Gulfside Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to ensure PASRR Level I was accurate for one Resident (#9) out of eight residents sampled Findings include:Review of the admission record, dated 06/11/2026, showed Resident #9 was admitted to the facility originally on 4/29/2025 and readmitted on [DATE] with diagnoses to include; Bipolar Disorder, current episode mixed, moderate, Schizoaffective Disorder, Bipolar Type, Major Depressive Disorder, recurrent, moderate, other specified anxiety disordersReview of Resident #9's Preadmission Screening and Resident Review (PASRR) Level I, dated 5/5/2025, revealed schizoaffective disorder listed as the only qualifying mental health diagnosis. On 06/11/2026 at 1:09 PM an interview was conducted with the Social Service Director and the Director of Nursing [SSD/ DON]. The SSD stated the Preadmission Screening and Resident Review [PASRR] starts with admission. When a resident is admitted they review and update the PASRR as needed. They conduct audits every 3 to 5…

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, record review, and interviews, the facility failed to ensure a care plan was revised for one resident (#53) out of twenty residents reviewed. Findings included: On 6/9/26 at 10:10 a.m., an observation of Resident #53 was conducted with Staff K, Certified Nursing Assistant (CNA) present. A Styrofoam cup on the bedside table revealed a handwritten, harmful phrase towards a political figure. The same message was written on a white sheet of paper located on the wall behind the head of the bed. Staff K, CNA said the resident writes the same phrase on the walls sometimes. She said he's had those behaviors. On 6/9/26 at 10:17 a.m., an interview was conducted with the Social Services Director (SSD). She said Resident #53 does not come out of his room. The SSD said he was quiet and kept to himself. She said the facility had to strategically place him with a roommate who does not yell, make loud noises or is aggressive. The SSD stated the phrase he wrote on his cup and behind his bed, she did not pay…

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, interviews, and medical record review, the facility failedto provide one resident (#39) with meals free from ingredients the resident wasallergic to during one of six meals observed. Findings included:On 6/10/2026 at 12:00 p.m. Resident #39 received her lunch meal tray while in her room. She received her lunch meal in a plastic (Styrofoam) container. Resident #39 lifted the lid and the contents included a regular textured alternate meal with chicken, rice, sweet peas and a small dinner roll. Resident #39 stated she did not order the alternate meal and she believed it is expected the kitchen will serve the primary meal unless requested otherwise. Resident #39 stated, It seems the kitchen just cannot get it right with my food, and I did not even get a tray with food at lunch yesterday (6/9/2026). Resident #39 stated she would have eaten the meatloaf, peas and carrots and mashed potatoes that was the primary meal for lunch. Review of Resident #39's meal ticket showed her receiving chicken,…

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, record reviews and interviews, the facility failed to ensure one resident (#12) received dialysis services consistent with professional standards of practice out of three residents sampled. Findings include: On 6/08 /2026 at 12:31 PM, Resident #12 was observed sitting in his room eating his lunch. He stated he went to dialysis today and he did not feel like talking. Review of an admission record showed Resident #12 was admitted to the facility on [DATE] with diagnoses to include End Stage Renal Disease, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, and dependence on renal dialysis.Review of a progress note, dated 5/18/2026, showed Resident #12 did not go to dialysis. Review of a progress note, dated 5/20/2026, showed Resident #12 refused to go to his scheduled dialysis appointment this morning. Resident #12 went to dialysis yesterday (Tuesday) after missing Monday's treatment due to transportation not arriving on time. Review of a progress note, dated 5/22/2026, showed Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to providetrauma informed care to eliminate or mitigate triggers that may cause re-traumatizationfor one resident (#39) diagnosed with Post Traumatic Stress Disorder (PTSD)out of four residents sampled. Findings included:On 6/8/2026 at 10:00 a.m. Resident #39's room was approached and the door was closed. The hallway was observed with many beds placed to one side, as well as various bedside dressers and other room equipment. Housekeeping services were deep cleaning resident rooms on the hallway. There were very loud floor cleaning machines and other machines overheard through the entire hallway. After knocking several times, the door was opened and Resident #39 was observed seated on the edge of her bed facing the door and had on very large ear/head phones. She stated she was listening to music and trying to drown out the loud noises in the hallway. Resident #39 stated housekeeping services had just come to the hallway this a.m. and without…

