Azure Shores Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to collaborate and coordinate with hospice representative for one (Resident #101) out of one sampled resident receiving hospice services as evidenced by: facility staff failed to obtain and keep hospice nursing notes in the hospice folder for Resident #101 since March 2026 when Resident #101 received a physician order for hospice services. There were four residents receiving hospice care residing in the facility at the time of survey. The findings included:On 04/06/2026 at 11:34 AM Resident #101 was observed in bed, call light in reach, no apparent distress and voiced no complaints. Record review of Resident #101's clinical records revealed the resident was admitted on [DATE] and readmitted on [DATE] with diagnosis that included but not limited to: Acute Myeloblastic Leukemia. Record review of a Quarterly minimum data set reference dated 02/10/2026 indicated Resident #101 had moderate cognitive impairment and was receiving hospice 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.

Based on observations, interview and record review, the facility's Quality Assurance and Performance Improvement Activities (QAPI/QAA) failed to demonstrate an effective plan of action to correct repeated deficiencies in the problem area as evidenced by repeated deficient practices for F761; failed to properly store and label medications during medication administration, F689; failed to prevent accident hazards, F690; failed to ensure a resident with an indwelling urinary catheter received care to prevent infection and F867; QAPI/QAA improvement activities. These repeated deficient practices have the potential to affect the 119 residents residing in the facility at the time of survey. The findings included:Record review of the facility's survey history revealed the facility was cited for F761, F690, F689, and F867 during the recertification and Relicensure survey with an exit date of 09/26/2024. Record review of the facility's Quality Assurance and Performance Improvement (QAPI) Plan revealed revised January 20, 2026 revealed Purpose: The purpose of QAPI in our organization is 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 observation, interview, and record review, it was determined that the facility failed to provide housekeeping and maintenance service to maintain a sanitary, safe, orderly, and comfortable interior for the first and second (2/2/) residential living floors. The findings included: During the resident screenings performed by the surveyors on 09/23-24/25, and environment tours conducted on 09/25-26/24 accompanied with the facility's Administrator, Infection Control Preventionist, Corporate Housekeeping Director. and Corporate Registered Nurse, the following were noted: The findings included: FIRST FLOOR: room [ROOM NUMBER] - Room windows screens (2) heavily torn and in disrepair. room [ROOM NUMBER]: Exterior of room chair was stained, worn, and torn. room [ROOM NUMBER] - Fall mat (A-bed) soiled and stained, exterior of over-bed table damaged and in disrepair, bathroom floor soiled and large black stains, and exterior of night-stand (B-bed) damaged and in disrepair. room [ROOM NUMBER] - Exteriors of over-bed…

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, it was determined that the facility's menu failed to meet the nutritional needs for 28 facility residents (included Sampled Resident's #21, #57, #65, #69, #76, #97, #102 and #140) residents with physician ordered Dysphagia Advanced/Dysphagia Mechanical Soft, and 9 facility resident's (included Sampled Resident's #53, #58, #59, and #95) with physician ordered Dysphagia Pureed. The findings included: During the review of the approved menu for the Lunch meal for 09/24/24, the following were noted: Lettuce & Tomato Plate (4 ounces) and Pickle Spear (1) to be server to Regular diet. Further review noted that there was no planned vegetable substitution documented for Dysphagia Advanced Diet, Dysphagia Mechanical Soft Diet, and Dysphagia Pureed Diet. Interview with the Corporate Food Service Director (CFSD) at the time of the review confirmed diets failed to have a documented vegetable substitution planned on the approved menu. It was discussed with the CFSD that the menu failed to meet the nutritional requirements for vegetable serving…

