Advanced Center For Nursing & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, observations, facility documentation, facility policies and interviews for two (2) of seven (7) sampled residents (Residents #6 and #7) who required supplemental oxygen usage via a concentrator, the facility failed to ensure the oxygen concentrators were inspected annually for function and safety. The findings include:1. Resident #6's diagnoses included Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), Shortness of Breath (SOB) and anxiety disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #6 had a Brief Interview for Mental Status (BIMS) score of seven (7) out of fifteen (15) indicating Resident rarely or never made decisions regarding tasks of daily life. A physician's order for 8/1/25 through 9/26/25 directed to administer oxygen via nasal cannula at two (2) liters per minute every shift to maintain oxygen saturation greater than 91 percent (%) and to prevent hypoxia (low levels of oxygen in the body's tissues).…

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 clinical record review, facility documentation review, facility policy review and interviews for one of three residents (Residents #1) reviewed for medication administration, the facility failed to ensure the physician/APRN was notified timely when medications were not administered in accordance with orders, and for two (2) of three (3) residents (Resident #14 and Resident #16) reviewed for medication administration, the facility failed to notify the physician/APRN timely when medications were not available for administration in accordance with physician orders. The findings include: The findings include:Based on clinical record review, facility documentation review, facility policy review and interviews for one of three residents (Residents #1) reviewed for medication administration, the facility failed to ensure the physician/APRN was notified timely when medications were not administered in accordance with orders, and for two (2) of three (3) residents (Resident #14 and Resident #16) reviewed for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review and interviews for three sampled residents (Residents #1, #12, and #13) reviewed for medication administration, the facility failed to ensure the resident was free from misappropriate of resident property. The findings include:Based on clinical record review, facility documentation review, facility policy review and interviews for three sampled residents (Residents #1, #12, and #13) reviewed for medication administration, the facility failed to ensure the resident was free from misappropriate of resident property. The findings include:A. Resident #1 was admitted with diagnoses that included chronic pain syndrome, opioid dependance, osteomyelitis of the vertebra (back bone infection), and bacteremia (blood infection). The Resident Care Plan (RCP) dated 6/21/2025 identified Resident #1 had pain. Interventions directed to administer pain medication as ordered. An admission Minimum Data Set (MDS) dated [DATE] identified 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 clinical record review, facility documentation review, facility policy review and interviews for three sampled residents (Residents #1, 12, and 13) reviewed for medication administration, the facility failed to ensure services provided met professional standards to include controls of narcotic medications as per facility policy. The findings include:Based on clinical record review, facility documentation review, facility policy review and interviews for three sampled residents (Residents #1, 12, and 13) reviewed for medication administration, the facility failed to ensure services provided met professional standards to include controls of narcotic medications as per facility policy. The findings include: Although requested, the facility was unable to provide the facility monthly or bi-monthly audits of controlled substances as per facility policy for June or July 2025 and indicated any audits could not be located at time of survey. Interview and documentation review with the DON on 8/13/2025 at 10:13 AM identified that staff signed Hydromorphone medication out on 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 clinical record review, facility documentation review, facility policy review and interviews for three of six residents (Residents #1, Resident #14 and Resident #16) reviewed for medication administration, the facility failed to ensure medications were available and administered in accordance with physician orders. The findings include: Based on clinical record review, facility documentation review, facility policy review and interviews for three of six residents (Residents #1, Resident #14 and Resident #16) reviewed for medication administration, the facility failed to ensure medications were available and administered in accordance with physician orders. The findings include: 1. Resident #1 was admitted with diagnoses that included chronic pain syndrome, opioid dependance, osteomyelitis of the vertebra (back bone infection), and bacteremia (blood infection). A hospital Discharge summary dated [DATE] identified Resident #1 was discharged on Cefazolin (antibiotic) two (2) grams (gms) per fifty (50)…

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, clinical record review, facility documentation, facility policy, and interviews for one of three residents (Resident #2) reviewed for abuse or neglect, the facility failed to ensure the resident was free from physical abuse. The findings include: A. Resident #2 was admitted to the facility with diagnoses that included encephalopathy, heart failure and depression. ] A significant change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had severe cognitive impairment (Brief Interview for Mental Status (BIMS) score of 7), required maximal assistance for rolling side to side and was dependent for transfer and personal hygiene. A resident care plan (RCP) dated 3/22/2025 identified Resident #2 had major depression. The RCP directed supportive counseling and individual psychotherapy. B. Resident #3 was admitted to the facility with diagnoses that included dementia and hypertension. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had severe…

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 clinical record review, facility documentation, facility policy, and interviews for one of three residents (Resident #1), reviewed for abuse or neglect, the facility failed to obtain vital signs according to provider order for a resident who required monitoring after a newly discontinued medication. The findings include: Resident #1 was admitted to the facility with diagnoses that included multiple sclerosis, functional quadriplegia (loss of function of the four limbs and torso), neurogenic bladder (lack of bladder control) and a pressure ulcer of the right buttock. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderate cognitive impairment (Brief Interview for Mental Status (BIMS) score of 9) and was dependent for bed mobility, transfer, and personal care. An APRN progress note dated 4/28/2025 identified Resident #1 was seen for chronic medical problems. Assessment and plan identified Resident #1 had intermittent hypotension with improved anemia. Blood pressure…