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 record review and interviews, the facility failed to ensure side effect monitoring was implemented based on pharmacy recommendations for psychotropic medications for one resident (#2) out of five residents sampled. Findings included: A review of Resident #2's admission record revealed an initial admission on [DATE] and a re-admission on [DATE] with diagnoses to include major depressive disorder, recurrent, moderate, bipolar disorder, unspecified, generalized anxiety disorder, and mood disorder due to known physiological condition with mixed features.A review of Resident #2's physician orders revealed the following: - trazodone hcl [hydrochloride] oral tablet 50 mg [milligrams] (trazodone hcl) give 0.5 tablet by mouth two times a day for mdd [major depressive disorder], with a start date of 1/31/26. - oxcarbazepine oral tablet 300 mg (oxcarbazepine) give 1 tablet by mouth two times a day for mdd, with a start date of 1/31/26. - depakote sprinkles oral capsule delayed release sprinkle 125 mg (divalproex…

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, record reviews, and interviews the facility failed to ensure a medication error rate of less than 5.00%. Forty-seven medication administration opportunities were observed, and three errors were identified for two residents (#23 and #47 ) out of four residents observed. These errors constituted a 6.38% medication error rate.Findings included:On 6/9/26 at 9:00 a.m. observed Staff N, Registered Nurse (RN) preparing and administering medications to Resident #23 she said the resident's blood pressure was (BP) 130/72 and blood sugar was 293 mg/dL. Staff N, RN administered the following medications:-Cetirizine HCl (hydrochloride) 10 mg (milligrams) tablet-Cyanocobalamin 1000 mcg (micrograms) tablet-Duloxetine HCl 60 mg Delayed Release- Folic Acid 1 mg tablet-Gabapentin 300 mg capsule-Risperdal 1 mg tablet- Sertraline HCl 50 mg tablet- Xarelto 20 mg Tablet- Advair Diskus Inhalation Aerosol Powder 250-50 MCG/ACT 1 inhalation - Docusate Sodium 100 mg- Lantus SoloStar 100 units/ml (milliliter) pen-injector Inject 20 units- Magnesium Oxide 400 mg tablet- Metoprolol…

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, interviews, and record reviews, the facility failed to ensure medications were properly labeled, dated, and stored according to manufacturer guidelines and professional standards of practice in one medication cart (2 North) of three medication carts observed.Findings Included:During an interview and observation of the 2 North medication cart on 6/8/26 at 9:45 a.m. with Staff A, Licensed Practical Nurse (LPN) the following improperly labeled and undated medications were stored:Resident #17: Albuterol AER HFA inhaler found undated, with no open date or expiration date visible.Resident #7: Fluticasone/Salmeterol inhaler open and undated, with no open date or expiration date recorded.Resident #34: Novolog FlexPen found open but not dated, leaving the beyond-use date unable to be determined.During the observation in reference to the dating of the open multiuse medications, Staff A. LPN said medications should be labeled with the open and expiration dates and when first used sometimes staff do not take time to add the dates. During an interview on 6/11/26 at 3:44…

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, record reviews, and interviews, the facility failed to coordinate and ensure follow up dental services for one resident (#27) out of eight residents sampled.Findings included: Review of the admission record dated 06/11/2026 showed Resident #27 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including unspecified convulsions, hemiplegia and hemiparesis following cerebral infarction affecting the left non dominant side, and muscle wasting and atrophy. A review of the Quarterly minimum data set (MDS) dated [DATE] showed a brief interview for mental status (BIMS) score of 15, indicating the resident is cognitively intact.Review of the active order summary dated 06/11/2026 showed an appointment for Dental (oral surgery) scheduled for April 30th at 2:00 PM, entered on 04/22/2026. Review of a Health Status progress note dated 12/22/2025 documented that the resident underwent a partial tooth extraction, reported increased pain, and that follow up monitoring would continue…