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, it was determined that the facility failed to prepare foods by methods that conserve nutritive value, palatable flavor and appearance for Dysphagia Mechanically Altered Diet, Mechanical Soft Diet, Dysphagia Pureed Diet, and Regular Diet . The findings included: 1) During the initial dietary/food service observation tour conducted on 09/23/24 at 8:45 AM accompanied with the Corporate Food Service Director (CFSD) , it was noted that quarter and half pans of prepared foods were located within the steamer , however the unit was not on. Further observation noted that the steamer contained fully cooked/prepared foods that included the following half pan of Ground Chicken, half pan of Pureed Chicken, quarter pan Pureed Rice, quarter pan Pureed Macaroni Noodles, half pan Purred Spinach, and quarter pan Pureed Carrots. Further observation noted that the foods appeared non-appetizing and tasteless when tested by the surveyor. Interview with the breakfast/lunch cook (Staff I) revealed the ground and pureed foods were prepared in the early…

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, it was determined that the facility failed to prepare food in a Mechanically Altered and Pureed Form designed to meet resident needs for 28 (Includes Sampled Resident's # 21, #24, #57, #65, #69, #76, #97, #102, and #04) physician ordered Mechanically Altered Diet, and 9 (Includes Sampled Resident's #53, #58, 59, and #95) physician ordered Dysphagia Pureed Diet. The findings included: During the review of the facility's approved Diet and Nutrition Care Manual - Chapter 2: Consistency Alterations 2-16, 2019 .Noted the following: (A) Mechanically Altered (Level 2) of Mechanical Soft Diet: This diet is used for residents with mild to moderate oral and/or pharyngeal dysphagia. Some chewing is required and difficult to chew foods that are chopped, ground, shredded, cooked, or altered to make it easier to chew and swallow. Foods should be soft and moist enough to form a bolus. (B) Dysphagia Puree (Level 1) Diet: The diet is used for resident who have sever chewing and/or swallowing problems. All foods are pureed to simulate a soft 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to ensure that a therapeutic diet of Lactose Intolerance/No Dairy was obtained from the attending physician and followed by the facility for 1 (Resident #324) of 5 residents sample for nutrition review. The findings included. On 09/25/24 at 9:00 AM during observation of Resident #324 in his room the resident appeared to be underweight/malnourished, but was alert and oriented. Observation of the breakfast tray noted the tray ticket document NO Dairy/Double Entree Portions, however the food tray contained an 8-ounce carton of whole milk and a single portion of sausage gravy that the ingredients include whole milk. The resident at the time of the observation stated he became Lactose intolerant approximately 5 years ago and has suffered weight loose due to the side effects of being Lactose Intolerant and receives milk and foods made with milk for almost all meals served. Resident #324 revealed he continuously spoke to…

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

Based on observation and interview, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for potentially 104 of the 116 residents who eat foods by mouth. The findings included: 1) During the initial dietary/food service observation tour conducted on 09/23/24 at 8:45 AM, and accompanied with the facility's Certified Dietary Manager and Corporate Food Service Director (CFSD), the following were noted: (a) Observation of the cook's preparation sink noted a large cooking pot full of water that contained a 10 pound package of raw chicken. Further observation noted that no cold water was running over the chicken and the CFSD stated that the chicken was thawing, and staff failed to ensure that the cold water was running into the pot at full volume. At the request of the surveyor the temperature of the water within the pot was taken by the CFSD with the facility's calibrated food thermometer and was recorded at 100 degrees Fahrenheit (F). The surveyor reviewed that the regulatory temperature…

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, it was determined that the facility failed to dispose of garbage and refuse properly that potentially effected all of the 116 facility residents. The findings included: During the kitchen/food service observation tour conducted on 09/23/24 at 8:45 AM and accompanied with the Certified Dietary Manager and Corporate Food Service Director the garbage/refuse noted to have the garbage/trash container with the lid open and had open garbage and trash spewing onto the [NAME] area around the unit. Further observation of the garbage/refuse area noted that the area behind the dumpster was heavily covered in soiled PPE's (gloves, gowns, masks, unidentifiable resident and nursing waste materials, rotting trash and garbage, and presence and evidence insect and rodent activity. It was estimated that the area was approximately 25 feet long and 5 feet wide and a large area of stagnant, fowl, garbage and trash was located at one end. The surveyor requested that the 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.