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 clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #3) reviewed for accidents, the facility failed to ensure that the medical provider was notified timely of a change in condition. The findings include: Resident #3 was admitted with diagnoses that included dementia and chronic obstructive respiratory disease (COPD). A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 3 was alert and oriented (Brief Interview for Mental Status (BIMS) score of 14), and was independent with mobility and ambulation. The Resident Care Plan (RCP) dated 7/19/2023 identified Resident #3 had altered respiratory status due to COPD. The RCP directed to assess for changed in respiratory status and advise MD and administer oxygen as ordered. A nursing note dated 11/21/2023 at 3:13 PM identified that Resident #1 was alert and responsive, and was observed with shortness of breath (SOB) and oxygen (02) saturation was 88 percent…

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 clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2), reviewed for accidents, the facility failed to ensure the care plan was revised timely after a fall. The findings include: Resident #2 was admitted with diagnoses that included traumatic brain hemorrhage and Schizophrenia. An annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had severely impaired cognition and required extensive assistance for bed mobility and assistance for transfers into a wheelchair. The Resident Care Plan (RCP) dated 5/3/2023 identified Resident #2 was at risk for falls due to a history of falls and cognitive impairment. Interventions directed to remind Resident to use the call bell to request assistance before getting out of bed and to toilet promptly. A facility incident report dated 5/31/2023 at 10:50 AM identified Resident #2 had an unwitnessed fall and was observed on the floor by housekeeping. Resident #2 had 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 clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2), reviewed for accidents, the facility failed to ensure neurological assessments were completed timely after an unwitnessed fall in accordance with facility Monitoring guidelines. The findings include: Resident #2 was admitted with diagnoses that included traumatic brain hemorrhage and Schizophrenia. An annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had severely impaired cognition and required extensive assistance for bed mobility and assistance for transfers into a wheelchair. The Resident Care Plan (RCP) dated 5/3/2023 identified Resident #2 was at risk for falls due to a history of falls and cognitive impairment. Interventions directed to remind Resident to use the call bell to request assistance before getting out of bed and to toilet promptly. A facility incident report dated 5/31/2023 at 10:50 AM identified Resident #2 had 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 a review of clinical records, facility documentation, facility policies, and interviews with one of three residents (Resident #3) reviewed for accidents, the facility failed to ensure the medical record was complete and accurate to include timely documentation of a medical evaluation. The findings include: Resident #3 was admitted with diagnoses that included dementia and chronic obstructive respiratory disease (COPD). A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 3 was alert and oriented (Brief Interview for Mental Status (BIMS) score of 14), and was independent with mobility and ambulation. The Resident Care Plan (RCP) dated 7/19/2023 identified Resident #3 had altered respiratory status due to COPD. The RCP directed to assess for changed in respiratory status and advise MD and administer oxygen as ordered. A nursing note dated 11/21/2023 at 3:13 PM identified that Resident #1 was alert and responsive, and was observed with shortness of breath (SOB) and oxygen (02)…

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 clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for medication administration, the facility failed to notify the physician regarding the resident not receiving his/her medication for two (2) days. The findings include: Resident #2's diagnoses included dementia, prostate cancer, schizophrenia, diabetes mellitus, seizures, and encephalopathy. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of five out of fifteen (3/15), indicative of severely impaired cognition and was dependent with ADLs (activities of daily living). Physician order dated 8/27/2024 directed to administer Abiraterone (antineoplastic) 1000 milligrams (mg) every day at 8:30 PM. The Resident Care Plan (RCP) dated 10/10/2024 identified Resident #2 had an alteration in health maintenance related to physical and psychological conditions. Interventions directed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for medication administration, the facility failed to ensure a medication provided by the family for facility staff to administer was verified/confirmed to be the drug ordered by the physician and failed to ensure the contents of each container have been verified by a licensed pharmacist in accordance with facility policy. The findings include: Resident #2's diagnoses included dementia, prostate cancer, schizophrenia, diabetes mellitus, seizures, and encephalopathy. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of five out of fifteen (3/15), indicative of severely impaired cognition and was dependent with ADLs (activities of daily living). Physician order dated 8/27/2024 directed to administer Abiraterone (antineoplastic) 1000 milligrams (mg) every day at 8:30 PM. 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 clinical record reviews, facility documentation, facility policy, and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for pressure ulcers, the facility failed to ensure the treatment plans recommended by the wound care physician were entered into the clinical record and implemented. The findings include: Resident #1's diagnoses included pressure ulcer, diabetes mellitus, malnutrition, peripheral vascular disease, and dementia. The Resident Care Plan dated 1/12/25 identified a potential for skin impairment related to poor physical condition. Interventions directed to apply barrier cream, turn and reposition every two (2) hours, and weekly skin checks. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status score of three (3) out of fifteen (15) indicating Resident #1 rarely or never made decisions regarding tasks of daily living, had an altered level of consciousness, required staff assistance for personal care 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 clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for resident rights, the facility failed to ensure Resident #1 was treated with dignity and respect. The findings include: Resident #1's diagnoses included chronic pulmonary edema, depression, anxiety and chronic pain. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #1 was alert and oriented to person, place, and time and received an antidepressant medication. The Resident Care Plan dated 1/16/25 identified Resident #1 exhibited behavioral symptoms of being verbally and physically abusive, refusal of care, delusions, hallucinations, aggression, psychiatric conditions, and was a risk of injury to self or others. Interventions directed to approach in a calm and consistent manner, for refusals of care re-approach resident at another time, monitor…

