Woodland Post-Acute

Based on observation, interview, and record review, the facility failed to ensure respiratory care and services were provided according to professional standards of care for one of 24 sampled residents (Resident 74) when: 1. Resident 74's nebulizer (a small machine that turns liquid medicines into mist to deliver medication) tubing was not replaced every 7 days; and,2. Resident 74's oxygen use was not accurately documented. These failures had the potential to result in respiratory infection and undetected deterioration of respiratory function for Resident 74. A review of the admission Record indicated Resident 74 was readmitted early February 2026 with diagnoses including chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing) and acute respiratory failure (lungs cannot get enough oxygen into the blood) with hypercapnia (too much carbon dioxide in the blood). A review of Resident 74's Medication Administration Record (MAR) for March indicated the following physician orders:-Ipratropium- Albuterol solution (used to treat breathing…

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 Certified Nursing Assistants (CNAs) had an annual performance review for one of five sampled CNA staff (CNA 3).This failure had the potential for CNA 3 to provide inadequate care to residents.During a concurrent interview and record review on 3/19/26, at 12:14 p.m., with Director of Staff Development (DSD) CNA 3's personnel file was reviewed. CNA 3's personnel file indicated, he was hired on 2/4/25. Personnel file indicated, no annual performance review was completed. DSD stated, I am not sure how we track when they [annual performance reviews] are due. DSD stated, he did not see an annual performance review in the file, and there should be one in the personnel file. During a review of the facility's Employee Handbook dated 2023, Handbook indicated, Performance Evaluations, Performance feedback should be on-going between supervisors and employees. However, we established annual, documented reviews as a standard to formalize an interactive conversation about what is going well, where there could be improvements, goals…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5 percent (%)) when two medications out of 31 opportunities were not given in accordance with the physician's orders for two residents (Resident 93 and Resident 79). This failure resulted in a medication error rate of 6.45%.1a. A review of the admission Record indicated Resident 93 was admitted [DATE] with diagnoses including acute osteomyelitis (sudden, severe infection of the bone) of left ankle and foot and sepsis (a life- threatening blood infection). A review of Resident 93's Order Summary Report indicated Resident 93 had an order for Prasugrel (antiplatelet or blood thinner- medication used to prevent blood clots) HCL (hydrochloride) 10 milligram (mg, unit of measurement) give 1 tablet by mouth one time a day for Antiplatelet therapy on 3/6/26. During a medication pass observation on 3/18/26 starting at 7:23 a.m. with Licensed Nurse 6 (LN 6), Resident 93's Prasugrel 10 milligram was 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.

Based on interview and record review, the facility failed to ensure a written agreement was obtained for services furnished by outside resources for one of 24 sampled residents (Resident 10) receiving dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed). This failure had the potential to result in the lack of accountability in the dialysis services. A review of the admission Record indicated Resident 10 was admitted October of 2025 with diagnoses including atherosclerotic heart disease (build up of fat or cholesterol in the heart's arteries causing them to narrow and harden) and end stage renal disease (ESRD, irreversible kidney failure). A review of Resident 10's physician order dated 3/6/26 indicated, HEMODIALYSIS AT [Dialysis company name and address] .MWF [Monday, Wednesday, Friday] .During an interview on 3/19/26 at 4:36 p.m. with the Administrator (ADM), the ADM stated he would look for the agreement between the facility and the dialysis clinic. During a follow up interview on 3/20/26 at 12:04 p.m.…

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 infection prevention and control practices for two of 24 sampled residents (Resident 15 & Resident 19) when:The facility did not implement Enhanced Barrier Precautions (EBP: an infection control strategy in nursing homes requiring staff to wear gowns and gloves during high-contact care for residents at risk of carrying multidrug-resistant organisms) for Resident 15 andFacility staff left soiled linens and trash on Resident 19's bed.These failures had the potential to spread communicable disease to an at risk population.1.During an observation on 3/17/26, at 10:21 a.m., Resident 15's room did not have any isolation precautions signs. Multiple care staff were observed entering and exiting Resident 15's room without wearing PPE (Personal protective equipment). During an observation on 3/18/26, at 8:35 a.m., Resident 15's room did not have any isolation precautions signs.During a review of Resident 15's Facesheet (a summary document,…

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 their Policy and Procedures to process a refund for one of four sampled residents (Resident 1) when the resident's share of cost (the amount of money an individual is responsible to pay towards their medical related services, supplies, or equipment before Medi-Cal will begin to pay) was not returned to the family within 60 days upon Resident 1's death.This failure had the potential to result in fiduciary abuse and a violation of Resident 1's rights. Findings:A review of Resident 1's admission Record indicated; Resident 1 was admitted to the facility in 2020 with a diagnoses that included Encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition). The admission Record further indicated Resident 1 was their own responsible party. A review of Resident 1's Minimum Data Set (MDS - an assessment tool used to guide care) Cognitive (having full understanding) Patterns, dated [DATE], indicated Resident 1 had a…