Based on observations, interview and record review the facility failed to assure services being provided to residents meet professional standards of quality for 1 of 4 of residents observed during med pass (Resident #54). The findings included: Review of the facility's employee handbook with revised date of 2024 under section titled, Personal Appearance, Dress Code and Uniform Policy included the following in part: Nails must be clean, neat and trimmed to ¼ inch for resident/patient care responsibilities; acrylic and gel nails or any other artificial nails are prohibited under any circumstances. Review of the CDC's (Center for Disease Control) website titled, Clean Hands at https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html Under the section Maintain fingernail and jewelry safety included in part the following: Natural nails should not extend past the fingertip. Do not wear artificial fingernails or extensions when having direct contact with high-risk patients like those at intensive-care units or operating rooms. Germs can live under artificial fingernails both before…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review observations and interviews the facility failed to ensure resident with indwelling urinary catheter receives care to prevent to prevent infection and to provide nephrology consult appointment for 1 of 1 resident observed for catheter care (Resident #117). The findings included: Record review for Resident #117 revealed the resident was admitted to the facility on [DATE] with diagnoses that included the following in part: Sepsis Unspecified Organism, Chronic Kidney Disease Stage 3, Chronic Prostatitis, Retention of Urine Unspecified, Personal History of Urinary (Tract) Infections, and Obstructive and Reflux Uropathy Unspecified. Review of the Minimum Data Set for Resident #117 dated 09/08/24 documented in Section C a Brief Interview of Mental Status score of 15 indicating a cognitive response. Review of the Physician's Orders for Resident #117 revealed an order dated 08/19/24 for Urinary Catheter: Provide catheter care every shift and as needed. On 08/23/24 a physician's order was written…

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 reviews, the facility failed to monitor food and supplement intake for 1 (Resident #69) of 7 residents reviewed for nutrition and failed to ensure accurate weights for new admission for 1 (Resident # 323) of 7 residents reviewed for nutrition. The findings included: 1). Resident #69 was admitted to the facility on [DATE]. According to the resident's most recent complete assessment, a quarterly Minimum Data Set (MDS), dated [DATE], resident #69 had a Brief Interview for Mental Status (BIMS) score of 11, indicating that the resident was moderately cognitively impaired. Resident #69's diagnoses at the time of the assessment included: Diabetes Mellitus, Dysphagia and Vitamin deficiency. Resident #69's orders included: Regular diet, Dysphagia Mechanical Soft texture, Regular/Thin Liquids consistency - Fortified food at all meals - 04/11/24 with a revision date of 08/30/24 Health Shake put Amt (Amount) ordered PO (by mouth) - three times a day for supplement 4 oz (ounces)…

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 physician's orders for tube feeding were followed for 2 of 3 residents reviewed for tube feeding (Residents #18 and #85) The findings included: On 09/23/24 at 11:45 AM an observation was made of Resident #85 lying in bed with bottle of Glucerna 1.2 (formula type) tube feeding at the 800 milliliter mark out of a 1,000 milliliter capacity bottle. The bottle was labeled as started at 09/23/24 at 6:00 AM, the tube feeding was not infusing. On 09/24/24 at 8:30 AM an observation made of Resident #85 lying in bed with bottle of Glucerna 1.2 tube feeding just above the 900 mark out of a 1,000 milliliter capacity bottle. The bottle was labeled as started at 09/24/24 at 5:45 AM the tube feeding was infusing at 70 milliliters per hour. On 09/24/24 at 1:45 PM an observation was made of Resident #85 lying in bed with bottle of Glucerna 1.2 tube feeding just below the 800 mark out of a 1,000 milliliter capacity bottle. The bottle was labeled as…