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 a scheduled meal was provided for one resident (#39) out of forty-one observed, during one of four days observed. Findings included: On 6/9/2026 at 11:45 a.m., Resident #39 was interviewed in her room prior to lunch service. She reported she had been eating meals in her room for several weeks due to her preference to avoid larger groups. She stated she previously ate in the main dining room but had not done so for nearly a month. At 12:04 p.m., meal carts were present in the hallway, however, the resident was not provided a lunch tray.On 6/9/2026 at 1:30 p.m., Resident #39 was observed sitting on the edge of her bed with a box of food from an outside restaurant, which she said had been given to her by another resident. She stated she had not received a lunch meal from the facility and explained she had asked an aide and a nurse twice, but no meal was ever brought to her. She confirmed she would have eaten the facility's lunch if 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 observations, interviews, and record review, the facility failed to ensure: a) residents were provided a nourishing nighttime snack by failing to follow the standardized recipe and b) cartons of milk were held under 41 degrees Fahrenheit during one (on 6/10/26) of six meal services observed. Findings included: 1. On 6/8/26 at 1:02 p.m., a resident council meeting was conducted with four participants who regularly attended the resident council meetings. Resident #17 and Resident #23 said the peanut butter and jelly sandwiches available before bedtime are half sandwiches that are thin, no color from the jelly, and contain a small amount of peanut butter. The residents stated, The jelly used to ooze out. The residents said when they have voiced this concern to the staff who provided the sandwiches, as well as to the dietary staff. On 6/9/26 at 7:10 a.m., an interview was conducted with the Dietary Manager. She confirmed the snacks provided at night included peanut butter and jelly sandwiches. The Dietary Manager said when they prepared the peanut butter and jelly sandwiches,…

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, record review, and interview, the facility failed to provide adequate supervision for four (#5, #6, #3, and #7) of four residents in a manner that protected them from falls resulting in injuries. Findings included: 1. Review of the facility's Incident Log, revealed Resident #5 had unwitnessed falls on 9/23/24 at 11:45 p.m. and 9/28/24 at 8:30 p.m. Review of Resident #5's admission Record revealed the resident was admitted on [DATE]. The resident's record included admission diagnoses not limited to unspecified severity unspecified dementia with other behavioral disturbance, delirium due to known physiological condition, other encephalopathy, generalized muscle weakness, and need for assistance with personal care. Review of Resident #5's Admit/Readmit Screener, dated 9/17/24, revealed the resident was admitted due to Urinary Tract Infection (UTI), Altered Mental Status (AMS), and dementia. The evaluation showed the resident was alert to person only, required supervision or touching assistance…

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 record reviews and interviews the facility failed to report an injury of unknown origin following an unwitnessed fall for one (#5) out of two residents sampled. Findings included: Review of Resident #5's admission Record revealed the resident was admitted on [DATE]. The resident's record included admission diagnoses not limited to unspecified severity unspecified dementia with other behavioral disturbance, delirium due to known physiological condition, other encephalopathy, generalized muscle weakness, and need for assistance with personal care. Review of the facility's Incident Log, revealed Resident #5 had unwitnessed falls on 9/23/24 at 11:45 p.m. and 9/28/24 at 8:30 p.m. Review of Resident #5's Situation, Background, Appearance, and Recommendation (SBAR) Change in Condition, dated 9/23/24 at 11:30 p.m. revealed the resident was observe(d) walking across the hall from her room the the [sic]) room across the hall. Resident was seen one minute then she was not seen. When staff walked around the nurses…

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 interviews, record reviews, and review of facility policy, the facility failed to provided physician ordered medications to one (Resident #2) of three residents sampled for pharmacy services. Findings included: A review of Resident #2's medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses of Wilson's Disease, autistic disorder, borderline personality disorder, and generalized anxiety disorder. Resident #2 was discharged from the facility on 1/13/2024. A review of Resident #2's physician's orders revealed an order, dated 12/21/2023 for Lorazepam 1 milligram (mg) by mouth two times a day at 9:00 AM and 5:00 PM for anxiety. A review of Resident #2's care plan revealed a focus area, initiated 12/21/2023, Resident #1 used anti-anxiety medications related to a diagnosis of generalized anxiety disorder. Interventions included to administer anti-anxiety medications as ordered by the physician and monitor for side effects and effectiveness every shift. A review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and review of the facility's policy, the facility failed to complete the Preadmission Screening and Resident Review (PASARR) Level II upon a new qualifying mental health diagnosis and / or ensure the accuracy of a PASARR Level I for 4 (#13, #17, #46, #42) of 7 sampled residents with mental health diagnoses Findings included: 1. Review of the clinical record revealed Resident #13 was admitted on [DATE] and readmitted on [DATE]. Further review of the admission face sheet revealed diagnoses that included but were not limited to, psychosis as of 08/06/2012, recurrent major depression disorder as of 08/06/2012, cerebral vascular accident (CVA) as of 08/06/2012, anxiety as of 08/06/2012, diabetes as of 07/24/2014, vascular dementia as of 02/17/2015, mood disorder as of 08/28/2018, and dementia as of 06/12/2020. Review of the annual Minimum Data Set (MDS) dated [DATE] showed in Section C, Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 06 (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.