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

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of six sampled Residents (Resident 1) despite Resident 1's admitting diagnosis of stimulant (drugs that increase the activity of the central nervous system) use and a positive illicit drug test results from the urine drug screening during the recent hospitalization. This failure placed Resident 1 at risk for undetected drug use or relapse, undetected overdose that could result in medical emergency and had the potential for delayed delivery of care and mental health decline. Findings: Resident 1 was admitted to the facility mid-2025 with a diagnoses of deep skin infection caused by bacteria and other stimulant abuse. A review of Resident1's Brief Interview for Mental Status (BIMS), dated 5/15/25, the BIMS indicated Resident 1 had a score of 15 out of 15 which indicated Resident 1 was cognitively intact. A review of Resident 1's Order Summary Report (OSR), dated 5/14/25, the OSR indicated, .Resident has mental capacity to make decisions. 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 ensure an allegation of abuse was reported within the required timeframe for one of three sampled residents (Resident 1) when an allegation of abuse was not reported per facility policy. This failure of timely reporting had the potential to cause a delayed response by enforcement agencies to ensure resident safety. Findings: A review of a facility document, dated 1/15/25 and received by the Department on 1/15/25, indicated an allegation of suspected dependent adult/elder abuse had been made related to an employee to resident verbal and physical abuse between Registry Staff 1 (RS 1) and Resident 1. During an interview, on 1/17/25 at 12:49 p.m., Licensed Nurse 1 (LN 1) confirmed that the allegation was reported to her on 1/9/25 and she did not report it to the Administrator who is the Abuse Prevention Coordinator (APC). During an interview, on 1/17/25 at 1:33 p.m., Certified Nursing Assistant 1 (CNA 1) confirmed she heard the allegation of abuse on 1/9/25 at the nurse ' s station and acknowledged that it was not reported to…

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

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received care which met professional standards when he was involved in an employee to resident abuse allegation, and it was not documented by nursing and social services department. This failure resulted in inaccurate assessment documentation and had the potential to result in unmet nursing and psychosocial needs for Resident 1. Findings: A review of Resident 1 ' s admission record indicated he was last admitted in late 2024 with diagnoses including encephalopathy (brain dysfunction) and dementia (a progressive state of decline in mental abilities). A review of Resident 1 ' s clinical record included the following documents: A Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 12/23/24, indicated Resident 1 had severe memory impairment. A Skilled Services Documentation, dated 1/8/25 and 1/15/25, indicated no documented evidence of abuse allegation. Further review of document indicated no body check was done on Resident 1, no documented evidence 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 protect resident privacy when tray tickets were thrown into the trash for a census of 87 who were eating facility prepared meals This failure had the potential for 87 residents' personal and health information unprotected form unintended access. Findings: During the initial kitchen tour on 1/6/25 at 9:49 a.m., the Dietary Supervisor (DS) showed the path taken of kitchen trash to the outside dumpsters in the parking lot. The parking lot was not gated or secured from the public. During a return visit on 1/7/25 at 8:46 a.m., Diet Aide 1 (DA 1) was washing the breakfast dishes. She removed the trays from the cart, dumped leftover food and paper products (including at least 12 tray tickets) into the garbage can, before separating like items for wash. When questioned, DA 1 stated this was her usual process. During a subsequent interview on 1/7/25 at 8:58 a.m., with the DS, the DS stated the tray tickets should be placed in a bin (found in the dry storage) that collected paper for shredding. The DS further 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.

Based on observation, interview, and record review, the facility failed to identify and provide care for one of 24 sampled residents (Resident 1) when no wound care orders, monitoring, or care plans were created for Resident 1's left great toe wound. This failure placed Resident 1 at increased risk for wound deterioration and infection. Findings: Resident 1 was re-admitted to the facility 12/13/24 with diagnoses which included hardening of left leg arteries, diabetes (a condition in which the body has trouble controlling blood sugar), vascular disease that occurs when diabetes damages blood vessels, reducing blood flow to organs, and gangrene (dead tissue caused by an infection or lack of blood flow). During a review of Resident 1's SKILLED NURSING FACILITY admission ORDERS dated 12/13/24, the orders indicated, Diagnosis .GANGRENE OF LEFT TOE .wound .Anterior Left Toe. During a review of Resident 1's admission NURSING ASSESSMENT, undated (uploaded into electronic record 12/17/24), the assessment indicated, Left Great Toe Meta [illegible] Joint Black Toe Nail (sic). During 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.

