decline in the resident's PI healing process. Cross reference F755 Findings: During a review of Resident 39's Face Sheet, the Face Sheet indicated the facility admitted the resident on 4/18/2018. During a record review of Resident 39's Patient Diagnosis Information, the Patient Diagnosis Information indicated the resident had diagnoses that included…

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 reduce the risk of adverse events (an undesirable experience or harm that happens to a patient as a result of medical care), including the development of antibiotic-resistant organisms (occurs when bacteria develop defenses against the antibiotics designed to kill them), from unnecessary or inappropriate antibiotic use for one of three sampled residents (Resident 21) reviewed for antibiotic use by failing to clarify with the ordering physician the appropriate indication of Azithromycin (also known as Zithromax, a type of antibiotic) used as a prophylaxis (an attempt to prevent disease) for pneumonia (an infection/inflammation in the lungs). This deficient practice had the potential to cause adverse side effects and risk for resistance associated with the use of inappropriate antibiotic therapy. Findings: During a review of Resident 21's Face Sheet, the Face Sheet indicated the facility admitted the resident on 11/30/2023. During a review of Resident 21's History and Physical (H&P), dated 11/24/2024, the H&P indicated the…

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

Based on interview, and record review the facility failed to establish and implement policies and procedures regarding the use of side rails (SR, adjustable rigid plastic bars attached to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) and physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body). This deficient practice had the potential to result in psychosocial harm, decline in physical functioning, physical harm from entrapment (occurs when a resident is caught between the mattress and SR or wall, or within the SR itself), and death of residents affecting 87 of 87 residents residing in the facility. Cross refernce to F604 and 700. Findings: During an interview and record review on 4/3/2024 at 8:00 a.m., with the Director of Nursing (DON), the DON stated the facility did not have a policy regarding the use of SRs or restraints because they…

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 the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach of the resident for four out of five sampled residents (Residents 77, 56, 70 and 13) investigated during review of environment facility task. These deficient practices had the potential for delaying care and services requested by the residents and placing the residents at risk for falls and injuries. Findings: 1. A review of Resident 77's Face Sheet indicated the facility admitted the resident on 12/14/2023, with diagnoses of nontraumatic (not caused by trauma) subdural hemorrhage (a type of bleeding near your brain), seizures (a sudden, uncontrolled burst of electrical activity in the brain), and dementia (the loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 77's History and Physical (H&P), dated 12/14/2023, indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the patient ' s body that he or she cannot easily remove that restricts freedom of movement or normal access to one ' s body) for four of four sampled residents (Residents 8, 77, 56, and 70) investigated during review of use of restraints by failing to: 1. Ensure side rails (SR, adjustable rigid plastic bars attached to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) were not used without assessing for the need, assessing for risk for entrapment (occurs when a resident is caught between the mattress and bed rail or within the bed rail itself), obtaining informed consent (process in which residents or resident representatives are given important information, including…

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 consistent with professional standards of practice to prevent pressure ulcer/pressure injury (ulcers that happen on areas of the skin that are under pressure from lying in bed, sitting in a wheelchair, or wearing a cast for a long period) to two out of three sampled residents (Resident 58 and 45) being investigated under pressure ulcers by failing to: 1. Set Resident 58's low air loss mattress (LALM, designed to distribute the resident's weight over a broad surface area and help prevent skin breakdown) according to resident's weight and apply Heel Protectors 1 (HP 1, have a cushioned bottom that floats the heel off the surface of the mattress, helping to reduce pressure) on both lower extremities of the resident. 2. Set Resident 45's alternating pressure mattress (APP, a mattress used to prevent or treat pressure ulcers/injuries) according to the user manual. The deficient practices had the potential for development and worsening of pressure ulcers/injuries to the residents. Findings: 1. A review…