Based on observation, interviews and review of the facility's policy titled Use and Storage of Food brought in by Family of Visitors, the facility failed to ensure food items were stored in accordance with professional standards for food service safety for one refrigerator (dining area) out of three refrigerators reviewed in the facility. Findings included: An observation on 01/16/24 at 12:12 p.m., revealed a refrigerator designated for residents located in the dining area. The resident refrigerator had a sign on it that stated, Resident Refrigerator Only This refrigerator will be checked every Tuesday any items expired or not dated will be thrown in the trash. On the inside of the resident refrigerator revealed an expired egg nog with an expiration date of 12/23/23, a container of a red substance not labeled or dated and a bag of food items that were not labeled or dated. On the outside of the resident refrigerator showed an empty sleeve with no temperature log available. (photographic evidence obtained) During an interview on 01/16/24 at 12:13 pm., Staff F, Director of Food…

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 record review and interview, the facility failed to ensure one (Residents #29) of three residents sampled for Beneficiary Notice, received Beneficiary Notice when discharged from a Medicare covered Part A stay and remained in the facility. Findings Included: Review of documentation provided by the facility's Director of Social Services related to Beneficiary notification for Resident #29 revealed a last covered Medicare Part A Day was 10/27/2023 and he remained in the facility. Documentation on the SNF Beneficiary Protection Notification Review form revealed a SNF ABN Form CMS -10055 (Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN)) form was not provided to the resident. Continued review of the form revealed a handwritten note under Other Explain which indicated Resident payor source changed on 10/28/2023 and remained in the facility. On 01/17/24 at 11:00 a.m., an interview was conducted with the Social Service Director (SSD). The SSD said she did not really know the beneficiary notices process until the new administrator started. She confirmed…

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 interviews and record review, the facility failed to provide discharge documentation for two residents (#265, # 61) out of eight residents sampled. Findings Included 1. Review of the admission Record revealed Resident #265 was admitted [DATE] with a primary diagnosis of Type 2 Diabetes Mellitus without Complications, Difficulty in Walking, not elsewhere classified, major depressive disorder, recurrent, moderate, other specified persistent mood disorders, depression, unspecified. Review of Nursing progress note dated 12/22/2023 showed Resident #265 wanted to discharge Against Medical Advice (AMA) and had been informed of the risk. It was noted that he signed all the paperwork and was escorted to the front door with all his belongings. Further clinical record review showed no evidence of Resident #265 AMA paperwork and no physician notification related to the resident leaving the facility AMA. During an interview on 01/18/2024 at 4:21 p.m., with the Director of Nursing (DON). She confirmed the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the comprehensive Minimum Data Set (MDS) assessment was accurately coded for one (Resident #8) of fifteen sampled residents. Findings included: During an interview on 01/16/24 at 9:56 a.m., Resident #8 stated she was not a diabetic and did not receive insulin. Review of the admission Record showed Resident #8 was originally admitted to the facility on [DATE] with diagnoses that included but was not limited to Multiple Sclerosis, Myelodyplastic Syndrome, Paraplegia, Epilepsy and Cervicalgia. A diagnoses of Diabetes was not noted in the diagnoses information. Review of all current and discontinued physician orders showed insulin was never ordered, or administered, for Resident #8. Review of Resident #8's care plan did not identify a Focus of diabetes mellitus or insulin administration. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] Section N0350 Insulin showed Resident #8 received seven days of insulin injections. During an interview…