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, interview and record review the facility failed provide pharmaceutical services to ensure the accurate administering and documenting of medications to meet the needs of each resident for 1 of 4 resident reviewed for medication administration observation (Resident #54) and for 2 of 9 residents reviewed for controlled medications (Residents #6, and #54), and failed to ensure a discontinued medication was removed from the med cart for 1 of 9 residents reviewed during med reconciliation review (Resident #6) The findings included: Record review for Resident #54 revealed the resident was originally admitted to the facility on [DATE] with the most recent readmission on [DATE] with diagnoses that included in part the following: Spondylosis Lumbar Region, Respiratory Disorders in Diseases Classified Elsewhere, Chronic Obstructive Pulmonary Disease (COPD), Type 2 Diabetes Mellitus, Acquired Absence of Left Leg Below Knee, Other Specified Depressive Episodes, Peripheral Vascular Disease, and Bipolar…

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 the medication error rate was not 5% or greater. The medication error rate was 28% with 7 medication errors identified while observing a total of 25 opportunities, affecting Resident #54. The findings included: Record review for Resident #54 revealed the resident was originally admitted to the facility on [DATE] with the most recent readmission on [DATE] with diagnoses that included in part the following: Spondylosis Lumbar Region, Respiratory Disorders in Diseases Classified Elsewhere, Chronic Obstructive Pulmonary Disease (COPD), Type 2 Diabetes Mellitus, Acquired Absence of Left Leg Below Knee, Other Specified Depressive Episodes, Peripheral Vascular Disease, and Bipolar Disorder. Review of the Minimum Data Set (MDS) for Resident #54 dated 07/09/24 documented in Section C a Brief Interview of Mental Status score of 14 indicating a cognitive response. Review of the Physician's Orders for Resident #54 revealed the following…

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, interview the facility failed to ensure all disposed medications are stored in a secure manner for 1 of 4 residents observed during med administration (Resident #54). The findings included: On 09/23/24 at 9:45 AM an observation of med administration with Staff D Licensed Practical Nurse (LPN) for Resident #54 was conducted. While preparing the medications for Resident #54, the nurse spilled a pill out of the med cup and put the pill into the uncovered trash bin located on the side of the med cart. During an interview conducted on 09/23/24 at 10:00 AM with Staff D LPN who stated she has worked at the facility for 1 month and she is a new graduate nurse. When asked about drug disposal, the LPN stated the medication should go in the drug buster that is located on her cart in the bottom drawer. The LPN acknowledged she did not dispose of the medication properly.

Based on observations, interview and record review, the facility's Quality Assurance and Performance Improvement Activities (QAPI/QAA) failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area as evidenced by repeated deficient practices for F584, safe, clean, comfortable, homelike environment; F693, tube feeding management; F814, dispose garbage and refuse properly; and F867, QAPI/QAA improvement activities. These repeated deficient practices have the potential to affect all 116 residents residing in the facility at the time of this survey. The findings included: Review of the facility's survey history revealed the facility was cited F584, F693, F814 and F867 during the recertification and Relicensure survey with an exit date of 06/18/23. During an interview with the facility's Administrator on 09/26/24 at 1:05 PM, the Administrator was apprised that these 4 deficiencies will be cited again on this current survey. The Administrator stated he will be working to remedy this.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to provide adequate supervision and a secured environment for one (Resident #1) out of three sampled residents. This deficient practice enabled resident #1 to exit the facility at 4:30 PM on 10/04/23, undetected. The findings included: Record review of the facility's policy titled, Nursing Elopement Prevention effective April 2022 documented: Purpose: It is the policy of this facility to provide a safe environments for all residents and to eliminate and/or control elopement behavior of residents. The facility shall do all that is reasonable to identify and prevent elopement and to act quickly and prudently should it occur. Elopement occurs when a resident leaves the premises or a safe area without authorization (for example, an order for discharge or leave of absence) and/or any necessary supervision to do so. Procedure: 1) During the preadmission screening process, through record review/interview all reasonable efforts are made to ascertain…

