Community Convalescent Center

Based on record reviews and interviews, the facility failed to ensure the grievance process was followed for one resident (#45) and Resident Council members out of three residents reviewed for grievances. Findings included: On 8/27/25 at 1:13 p.m., an interview with Resident #45 revealed that the resident has been missing three pairs of cargo pants, has had a second pair of pants discolored/damaged from laundry, and complains that staff is not taking his soiled linens daily to be washed. Resident #45 expressed that the facility has yet to replace the damaged and lost items despite advising Resident #45 that they will be replaced and creating a grievance for each occasion. A review of Resident #45's admission record revealed an original admission date of 2/15/2024, and a re-admission date of 8/14/2025 with diagnosis to include type 2 diabetes, and chronic kidney disease. Review of the facility's Grievance Log dated from August 2024-August 2025 showed two documented grievances for Resident #45 in regard to laundry. A review of Resident #45's Grievance/Concern Report dated 11/23/2024…

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 complete a Level II Pre-admission Screening and Resident Review (PASRR) for one resident (#3) and failed to ensure the accuracy of a Level I PASRR for one resident (#4) out of thirty-five initial pool residents. On 8/24/25 at 12:25 p.m. Resident #3 was observed lying in bed, with eyes closed and rhythmically breathing. Review of Resident #3’s admission Record showed the resident had been admitted on [DATE]. The record included diagnoses not limited to unspecified bipolar disorder, unspecified insomnia, and unspecified depression. Review of Resident #3’s PASRR dated 7/11/25 revealed it was completed at this facility and showed the resident had diagnoses of bipolar disorder, depressive disorder, and Post-Traumatic Stress Disorder (PTSD). The screening showed the resident was exhibiting signs and symptoms (s/s) of depression as spouse recently passed. The decision-making portion of the PASRR did not reveal the resident had any disorder…

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 provide nail care for two residents (#97 and #45) out of five residents sampled for activities of daily living.Findings included: 1. On 8/24/25 at 12:35 p.m. Resident #97 was observed lying in bed. The resident was very pleasant and answered questions appropriately. The observation revealed the resident’s fingernails on both hands extended approximately 1/3 to ½ inch past the fingertips and were discolored. The resident reported not wanting long fingernails and staff had not offered to cut them. Resident #97 said it had been at least one month since the fingernails had been clipped. On 8/26/25 at 12:03 p.m. Resident #97 was observed with fingernails 1/3 to ½ inch past the tips of the fingers. The fingernails were discolored with a dark substance. The resident stated staff had not offered to cut them and yes, the resident would allow them to do so. On 8/27/25 at 9:09 a.m. Resident #97’s fingernails continued to be long and discolored.…

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 provide assistance out of the bed for one dependent resident (#127) out of four residents sampled.On 08/24/2025 at 10:00 a.m., Resident #127 was observed lying down in bed with her call light within reach. She said staff will not assist her on the toilet whenever she asked them.On 08/24/2025 at 1:00 p.m., and on 08/24/2025 at 11:00 a.m., Resident #127 was observed lying down in bed. She said she has not been able to go to activities because staff will not get her up.Review of Resident #127's admission Record revealed Resident #127 was admitted to the facility on [DATE] with diagnoses to include but not limited to muscle wasting and atrophy, not elsewhere classified, multiple sites, unspecified fracture of right femur, sequela, type 2 diabetes mellitus with unspecified complications.Review of Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicated intact cognitive…

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 assess and obtain podiatry services for one (#114) of one resident sampled for foot care and podiatry needs. Findings included: On 8/26/25 at 12:21 p.m., Resident #114 was observed lying in bed. The resident reported wanting to keep fingernails long however needs a podiatrist to cut toenails.On 8/26/25 at 12:35 p.m. an observation was conducted with Staff K, Licensed Practical Nurse (LPN) of Resident #114s toenails on both feet. The toenails were malformed lifting up from nailbed, thickened grayish brown in color, and extending past the tip of toes.An interview was conducted on 8/26/25 at 12:38 p.m. with Staff K. The staff member placed the resident's name in the Social Service folder and stated the resident was on the list for Social Worker to put on the podiatry list. Staff K stated the aides see resident daily and the issue with Resident #114s toenails was not brought to the staff members attention.Review of Resident #114s admission…