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 record review, interviews, and review of the facility's policy titled Resident Assessment-Coordination with PASARR Program, the facility failed to ensure the Level I Preadmission Screening and Resident Review (PASRR) was accurate upon admission for two (Resident #38 and #47) of fifteen residents sampled for PASRR review. Findings included: 1. Review of the admission Record showed Resident #47 was admitted to the facility on [DATE] with diagnoses that included but was not limited to Major Depressive Disorder, Anxiety Disorder and Schizophrenia. A review of Resident #47's PASRR assessment, dated 01/27/23 revealed, under the section titled A. MI (Mental Illness) or suspected MI (check all that apply), the checkbox for the selection Schizophrenia was not checked. Review of Resident #47's Quarterly Minimum Data Set (MDS) dated [DATE] Section I-Active Diagnoses showed Resident #42 had diagnoses of Anxiety Disorder, Depression and Schizophrenia. During an interview on 01/18/24 at 2:00 p.m., the Director 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 record review and interview, the facility failed to provide care and services related to 2 of 2 sampled residents (#13 and #49). Resident #13 lacked documentation related to a new diagnoses of melanoma, biopsy, care, and documentation of the characteristics of the wound. Resident #49 lacked follow up regarding need for antibiotics with the physician and Hospice. Findings included: Review of the clinical record revealed Resident #13 was admitted on [DATE] and readmitted on [DATE]. Further review of the admission face sheet revealed diagnoses that included but were not limited to, psychosis as of 08/06/2012, recurrent major depression disorder as of 08/06/2012, CVA as of 08/06/2012, anxiety as of 08/06/2012, diabetes as of 07/24/2014, vascular dementia as of 02/17/2015, mood disorder as of 08/28/2018, and dementia as of 06/12/2020. Review of the annual Minimum Data Set (MDS) dated [DATE] showed in Section C, Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 06 (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 interview and record review, the facility failed to provide adequate care related to pressure ulcer care for 1 of 3 sampled residents (#17). The facility failed to document the characteristics of the pressure ulcer in the medical record. Findings included: Review of the clinical record revealed Resident #17 was admitted on [DATE] and readmitted on [DATE]. Further review of the admission face sheet revealed diagnoses that included but were not limited to paraplegia due to an injury of T7-T10 as of 03/20/2014, Stage IV pressure ulcer on sacrum as of 09/30/2019, contractures of right and left feet and ankles as of 08/18/2021, unspecified protein-calorie malnutrition as of 02/28/2023, hypertension as of 11/23/2020, and recurrent major depressive disorder as of 05/21/2020. Review of the quarterly Minimum Data Set (MDS) dated [DATE] showed in Section C, Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). Section I, Active Diagnoses showed hypertension,…

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, interviews, and record review, the facility failed to ensure one resident (# 4) was assessed to conduct self- catheterization out of four residents sampled. Finding included: On 01/16/24 at 12:16 p.m., Resident # 4 observed laying down in bed with his call light within his reach and bedside table next to him. Resident was observed with his catheter bag stored in a trash can with two urinals placed on the side of the trash can. The room was observed little cluttered, proper lightening and home like environment. On 01/17/2024 at 3:00 p.m., Resident # 4 observed laying down in bed with his call light within his reach. 12-inch catheter products were observed on the resident nightstand. He said he took his indwelling catheter out yesterday and inserted the 12-inch catheter. His 12 inch catheter products came in that he normally uses, which is easier for him to insert himself. He wishes the facility keeps the 12-inch catheter in stock because they are easier from him to insert instead 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.

Based on observation, interview and record review, the facility failed to ensure the medication error rate was below 5% for three (#10, #31, #35) of 6 sampled residents who were administered medications. This resulted in 3 errors of 30 medication administration opportunities for a medication error rate of 10%. Findings included: On 01/16/2024 at 9:45 a.m. Staff I, Registered Nurse (RN) was observed performing medication administration for Resident #10. She administered -Oscal 500/200, D-3 milligrams (mg)-unit daily for supplement; -Vitamin B 12 extended release 1000 micrograms (mcg) daily for supplement; -Refresh solution 1.4-0.6%, instill 1 drop in both eyes four times a day for dry eyes Review of the Medication Administration Record (MAR) showed: Lysine 500 mg in the morning for a supplement was documented as given by Staff I. During an interview on 01/18/2023 at 1:45 p.m., Staff I stated that was an error, she did not have any Lysine in the medication cart or facility to give the resident. She did not receive her Lysine that day. The Director of Nursing (DON) verified 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, interviews and review of the facility's policy titled Food: Quality and Palatability the facility failed to serve food at an appetizing temperature for one Resident (#48) out of 15 sampled residents reviewed for food services. Findings included: During an interview on 01/16/24 at 10:43 a.m., Resident #48 stated hot food was being served cold. Resident #48 stated dinner on 01/14/24 was cold. The State Surveying Agency (SSA) requested a test tray be placed on the last tray cart leaving the kitchen for 01/17/24 lunch meal. An observation on 01/17/24 at 12:25 p.m., showed the test tray remained on the tray cart until the last resident tray was delivered. The test tray was then removed by Staff F, Food Service Director (FSD) for food temperatures. During an interview on 01/17/24 at 12:25 p.m., Staff F, FSD stated the thermometer had been calibrated and was ready to take food temperatures. Staff F, FSD stated he expected all cold food to be under 41 degrees Fahrenheit (F) and would expect all hot…