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 services and treatments to monitor and maintain joint range of motion (ROM, full movement potential of a joint) for four of five sampled residents by failing to: 1. Provide Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatments as ordered for two of five sampled residents (Residents 2 and 12) and 2. Provide a baseline upper extremity (UE, shoulder, elbow, wrist, hand) range of motion assessment for two of five sampled residents (Residents 45 and 63) upon admission to monitor ROM decline. These deficient practices had the potential to cause decline in ROM, mobility, and overall quality of life for Resident 2, 12, 45, and 63. Cross reference to F725 and F825 Findings: 1a. A review of Resident 2's Face Sheet indicated the facility admitted Resident 2 to the facility on 9/17/2020. A review of Resident 2's Patient Diagnosis Information indicated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the safe and appropriate use of side rails (SR, adjustable rigid plastic bars attached to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) for three of four sampled residents (Resident 8, 77 and 70) investigated during review of restraints by failing to: 1. Conduct an assessment including the risk for entrapment (occurs when a resident is caught between the mattress and bed rail or within the bed rail itself) from side rails. 2. Review the risk and benefits of side rails with the resident or resident representative and obtain informed consent (process in which residents or resident representatives are given important information, including possible risks and benefits, about a procedure or treatment). These deficient practices had the potential to result in psychosocial harm and physical harm from entrapment and death of residents. Cross refernec to F604 and F656. Findings: 1. A…

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

Based on interview and record review, the facility failed to provide adequate and sufficient nursing staff to provide care for residents requiring Restorative Nursing Aide (RNA, nursing aide program that helps residents to maintain their function and joint mobility) services. This deficient practice had the potential for 70 residents with physician's orders for RNA to experience a decline in range of motion (ROM, full movement potential of a joint), mobility, and activities of daily living (ADL, basic activities such as eating, dressing, toileting) function. Cross Reference to F688 and F825 Findings: A review of the physician's orders for residents on RNA services dated 4/3/2024 indicated 70 residents had physician's orders for RNA to provide treatments and services including but not limited to, ROM exercises to upper extremities (UE, shoulder, elbow, wrist, hand) and lower extremities (LE, hip, knee, ankle, foot), application of splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) or braces (an external device to support, align, or…

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 ensure proper storage, preparation, and distribution of food in accordance with professional standards for food service safety by failing to: 1. Ensure a sandwich labeled with a use by date (the date a food item should be discarded) of 3/31/2024 was not readily available for consumption in the resident's room for one of two sampled residents (Resident 24) investigated under the food care area. This deficient practice had the potential to place residents at increased risk of experiencing foodborne illness (an illness that comes from eating contaminated food or drinks). 2. Ensure food was served at a warm temperature for one of two sampled residents (Resident 38) investigated under the food care area and for one of nine residents (Resident 4) present during the Resident Council task. This deficient practice had the potential to affect residents' palatability leading to weight loss or malnutrition. 3. Dispose of a box of lemons…

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 rehabilitative therapy services, including occupational therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) and physical therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) services to two of five sampled residents by failing to: 1. Provide OT services to any residents from 10/7/2023 to present, 2. Provide Residents 45 and 63 with an OT evaluation upon admission per the facility's stated standard of care for all admissions, 3. Provide adequate physical therapy treatments and services to meet Resident 45 and Resident 63's PT care plans and goals. These failures prevented residents from receiving OT evaluation and services to address residents' ROM (ROM, full movement potential of a joint), performance in activities of daily living (ADL, basic activities such as eating,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections for two of four sampled residents observed during medication administration (Resident 2 and 87) and one of two residents investigated for respiratory care (Resident 38) when: 1. Licensed Vocational Nurse 3 (LVN 3) failed to perform hand hygiene prior to preparing Resident 2's medications. 2. LVN 4 failed to perform hand hygiene prior to donning (to put on) gloves and administering eye drops to 3. The facility failed to ensure nasal cannulas (NC, flexible plastic tubing with prongs fitted to the nose that is used to deliver supplemental oxygen or increased airflow to a resident in need of respiratory health) was labeled and dated within the last seven days. These deficient practices had the potential for residents to experience cross-contamination (the process by which bacteria or other…

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

Based on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhance a resident's dignity and respect in full recognition of their individuality during one (Resident 11) of one random observation by failing to ensure the resident's urinary catheter drainage bag (a bag designed to urine drained from the bladder via a catheter) was covered with a privacy bag. This deficient practice had the potential to affect the residents' sense of self-worth and self-esteem. Findings: A review of Resident 11's Face Sheet indicated the facility admitted the resident on 2/14/2024 with diagnoses including neuromuscular dysfunction of bladder (refers to a number of urinary conditions in people who lack bladder control due to a brain, spinal cord or nerve problem), spinal stenosis (narrowing of the spinal column that causes pressure on the spinal cord, and benign prostatic hyperplasia (BPH - a condition in which the prostate gland becomes very enlarged and may cause problems associated with urination). A review of Resident 11's History and…