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 initiate care plan interventions related to the placement and functioning of an electronic wander device for one (#97) of one resident sampled and to ensure staff followed protocol when a door alarm system alerted of an issue. Findings included: On 8/24/25 at 12:35 p.m. Resident #97 was observed in a room near the end of the 100 high hallway. The resident was very pleasant and able to answer questions appropriately. On 8/24/25 at 1:55 p.m. an alarm for the exterior double doors at the end of the 100 high hall was beeping. Staff N, Certified Nursing Assistant (CNA) was observed passing ice to two residents on the hallway, then the staff member went to the end of the hallway and shut off the alarm (keypad). The staff member did not look outside of the door. On 8/25/25 at 11:34 a.m. the alarm for the exterior double doors at the end of the 100-high hall was alarming. Resident #97 was observed lying in bed. On 8/26/25 at 12:01 p.m. Staff K,…

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 maintain acceptable parameters of nutritional status, such as body weight for two (Resident #3 and #28) of three residents sampled. Review of Resident #28s admission Record revealed the resident was admitted on [DATE] and included diagnoses not limited to Muscle Wasting and Atrophy not elsewhere classified multiple sites, Iron Deficiency Anemia, Oropharyngeal Phase Dysphagia, Type 2 Diabetes Mellitus, and Depression. Review of Resident #28s weight summary showed on 4/3/25 the resident weighed 233.6# via mechanical lift, on 5/14/25 the resident weighed 224# via mechanical lift, a weight loss of 9.6#s and weight loss of 4.11%, and on 8/12/25 the resident weighed 198.2# via mechanical lift, a total weight loss of 35.4# and a total weight loss of 15.15% since admission. Review of Resident #28s Weight Change Note created on 8/18/25 by the Dietitian showed the resident triggered for significant weight loss. “Weight loss not new. Weight loss related 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 observations, record reviews, and interviews the facility failed to ensure the intravenous catheter dressing for one (#97) of one resident sampled for catheter dressing was changed per professional standards and per facility expectation. Findings included:On 8/24/25 at 12:40 p.m. Resident #97 was observed lying in bed. The observation showed the resident had a single lumen peripherally inserted central catheter (PICC) inserted into the right upper arm. The area under the clear inclusive dressing showed a dark dry-looking substance and a red wet-looking substance. The dressing was dated 8/19. On 8/27/25 at 9:09 a.m. Resident #97s PICC line dressing was observed, the dressing continued to be soiled and dated 8/19. Review of Resident #97s physician orders, active as of 8/27/25 at 3:24 p.m. showed orders dated 8/15/25 instructing to Change Intravenous (IV) dressing every 7 days as well as as needed (PRN) for soiling and /or dislodgement as needed and Change IV dressing every 7 days as well as PRN for soiling and/or dislodgement every evening shift every 7 day(s). Review 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, record review and interviews the facility failed to post the Daily Nursing Staffing form appropriately.Findings Included: During an observation on 08/24/2025 at 9:00 a.m., the Daily Nursing Staffing form was located on the wall near the reception area. The date on the form was 08/21/2025. (Photographic Evidence Obtained)During multiple observations from 08/24/2025 thru 08/27/2025 revealed the Daily Nursing Staffing form was not posted on the 2nd floor. During an interview on 08/27/2025 at 12:30 p.m., Staffing Coordinator stated the daily nursing staffing form is only posted at the entrance. The supervisor is responsible for updating and posting the form on the weekends.During an Interview on 08/27/2025 at 2:06 p.m., the Nursing Home Administrator (NHA) stated the daily nursing staffing form is only posted up front. Nurse management or staffing is responsible for posting the form. The nursing staffing form should be posted each day. The facility did not have a policy related to this cite.

