Treasure Isle Care Center

Based on observations, record reviews, interviews, the facility failed to ensure medications and biologicals are stored in accordance with professional standards in keep the unit one medication storage room and three medications: as evidence by twelve expired Nutritional Supplement in the medication storage room on unit one and expired insulin on medication cart three. There were 160 residents that resided in the facility at the time of survey.The findings include: On 09/29/2025 at 02:45 PM, the medication storage room in unit 1 was observed with the Assistant Director of Nursing (ADON). It was revealed that the medication log was signed for daytime on 09/29/25. Twelve Nutritional Supplement feedings were found to be expired, with an expiration date of 05/01/2025 (photo evidence available). Termite and rodent droppings were observed in the cabinets. Interview with the Director of Nursing on 10/02/2025 at 06:26 PM stated Expired medications should never be present in the medication carts or medication storage rooms. On 9/29/25 at 3:50 PM, during a medication storage check 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.

Based on observations, records reviewed and interviews, the facility failed to ensure privacy of confidential information on three (units three, four and five) out of five nursing stations as evidenced by an unattended unlocked computer screen with information visible and information was on top of a treatment cart. The findings included: Observation on 7/23/25 at 6:50 AM of the unit three nursing station revealed an unattended unlocked computer screen with visible resident information. (Photographic evidence). The surveyor notified Staff C, Licensed Practical Nurse (LPN) who was on the unit away from the computer at the time of observation. Staff C, LPN was asked about the facility's protocol for protecting resident information and stated: When I am away from the computer the screen should be turned off to protect residents' information. On 7/23/25 at 6:55 AM an observation on unit four nursing station revealed a document with Resident information was left on top of a treatment cart in the hallway unattended. (Photographic evidence). The surveyor notified Staff D, LPN and asked…

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 facility failed to protect one (Resident #1) out of three sampled residents' right to be free from abuse and neglect, as evidenced by a staff member witnessed Resident #1 being physically abused (slapped on the buttocks) during hygiene. The findings included:On 7/14/25 a federal report of allegation of abuse was received. The facility reported an incident of Staff B, Licensed Practical Nurse witnessing Staff A, Certified Nursing Assistant (CNA) slap Resident #1 on the buttocks during hygiene care. The facility suspended the alleged perpetrator, investigated and notified the required government authorities, physician and family member of Resident #1. The facility concluded that the incident was verified. On 7/23/25 at 7:30 AM Resident #1 in bed, eyes closed, no apparent distress; at 1:00 PM Resident#1 observed in a recliner in room speaking incoherently. Record review of a demographic sheet revealed Resident #1 was admitted on [DATE] with diagnosis that included: Cerebral…

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, records reviewed and interviews, the facility failed to properly secure medications on two (Units 1 and 5 out of five Nursing Units as evidenced by an unattended unlocked medication cart on Unit one and medication left on top of an unattended medication cart on Unit five. There were 162 residents residing in the facility at the time of the survey The findings included: On 7/23/25 at 6:58 am An observation was made on Nursing unit 1 of an unlocked unattended medication cart on (photographic evidence). The Surveyor notified Staff F, supervisor Registered Nurse (RN) who was in the hallway away from cart. The surveyor asked Staff F, supervisor Registered Nurse (RN) about the facility's protocol for storing medication and Staff F, RN replied, The cart should be locked when I am not in front of it. On 7/23/25 at an observation was made on Nursing Unit five unattended medication cart on top of the medication cart (photographic evidence). The Surveyor notified Staff E, Licensed Practical Nurse (LPN) and asked about the facility's protocol for storing medication 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 observations records reviewed and interview , used the facility failed to implement infection prevention and control practices; as evidence by several observations revealed residents' rooms were cluttered, had open food items, spoiled food items, linen observed on floor, dirty bathroom and showers, urinal on floor with urine seen from hallway, soiled gauze pads observed on resident's nightstand, used syringe, suction tubing and disposable gown on top of residents' wardrobe, staff failure to wear Personal Protective Equipment (PPE), drainage bag for indwelling catheter on floor, empty food container in residents' room swarmed with flies, soiled floors and trash on floors, increasing the potential for the contracting and spreading of diseases. The findings include. On 03/03/2025 starting at 7:10 AM, during observational tour of the facility; infection prevention and control concerns identified included but not limited to several residents' rooms were noted unorganized, cluttered, dirty bathrooms, soiled…