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

Based on interview and record review, the facility failed to provide the resident and the resident's representative information regarding formulating an advance directive for one of one sampled resident investigated during review of advance directive care area (Resident 38). This deficient practice had the potential for Resident 83 and their responsible person to not be informed of their right to formulate an advance directive and not honor the resident's wishes regarding end-of-life care. Findings: A review of Resident 83's Face Sheet (admission Record) indicated the facility admitted Resident 83 on 6/28/2023. A review of Resident 83's Patient Diagnosis Information, dated 6/28/2023, indicated Resident 83's diagnoses included, but were not limited to, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). A review of Resident 83's History and Physical (H&P), dated 6/29/2023, indicated Resident 83 was awake, alert, and unable to engage in conversation. A review of Resident 83'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 develop a comprehensive person-centered care plan (CP, a written course of action that helps a patient achieve outcomes that improve their quality of life) reflective of resident preferences and consistent with the resident rights to meet a resident's medical, nursing, mental, and psychosocial needs for four of four sampled residents (Residents 8, 77, 56, and 70) reviewed during investigation of restraint (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) use by failing to: 1. Develop and implement a CP for side rail (SR, adjustable rigid plastic bars attached to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) and placement of bed against a built-in dresser wall cabinet for Resident 8. 2. Develop and implement CPs…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice by failing to follow the physician's order to apply thromboembolic deterrent (TED hose- stockings that help prevent blood clots and swelling in the legs) in two of twenty-two random observations (Residents 77 and 56) during the initial screening. The deficient practice had the potential for residents to have poor circulation to the extremities that could lead to thrombosis (the formation of a blood clot within blood vessels). Findings: 1. A review of Resident 77's Face Sheet indicated the facility admitted the resident on 12/14/2023, with diagnoses including acute embolism (when a clump of material, most often a blood clot, get stuck in an artery in the lungs, blocking the flow of blood) and thrombosis, and nontraumatic (not caused by, or not causing, trauma) subdural hemorrhage (a type of bleeding near your brain). A review of Resident 77's…

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

Based on observation, interview, and record review, the facility failed to provide an environment free from accidents and hazards by: 1. Failing to ensure Certified Nursing Assistant 5 (CNA 5) did not transfer one out of one sampled resident (Resident 82) from bed to wheelchair while using a Hoyer lift (a patient lift used by caregivers to safely transfer patients) without another staff assistance investigated during a random observation. This deficient practice placed Resident 82 at risk for falls and serious injuries that include possible fractures and bleeding. 2. Failing to ensure residents did not have lidocaine (a topical [placed on the skin] medication used to treat pain) 4 percent (%, concentration of medication in a solution) roll-on bottle at bedside for one of one sampled resident (Resident 24) investigated under the care area Pain Management. This deficient practice had the potential to result in residents self-administering medications without staff knowledge resulting in overdose, loss of resident medication, or a delay in care and services. Findings: 1. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to label the valproic acid (used to treat seizure disorders [a sudden, uncontrolled burst of electrical activity in the brain], mental/mood conditions) 250 milligrams (mg, a unit of mass or weight) / 5 milliliter (ml, a unit of volume) 125 mg (2.5 ml) solution bottle with an expiration date, affecting Resident 70 in one out of three inspected medication carts (Med Cart A). The deficient practice of failing to label the medication with the expiration date increased the risk that Resident 70 could have received medication that had become ineffective or toxic and could result in health complications. Findings: A review of Resident 70's Face Sheet indicated the facility admitted the resident on 12/30/2024, with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking…