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

Based on observation and interview, the facility failed to provide accommodation of needs for 3 out of 30 sampled residents (Resident #359 for dialysis machine in the bathroom, Resident #62 for the broken call light and Resident #55 unable to use his bathroom). This has the possibility to affect those residents who share a room with a dialysis patient as well as the 109 residents at the facility at the time of this survey. The findings included: 1. On 06/06/23 at 11:33 AM, observed Resident # 359 in bed, awake, alert, call light within reach and he was able to locate the call light button. He stated, I'm getting dialysis in the room they store the equipment in the bathroom. Surveyor observed some of the equipment next to his bed. On 06/06/23 at 11:35 AM, observed Resident #55 in bed, alert and oriented x3, watching TV, call light within reach. He stated, they are bringing my roommate's dialysis in the room, and I cannot use the bathroom, this happens three times a week, equipment is all over the place, I have peed on myself at times as I cannot use the bathroom. On 06/07/23 at 08:30…

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, interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) for three residents (Resident # 12, the resident's diagnosis was coded wrong, Resident # 75, the MDS was coded wrong for wander guard not in use, Resident # 29, the discharge status was coded wrong), out of 30 sampled resident's at the time of survey. This deficiency has the potential to affect 109 residents residing in the facility at the time of survey. The Findings included: 1. Record review of the clinical records for Resident # 12 revealed, the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses included, but were not limited to, Other sequelae of Cerebral Infarction Affecting Unspecified Side, Type 2 Diabetes Mellitus with Unspecified Complications; Unspecified Dementia, Unspecified Severity, Without Behavior Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. Record review of Orders dated 05/24/2022 revealed, the resident was receiving…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow physician's order for changing the midline (intravenous(IV) catheter) dressing for one (Resident #77) out of one resident's who was receiving intravenous therapy as evidenced by the midline dressing date being over 7 days old. The findings include: Observation on 6/5/23 at 7:32 AM, Resident #77 was receiving intravenous antibiotics. On 6/6/23 at 8:43 AM, it was observed that Resident #77 midline dressing to right arm appeared to be dated 5/11/23 or 5/17/23 (See photo evidence). It was noted that Resident #77 readmission to the facility was on 5/19/23. It was observed on 6/6/23 at 12:32 PM, 6/7/23 at 3:00PM (see photo evidence) and 6/8/23 at 9:20 AM the midline dressing was observed with dates that appeared to be 5/11/23 or 5/17/23. On 6/8/23 at 9:20 AM, an interview with Staff H, Licensed Practical Nurse (LPN) revealed, when asked What date is on Resident #77's midline dressing and how frequently are they changed? Staff H, L.P.N…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow prescribed doctor's orders for enteral feedings for three out of 22 residents receiving enteral feedings (Residents #67, #310 and #311) as evidenced by the enteral feeding rates were incorrect. This practice has the potential to affect 22 residents who receive tube feeding at the facility. The findings include: 1. On 6/6/23 at 8:48 AM and on 6/6/23 at 12:33 PM observations of Resident #67 revealed, the enteral feeding rate was set at 40 milliliters(ml) an hour. On 6/7/23 at 11:11 AM, the Enteral feeding rate was set at 70 milliliters an hour. Record review of Resident #67 revealed, Medical diagnoses were respiratory failure, tracheostomy, gastrostomy status, cerebral infarction (stroke) and dependence on respirator (ventilator) status. Review of the Physician orders of Resident #67 revealed, a start date of 5/30/23 for Enteral formula to run at 70 milliliters an hour for 22 hours or until 1540 ml is infused within 24 hours. Record…

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 ensure one (Resident # 209) out of 23 residents receiving oxygen treatments, had a doctor's order for oxygen therapy before administration. The facility failed to follow doctor's orders as evidenced by one resident (Resident # 209) out of 23 residents receiving oxygen therapy, the doctor's prescribed 2 Liters per Minute (LPM) and resident #209 was observed to be receiving 1.5 LPM of oxygen. The findings included: Observation of Resident # 209 on 06/05/2023 at 10:09 AM, the resident was sleeping. The resident was observed with a nasal cannula and the oxygen concentrator gauge was set up at 1.5 LPM. (Photographic evidence). Review of the residents physician orders revealed, there was no order for oxygen found. Observation of Resident # 209 on 06/06/2023 at 10:29 AM, the Resident was sleeping. The resident did not have the nasal cannula in place in nose. The oxygen concentrator gauge was set up at 1.5 LPM. (Photographic evidence). Review if…