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, records reviewed and interviews the facility failed to ensure residents residing in the facility had a safe clean and clutter free environment; as evidenced by observations of several residents that included but not limited to: Resident #6, Resident #7, Resident #8, Resident #11 and Resident #12 call lights were not within the residents reach in the event immediate assistance is needed. (photographic evidence). 2)The facility failed to ensure residents' rooms were organized in a manner that provided a pest free and safe environment. 3} The facility failed to ensure emergency exits were clear and unobstructed. (photographic evidence) The findings include: On 03/03/2025 during multiple observations conducted between the hours 7:29 AM to 8:32 AM revealed call lights were out of reach for several residents that included but not limited to Resident # 4, Resident #6, Resident # 7, Resident # 8, Resident #11 and Resident # 12. Observations on 03/03/2025 at 11:54 AM revealed call lights remained…

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, records review and interviews, the facility failed to provide adequate respiratory care and services for two residents, (Resident #4 and Resident # 5) as evidenced by failure to ensure oxygen was being administered at the correct flow rate ordered. (Photographic evidence) The findings include. On 03/03/2025 at 8:16 AM Resident # 4 was observed in bed awake with oxygen at a flow rate of 4 Liters Per Minute (LPM) via nasal cannula. Review of Resident #4's clinical records revealed the resident was initially admitted [DATE] and readmitted to the facility on [DATE]. Clinical diagnoses include Chronic Obstructive Pulmonary Disease with Exacerbation, Acute Respiratory Failure with Hypoxia and Shortness Of Breath (SOB). Review of the Physicians orders for March 2025 revealed the resident should be receiving oxygen at 2 LPM PRN (as needed) for SOB. Observation on 03/03/2025 at 12:01 PM, Resident # 4 was awake in bed with oxygen at a flow rate of 4 LPM. On 03/03/2025 at 8:17 AM, Resident # 5 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.

Based on interview and record review, 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 F880 Infection Prevention & Control. These deficient practices have the potential to affect 168 residents residing in the facility at the time of the survey. The findings included: Record review of Quality Assessment and Assurance (QA & A) Compliance policy and procedure (effective date July 2022). The purpose of the committees is to review and analyze facility related data, evaluate improvement plans effectiveness and direct appropriate actions for the facility response. Systems failures and/or in-depth analysis of processes are addressed through development of a QAPI. QAPI requires a systematic review of data, identification of the root cause(s) of the systems failure and implementation of corrective actions. Review of the facility's survey history revealed, during a recertification survey with exit dated June 13, 2024, F880 Infection Prevention & Control 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 observations, record review and interview, the facility failed to ensure safety for all residents the residents in the facility as evidence by a knife was observed in one (Resident #46) out of eight residents sampled. Staff failed to intervene in a timely manner during an argument between two residents (Resident #128 and Resident #170) that enabled Resident #170 to strike Resident #128, which led to Resident #170 being arrested by local law enforcement. The facility's incidents by incident types report from January 2023 to June 10, 2024 revealed there were six alleged abuse incidents and nine incidents of resident-to-resident altercation. There were 136 residents residing in the facility at the time of this survey. The findings include. 1) During initial observation on 6/10/2024 at 9:15 AM in the room shared between Resident #115, Resident # 46, Resident # 130 and Resident #138, it was noted upon entrance that a small white pill was on the floor (photo taken). observation of Resident # 46's top drawer…

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 their Quality Assurance Performance Improvement policy and demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F550-Resident Rights/Exercise of Rights and F725 Sufficient Nursing Staff. The findings included: Review of the facility's survey history revealed, during a recertification survey with exit dated January 12, 2023 the facility was cited F550-Resident Rights/Exercise of Rights based on staff failure to ensure dignity during dining and F725 Sufficient Nursing Staff. During this survey with exit date of June 13, 2024, the facility was cited F550-Resident Rights/Exercise of Rights related to staff standing while feeding a resident (Resident #131) and observation of two residents (Resident #27 and Resident #473) wearing hospital type gowns in dining area and F725 Sufficient Nursing Staff. On 6/13/2024 at 3:02 PM Quality Assurance and Performance Improvement (QAPI) overview was conducted with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation record review and staff interviews, the facility failed to ensure a splint device was in place for one resident (Resident #131) out of one resident reviewed for splint devices and range of motion. There were nine residents in the facility that required splint devices. The findings include. On 06/10/24 at 8:12 AM Resident #131 was observed in bed on his left side. There was a blue hand splint device on the side table and the resident had a rolled washcloth in his left hand. The resident is non-verbal. On 6/10/2024 at 10:23 AM Resident #131 was observed in bed on his left no splint device in place. On 06/10/2024 at 11:07 AM Resident #131 was observed in bed on his left side with the splint device on the left hand. On 06/10/2024 at 12:15 PM Resident # 131 was observed in bed on his left side a rolled was cloth was in his left hand. On 06/11/2024 at 8:02 AM Resident on his left side with one rolled wash cloth in the left hand. On 06/11/2024 at 10:05 AM, Staff B a Certified Nursing Assistant 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.