Based on observation, record review, and interview the facility failed to ensure the medication error rate was less that 5.00%. Thirty medication administration opportunities were observed and two errors were identified for one (#17) of five residents observed. These errors constituted a 6.67% medication error rate.Findings included: On 8/26/25 at 9:13 a.m., an observation of medication administration with Staff Member I, Licensed Practical Nurse (LPN), was conducted with Resident #17. The staff member dispensed the following medications:- Amolodipine 5 milligram (mg) oral tablet- Buspirone 5 mg oral tablet- Famotidine 10 mg over the counter (otc) tablet - 2 tablets- Ferrous sulfate 325 mg otc tablet- Polyethylene glycol 3350 1 capful powder- Potassium chloride Extended Release (ER) 20 milliequivalents (meq)- Senna 8.6 mg otc tablet- Sodium Chloride 1 gm, 15.4 grain otc tabletThe staff member reported having to see about changing the resident's lactobacillus tablet to the house probiotic and change the docusate from capsule to tablet. The staff member confirmed dispensing 9…

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 policy review, the facility failed to maintain a clean and sanitary kitchen as evidenced by dust attached to the wall above the coffee pot and plate covers, the outside of the oven appeared to have dried grease collected on it, and inside the one of one ice machine contained black biogrowth. Findings included: An observation conducted on 2/5/24 at 9:00 a.m. of the ice machine located in the kitchen revealed a black wet-looking substance inside the bin, above fresh ice, and around the chute. The observation showed staff continuing to plate breakfast meals. The observation of the outside of the oven showed the front of the doors appeared to have dried grease spills and the shelf above the stove was dusty. At the time of the observation, Staff F, Food Service Manager (FSM) stated the oven has been broken since Thursday, was fixed over the weekend, and the oven was normally cleaned over the weekend. An observation of the wall above the staff sink, coffee machine and above a stack of plate covers showed dark-colored dust and a splattering of a brown…

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 provide care and services related to wound care including following standard infection control practices for 4 (#5, #6, #7, #24) of 4 sampled residents. Findings included: 1. Resident #5 was admitted on [DATE]. Review of the admission record showed diagnoses included but were not limited to fracture of second thoracic vertebrae, protein-calorie malnutrition, muscle wasting, morbid obesity, dementia, peripheral vascular disease, muscle weakness, heart failure and Chronic Obstructive Pulmonary Disease. Review of the Minimum Data Set (MDS) dated [DATE] showed in section C, Brief Interview for Mental Status (BIMS) score of 11 (moderately impaired). Section GG, Functional Abilities and Goals showed she was dependent for toileting. Section M, Skin Conditions showed she was at risk for developing pressure ulcers / injuries. Review of the Physician Order Recap report, Treatment Administration Record (TAR) for January and February showed: -Cleanse…

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 arrange and provide transportation to medical appointments for 2 out of 4 sampled residents (#11 and #14). Findings included: 1. Resident #11 was admitted on [DATE] and readmitted on [DATE]. Review of the admission record showed diagnoses included but not limited to difficulty walking, muscle wasting, convulsions, chronic pain syndrome. Review of the progress notes showed on 01/15/2024 the Advanced Registered Nurse Practitioner (ARNP) documented, pt reports still has not gotten her scheduled to see spinal specialist following MRI results. Will speak to DON to see if this can get expedited as pt would like to see spine specialist before she moves to an [name of assisted living facility]. During an interview on 02/06/2024 at 1:45 p.m. the Director of Nursing (DON) reviewed ARNP note. She stated, I will look into it and get back with you. During an interview on 02/06/2024 at 3:05 p.m. Resident #11 stated, I still had not gone to the spinal doctor. I hope…

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 ensure the medical record of two (#1 and #10) of 4 residents was complete and contained accurately documented incidents requiring a transfer to an higher level of care. Findings included: 1. Review of Resident #1's admission Record showed the resident was originally admitted on [DATE] and later re-admitted on [DATE]. The admission Record revealed the resident's diagnoses included fibromyalgia, unspecified quadriplegia, and mild dementia in other diseases classified elsewhere without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of a Situation, Background, Appearance, and Review and Notify (SBAR) communication form dated 9/13/23 showed Resident #1 had a change in skin color or condition. The evaluation revealed there was no changes observed in the resident's mental status or functional status and the behavioral, respiratory, cardiovascular, abdominal/gastrointestinal, genitourinary/urine, pain, and neurological…