Based on observation, interview, and record review, the facility failed to ensure pharmacy services were maintained for a census of 87 residents when: 1. An unsealed e-kit (emergency supply kit) was found in the medication storage room, which resulted in prescription medications being at risk for diversion and use without a prescription. 2. An e-kit was previously accessed multiple times without medications being replaced by the pharmacy which had a potential to cause harm by not having enough emergency medication for the residents. These failures had the potential for drug diversion, medication errors, and not having medications readily available in emergency situations. Findings: 1. During the medication storage room observation on 1/6/25 at 12:05 p.m. in the first-floor medication storage room with Licensed Nurse (LN) 8, an IV (Intravenous, medications given through the veins) e-kit #368 was observed unlocked. Inside e-kit, there was a bag of yellow zip-ties in a bag sitting on top of multiple prescription medications and medical supplies. During an interview on 1/6/25 at 12:05…

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 three of 87 sampled Residents (Resident 10, Resident 30 and Resident 25) were free from unnecessary antipsychotic medications (drugs that alter a person's thoughts, feelings, moods, awareness, and behaviors used to treat mental health conditions) when: 1. An Antipsychotic was prescribed for treatment of schizoaffective disorder (a condition that affects a person's ability to think, feel, and behave clearly with mood symptoms) in a dosage indicative for treatment of sleep disturbance without an FDA approved diagnosis for Resident 10. 2. An Antipsychotic was prescribed for Resident 30 with no previous documented serious mental health diagnosis prior to admission. 3. Resident 25 received an as needed antianxiety medication without a 14 day stop date. These failures placed Resident 10 and Resident 30 at an increased risk for adverse drug effects and Resident 25 for receiving psychotropic medication without proper evaluation. Findings: 1. Resident 10 was admitted to the facility in 01/2017 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.

Based on observation, interview, and record review, the facility failed to ensure the medication rate did not exceed 5% for three of four sampled residents (Resident 16, 486, and 55) for a census of 87 when five medication errors occurred out of 29 opportunities that resulted in 17.2% medication error rates. 1. For Resident 16, a Licensed Nurse 2 (LN 2) administered Resident's calcium and vitamin D (a supplement used to raise calcium and vitamin D levels), not in accordance with Physician Orders when one tablet of calcium 600mg (milligram, unit of measurement) + 400 units (unit, a measurement) vitamin D was administered when the physician ordered calcium-vitamin D tablet 600-200mg/unit, give 2 tablets by mouth one time a day. 2. For Resident 486, a Licensed Nurse 7 (LN 7) did not administer hydroxyzine (a medication used to treat anxiety and tension caused by nervous and emotional conditions) when hydroxyzine was not stocked on the medication cart nor available for administration. 3. For Resident 55, LN 2: a. did not administer buspirone (a medication that treats anxiety) when it…

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 medications were stored and labeled correctly, when: 1. Unopened insulin pens were not kept refrigerated, 2. Opened multidose inhalers did not have open dates to determine expiration dates, 3. Personal items and non-pharmaceutical items were stored in a medication cart and a medication room, 4. Expired insulin pens were not discarded and still available for use, 5. Loose pills were found in a medication carts and a medication room, 6. Prescription pharmaceutical products did not have patient specific labels, and 7. A prescription blister pack and a prescription eye drop were dropped in the back of a medication cart and not accessible to be used for Resident's needs. These failures had the potential for accidental use of expired medications, drug diversion, infection control risk, and safety risk for a census of 87. Findings: 1. a. During a medication cart check of medication cart #1 on 1/6/25 starting at 11:17 a.m. at the first-floor nurse's station with LN 4, a Basaglar Kwikpen (an insulin pen used to…

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

Based on observation, interview, and record review the facility failed to provide food storage and preparation in accordance with professional standards for food service safety when: 1. Kitchen containers and steam table pans were found stored wet, 2. Several food items in freezer and refrigerator were not securely closed, 3. A stored steam table pans found to have food residue in the pan, 4. Red cutting board for meat found with deep grooves, 5. Shelf under cook's food preparation table was found with rust and white discoloring, and 6. Floor drain near cook's station had green-colored build up around drain along with chipped and worn flooring. Theses failures had the potential of leading to food borne illness for 87 residents out of a census of 87 who are eating facility prepared foods. Findings: 1. During the initial kitchen tour on 1/6/25 at 9 a.m., 2 kitchen containers and container lids, 2 carafes, and 4 steam table pans were observed stored wet. During a concurrent interview on 1/6/25 with Dietary Supervisor (DS), DS stated, The kitchen equipment should be clean and dry before…