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 clinical reviews, observations, review of policy and interviews for 1 of 4 residents reviewed for smoking (Resident #21), the facility failed to provide a safe smoking environment and for 1 of 4 residents (Resident #187) reviewed for accidents, the facility failed to ensure staff reported resident behavior that presented as a fire hazard. The findings included: 1. Resident 21's diagnoses included dementia and schizophrenia. The quarterly MDS assessment dated [DATE] identified Resident #21 as cognitively intact and required partial/moderate assistance with personal hygiene and substantial/maximal assistance for lower body dressing. The Facility Smoker list documentation dated 1/10/2025 identified Resident #21 as a smoker. Observation on 1/27/202 from 1:31 PM to 1:55 PM during the facility smoking break identified the following: a.There were 12 residents participating in the smoking break. Resident #21 was observed sitting in his/her wheelchair near the edge of the tent in the smoking patio. Resident #21…

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 clinical record reviews, reviews of facility policy and staff interviews for 1 of 1 resident (Resident #166), reviewed for physician visits, the facility failed to ensure that physician visits were completed timely. The findings include: Resident #166 was admitted on [DATE]. The residents' diagnoses included chronic kidney disease, and atrial fibrillation (an abnormal heart rhythm). The quarterly MDS assessment dated [DATE] indicated Resident #166 was cognitively intact and had clear speech. Additionally, the MDS identified Resident #166's primary medical condition category as medically complex conditions. On 1/16/2025 at 12:49 PM an interview with Resident #166 identified the resident would like to see his/her primary care physician (PCP) to coordinate his/her care. Resident #166 indicated she/he has seen five different APRN's while at the facility but has not seen a Medical Doctor (MD). A review of the clinical record from 6/4/2022 through 1/16/2025 identified the last note by a physician (MD) was 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 clinical record reviews, observations, facility documentation, facility policy and interviews for 28 of 28 sampled residents (Resident #105, #89, #151, #183, #19, #474, #113, #475, #190,# 476, #96, #163, #148, #133, #21, #100,# 200, #199, #177, #479, #185, #182, #188, #143, #198, #147, #193,# 211) reviewed for medication storage, the facility failed to develop and implement policies for the recordkeeping of individual use and chain of custody controlled substances, failed to maintain an unbroken chain of custody for controlled medications once received and distributed to nursing unit(s) and failed to document inventory across shifts and failed to maintain an accurate disposition log for the destruction and return of unused controlled medication. The findings included: 1 a Resident #143's diagnosis includes Opioid dependence. The quarterly MDS assessment dated [DATE] identified Resident # 143 had intact cognition and required set up assist with eating and independent with dressing. The care plan dated…

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

Based on tour of the dietary department and staff interview, the facility failed to ensure food was served at an appropriate temperature to maintain palpable taste. The findings include: A tour of the dietary department between 1/16/25 through 1/27/25 with the Food Service Director identified below: Observation of the tray line on 1/22/25 at 7 :00 AM identified the eggs temperature for scrambled eggs at 196 degrees Fahrenheit and hot cereal was at 195 degrees Fahrenheit. During the plating, the scrambled eggs were placed in a heating tray. Observation on 1/22/25 at 7:40 AM of the plating for the last (4th) food chart identified the food chart leaving the kitchen at 8:19AM. Observation on 1/22/25 at 8:23 AM of food cart arrival to third floor, unit D3. Observation on 1/22/25 at 8: 36AM of the food cart identified the door was left open. Observation on 1/22/25 at 8:48AM of last meal tray leaving the kitchen in a food cart identified during a test tray scrambled eggs were tempted at 88.2 degrees and Oatmeal was 131.2 degrees. An interview with the Food Service Director on 1/22/25 at…

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

Based on review of facility Infection Control Program, facility documentation and interviews, the facility failed to ensure staff conducted and maintained documentation of yearly ongoing review of antibiotic use within the facility based on Antibiotic stewardship guidelines. The findings included: On 1/22/2025 9:30 AM and interview and review of facility documents with LPN # 9, the Infection Preventionist (IP) in the role at the facility for last 2 months identified no evidence of ongoing surveillance of infections only a binder containing the past two years 2023 and 2024 of the monthly list of antibiotics used in the facility for each resident which was provided by the pharmacy to nursing. Although the IP, LPN #9 provided blank McGeer's forms to use during the antibiotic surveillance process, s/he identified she/he had not utilized them the form yet. LPN #1 identified she/had state infection control training which was minimal training and indicates she/he had been pulled away frequently from Infection Control duties to provide resident care for the shift when licensed nurses called…

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 clinical record review, facility documentation, and staff interviews for 1 of 5 for (Resident # 70), reviewed for dignity, the facility failed to ensure staff interacted with the resident respectfully. The findings includes: Resident #70's diagnosis included Chronic Congestive Heart Failure (CHF), back pain, diabetes mellitus, anxiety and depression. The Annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #70 as cognitively intact, used a walker, was independent with toileting hygiene and had occasional pain that interfered with sleep and day-to-day activities. The care plan dated 1/7/2025 for Resident #70 requires assistance with toileting using a wheeled walker and has a history of falls. An intervention is directed to call for assistance when needed. On 1/16/2024 Resident #70 reported to a surveyor on 1/15/2025 that urine was on the bedside floor, and she/he was attempting to clean the urine up with linens on the floor but instead called staff for assistance. Nurse Aide (NA #8)…