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 policy review the facility failed to ensure food items in the walk-in refrigerator were labeled, dated, and discarded when expired. The failed practice had the potential to effect 108 of 110 residents who received food from the facility's kitchen. Findings included: An observation on 07/16/23 at 9:10 a.m., revealed the walk-in refrigerator that contained items that were not labeled or dated. Photographic evidence was obtained. The items included: -Two (2) quart container of barbeque chicken -Two (2) quart container of mushroom soup -Two (2) quart container of corn -Two (2) quart container of mashed potatoes -Four (4) quart container of sausage rice -A Styrofoam container of three (3) sandwiches Continued observation, on 07/16/23 at 9:15 a.m., revealed the walk-in refrigerator contained items that were expired. Photographic evidence was obtained. The items included: -Two (2) quart container of pears with expiration date 07/09/23 -Two (2) quart container of cream of broccoli soup with expiration date 07/11/23 -Two (2) quart container of tuna salad…

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 interview, the facility failed to ensure resident dignity for residents who require assistance while eating their meals for two (Residents #45 and #307)) of 48 sampled residents. Findings included: Observations on 07/16/23 at 9:25 AM revealed Resident #45 was sitting up in his bed with his morning meal in front of him on his over-bed table. Continued observations at this time revealed a staff person was assisting the resident by placing the food on his fork, placing the fork in the resident's hand, and encouraging the resident to place the fork in his mouth. The staff was noted to stand over the resident while she assisted the resident to complete the entire meal. An interview on 07/16/23 at 9:38 AM with Staff A, Certified Nursing Assistant (CNA) revealed Resident #45 could feed himself but needed assistance and cueing. She reported the process when feeding, cueing or assisting residents was to get the resident tray, set it up, ask them what they want, and stand next to the bed and assist. She reported this was the same process with anyone…

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, staff interview, and review of the facility's policy titled Pre-admission Screening and Resident Review (PASARR), the facility failed to complete the Preadmission Screening and Resident Review Level II upon a new qualifying mental health diagnosis for five (Resident #10, #40, #80, #78, and #30) of thirty-two residents sampled for PASARR Level II. Findings included: 1. Resident #10 was admitted on [DATE] with diagnoses of unspecified psychosis not due to substance or known physiological condition. Review of Resident #10's PASARR Level I assessment dated [DATE] revealed no qualifying mental health diagnosis and that no PASARR Level II was required. Review of Resident #10's medical record revealed a new diagnosis of unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety on 03/21/19, schizoaffective disorder on 10/31/18, major depressive disorder on 10/30/18, and generalized anxiety disorder on 10/30/18 and 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 observations, staff interviews and facility record review, the facility failed to ensure resident areas and shower equipment were clean, maintained and sanitized during four of four days observed (8/3/2021, 8/4/2021, 8/5/2021, and 8/6/2021), in three community shower rooms (1st floor 100 Unit, two on 2nd floor 200 Unit) of four community shower rooms, one dining room (main) of two dining rooms, and one smoking porch of one smoking porch. It was determined that 1. a constant water drip from the ceiling was pooling and flowing down the main hallway (100 Unit); 2. shower room chairs, walls, and water nozzles were observed with black biogrowth (where); 3. the main dining room was observed with ceiling vents caked with black and gray dust/debris; and 4. the outside smoking porch was observed with a ceiling fan that had all fan blades in disrepair, water-logged and pointing down to the ground. Findings included: Tours of facility to include the 2nd floor (200), and 1st floor (100), on 8/3/2021 at 10:30 a.m.,…

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

Based on observations, staff interviews the facility failed to maintain the kitchen and kitchen equipment were maintained in a clean and sanitary manner during two of two days observed (8/3/21 & 8/6/21) related to heavy black biogrowth and dust debris observed on two of two large air return vents and a motor housing with plastic venting, positioned directly above food items in one of one walk in refrigerators. Findings included: On 8/3/2021 at 9:35 a.m. the kitchen was toured with the Dietary Manager. During the tour, the walk in refrigerator was observed to have a fan motor housing vent grating with heavy black biogrowth matter throughout the entire grating. (Photographic Evidence Obtained) Also, the main kitchen area was observed with two large air conditioning air ducts hanging down from the ceiling. One above and to the side of the steam table, and the other hanging above and to the side of a food preparation table. Both were observed to be caked heavily with dust and debris. Further, the areas around the vents and ceiling were observe with heavy cracking/blistering and chipping…