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

Based on observation, interview, and record review, the facility failed to provide a resident refrigerator and microwave for staff to store and heat residents' food. This failure had the potential of leading to poor food intake, weight loss, and food borne illness for the 87 residents eating meals. Findings: During the initial kitchen tour on 1/6/25 at 9:09 a.m., the Dietary Supervisor (DS) stated that resident food was not kept in the kitchen and that residents did not have a place to store food in the facility. During an interview on 1/8/25 at 9:12 a.m. on the first floor with Licensed Nurse 4 (LN 4), the handling of food from outside sources was discussed. LN 4 stated residents were allowed food from outside, and staff would check the food against the diet order to see if the food was appropriate before giving to the resident. When the resident had finished eating, the food would not be kept as the facility had no refrigerator or microwave for resident food. During an interview on 1/8/25 at 9:28 a.m., on the second floor with Certified Nursing Assistant 5 (CNA 5), CNA 5 explained…

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 prevent the development and transmission of communicable diseases and infections for 4 residents (Residents 32, 53, 61 and 57) in a census of 87 when: 1. Resident 32's nebulizer (machine that turns liquid medication into a mist so that it can be breathed directly into the lungs through a face mask or mouthpiece) and Resident 53 and Resident 61's oxygen tubings were not covered or labeled, and when 2. Resident 57's urinary catheter (a thin tube used to drain urine from the bladder to an outside collection bag) was found touching the floor multiple times during the survey period. These failures increased the potential for infection for the residents . Findings: 1. Resident 32 was admitted to the facility in the fall of 2024 with diagnoses which included irregular heartbeat and not having enough healthy red blood cells. During a review of Resident 32's Minimum Data Set (MDS, 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.

Based on interview and record review, the facility failed to follow physician orders for one of 24 sampled residents (Resident 41) when Resident 41's medication to treat high blood sugars was not given as ordered by the physician. This failure had the potential for Resident 41 to have unmanaged blood sugars. Findings: Resident 41 re-admitted to the facility late 2023 with diagnoses which included trouble controlling his blood sugars. During a review of Resident 41's Order Summary Report [OSR], order start date of 12/4/23, the OSR indicated, HumaLOG [fast acting insulin that is used to lower blood sugar] Inject as per sliding scale: if 70-150=NONE; 151-200=NONE; 201-250=1; 251-300=2 NOTIFY MD [medical doctor] if BS [blood sugar] is < [less than] 70 or > [greater than] 301, intramuscularly at bedtime . During a review of Resident 41's Medication Administration Record [MAR], dated 11/1/24-12/31/24, the MAR indicated Resident 41 had a BS of 340 on 11/3/24, a BS of 320 on 11/6/24 and a BS of 304 on 12/2/24. The MAR indicated Humalog was not administered on any of these dates with a…

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

Based on observation, interview, and record review, the facility failed to implement wound prevention measures for one of 24 sampled residents (Resident 65) when Resident 65's heel foam protectors were not put on per physician order. This failure had the potential to worsen or complicate Resident 65's wound. Findings: Resident 65 was admitted to the facility in October of 2024 with diagnoses that included diabetes (disorder causing blood sugar to be high) and non-pressure open wound to heels. A review of Resident 65's, Wound Physician Consultation Note [WPCN], dated 12/30/24, indicated Resident 65 had a stage three pressure ulcer (damage to the skin from prolonged pressure ranging from stage one to stage four with four being the most severe) to his left heel and a stage two pressure ulcer to his right heel. The WPCN indicated there was no change in the wound status since the last visit. A review of Resident 65's Order Details (OD), dated 1/2/25, indicated, TX [treatment]- Apply foam booties [foam placed on heels to prevent wound or wound progression] as tolerated when in bed. Three…

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 Resident 14's weight when resident 14 lost 14.5% of his body weight in a 6-month period. This failure had the potential of leading to malnutrition and increased mortality. Findings: During the initial dining observation on 1/7/25 at 12:04 p.m., in the dining room, resident 14 was observed eating his meal. Resident 14 was noted to eat independently but was easily distracted and needed to be redirected to eat twice. Resident 14 left the dining room with approximately 50% of his meal consumed. During an observation on 1/8/25 at 12:03 p.m. in the dining room, Resident 14 had finished eating his lunch meal having eaten most of the hamburger but no other tray items. During an observation on 01/09/25 at 11:48, in the dining room, Resident 14 ate 1 (4 ounce) ice cream container, drank 100% of an 8 ounce milk carton, and few bites of the pasta entree. During a review of resident 14's electronic record on 1/7/25 at 3:04 p.m., Resident 14…