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

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly by not covering the garbage container next to the hand washing station in the kitchen during the initial tour of the kitchen conducted on 4/2/2024 between 7:54 a.m. to 9:00 a.m. This deficient practice had the potential for the spread of bacteria and cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) after hand washing. Findings: During a concurrent observation and interview with the Director of Hospitality (DH), on 4/2/2024, at 7:54 a.m., inside the kitchen, the garbage container next to the sink did not have a lid and contained crumpled white paper towels. The DH stated the observed sink was used in the kitchen as the hand washing station. The DH confirmed the garbage container next to the hand washing station did not have a lid. The DH further stated he was unsure if the garbage container next to the hand washing station should be lidded. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain timely resident medical records for one of four (Resident 38) when Resident 38's Physical Therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function)) Initial Evaluation dated 11/8/2023 was not documented until 4/4/2024. This deficient practice had the potential for inaccurate medical documentation and cause a delay in provision of appropriate interventions for Resident 38. Findings: A review of Resident 38's Face Sheet indicated the facility admitted Resident 38 admitted on [DATE]. A review of Resident 38's Patient Diagnosis Information indicated Resident 38 had diagnoses including, but not limited to polyosteoarthritis (swelling and tenderness of a joint causing pain and stiffness), morbid (severe) obesity due to excess calories (disorder involving excessive body fat that increased risk for health problems), abnormalities of gait (walking) and mobility. A review of Resident 38's Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide Restorative Nursing Assistance (RNA, a program designed to ensure each resident maintains their physical and functional abilities) services as ordered by the physician to four of thirteen sampled residents (Residents 2 and 43, 29, and 37). This deficient practice had the potential to result in a decline in mobility and range of motion (the extent or limit to which part of the body can be moved around a joint or a fixed point) for residents. Findings: a. A review of Resident 2's Face Sheet indicated the facility admitted the resident on 1/23/2020 and readmitted the resident on 9/12/2020, with diagnoses including, abnormalities of gait (a manner of walking or moving on foot) and mobility, polyosteoarthritis (a joint disease that involves at least five joints), and venous insufficiency (a condition in which the veins have problems sending blood from the legs back to the heart). A review of Resident 2's Minimum Data Set (MDS - a standardized…

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

Based on observation, interview, and record review, the facility failed to store food in a sanitary manner by failing to ensure food items were not expired. These deficient practices had the potential to result in foodborne illnesses (also called food poisoning, illness caused by eating contaminated food) for residents living in the facility. Findings: During a concurrent initial kitchen tour observation and interview on 4/10/2023 at 8:38 a.m. with the Director Hospitality (DH) and the Facility Chef (FC), observed the following: 1. A package of strawberries with grayish white fluff. 2. Two (2) cases of graham cracker crumb a total of four (4) bags that had an expiration date of November 28, 2022. 3. Frozen food with use by of 3/23/2023 stored in the freezer. 4. Prepared food with use by date of 3/11/2023 stored in the freezer. The DH and the FC verbally acknowledged the items were expired and stated it should have been discarded. The DH stated expired items have the potential to cause residents to get sick when ingested. During an interview on 4/11/2023 at 12:53 p.m. with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program by: 1. Failing to ensure Food Service Worker (FSW 1) and FSW 2 washed their hands before donning and after removal of gloves 2. Failing to ensure the Transportation Coordinator (TC) observe hand hygiene and change gloves between residents during meal tray pass. 3. Failing to ensure CNA 1 provide hand hygiene to one out of six sampled residents (Resident 75) prior to meals. These deficient practices had the potential to result in contamination of residents' food through cross contamination (bacteria or other microorganisms are unintentionally transferred from one substance or object to another with harmful effect). Findings: 1.a. During an observation of the tray line service on 4/10/2023 at 11:17 a.m. observed Food Service Worker (FSW 1) wearing gloves while serving the trays. FSW 1 was observed removing gloves and applying new gloves, without washing his hands. observation of hand…

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 Transportation Coordinator (TC) sat at eye level to the resident while assisting the resident with feeding for one of two sampled residents (Resident 24). This deficient practice had the potential to affect the resident's sense of self-worth and self-esteem. Findings: A review of Resident 24's Face sheet indicated the facility admitted the resident on 2/5/2021 and readmitted the resident on 11/1/2021 with diagnoses including Alzheimer's diseases (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 24's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/10/2023 indicated Resident 24 can usually make self-understood and sometimes understands other. The MDS indicated Resident 24 was totally dependent on bed mobility, transferring, dressing, eating, and toilet…

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 call light was within reach of the resident for one of two sampled residents (Resident 11). This deficient practice had the potential to result in residents not being able to ask health care workers for assistance and increase the resident's risk for injury due to fall. Findings: A review of Resident 11's Face sheet indicated the facility admitted the resident on 6/11/2020 with diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy). A review of Resident 11's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/24/2023 indicated Resident 11 can usually make self-understood and can…