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 staff followed acceptable standards of practice related to infection control including hand hygiene, disinfecting of the glucose monitoring machines, and water testing. Findings included: On 01/16/2024 at 9:55 a.m. Staff H, Licensed Practical Nurse (LPN) was observed performing medication administration for Resident #34. During the medication administration hand sanitizing was not performed. On 01/16/2024 at 10:00 a.m. Staff H, LPN was observed performing medication administration for Resident #50. No hand sanitizing was performed prior to gathering medications, before entering room and none post medication administration. On 01/16/2024 at 11:45 a.m. Staff H, Licensed Practical Nurse (LPN) was observed performing a blood glucose monitoring procedure and insulin injection for Resident #35. Staff H, LPN removed blood glucose monitoring machine and placed it, the container of strips and lancet on top of the medication cart. Staff H applied gloves without hand sanitizing and removed a wipe from the purple…

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 review and revise the Person-Centered Comprehensive Care Plan for 1 (#13) of 28 sampled residents related to a new diagnoses of Melanoma requiring a biopsy and wound care. Findings included: Review of the clinical record revealed Resident #13 was admitted on [DATE] and readmitted on [DATE]. Further review of the admission face sheet revealed diagnoses that included but were not limited to, psychosis as of 08/06/2012, recurrent major depression disorder as of 08/06/2012, CVA as of 08/06/2012, anxiety as of 08/06/2012, diabetes as of 07/24/2014, vascular dementia as of 02/17/2015, mood disorder as of 08/28/2018, and dementia as of 06/12/2020. Review of the annual Minimum Data Set (MDS) dated [DATE] showed in Section C, Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 06 (severe impairment). Section I, Active Diagnoses showed non-Alzheimer's dementia, anxiety disorder, depression, psychotic disorder (other than schizophrenia).…

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 medical record review, staff and resident/resident representative interviews, the facility failed to provide requested medical record access, and copies of medical records for one (#2) of two sampled residents. Findings included: Review of the medical record for Resident #2 revealed admission to the facility on [DATE] as per the admission face sheet. Review of the advance directives revealed resident #2 had a POA (power of attorney) for care and financial decisions, and was confirmed as a family member. Further review of the POA document, revealed it was signed and dated as of 11/11/2022 and signed by the resident, notary public and two witnesses. Further review of the medical record did not indicate any further change of POA status, leading up to Resident #2's transfer to the hospital on [DATE]. Review of the 10/2/2023 8:30am - SBAR (situation, background, assessment and recommendation) note revealed; Shortness Of Breath (SOB) and seems different as usual, talks less. Recommendation to send 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 staff and resident representative interviews, and medical record review, the facility failed to provide one (#2) of two sampled residents with a Bed Hold Notice, prior to and/or after the resident was transferred to a higher level of care facility. Findings included: On 11/2/2023 during medical record review for Resident #2, the admission record revealed she was admitted to the facility on [DATE]. Review of the electronic nurse notes revealed the following: 1. SBAR (situation, background, assessment and recommendation) note dated 10/2/2023 8:30am- Shortness of Breath and seems different as usual, talks less. Recommendations to send to ED [emergency department] for evaluation. 2. Nurse progress note dated 10/2/2023 8:30am - Resident presented with Shortness of Breath RR [respiratory rate] 22, O2 [oxygen] 65@ 2L/M [liters per minute] via NC [nasal cannula], productive cough, wheezing and rales in lower bilateral lobes. Patient did not respond to verbal stimuli. BP [blood pressure] 86/50 HR [heart rate]…

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, staff and resident interview and record review, the facility failed to ensure two residents (#21 and #16) of twenty-four sampled residents were invited and accommodated with activities that met their interest, and to group activities scheduled during three of three days observed (12/27/2021, 12/28/2021 and 12/29/2021). Findings included: 1. On 12/27/2021 at 10:50 a.m. Resident #21 was observed in her room lying in bed, on top of the covers, dressed for the day and with her eyes closed. An interview on this day at 12:22 p.m. with Resident #21 while in her room revealed her seated in her wheelchair at the bedside. Resident #21 was asked if she attended any out-of-the-room activities and she shook her head side to side indicating, no. Resident #21 explained she was told by staff that she should stay in her room and not attend any group activities due to her health concerns. Resident #21 confirmed she would attend most of the group activities, if she could. Resident #21 explained several staff…

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.