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 clinical record reviews, observations, facility documentation, facility policy and interviews for 1of 3 residents (Resident # 173) reviewed for personal property, the facility failed to ensure the resident's personal medication was not missing and for 2 of 2 residents ( Residents # 164 and # 181) reviewed for environment, the facility failed to ensure a shared room had a functioning bathroom sink and for 1 of 2 residents (Resident #118) reviewed for environment, the facility failed to ensure resident furniture was maintained and in proper working order. The findings included: 1.Resident #173 's diagnoses included carcinoma in situ of prostate, secondary malignant neoplasm of genital organs and Type 2 diabetes mellitus. The annual Minimum Data Set assessment dated [DATE] identified Resident #173 as cognitively intact and requires set up for eating. The resident is independent with bed mobility and toilet transfers. The care plan dated 12/10/24 identified Resident #173 has a diagnosis of cancer and noted…

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 clinical record reviews, facility documentation, facility policy and interviews for 2 of 5 sampled residents (Resident #144) reviewed for abuse, the facility failed implement policies to ensure the protection residents following an allegation of abuse and for (Resident # 214), the facility failed to timely followed up on Resident # 214 concerns regarding Resident # 1's physical and verbal abuse toward staff to rule out Resident # 1 was not a danger to self and others. The findings include: 1. Resident #144's diagnoses included history of dysuria (painful urination )and bipolar disorder. The annual MDS assessment 10/1/24 identified Resident #144 as cognitively intact, frequently incontinent of urine and required one person assist with ambulation and toileting needs. The Resident Care Plan (RCP) dated 12/30/24 identified Resident #144 had a concern related to ADL function. Interventions included providing assist of one with transfers and toileting. A Reportable Event Summary dated 1/16/25 identified Resident #144 alleged the nurse, LPN #6 offered Tylenol and stated s/he could…

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 clinical record reviews, observations, facility policy and interviews for 1 of 6 residents (Resident #111) reviewed for specialized treatment, the facility failed to ensure staff developed a care plan reflecting the needs of a resident receiving dialysis care and for1 of 2 residents (Resident # 109), reviewed for communication- Sensory, the facility failed to ensure that the care plan reflected the residents' sensory needs. The findings included: 1. Resident #111's diagnosis includes end stage renal disease with dependence on renal dialysis. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #111 as cognitively intact. The care plan dated 12/20/2024 for Resident was at increased risk for alterations in nutritional status secondary to renal dialysis. Interventions included providing a renal diet and supplements. An interview and record review with RN #1 (Nursing Supervisor) on 1/25/2025 at identified there was no specific care plan related to the resident's dialysis access site…

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 clinical record reviews, policy the facility and interviews for 2 of 4 residents ( Resident # 104) reviewed for urinary retention, the facility failed to revised the care plan after the resident returned from an inpatient stay and for 1 of 1 resident ( Resident # 207)reviewed for care planning, the facility failed to ensure staff revised the residents a resident's care plan to reflect resident's choice regarding bathroom preferences . The findings included: 1.Resident #104 's diagnoses included urinary retention, and Urinary Tract Infection (UTI). The annual Minimum Data Set assessment dated [DATE] identified Resident #104 as cognitively intact and required maximum assistance with personal hygiene, toileting and bathing. A physician's order dated 12/17/24 directed to begin voiding trials in 5 days of discharge as a Foley catheter was in placed while in the hospital. A nurse's note dated 12/17/24 at 10:37 PM identified Resident # 104 returned from the hospital with a diagnosis of urinary retention. 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 clinical review, facility documentation, facility policy and interviews for of 1 of 5 sampled residents (Resident #144) reviewed for abuse, the facility failed to offer Activities of Daily Living (ADL) care to a resident who required toileting assist. The findings include: Resident #144 's diagnoses included the history of dysuria (painful urination) and bipolar disorder. The annual MDS assessment 10/1/24 identified Resident #144 as cognitively intact, frequently incontinent of urine and required one person assist with ambulation and toileting needs. The RCP dated 12/30/24 identified Resident #144 had a concern related to ADL function. Interventions included providing assist of one with transfers and toileting. The Point of Care History dated 1/15/24 at 5:41 AM during the 11:00 PM to 7:00 AM identified Resident #144 was last provided incontinent care on 1/15/25 at 8:44 PM and noted incontinent care and toileting needs 'Did not occur' during the 11:00 PM to 7:00 AM shift. An interview with Resident #144 on 1/16/25 (no time) identified s/he was last provided incontinent 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 clinical record reviews, review of facility documents, policy review and interviews for 1 of 2 residents ( Resident # 144) reviewed for pain, the facility failed to ensure a a resident with reports of increasing pain was reported/assessed by an Registered Nurse and for 1 of 5 residents (Resident #324), reviewed for dignity, the facility failed to ensure a follow-up appointment with a specialist provider was provided as scheduled . The findings included: 1. Resident #144's diagnosest included history of dysuria (painful urination) and bipolar disorder. The annual MDS assessment 10/1/24 identified Resident #144 was cognitively intact, frequently incontinent of urine and required one person assist bed mobility and ambulation. The RCP dated 12/30/24 identified Resident #144 had a positive Preadmission Screening and Resident Review (PASRR) for a serious mental illness, refused medications and exhibited aggression at times. Interventions included providing education on the importance of taking medications 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 clinical record reviews, facility policy and documentation for 1 of 1 resident (Resident # 104) reviewed for urinary retention, the facility failed to follow the resident's discharge summary physician's order for urinary retention and for 1 of 1 resident reviewed for Bowel and Bladder Incontinence (Resident #207), the facility failed to assess a resident with frequent incontinence for participation in a bowel and bladder re-training program. The findings included: 1.Resident #104 's diagnoses included urinary retention, and Urinary Tract Infection (UTI). The annual Minimum Data Set assessment dated [DATE] identified Resident #104 as cognitively intact and required maximum assistance with personal hygiene, toileting and bathing. A nurse's note dated 12/17/24 at 10:37 PM identified Resident # 104 returned from the hospital with a diagnosis of urinary retention. A physician's order dated 1/13/25 directed to perform a bladder scan every 6 hours while awake if possible and to conduct intermittent…