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 interviews and medical record review, the facility failed to ensure one resident (#161) was not able to self-administer medications by one staff member (C ) leaving the resident without ensuring the resident took the nine medications, and without returning during a medication pass out of a total of thirty-eight sampled residents. Findings included: On 8/3/21 at approximately 10:00 a.m. prior to entering the Resident #161's room, Staff C, Licensed Practical Nurse (LPN) was observed at a medication cart, parked approximately fifteen feet away and at another resident's room. Staff C was observed preparing medications for other residents. On 8/3/2021 at 10:01 a.m. Resident #161 was observed in her room and in bed seated at 45 degrees. Further observations revealed she had the over the bed table positioned over her lap with various items to include two cups of hydration, and a small clear cup of nine medication tablets, which varied in colors to include white, yellow, pink, and orange.…

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 that one resident (#47) out of 9 sampled vulnerable residents was free from a physical restraint which could not be self-released. There was no medical symptom identified as the basis of the need for the restraint, and the facility failed to ensure that monitoring and evaluation for the continued use of the physical restraint was ongoing. Findings included: Resident #47 was observed on 08/03/21 at 12:00 p.m. She was seated in a wheelchair in her room and there was a wide brown belt observed attached to the wheelchair and fastened across her lap with fabric hook and loop fasteners. The resident was not able to respond coherently to questions, not able to identify what the belt was for, and was unable to bring her attention or gaze to the belt, touch the belt, or release the belt when asked about it. On 08/04/21 at 9:39 a.m. the resident was observed seated in a wheelchair in her room with the same belt fastened across her lap. 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, medical record review and staff interviews, the facility failed to implement care plan interventions related to monitoring and providing assistance for eating for one resident (#160) of thirty-eight sampled residents. Findings included: On 8/4/2021 at 7:55 a.m. floor staff were observed to bring in a breakfast meal tray into Resident #160's room and placed it on the over the bed table. The resident was observed in bed lying on her right side, facing the window. Staff placed the meal tray on the table and left the room. The lid was left on and the tray, along with lids left secured on the hot cereal bowl and the milk carton was left unopened. The staff member did not set the meal tray up for the resident. Then at 8:10 a.m. Resident #160's meal tray was still observed in the same place with the lids on and with the resident still lying on her side facing the window. No staff were observed coming back into the room to set up the meal tray or assist with eating. Following this observation, at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to provide needed treatment and services related to a leakage of a suprapubic tube for one resident (#64) out of 9 residents receiving catheter care. Findings included: A review of Resident 64's admission Record revealed a readmission date of 1/15/2021 and diagnoses to include seizures, urinary tract infection, and neuromuscular dysfunction of bladder. A review of the most recent Quarterly Minimum Data Set (MDS) dated [DATE] Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status score of 13, which indicated that Resident #64 had no cognitive impairment. Section G (Functional Status) revealed that Resident # 64 required two-person physical assist for toileting, personal hygiene, and bed mobility. Section H Bladder and Bowel revealed Resident #64 had an indwelling catheter. On 08/03/21 at 10:15 a.m. Resident #64 was observed lying in bed and a strong foul-smelling odor was noted. Upon entering the room, a catheter…

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 did not ensure that suction canisters were changed consistent with the physician order for two residents (#64 and #101) out of four sample residents reviewed for tracheostomy care/tracheal suction. Findings included: 1. A review of the admission Record revealed Resident #64 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include chronic respiratory failure, benign neoplasm of larynx, cervicalgia, dysphonia, and dysphagia, chronic obstructive pulmonary disease and tracheostomy status. On 08/03/21 at 10:15 a.m. Resident #64 was observed lying in bed, with the trachea in place connected to a humidified air at 2 liters per minute via oxygen and dated 7/28/21. The suction and canister were observed on the nightstand at ¾ full and dated 7/28/21. A review of Resident #64's Treatment Administration Record (TAR) dated 7/1/21-7/31/21, revealed a physician order to change the suction canister every 3 days and or…

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