Based on observations, interviews and record review facility failed to provide sufficient staffing to provide services to residents. This deficient practice has potential to affect 168 residents residing in the facility at the time of the survey. The findings included: During multiple observations starting on 06/11/2024-06/13/2024, residents were observed sitting in the activity area, with urine odor and residents wearing the night gowns at the time for breakfast. It was observed resident in bed waiting to be bathed and dressed around mid-morning. During multiples observations starting on 06/11/2024 through 06/13/2024, the nursing boards were posted with enough nursing staffing for current census following regulations. Interview with Staff A Certified Nursing Assistant (CNA) on 06/13/24 at 11:40 AM She stated she has been working in the facility for 30 years. She stated she is not happy with the workload that she had, she had 15 residents almost every day. She stated she had 3 or 4 residents they care for themselves, but she must supervise them, the rest of the residents needed…

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 pantry refrigerator in Section 1 used exclusively for all resident's food contained foods that were labeled with the resident's name and dated. This has the potential to affect one-hundred and forty-five residents out of one hundred and sixty-nine residents who eat orally residing in the facility. The findings included: Record review of the Safe Handling, Storage and Reheating for Food From Visitors or Outside Source Policy and Procedure (effective date March 2022); Policy Statement-Residents will be assisted in properly storing and safely consuming food items brought into the facility for residents by visitors; Procedure: 1) The facility staff will request that visitors bringing in food, and/or residents that receive food, must notify a member of the nursing or activities departments. This information is located in the resident handbook; Later Consumption: When food items are intended for later consumption, the nursing staff will: 1) Ensure the food item(s) are in a sealed container, stored in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to follow infection control standards and transmission-based precautions to prevent the spread of infections as evidenced by observations of trash in hallways and Staff not donning appropriate Protective Equipment before entering Resident #136's room. There were 136 residents residing in the facility at the time of survey. The findings included: On 06/10/2024 at 6:41 AM, a bag of trash was observed on the floor in nursing section four in front of a residen's room. (see photo evidence) On 6/11/2024 at 9:45 AM Staff F, Registered Nurse (RN) was observed entering room without donning appropriate personal protective equipment (PPE). Staff F, RN stopped by surveyor and asked if it was according to protocol to enter without donning gloves for a resident under contact precaution and Staff F, RN replied: No, according to the sign I am supposed to don gloves before I enter the room. On 6/11/2024 at 10:00 AM Staff G, charge nurse revealed, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, the facility failed to ensure 3 residents (Resident # 131, Resident #27 and Resident #473) out of 33 sampled residents were treated in a dignified manner as evidenced by the facility's staff was observed standing while feeding Resident #131. Furthermore Resident # 27 and Resident #473 were not dressed in their own clothing, rather than hospital gowns, to promote dignity. The findings included. Resident #131 On 06/10/2024 at 8:50 AM, during an observation, Resident #131 was observed in bed slouched leaning to the left while Staff L, a Certified Nursing Assistant (CNA) was standing while feeding Resident # 131. There was a chair on the left side of the bed with a plastic bag containing linen and other items, there were individual storage areas in the room for each resident occupying room At 9:00 AM Staff B entered the room and assisted Staff L to pull Resident #131 up in the bed. At 9:05 AM Staff L was asked about her standing while feeding the 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 and record review, the facility failed to ensure a delivered package for one resident (Resident #118) out of one resident reviewed was received by the resident in a timely manner. The delivered package contained frozen foods and they were defrosted and spoiled when delivered to the resident. This has the potential to affect 169 residents residing in the facility at the time of this survey. The findings included: Record review of the Mail Resident/Patient/Employee Policy and Procedure (effective dated June 2013); Policy-Mail, flowers, gifts and packages are delivered unopened daily to individual resident/patient rooms; Procedure: 5) Deliver mail, flowers, gifts and packages unopened to the resident/patient's room in a timely manner. Review of the Safe Handling, Storage and Reheating for Food From Visitors or Outside Source Policy and Procedure (effective date March 2022); Policy Statement-Residents will be assisted in properly storing and safely consuming food items brought into 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 observation record review and staff interviews, the facility failed to ensure one (Resident #131) out of 33 sampled resident Minimum Data Set (MDS) assessment was accurately coded as evidence by Resident #131 use of a splint device was not accurately coded on the MDS. There were nine residents in the facility that required splint devices. The findings included. Review of clinical records revealed Resident # 131 a vulnerable resident was admitted to the facility on [DATE]. Clinical diagnoses include but not limited to Osteomyelitis of the vertebrae and communication deficit. Record review of orders and the Medication Administration Records for June 2024 revealed active orders for Right hand Range of Motion and mobility. Order dated 5/25/2023, Splinting: Ensure right hand splint is applied daily as tolerated. May remove for care or skin sweep. On before breakfast time, off after lunch time. Review of Resident #131's Quarterly MDS (Minimum Data Set, dated [DATE] Section O for Special Treatments,…