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 review of the clinical record, facility policy review and interviews for 1 of 5 residents (Resident #105) reviewed for nutrition, the facility failed to ensure staff obtained a readmission weight timely and obtained re-weights for a resident at nutritional risk. The findings include: Resident #105's diagnoses included diabetes mellitus and abnormal weight loss. Resident #105's weight on 9/2/2024 was 120.3 pounds. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #105 was cognitively intact had no or no known weight loss and the resident weighed 120 Pounds. The readmission Quarterly Nutritional Assessment indicated Resident #105 was readmitted from the hospital on 9/11/2024. The readmission weight was still pending but the hospital weight was 125 pounds with weights stable for 3 months and Resident #105 remained at nutritional risk. Resident #105's weight on 9/30/2024(14 days after readmission) was 125.4 pounds (a 5.1-pound weight gain since 9/2/2024). Resident #105's weight…

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 clinical record review, observation, facility documentation, facility policy and interviews for 1 or 2 residents (Resident #78) reviewed for specialized treatment, the facility failed to ensure respiratory equipment was in working condition. The findings include: Resident #78 's diagnoses included Malignant Neoplasm of the Larynx, acute respiratory failure with hypoxia, and pulmonary hypertension. The Resident Care Plan dated 4/6/24 identified resident had an alteration in respiratory status. Interventions included to assess for changes in respiratory status and suction as needed. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #78 was cognitively intact and required maximum assistance with toileting, bathing, and supervision with personal hygiene. A physician's order dated 12/27/24 directed to clean and suction stoma/laryngectomy tube several times per day and to use saline irrigations to loosen any mucous. If patient is still having trouble breathing, remove the laryngectomy…

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 clinical record reviews, review of facility policy and interviews for 5 of 6 residents ( Residents #14, #39, #84, #111 and #424) reviewed for dialysis, the facility failed to ensure staff consistently monitored vital signs, the resident's hemodialysis access sites and follow facility policy. The findings included. 1. Resident #14's diagnosis includes diabetic chronic kidney disease. A physician's order dated 9/3/2024 directed for Resident #14 to go to specialized treatment center 3 times per week due to renal failure. The quarterly Minimum Data Set (MDS) dated [DATE] indicted Resident #14 was cognitively intact and had received dialysis. The care plan dated 11/29/2024 indicated Resident #14 was at risk for complications related to renal function requiring dialysis. Interventions included checking hemodialysis access site for signs of bleeding, infection or abnormality, to check access bruit and thrill daily and to monitor vital signs. An interview clinical record review and review of facility policy…

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, facility policy review and staff interviews, the facility failed to ensure staff followed correct infection control practices for a resident ( Resident #86) requiring droplet and contact precautions and failed to ensure staff followed appropriate infection control practices when a resident bathroom sink ( Resident #164 and #181) was out of service. The findings included: 1. On 01/21/25 at 12:11 PM observation identified NA # 4 entering Resident #86's room wearing an isolation gown, gloves, and face shield over a regular face mask. Signage outside the door indicated the need for contact and droplet precautions and a cart with Person Protective Equipment ( PPE) including N95 masks was located just outside the doorway. Further observations identified after NA #4 doffed the gown into the trash in the room along with the gloves and carried the face shield to the sink at the nurse's station, washed hands and place the face shield in another location behind the nursing station. An interview with NA #4 on 1/21/2025 at 12:15 PM indicated s/he should have worn, and N-95…

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 review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for medication administration, the facility failed to notify the Advanced Practice Registered Nurse (APRN) timely of missed anti-seizure medication. The findings include: Resident #1's diagnoses included conversion disorder (a mental health disorder that affects how the brain works) with seizures/convulsions and anxiety disorder. The Resident Care Plan (RCP) dated 7/27/24 identified that Resident #1 requires assistance with Activity of Daily Living (ADLs) with interventions that included providing assistance to the resident as needed. The 5-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was cognitively intact and required substantial assistance with Activities of Daily Living (ADLs). A physician's order dated 7/26/24 directed to administer Banzel 400 milligrams (mg) ( a anti-seizure medication), give four (4) tablets twice daily at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for medication errors the facility failed to ensure that a resident received an anti-seizure medication as ordered by the physician. The findings include: Resident #1's diagnoses included conversion disorder (a mental health disorder that affects how the brain works) with seizures or convulsions and anxiety disorder. The Resident Care Plan (RCP) dated 7/27/24 identified that Resident #1 requires assistance with ADLs. Interventions included providing ADL assistance to the resident as needed. The 5-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was cognitively intact and required substantial assistance with Activities of Daily Living (ADLs). A physician's order dated 7/26/24 directed to administer Banzel 400 milligrams (mg), give four (4) tablets twice daily at 9:00 AM and 5:00 PM. Review of the electronic Medication Administration…

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 (1) of three (3) sampled residents (Resident #2) who were reviewed for comprehensive care planning, the facility failed to develop a comprehensive person-centered care plan to address the resident's wound that was present on admission. The findings include: Resident #2's diagnoses included traumatic brain injury, quadriplegia, conversion disorder with seizures, and pneumonitis. The admission assessment dated [DATE] at 8:17 PM identified Resident #2 was non-verbal, responded to pain only, required a tracheostomy (an opening in the trachea to help air and oxygen reach the lungs by creating an opening from outside the neck), required a tube feed (a tube that goes directly into the stomach to provide nutrition) and had an open area on the right big toe. A physician's order dated 7/2/24 directed to cleanse the right great toe ulcer with normal saline, apply Puracol (a collagen dressing) followed by Aquacel (a wound dressing used to treat open wounds and surgical incisions) daily and as needed for soiling 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.