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 maintain accurate and consistent medical records for two of 24 sampled residents (Resident 1 and Resident 41) when: 1. Resident 1's progress notes (PN) did not include any reason medications were not administered; and 2. Resident 41's insulin (a medication to treat high blood sugars) administration documentation was inconsistent. These failures created inaccurate health records which increased the potential for incorrect assessment of the residents and for creating miscommunication among healthcare professionals regarding the residents health status. Findings: Resident 1 was re-admitted to the facility in late 2024 with diagnoses which included a condition in which the heart does not pump adequately, progressive damage and loss of kidney function, high blood pressure, and irregular rapid heart rate that causes poor blood flow. During a review of Resident 1's Order Summary Report [OSR], dated 1/7/24, the OSR indicated, Metoprolol Tartrate [medication to treat high blood pressure and heart failure] .two times a day for htn…

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 an allegation of sexual abuse was reported within the required timeframe for two of seven sampled residents (Resident 4 and Resident 6), when the Department did not recieve a report of the alleged sexual abuse incident within two hours of occurence. This failure to report timely had the potential to compromise vulnerable residents' health and safety. Findings: A review of an admission record indicated Resident 4 was admitted to the facility on [DATE], with diagnoses including paranoid schizophrenia (brain condition in which the mind does not agree with reality), difficulty walking; spinal stenosis in lumbar region (nerve damage to lower back); and cognitive communication deficit (mental processing communication problem). A review of an admission record indicated, Resident 6 was admitted to the facility on [DATE], with diagnoses including unspecified dementia without behavioral disturbance (progressive decrease in brain function with no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free from abuse when he was struck in the head and chest several times by Resident 2. This failure had the potential to result in serious physical harm. Findings: According to Resident 1's admission record, he was admitted on [DATE] with diagnoses that included Degeneration of Nervous System Due to Alcohol (trouble with balance and body coordination due to chronic alcohol use) and anxiety. A Minimum Data Set (MDS, an assessment tool), dated 4/24/24, indicated Resident 1 had no memory impairment. A nursing note, dated 6/9/24, indicated Resident 1 had been involved in a resident to resident altercation on 6/8/24. The note indicated Resident 1 had been hit in the chest and head area 4-5 times by Resident 2. According to Resident 2's admission record, he was last admitted on [DATE] with diagnoses that included Antiphospholipid Syndrome (a disorder of the immune system that can cause blood clots) and…

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

Based on interview and record review, the facility failed to ensure an allegation of abuse was reported within the required timeframe for two of four sampled residents (Resident 1 and Resident 2) when an allegation of abuse was not reported to the Department until the following day. This failure to report timely had the potential to compromise resident health and safety. Findings: A review of a facility document, Report Of Suspected Dependent Adult/Elder Abuse , dated 6/8/24 and received by the Department on 6/9/24, indicated an allegation of suspected abuse had been made related to a resident to resident altercation between Resident 1 and Resident 2. In an interview, on 6/24/24 at 12:22 p.m., the Director of Nursing (DON) stated it was the facility's policy to report an allegation of abuse to the Department within 2 hours. The DON 1 confirmed the 6/8/24 allegation had not been reported to the Department until 6/9/24. A review of the facility's policy titled, Elder/Dependent Adult Abuse, revised 7/17, indicated reports of physical abuse would be made within two hours to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure call lights were accessible for seven of 28 sampled residents (Resident 70, Resident 43, Resident 6, Resident 26, Resident 10, Resident 27, and Resident 64), when the call light buttons were not reachable. This failure increased the potential staff would not be alerted to resident needs or emergencies, and the residents not attaining their highest practicable physical and psychosocial well-being. Findings: 1. Resident 70 was admitted to the facility in the fall of 2023 with diagnoses which included chronic obstructive pulmonary disease (COPD, a lung disease), anxiety and heart failure. During a review of Resident 70's Minimum Data Set (MDS, an assessment tool), dated 9/29/23, the MDS indicated Resident 70 had severe memory impairment. During a review of Resident 70's undated Nursing Care Plan (NCP) titled, Communication Deficit R/T [related to]Dementia, the NCP indicated, Keep call light within reach .All Staff . During and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement care plans for two of 28 sampled residents (Resident 50 and Resident 3), when: 1. No care plan was developed or implemented on smoking for Resident 50; and 2. No care plan was developed or implemented on wound care for Resident 3. These failures had the potential to result in residents not attaining their highest practicable physical, mental and psychosocial well-being. Findings: 1. Resident 50 was admitted to the facility in the fall of 2023 with diagnoses which included chronic obstructive pulmonary disease (a lung disease). During a review of Resident 50's Minimum Data Set (MDS, an assessment tool), dated 10/26/23, the MDS indicated Resident 50 was alert and oriented. During a review of Resident 50's document titled, Smoking Safety Evaluation [SSE], dated 11/1/23, the SSE indicated Resident 50 smoked 2-5 times a day. During a review of Resident 50's Nursing Care Plan (NCP) titled, Resident wishes to smoke and is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement its pharmaceutical policies and procedures for a census of 85 when an expired E-Kit (Emergency-Kit, storage box containing emergency supplies of medication) was not removed and replaced with the potential for not having all the emergency medications available to the residents and increased risk of drug diversion. Findings: During an inspection of medication room on [DATE] at 9:40 a.m. on the second floor, E-kit #1043 was found to be previously opened by the staff on [DATE] at 1600 [4 p.m.] and then again on [DATE] at 0800 [8 a.m.] and 2100 [9 p.m.], but it was not replaced by the pharmacy. During an interview on [DATE] at 9:41 a.m. with Licensed Nurse 2 (LN 2), LN 2 stated, the E-kit was originally opened on [DATE] and twice again on [DATE]. I [LN 2] called the pharmacy today [[DATE]] to replace it. It needs to be replaced to have all the medications available for the residents. If not replaced right away other staff can gain…