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 ensure the Preadmission Screening and Resident Review (PASRR) Level I PASRR was not completed for residents (Resident # 103, Resident # 108) and Level II PASRR was not requested for Resident # 164, out of five residents investigated. This deficiency had the potential to affect 168 residents residing in the facility at the time of the survey. The findings included: Resident # 108 During multiple observations starting on 06/11/2024-06/13/2024, Resident #108 was in the room in bed sleeping, or awake. Call light was always in reach, and distress or anxiety was noted. The resident never responded to questions asked. Record review of the clinical records for Resident # 108 revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses include, but not limited to, Other intervertebral Disk Degeneration, Lumbar Region; Unspecified Dementia, Unspecified Severity with Other Behavioral Disturbance;…

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's staff failed to implement the care plan to prevent further decline in the resident's range of motion and maintain skin integrity as evidence by failure to ensure splint devices is in place for one resident (Resident #131) out of one resident reviewed for splint devices and range of motion. There were nine residents in the facility that required splint devices, and failed to reposition Resident #131 at a minimum of two hours. The findings include. On 06/10/24 at 8:12 AM Resident #131 was observed in bed on his left side. There was a blue hand splint device on the side table and the resident had a rolled washcloth in his left hand. The resident is non-verbal. On 6/10/2024 at 10:23 AM Resident #131 was observed in bed on his left side. On 06/10/2024 at 11:07 AM Resident #131 was observed in bed on his left side with the splint device on the left hand. On/6/10/2024 at 12:15 PM Resident # 131 was observed in bed on his left side. On 06/11/2024 at 8:02…

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 observations, interviews and record review the facility failed to provide the necessary interventions, consistent with professional standards of practice, to promote healing of pressure ulcers for one resident (Resident #146) out of eight sampled residents as evidenced by observations of Resident#146 in supine position for more than 2 hours. There were 27 Residents with wounds residing in the facility. The findings included: On 06/10/2024 at 10:38 AM Resident#146 was observed in supine position on an air mattress. On 06/10/2024 at 12:25 AM, Resident #146 was observed in a supine position on an air mattress. On 06/12/2024 at 8:06 AM Resident #146 was observed in supine position on an air mattress. 06/12/2024 10:02 AM, the wound care nurse entered Resident #146's room to perform wound care. Upon entering the room Resident #146 was observed in supine in bed. The wound care nurse performed the wound care as per physician's order assisted by Staff I, Certified Nursing assistant (CNA). The resident 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 observations record review and interview the facility failed to provide foot care according to professional standard for one (Resident #35) out of eight residents sampled. The findings included. On 06/10/2024 at 7:10 AM Resident #35 was observed in bed, his toenails were observed long and curling over the top of his toes. On 06/11/2024 at 9:02 AM Resident #35 was observed in bed awake with no socks or shoes on; his toenails were long and curved over. Resident # 35 was asked if he had seen the podiatrist for his feet and had his toenails been trimmed since his admission into facility. Resident #35 stated: No never done here. Review of his clinical records revealed Resident #35 was admitted to the facility on [DATE]. With diagnoses that include but not limited to type two diabetes, difficulty walking and acute bilateral embolism and thrombosis of unspecified deep vein lower extremity. Review of Resident #35 admission Minimum Data Set (MDS) dated [DATE] Section C for Cognitive Pattern documented 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 observations, record review and interviews facility failed to dispose of medication as per policy for one resident (Resident #50) and facility failed to keep an accurate reconciliation of controlled narcotics for two residents (Resident #141 and Resident #99 ) out of eight residents sampled as evidenced by an observation of staff member disposing of a medicated patch into the trash can in a resident's room and review of two narcotic count sheets with totals that did not match amount of pills in the corresponding bingo cards. There were 136 residents residing in the facility at the time of survey. The findings included: On 06/10/2024 at 9:00 AM a medication administration observation was conducted with Staff F, Registered Nurse (RN) in nursing section five Staff F, RN removed a previous patch from Resident 50's skin and disposed of it in the trash can in the room. Staff F, RN completed the medication pass with Resident #50 and left the room. The surveyor asked Staff F, RN if disposing of patch in the resident's trash can was within the policy and procedure and Staff F, RN…