Based on observations, clinical record review, facility documentation review, facility policy review and interviews for environmental review, the facility failed to ensure a sanitary and comfortable environment for residents, staff and the public and failed to ensure five of eleven resident's (Resident #1, #2, #3, #4, and #5) rooms were free of bugs/roaches. The findings include: Review of the maintenance log for unit (A2) identified on 2/21/2023, roaches were observed in Resident #2 and #3's room, and on 4/1/2023, roaches were observed in Resident #2's and #3's room. Review of the Pest Service Inspection Report dated 6/12/2023 identified in the service comments, Resident #2, #3, #4, and #5's room was scheduled for a clean out and indicated Resident #2 and #3's room is the host room. Baseboard treatments were completed around the perimeter as a barrier treatment for insects and glue boards were placed in the bathrooms and in the kitchen. Observation of Resident #1's room on 10/2/2023 at 10:15 AM identified a foul-smelling odor upon entrance and the room had excessive clutter…

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 clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for abuse, the facility failed to honor the resident's right by not providing assistance when requested. The findings include: Resident #2's diagnoses included diabetes mellitus, hemiplegia and hemiparesis, major depressive disorder with psychotic symptoms, and anxiety disorder. The Resident Care Plan (RCP) dated 02/29/23 identified Resident #2 requires a custom wheelchair with interventions that include the resident will utilize custom wheelchair provided by rehab that does not restrict the residents' movements or access to body. Nursing will transfer resident to the wheelchair per MD order. Rehab will screen for appropriateness as needed and ensure least restrictive device is used. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 made consistent and reasonable decisions regarding tasks of daily life and required extensive…

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 clinical record review, facility documentation review, facility policy review, and interviews for one (1) of three (3) residents, (Resident #2), reviewed for abuse, the facility failed ensure the State Agency was notified of an allegation of abuse in a timely manner. The findings include: Resident #2's diagnoses included diabetes mellitus, hemiplegia and hemiparesis, major depressive disorder with psychotic symptoms, and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 made consistent and reasonable decisions regarding tasks of daily life and required extensive assistance with assist of one person for ADL's. A reportable event form and investigation dated 08/21/2023 without a specified timeframe, identified an email from Resident #2's responsible party (Person #1) regarding concerns of resident's care. Review of Person #1's email to Administrator #2 (Chief Operating Officer) dated 08/21/23 at 8:06 PM identified he/she would like to address 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 review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #1) reviewed for quality of care, the facility failed to ensure medications were administered in accordance with physician orders. The findings include: Resident #1's diagnoses included Factor V Leiden mutation, recurrent deep vein thrombosis, prothrombin gene mutation, and major depressive disorder. Physician orders dated 10/02/22 directed to administer Arixtra (fondaparinux) syringe; 7.5 mg/0.6 mL, subcutaneous, at 9:00 PM. Special instructions: Resident can self-administer with nursing present. The quarterly Minimum Data Set (MDS) form dated 07/03/2023 identified that Resident #1 made consistent and reasonable decisions regarding tasks of daily life and required supervision with set-up assistance for ADL's. The Resident Care Plan (RCP) dated 07/26/2023 identified Resident #1 chooses to exercise right to personal preferences as evidenced by: Resident wishes to self-administer: Arixta with interventions that directed to allow the resident the right to express…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review and interviews for one observed resident (Resident #618), the facility failed to ensure the call bell was within reach. The findings include: Resident #618's diagnoses included Cerebral Vascular Accident (CVA) with Right hemiparesis (weakness or paralysis of one side of the body), history of falls, and dementia. Physician order dated 2/8/2022 directed to transfer Resident #618 with a mechanical lift and two (2) staff assistance. The Resident Care Plan (RCP) dated 2/8/2022 identified Resident #618 was at risk for falls related to impaired mobility and poor safety awareness. Interventions directed to remind Resident #618 to use the call bell to request assistance. The admission Minimum Data Set assessment dated [DATE] identified Resident #618 had moderate cognitive impairment, required extensive assistance with bed mobility, and had no limited range of motion of the upper extremities. Observation on 3/29/2022 at 12 PM identified Resident #618 was lying in bed and 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 review of the clinical record, facility policy review and interviews for one of three residents (Resident #119) reviewed for a pressure ulcer (R#119), the facility failed to ensure the responsible party notified timely when a wound was identified. The findings include: Resident #119 had diagnoses that included a sacral pressure ulcer. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #119 had no pressure ulcer and used pressure relieving devices in his/her chair and bed. Review of the clinical record identified on 3/11/2022 staff observed a new facility acquired pressure ulcer on Resident #119's coccyx (stage 2). The wound measured 3.5 centimeters (cm) by 5.0 cm by 0.2 cm. Review of the clinical record failed to identify Resident #119's responsible party was notified of the new pressure ulcer identified on 3/11/2022. Nurse's note written by RN #3/ICN dated 3/14/2022 at 1:32 PM indicated Resident #119's responsible party (Person #1) was upset that the facility had 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 observations, review of facility policy, facility documentation review, and interviews for on one of seven nursing unit shower rooms (S-3 Unit), reviewed for environment, the facility failed to ensure that the shower room was maintained in a clean, comfortable home-like manner and/or free from disrepair. The findings included: Observation of the shower room on the S-3 unit on 3/29/22 at 12:38 PM was identified as having cracked and missing tiles on the shower room floor. The wall-mounted heater had areas of rust and was dislodged from the wall on its upper right side. The walls surrounding the heater were noted to have rust-colored stains and the baseboard below the heater observed to have a black grime-like coating on the top edges. The ceiling in the shower room was observed with numerous rust-colored specks. Interview and observation of the S-3 shower room on 4/4/22 at 3:20 PM with the Director of Maintenance (DOM) identified the cracked and missing tiles should be replaced, the heater should be securely attached to the wall, and the rust-colored areas and black colored…