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

Based on observation, interview, and record review, the facility failed to promote the resident rights to examine the results of the most recent survey (a survey to determine compliance with state and federal regulations) of the facility by failing to: 1. Post the most recent survey results in a place that are prominent and accessible (a place where individuals wishing to examine survey results do not have to ask to see them) to residents and the public. 2. Ensure the residents know where to find the results of the most recent survey for eight out of eight (Residents 25, 65, 36, 44, 55, 35, 6, and 41). These deficient practices had the potential to impede the resident rights and negatively affect residents' psychosocial wellbeing. Findings: During the Resident Council meeting on 4/11/2023 at 10:40 a.m., Residents 25, 65, 36, 44, 55, 35, 6, and 41 were asked, Without having to ask, are the results of the State inspection available to read? Eight out of eight residents stated they do not know where to find the results of the most recent survey. During a concurrent observation and…

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

Based on interview and record review, the facility failed to offer the resident or resident representative assistance with formulating an Advance Directive (AD - a legal document telling the doctor one's wishes about their healthcare in the event they cannot make the decision for themselves) upon admission for one (Resident 37) of two sampled residents investigated under the care area Advance Directives. This deficient practice violated the resident and/or their representatives the right to be fully informed of the option to formulate an AD and had the potential to cause conflict due to lack of communication regarding residents' wishes about their medical treatment. Findings: A review of Resident 37's Face Sheet, the facility admitted the resident on 6/15/2017 with diagnoses including cerebellar stroke syndrome (a condition that happens when blood supply to the cerebellum [part of the brain that helps with body movement, eye movement, and balance] is stopped), aphasia (a disorder that affects your ability to speak, read, write and listen) following cerebral infraction [a stroke that…

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

Based on interview and record review, the facility failed to ensure licensed nurses provide care in accordance with professional standards by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin (a hormone that lowers the level of sugar in the blood) injection sites for one out of six sampled residents (Resident 39). This deficient practice had the potential to cause unnecessary tissue trauma and hardening of the area where frequent subcutaneous administration occurred that could lead to impaired absorption (a condition in which the body takes in another substance) of insulin. Findings: A review of Resident 39's Face Sheet indicated the facility admitted the resident on 11/4/2020 and readmitted the resident on 1/19/2023, with diagnoses including, type 2 diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, is too high), hypoglycemia (low blood sugar), and encephalopathy (any disease of the brain that alters brain function or structure). A review of Resident 39's…

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

Based on observation, interview, and record review the facility failed to ensure resident safety for one (Resident 41) out of two sampled residents investigated under the Accidents care area by failing to: 1. Implement its policy and procedure to provide supervision and smoking apron to the resident while smoking in the patio during scheduled smoking times. 2. Conduct a smoking risk assessment to determine if the resident required supervision during scheduled smoking times. These deficient practices placed Resident 41 at risk for smoking-related injuries Findings: A review of Resident 41's Face Sheet indicated the facility admitted the resident on 10/22/2020 with diagnoses including human immunodeficiency virus (HIV - a condition that weakens a person's immune system by destroying important cells that fight disease and infection), ataxia (lack of muscle coordination that may affect a person's speech, eye movements, and ability to swallow, walk, and pick up objects), spinal stenosis lumbar region (a condition that happens when the space inside the backbone is too small that may lead…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to discard expired needles and syringes (small hollow tube used for injecting or withdrawing liquids) stored in the medication storage room. The deficient practice had the potential for nursing staff using needles and syringes on residents that may no longer be sterile. Findings: During an observation and interview on [DATE], at 9:06 a.m., with the Director of Pharmacy (DP), observed an expired, unopened 24 gauge needles with expiration date of 11/2020 and 20 milliliter (ml, a unit of volume) syringes with expiration date of 11/2017, in a bin in the medication storage room. The DP stated she will dispose of the expired supplies to prevent accidental usage that may cause infection. During an interview on [DATE], at 2:07 p.m., with the Director of Long-Term Care (DLTC), the DLTC stated the expired supplies should not be used because it can cause infection. A review of the facility's policy and procedure titled Shelf Life of Sterile Supplies,…

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.