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 medications were stored properly according to the facility's policies and procedures for a census of 85, when: 1. An expired medication was available for Resident 17 to use in the medication cart which put residents 17 at risk of receiving an expired medication; 2. A tube of prescription medication was found in a treatment cart without a resident specific pharmacy label; 3. The temperature of a medication refrigerator on the second floor was out of range, which put medication requiring a specific temperature at risk of degradation; and, 4. An opened and used multidose vial of a testing solution, with a shorter expiration date when opened, did not have an open date which put residents at risk of having inaccurate test results. Findings: 1. During an inspection of medication cart 1 on [DATE] at 12:41 p.m. on the third floor, an expired insulin glargine pen (medication to treat high blood sugar levels) for Resident 17 was found in the…

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

Based on observation, interview and facility document review, the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety, when: 1. Dietary staff and vendors did not wear face masks during a Covid outbreak in the facility; 2. Trays were stored upright to dry; 3. Foods were not labeled with received, opened and/or use by date; and 4. Dietary Aid touched face with gloved hands and then touched the rim of tumblers meant for resident drinks. These failures increased the potential for food-borne illnesses and communicable diseases. Findings: 1. During a concurrent observation and interview on 12/11/23 at 8:10 a.m., the [NAME] opened the kitchen door and was noted not wearing a facial mask. The [NAME] was asked if kitchen staff were required to wear a mask with Covid in the facility and said, We don't go to patient area. I'll get a mask. During a concurrent observation and interview on 12/11/23 at 8:18 a.m., the Fire Safety Contractor (FSC) was noted to be up on a ladder in the kitchen and not wearing a facial mask. When…

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 Quality Assessment and Assurance (QAA) committee, a component of the facility's Quality Assurance Performance Improvement (QAPI) for a census of 85, when: 1. The QAA did not meet at least quarterly in 2023; and 2. The QAA committee meeting did not have the required members in attendance. This failure had the potential for quality care improvement activities to not be evaluated and revised as needed and the potential to negatively impact the quality of resident care. Findings: During a concurrent observation and interview on 12/14/23 at 1:32 p.m. with the Director of Nursing (DON), the DON reviewed the 2023 QAPI program binder looking for the quarterly QAA/QAPI committee meeting sign-in sheets. The DON acknowledged the facility could only produce a completed sign in sheet for the QAA/QAPI committee meeting that occurred on 10/27/23 and did not provide the other three quarters for the year. During an interview on 12/14/23 at 2:24 p.m. with the Administrator (ADM), the ADM stated his goal was for QAPI…

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 smoking policies were established, managed and implemented for safety on both smoking and non-smoking residents in accordance with applicable laws and regulations for three out of 28 sampled residents (Resident 4, Resident 50, and Resident 68) in a census of 85, when: 1. Resident 50 possessed and used a cigarette lighter in his room; 2. Resident 4 kept her own smoking paraphernalia in her room and provided cigarettes to other residents; and 3. Resident 68 kept his cigarettes and lighter and went to smoke outside the facility with no staff supervision. These failures had the potential to result in an increased risk of accidents, burns and injuries. Findings: During a review of the facility document titled, SMOKING LIST, dated 11/27/23, the document indicated 11 residents on the list who smoke independently, which included Resident 4, Resident 50 and Resident 68. 1. Resident 50 was admitted to the facility in the fall of 2023 with…

