Aventura At The Bay

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate related to diagnosis for three residents (#134, #211 and #226) of three residents reviewed for MDS assessments. Findings Included: 1. A review of Resident #134's admission record showed an original admission date of 3/1/2024 with a readmission date of 4/19/2024 with diagnoses to include but not limited to bipolar disorder, major depressive disorder, and anxiety disorder. A review of Resident #134's behavioral health progress note dated 11/6/2025 showed a diagnosis of Post Traumatic Stress Disorder (PTSD). A review of Resident #134's annual Minimum Data Set (MDS), dated [DATE], Section I, revealed PTSD was not marked. Review of Resident #134's care plan initiated, 3/20/2024 showed the following focus: [Resident #134's] anxiety level associated with her trauma will be minimized through next review. Interventions include ensure Resident #134's privacy before starting care, Resident #134 prefers…

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 an accurate Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability review (PASARR) was completed for five residents (#2, #112, #9, #211, and #226) of six residents reviewed for PASARR.Findings included:1. A review of Resident #2's admission record revealed an admission date of 12/9/2025 with diagnoses to include psychotic disorder with hallucinations due to known physiological condition, unspecified dementia, unspecified severity, with mood disturbance, depression, unspecified, epilepsy, unspecified, not intractable, without status epilepticus and other seizures.A review of Resident #2's physician orders revealed the following:- Sertraline hydrochloride (HCl) oral tablet 50 milligrams (mg), give one tablet by mouth one time a day for mood.- Donepezil HCl oral tablet 10 mg, give one tablet by mouth one time a day for memory.- Quetiapine fumarate oral tablet 100 mg, give one tablet by mouth…

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 ensure the resident had assistive devices to maintain hearing abilities for one resident (#3) of two residents reviewed for communication and sensory problems.Findings included:During an interview and observation on 3/2/2026 at 11:06 a.m. Resident #3 said to stand on the right side because there is no hearing in the left ear and stated difficulty hearing in the right ear. While speaking in a loud voice approximately six inches from Resident #3's ear, the same information had to be repeated multiple times before the resident was able to hear and understand it.A review of Resident #3's face sheet showed an original admission date of 3/21/2023 with a readmission date of 11/17/2025 and a primary diagnosis of acute gastroenteropathy due to Norwalk agent.A review of Resident #3's care plans showed the following focus: [Resident #3] has difficulty with communication due to hearing deficit, initiated on 3/23/2023. The interventions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to obtain physician orders for the percent of humidity to provide supplemental oxygen by tracheostomy according to professional standards of practice for one (#5) of two residents reviewed for respiratory care.Findings Included:On 03/02/2026 at 7:48 a.m. observed Resident #5's oxygen set to 3 L (Liters).Review of Resident #5's face sheet showed admission on [DATE] and readmission [DATE] with diagnoses to include acidosis, disorders of diaphragm, acute and chronic respiratory failure with hypoxia, pneumonitis and chronic respiratory failure.Review of Resident #5's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (3008 form) dated 12/12/25, Section V, Treatment Devices show order for oxygen at 6 liters (L) per [minute] means how much gas is moving and 28% how rich in oxygen the air is.Review of Resident #5's order recap report, dated 3/4/26 showed an order for Trach-continuous humidified oxygen 2.5 L via…

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 take a trauma-informed approach to deliver care that involves understanding, recognizing and responding to the effects of a specific trauma Post Traumatic Stress Disorder (PTSD) for one resident (#6) of five residents reviewed with PTSD. Findings included:On 3/2/2026 at 7:35 a.m. the facility's memory/dementia unit was toured and the dining room was observed with residents either being served their breakfast meal, or were waiting for their breakfast meal to be served. Resident #6 was observed seated in her wheelchair positioned at a table and awaiting her breakfast meal. Resident #6 appeared to be dressed for the day, well groomed and appeared generally in good spirits. She was observed interacting with other staff members and was laughing. Resident #6, who resides in the 200 memory/dementia unit, was observed with cognitive deficits and when attempted interview, she could not speak with relation to her medical care and services. She 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 observation and interviews facility did not ensure medications were stored properly related to 1) an unlocked treatment cart; 2) expired medications on one unit (C-Wing) out of two units observed for medication storage. Findings included:An observation on 3/2/2026 at 7:38 a.m. of a treatment cart on the C-Wing was unlocked (photographic evidence obtained).An observation on 3/2/2026 at 7:40 a.m. of the medication room on the C-Wing revealed 4 immunizations in the refrigerator were expired (photographic evidence obtained).An interview on 3/2/2026 at 7:45 a.m. with the Assistant Director of Nursing (ADON) was conducted. The ADON said those immunizations should not be in the refrigerator. The ADON stated, the resident's must not have received them. The ADON said the medication storage rooms are messy.An observation of C- Wing HIGH medication cart revealed 3 bottles of expired medications.Sodium Chloride Tablets 1 gram Expired: 11/2025Vitamin D Tablets 400 Expired: 12/2025Zinc Oxide Expired: 1/2026An interview on 3/5/2026 at 11:40 a.m. with Staff S, Registered Nurse (RN) 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, the facility did not ensure the physician was notified of missed doses of pain medications for one resident (#3) out of three residents sampled. Findings included: On 11/17/25 at 10:37 AM, Resident #3 reported waking up in the middle of the night in pain. The resident reported she calls the night nurse to ask if her scheduled pain medications could be administered. The resident stated there were concerns with the nurse being unresponsive to her request.On 11/17/25 at 2:03 PM Resident #3 stated that on the nights of 11/14/25 and 11/15/25 they woke up in pain in the right arm around 2:00-3:00 AM and called their night nurse to inquire if the scheduled pain medications could be received. Resident #3 stated being on a strict regime of every 4 hours to receive their pain medications to prevent oncoming pain per doctor's orders. Resident #3 said being on a consistent schedule with their pain medications helps to prevent them from feeling any additional pain. Resident #3 stated to strongly preferring for nurses to wake them up to take…