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

Based on observation, Interview, and record review, the facility failed to ensure that a Registered Nurse (RN) was providing services at least 8 consecutives hours a day, 7 days a week. This had the potential to affect the 109 residents who resided in the facility at the time of this survey. The findings included: During an observation at First floor Nurse's station, on 06/06/2023 at 7:32 AM, it was noted that the staffing information was posted. It was observed that 3 Licensed Practical Nurses (LPN) were providing nursing care to the residents. (Photographic evidence). During an observation at Second floor Nurse's station, on 06/06/2023 at 7:35 AM, it was noted that the staffing information was posted. It was observed that 2 Licensed Practical Nurse (LPN) were providing nursing care to the residents. (Photographic evidence) During an observation at First floor Nurse's station, on 06/07/2023 at 8:12 AM, it was noted that the staffing information was posted. It was observed that 3 Licensed Practical Nurses (LPN) were providing nursing care to the residents. (Photographic evidence).…

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 policy review, the facility failed to assure the garbage and refuse area was clean and discarded furniture were properly disposed and contained on the facility grounds. The findings included: Record review of the Pest Control Policy and Procedure dated 4/02/2022 documented: Purpose-Facility wide pest-control strategies are developed emphasizing kitchens, cafeterias, laundries, central supply areas. Loading docks, construction activities and other regions prone to pest infestations. Procedure- 6) Maintain garbage storage area(s) in a sanitary condition to prevent the harborage and feeding of pests. Observation of the garbage and refuse area with Staff I, Dietary Aide on 6/05/23 at 6:37 am. The area had three trash bins for trash and one trash bin for recycle. The garbage and refuse area had garbage on the ground in piles. Discarded furniture chairs, dressers, air conditioner vent covers, wood planks and empty boxes of exam gloves were scattered on the ground and not contained in the garbage bins. Photographic evidence submitted. Interview with…

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

Based on record review and Interview, the facility failed to demonstrate effective plan of actions were implemented to correctly identify quality deficiencies in the problem area related to repeated deficient practices for F641 Accuracy of Assessments, F695 Respiratory/Tracheostomy Care and Suctioning, and F908 Essential Equipment, Safe Operating Condition. This practice has the potential to increase the risk of negative resident outcomes and to affect all 109 residents residing in the facility at the time of this survey. The finding included: Record review of the facility's survey history revealed, during a recertification survey with exit 04/28/2022, Accuracy of Assessments was cited related to the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for three out 40 sampled residents whose MDS were reviewed, Respiratory/Tracheostomy Care and Suctioning was cited related to the facility failed to follow physician's orders for the administration of oxygen for 2 out of 11 residents receiving respiratory treatments at the time of last survey, and Essential…

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 policy review, the facility failed to ensure essential equipment was in proper working condition for two out of six laundry machines. This practice has the potential to affect 109 resident's residents at this facility at the time of survey. Findings include: On 06/07/23 at 03:07 PM In an observation/interview with Manager of Housekeeping in laundry room. It was observed that there were 3 washers, and one had a tag on it. It stated, power disconnected 7/17/21. It was observed that there were three dryers and 1 had a sign which stated, Out of order. When asked How long has the dryer been out of order? The Housekeeping Manager stated, About 2 weeks ago. (See photo evidence). It was asked of the Housekeeping Manager and Regional Director of Maintenance to provide documentation of work order for broken washer and dryer. On 06/08/23 at 12:35 PM. In an interview with Maintenance Director. When asked What is the status of the washer being repaired or replaced? The Maintenance Director stated that We are waiting for a quote for the washer, the clothes…

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.