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

Based on interview and record review, the facility failed to report an allegation of abuse involving one of 28 sampled residents (Resident 41), when the Department received the report of allegation of abuse greater than two hours after the facility was made aware of the allegation. This failure decreased the facility's potential to protect vulnerable residents and provide a safe environment. Findings: During a review of Resident 41's Minimum Data Set (MDS: an assessment tool), dated 11/29/23, the MDS indicated Resident 41 was admitted to the facility in the summer of 2019, with intact memory and cognition and diagnoses that include a history of stroke and weakness on one side of the body. During an interview on 12/11/23 at 11:45 a.m. with Resident 41, Resident 41 alleged, Licensed Nurse 6 (LN 6) raised his hand at me and added LN 6 made a balled up fist raised it over his head as if he would hit Resident 41. Resident 41 expressed, during this alleged incident, LN 6 had been intimidating. During an interview on 12/13/23 at 3:21 p.m. with the Social Services Director (SSD), the SSD…

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 Minimum Data Set (MDS, an assessment tool) accurately reflected the resident's current condition for one of 28 sampled residents (Resident 83), when the discharge MDS indicated the resident was discharged to an acute hospital. This failure resulted in Resident 83's MDS inaccurate assessment data submitted to CMS (Centers for Medicare-Medicaid Services). Findings: Resident 83 was admitted to the facility in the middle of 2023 with multiple diagnoses which included unsteadiness on feet and a history of falling. During a review of Resident 83's Notice of Transfer/Discharge (NT/D) dated 10/2/23, the NT/D indicated, [Resident 83] will be transferred/discharged to home on [DATE] for the following reason(s) .The resident's health has improved sufficiently . During a review of Resident 83's Order Summary Reports (OSR) dated 10/2/23, the OSR indicated, Resident [83] may discharge to home on [DATE] with home health nurse. During a review of Resident…

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

Based on observation, interview and record review, the facility failed to revise the care plan after a fall for one of 28 sampled residents (Resident 25). This failure increased the risk Resident 25 would not reach the highest practicable well being and have his needs met. Findings: Resident 25 was admitted to the facility in the fall of 2023 with diagnoses which included muscle weakness, abnormal posture, cerebral infarction (stroke), and low back pain. During a review of Resident 25's Minimum Data Set (MDS, an assessment tool), dated 11/7/23, the MDS indicated Resident 25 was alert and oriented. During a review of Resident 25's document titled, Fall Risk Screen (FRS), effective 11/7/23, the FRS indicated, Has the resident ever fallen .Yes. During a review of Resident 25's Nursing Care Plan (NCP) titled, High risk for falls and injury related to [limb description] amputation, Poor balance, Unsteady gait, dated 11/8/23, the NCP indicated, Goal .Resident will be able to adjust to a change in the usual environment and routine to prevent falls and injury through the next 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.

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents' physician was notified when two blood pressure medications were not given to Resident 39. This failure had the potential for Resident 39's blood pressure to be elevated and compromised hemodynamic (basic measures of heart function) stability. Findings: During an observation of medication administration on 12/11/23 at 8:15 a.m., Licensed Nurse (LN) 3 was observed to prepare and administer Resident 39's morning medications which did not include two blood pressure medications. During a review of Resident 39's Order Summary Report, dated 12/13/23, the Order Summary Report indicated, Resident 39 had an order for amlodipine [a medication to lower blood pressure] 5 mg [milligram, unit of measure] give 1 tablet by mouth one time a day for HTN [Hypertension, high blood pressure] and an order for lisinopril [a medication to lower blood pressure] 20 mg give 2 tablets by mouth in the morning for BP [blood pressure]. During an interview on 12/11/23 at 8:30 a.m. with LN 3, LN 3 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.

Based on interview and record review the facility failed to ensure care and services were met according to professional standards of practice for one of 28 sampled residents (Resident 44) receiving dialysis (procedure to remove waste products and excess fluids from the blood when the kidneys are not able to), when transportation to and from dialysis was not provided timely. This failure resulted in Resident 44's emotional stress, and had the potential to result in undetected complications such as increased fluid retention and toxic substances in the blood. Findings: Resident 44 was admitted to the facility in late 2023 with diagnoses which included end stage renal disease (ESRD, the kidneys can no longer support the body's needs), dependence on renal (kidney, organ that filters waste material out of the blood) dialysis. During a review of Resident 44's Clinical Laboratory Results (CLR), dated 10/18/23, the recent CLR indicated highly elevated creatinine at 7.7 (normal = 0.6 to 1.4) which indicated high amounts of waste products in the blood not filtered by the kidney. During a…

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

Based on observation, interview and record review, the facility failed to ensure irregularities reported by the pharmacist to the attending physician were acted upon for one out of 28 sampled residents (Resident 70) in a census of 85. This failure increased the potential for a PRN (as needed) antipsychotic being given without adequate indication. Findings: Resident 70 was admitted to the facility in the fall of 2023 with diagnoses which included Alzheimer's (memory loss), anxiety, heart failure, and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). During a review of Resident 70's Minimum Data Set (MDS, an assessment tool), dated 9/29/23, the MDS indicated Resident 70 had severe memory impairment. During a review of Resident 70's document titled, Consultant Pharmacist Medication Regimen Review [MRR] dated 10/1/23 through 10/31/23, indicated IDT [Interdisciplinary Team] recommends to provide a 14 day term of therapy. Per [federal regulatory body] Megarules effective November 28, 2017; If the prescriber believes the resident requires 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.