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 clinical record review and staff interviews for one of four residents reviewed for nutrition (Resident #119) and for one of two residents reviewed for indwelling catheters (Resident #119), the facility failed to ensure intake and output were monitored for a resident with a feeding tube and a Foley catheter. The findings included: Resident #119's diagnoses included hydronephrosis with renal and ureteral calculous obstruction, indwelling urinary catheter, left flank percutaneous nephrostomy drain, sepsis due to pseudomonas, adult failure to thrive, urinary retention, benign prostate hypertrophy (BPH) and gastric-tube insertion A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #119 had moderate cognitive impairment for decision-making skills, was always incontinent of urine and received 51% or more total calories via feeding tube. The Resident Care Plan (RCP) dated 3/25/22 and on 3/27/22 identified an indwelling catheter and a feeding tube as the problems. Interventions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, facility policy review and interviews for one of three residents reviewed for a pressure ulcer (Resident #119), the facility failed to ensure a wound treatment was provided in a clean manner with supplies placed on a clean surface. The findings included: Resident #119 had diagnoses that included a sacral pressure ulcer. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #119 had no pressure ulcer and used pressure relieving devices in his/her chair and bed. Review of the clinical record identified a facility acquired pressure ulcer was identified on 3/11/2022 on Resident #119's coccyx (stage 3). The Resident Care Plan (RCP) updated on 3/25/2022 identified a problem with a pressure ulcer. Interventions directed to provide wound treatments as ordered. Observation on 3/31/2022 at 11:20 AM of RN #3/ICN performing a wound treatment for Resident #119 identified RN #3 was observed setting up treatment supplies (i.e., 1-large sterile package 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 clinical record review, facility policy review and interviews for two of four residents (Resident #23 and #119), the facility failed to ensure a significant weight loss was addressed timely and the facility failed to ensure a reweight was obtained timely for a resident identified with a weight loss. The findings include: 1. Resident #23 was admitted with diagnoses that included dementia and diabetes. A quarterly Minimum data set (MDS) dated [DATE] identified Resident #23 had severe cognitive impairment and was independent with staff set up to eat. The Resident Care Plan (RCP) dated 12/16/2021 identified Resident #23 had an increased risk for alteration in nutritional status. Interventions directed to provide supplements and to monitor weight trends. Review of Resident #23's weights identified the following: on 1/5 was 125.1 pounds (lbs), on 2/1 was 100.2 lbs which identified a loss of 24.9 lbs, and weight on 2/7/2022 was recorded as 103.7 lbs. A Dietician note dated 2/10/2022 at 11:58 AM identified…

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, clinical record review, policy review, and interviews for one of two residents (Resident #616) reviewed for respiratory care, the facility failed to ensure oxygen tubing was changed timely. The findings include: Resident #616 had diagnoses that included COPD. Physician's order dated 2/3/2022 directed oxygen at three (3) liters per minute via nasal cannula, and to change the oxygen tubing every week (on Saturday) during the 11-7 shift. The Resident Care Plan dated 2/3/2022 identified an alteration in respiratory status. Interventions directed to administer oxygen as ordered and maintain oxygen equipment at bedside. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #616 was alert and oriented, and required use of oxygen. Observation and interview with RN #1 on 4/1/2022 at 9:35 AM identified Resident #616 was wearing oxygen and the tubing was dated 3/20/2022 (13 days prior to the observation). RN #1 indicated the tubing should be changed weekly. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility policy and procedures and interviews for one of three residents reviewed for a pressure ulcer (R#119), the facility failed to ensure the clinical record was maintained in a complete and accurate manner to include accurate dates weekly skin checks were completed. The findings include: R#119's diagnoses included a sacral pressure ulcer, indwelling urinary catheter, left flank percutaneous nephrostomy drain, adult failure to thrive, and gastric-tube insertion. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #119 had moderate cognitive impairment and required staff assistance for ADLs. The Resident Care Plan (RCP) dated on 2/2/2022 identified a problem with pressure ulcer. Interventions directed to report any changes to skin to APRN/MD as necessary and perform weekly skin checks. Physician monthly orders for March 2022 directed body audits weekly on shower days, edit day based on shower days once a day on Wednesday, 7:00…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, facility policy review and interviews for one of two residents (Resident #188) reviewed for tracheostomy care, the facility failed to ensure supplies were stored appropriately and not stored on the floor, and for facility Infection Control Review, the facility failed to ensure facility infections were tracked and expired IV supplies were removed from staff access timely. The findings include: 1. Resident #188 had diagnoses that included a terminal condition of the larynx. The quarterly MDS assessment dated [DATE] identified Resident #188 was alert and oriented and had a tracheostomy. The RCP dated [DATE] identified an alteration in respiratory sttus. Interventions directed to assess for changes in respiratory status and maintain oxygen and suction equipment at bedside. Observation on [DATE] at 11:17 AM identified Resident #188's personal belongings including trach dressings and supplies were located inside and on top of a clear see-through plastic bag which was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, clinical record review, and staff interview, for one of two residents in the survey sample reviewed for abuse (Resident #19), the facility failed to ensure a staff member reported an allegation of mistreatment in a timely manner. The findings include: Resident #19's diagnoses include asthma, depression, anxiety, and post traumatic stress disorder. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #19 had intact cognition and was independent with transfers and locomotion on and off the unit. A resident care plan dated 2/5/19 identified a problem related to behaviors as evidenced by: accusatory behaviors towards other residents, making false accusations, discussing her own personal health information, and sharing other resident's personal health information. Interventions included approach the resident in a calm, consistent manner, make eye contact, use the resident's name and explain the purpose upon approach, Psychiatric/psychological consult and follow-up…