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 and interviews facility failed to properly store drugs and biologics, as evidenced by an observation of unattended normal saline filled syringes in one resident's room (Resident #131) out of one resident observed for Intravenous (IV) medication administration. The facility failed to ensure expired treatment and biological supplies were discarded in one out of one medication storage room. The facility has only one medication storage room. The findings included: 1) On [DATE] at 9:43 AM a medication administration observation was conducted with Staff H, Registered Nurse, (RN) in nursing section two on medication cart one. On [DATE] at 9:48 AM Staff H, RN entered Resident#131's room and placed the Intravenous (IV) medication on the side table next to the resident, then entered bathroom and performed hand hygiene, leaving the IV medication on the side table out of direct vision. On [DATE] at 9:49 AM Staff H, RN returned to resident's bedside and surveyor asked if medication can be left out of…

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

Based on observation, interview, and record review the facility failed to provide sufficient staffing for 2 ( unit 2 and unit 3) out of 5 units. This had the potential to affect the 89 residents who resided in those units out of the 169 residents residing in the facility during this survey. The finding included: Upon entering the facility on 01/09/2023 at 6:00 AM, while the surveyors were in the lobby area the kitchen manager asked the team to wait in the lobby before entering the facility. After waiting in the lobby area for ten minutes, the team entered the facility towards the residents' rooms and no staff was observed leaving or entering the facility through the main door. At the time, there was a male staff from kitchen observed by surveyors who was also waiting in the lobby area. Observation on Unit 3 on 01/09/23 at 6:11 AM revealed the staffing information board did not have information for current staff working, the board only had the unit manager's name from day shift, census, and break times. At the time of this observation there was only one (1) nurse (Staff G, a…

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

Based on observation, interview, and record review, the facility failed to have daily nurse staffing posted prior to the beginning of shifts on 5 of 5 nursing stations. This had the potential to affect the 169 residents who resided in the facility at the time of this survey. The findings included: During an observation at unit 1 nurse's station, on 01/09/23 at 6:06 AM, it was noted that the staffing information posted was dated Saturday, 01/08/23 for the 3:00 PM to 11:00 PM shift not for the current 11:00 PM to 7:00 AM shift. (Photo Evidence) During an observation at unit 2 nurse's station, on 01/09/23 at 6:11 AM, it was noted that the staffing information posted was dated Saturday, 01/07/23. (Photo Evidence) During an observation at unit 3 nurse's station, on 01/09/23 at 6:08 AM, it was noted that staffing information was missing. The only information posted was the unit manager for the day shift, break times, and census. (Photo Evidence) During observation at unit 5 nurse's station, on 01/09/23 at 6:10 AM, it was noted that the staffing posted was dated 1/7/23, Census 17, Nurse…

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 staff interviews, the facility failed to ensure one ( Resident # 7) out of one resident observed during dining, was treated with respect and dignity, by not serving meals to all residents seated and the same dining table during meals; as evidenced by Resident # 7 meals were not served her meals at the same time as the other resident seated at the same table was served and being assisted with eating by facility staff. This deficient practice has a potential to affect the health and wellbeing of all the residents who eat by mouth and may need assistance with eating. The finding included: On 01/09/22 at 08:23 AM Resident #7 was observed in the dining room sitting at a dining table that she shared with another resident. Resident #7 was not served her meal, but the other resident was served her meal and was being assisted with eating by staff, while Resident # 7 was sitting without her meal. Observation on 01/09/23 at 01:40 PM revealed Resident #7 was in the dining room, sitting at the dining table that she shared with another resident. The 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 record review and interviews, the facility failed to ensure complete and accurate documentation of resident's Advanced Directives for 2 (Resident #94 and Resident #120) of 34 sampled residents. This had the potential to affect the 169 residents in the facility receiving care and services at the time of this survey. The findings included: 1. Review of the medical records for Resident #94 revealed the Advance Directive (AD) in the care plan reference date 12/13/22 documented resident/authorized responsible party request Full Code wish to be honored. On 1/10/23 at 2:45 PM physical copies of Resident #94' Advance Directives given to the surveyor by the facility's Social Services Director (SSD) revealed, Advance Directive for Resident #94 dated 11/05/2022 documented Do Not Resuscitate (DNR), signed by MD (Medical Doctor). Further review of the medical records for Resident #94 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Unspecified Sequelae 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.