Based on observation, interview and record review, the facility failed to honor food preferences for one of 28 sampled residents (Resident 435), when the resident did not receive hard boiled eggs at lunch. This failure increased the potential for the resident not to reach his highest practicable well being. Findings: Resident 435 was admitted to the facility in the fall of 2023 with diagnoses which included diabetes mellitus (a serious condition where your blood glucose level is too high) and depression. During a review of Resident 435's Minimum Data Set (MDS, an assessment tool), dated 12/7/23, the MDS indicated Resident 435 was alert and oriented, able to make his needs known. During a review of Resident 435's Order Summary Report (OSR), dated 12/7/23, the OSR indicated, CCHO [Consistent or Controlled Carbohydrate] diet Regular texture . During a review of Resident 435's document titled Dietary Profile [DP] /Malnutrition Risk Tool ., dated 12/8/23, the DP indicated, Food preferences .Likes: hard boiled egg for lunch . During a review of Resident 435's Nursing Care Plan (NCP)…

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 maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two out of 28 sampled residents (Resident 40 and Resident 77, and Resident 65) when: 1. Oxygen equipment was uncovered and unlabeled for Resident 65. 2. Stand fan was not cleaned for Resident 77; and 3. Urinal was unlabeled on top of the bedside table for Resident 40, and when 4. Resident 18's oxygen tubing was not changed in a timely matter. 5. Staff were not wearing N95 mask properly. These failures had the potential to result in the transmission of infection in a vulnerable population. Findings: 1. Resident 65 was admitted to the facility in the spring of 2023 with diagnoses which included cardiomyopathy (disease of the heart muscle) and atrial fibrillation (irregular heart beat). During a review of the Order Summary Report…

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 call light (a device to alert nursing staff when a resident is in need) was functioning for one resident (Resident 74) out of 28 sampled residents. This failure prevented Resident 74 from communicating his care needs and had the potential to delay care and treatments. Findings: During a review of Resident 74's Minimum Data Set (MDS: an assessment tool), dated 10/26/23, the MDS indicated Resident 74 was admitted to the facility in the fall of 2023, with diagnoses that included asthma (a disease in which the airways clog and narrow, making it hard to breathe). During a concurrent observation and interview on 12/11/23 at 10:32 a.m. in Resident 74's room, Resident 74 stated earlier that morning he had pressed his call light device in attempts to get his nurse to help with his asthma symptoms and added it had been a very long time. Resident 74 indicated he had been waiting and no one had responded to his call light. Resident 74 then pressed the call light button, but the device did not alert for help.…

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 orders were followed for three of three sampled residents (Resident 1, Resident 2, and Resident 3) when Peripherally Inserted Central Catheter (PICC, a long thin flexible tube that is placed into a vein in your arm and goes into larger veins near your heart) care was not performed per professional standards, and medication was not given as ordered to Resident 3. These failures increased the risk for infection, and delayed healing. Findings: Resident (Res 1)1 admitted to the facility fall of 2023 with diagnoses which included sepsis (life threatening complication of an infection). During a concurrent observation and interview on 10/3/23 at 3:17 p.m., with Res 1, in his bedroom. Observed Res 1's PICC dressing (a clear film with an adhesive boarder covering the insertion site of the PICC) to his right upper, inner arm. There were no date or initials on the dressing. Res 1 was asked if staff had changed his PICC dressing. Res 1 stated, They have not changed it since they put it in . During a concurrent…

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 safe medication storage for a census of 82 when an externally used topical cream was commingled with oral medications, an opened insulin bottle was not dated, scattered loose pills were found in two medication carts, and an opened bottle acetic acid (liquid used in wound care) did not have an open date. These failures had the potential for residents to receive ineffective medications and placed residents at risk for cross contamination. During a concurrent interview and inspection of medication cart 1-station 1 on [DATE] at 1:44 p.m., with Licensed Nurse (LN 1) 1: One compartment in the top drawer of the medication cart contained a tube of Triamcinolone Acetonide Cream (medication used to treat skin conditions), a clear plastic bag containing eye drops, an opened bottle of eye drops, and multiple foil packages of pills. LN 1 verified the findings and stated the different medications should not be stored together in the same…

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