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 clinical record review, review of facility documentation, review of facility policy, and interviews for one sampled resident (Resident #330) reviewed for anticoagulant medication, the facility failed to implement a care plan to reflect the use of an anticoagulant medication. The findings include: Resident #330 was admitted on [DATE] with a diagnoses that included acute embolism and thrombosis of unspecified deep veins of right lower extremity. The hospital Discharge summary dated [DATE] identified that hematology recommended six to twelve months of anticoagulation with apixaban which started on 9/17/19. Per hematology, a reassessment will be needed with the primary care physician as an outpatient at 6 months with repeat imaging to determine if anticoagulation should be stopped or continued based on risk/benefit assessment. A left lower extremity ultrasound dated 9/16/19 identified a non-occlusive thrombus again noted from the external iliac vein to the level of the popliteal vein, however, there…

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 clinical record review, review of facility documentation, review of facility policy, and interviews, for 1 of 5 residents, (Resident #126) reviewed for unnecessary medications, the facility failed to follow physician's order for orthostatic blood pressure monitoring and/or for one sampled resident (Resident #330) reviewed for anticoagulant medication, the facility failed to implement a care plan to reflect the use of an anticoagulant medication. The findings include: a. Resident #126 was admitted to the facility on [DATE] with diagnoses that included unspecified psychosis and major depressive disorder. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #126 had moderately impaired cognition, required extensive assistance of one for transfer, and required extensive assistance of two for toileting. The care plan review date of 4/10/19 identified psychotropic drug use. Interventions directed to attempt dose reduction to lowest possible therapeutic level and to monitor for adverse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, review of facility documentation, review of facility policy, and interviews, for one sampled resident (Resident #202) reviewed for enteral feeding, the facility failed to remove a gastrostomy tube (GT) feeding set up after 24 hours of use and/or failed to maintain complete daily intake measurements. The findings include: Resident #202's diagnoses included dysphagia. A physician's order dated 7/24/19 directed to change the enteral feeding bag daily on the 11:00 PM to 7:00 AM shift and provide 200 milliliters of free water flushes every six hours at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM. The 30 day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #202 was severely cognitively impaired, required assistance with eating, and required a feeding tube. A physician's order dated 9/12/19 directed to administer a tube feed regimen for Glucerna 1.5 @ 50 ml per hour for 10 hours, turn on at 7:00 PM and off at 5:00 AM and change the bag daily on the 11-7 PM…

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 clinical record review and staff interview, for one resident in the survey sample reviewed for laboratory services (Resident #97), the facility failed to ensure a laboratory test was completed to monitor a medication per physician's orders. The findings include: Resident #97's diagnoses included hypothyroidism, hypertension, and stroke. An admission Minimum Data Set (MDS) assessment dated [DATE] iidentified Resident #97 had no cognitive dysfunction, required extensive assist with transfers, and did not walk. A resident care plan dated 3/20/19 identified a problem with hypothroidism. Interventions included administer medications per physician (MD) order, evaluate/record/report effectiveness/adverse side effects, and monitor lab work per MD order. A laboratory report dated 5/2/19 indicated Resident # 97's TSH (thyroid stimulating hormone) level was 7.88 (0.34 - 5.60). A Physician's order dated 5/7/19 directed to increase the Synthroid dose to 125 mcg and repeat the TSH level in 4 weeks. A laboratory…

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, review of facility policy, and interviews, the facility failed to ensure that a beard guard was utilized during food handling and/or failed to properly maintain temperatures in nourishment refrigerator. The findings include: a. During the walk through of kitchen with Director of Dietary Services on 9/23/19 at 9:35 AM, observation of the Head Cook, who had a full beard, in the kitchen preparation food area identified he/she was mixing a very large bowl of molasses type food substance (identified as BBQ sauce) in an uncovered bowl without the benefit of a beard guard protector. Interview with Head [NAME] at this time, identified that he/she knew to wear a beard guard, but that it was itching him/her so he/she removed it. Interview with Director of Dietary Services on 9/23/19 at 9:37 AM identified that the hair and beard guards are required for all personnel in the kitchen environment if they have facial hair and/or hair on head. Interview with Administrator on 9/23/19 at 10:45 AM identified that administration had repeated this message several times and 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.