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

Based on observations, interviews and record review, the facility did not ensure to advise physicians or family representatives of missed scheduled pain medications for one resident (#3) out of three residents reviewed and sampled. Findings included: Findings included: On 11/17/25 at 10:37 AM, Resident #3 reported waking up in the middle of the night in pain. The resident reported she calls the night nurse to ask if her scheduled pain medications could be administered. The resident stated there were concerns with the nurse being unresponsive to her request. Resident #3 stated being on a strict regime of every 4 hours to receive their pain medications to prevent oncoming pain per doctor's orders. Resident #3 said being on a consistent schedule with her pain medications helps to prevent her from feeling any additional pain. Resident #3 strongly expressed her need for nurses to wake her up to take the scheduled pain medications in order to prevent the pain. On 11/17/25 at 2:40 PM an interview was conducted with Staff B, Unit Manager (UM). The interview revealed the physician must be…

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 interviews and record review, the facility failed to ensure the revision and/or implementation of a comprehensive care plan was completed for one resident (#213) out of five residents sampled for falls.Findings included: During an interview on 8/25/2025 at 9:05 a.m. Resident #213's representative (RR) stated being concerned with the facility's lack of identification of concerns and follow up on Resident #213's plan of care. Review of the admission Record for Resident #213 revealed an admission date of 11/28/24 with diagnoses to include: Parkinson's disease without Dyskinesia (involuntary erratic movement), without mention of fluctuations; difficulty in walking; unsteadiness on feet; recurrent falls; unspecified Dementia, severe, with other behavioral disturbance; and other co-morbidities. Review of Resident #213's care plan revealed: Focus: date initiated: 11/6/2023 - The staff have identified that I am at risk for falls because of these risk factors: muscle wasting, Impaired cognition, Unaware of safety needs, Dementia, History of falls, Hypotension. I place myself on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure 1) A clean and sanitary kitchen where food is prepared and served; and 2) an operating dish washing machine on a consistent manner observed during the four days of survey in the facility kitchen. Findings included: -On 8/25/2025 at 9:20 a.m. the kitchen was entered and toured with the Kitchen Manager. Upon entering the space, there was a clean handwashing sink with a soap dispenser and a paper towel holder. No trash can to dispose of the used paper towels was observed. There was no trash can anywhere within a twenty-five to thirty foot span to dispose of used paper towels. The Kitchen Manager revealed he did not know where the trash can went and left the space to find another one. He returned with a large tan trash can with a lid that was able to be opened with a foot pedal device. The trash can was visibly used and half full with refuse. The top of the trash can lid was observed with red and brown sticky substances, as well 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.

Based on observations, interviews, and record review the facility failed to ensure the large outside trash compactor area was free from refuse and trash debris during one of one days observed (8/25/2025). Findings included: On 8/25/2025 at 9:35 a.m. the Kitchen Manager provided an outside tour of the facility in the back alley way. During the observation, there was a very large tan colored trash compactor/dumpster positioned in the alley on a non porous surface. The trash compactor door was observed closed. However, further observations revealed many pieces of trash/refuse on the ground on either side, and the back behind and front of the compactor. The refuse/debris included used/soiled clear plastic gloves, clear full bags of opened trash/refuse, used/soiled plastic Styrofoam containers, many used plastic straws, and loose used crumpled napkins and paper. Photographic evidence was taken. On 8/28/2025 at 1:00 p.m. an interview with the Maintenance Director revealed they have been having issues with trash debris surrounding the trash dumpster/compactor. He revealed the trash/refuse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure the residents or their representatives acknowledged understanding of the binding arbitration agreement and the agreement is not required as a condition of admission or as a requirement to continue to, receive care for three residents (#19, #117 and #215) of three residents sampled. Findings included: 1. On 8/27/25 at 10:04 a.m., an interview was conducted with the Nursing Home Administrator (NHA). She presented a list of residents who have recently signed arbitration agreements. Review of the admission Record for Resident #19 revealed an admission date of 7/24/25 with diagnoses to include Type 2 diabetes, peripheral vascular disease; acquired absence of right leg above knee and other co-morbidies. Review of the admission Minimum Data Set (MDS), dated [DATE], showed Resident #19 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Review of the admission Agreement attachment titled, Agreement 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 record review and interviews, the facility failed to ensure the arbitration agreement provided for the selection of a neutral arbitrator agreed upon by both parties for three (#19, #117 and #215) of three residents sampled. Findings included: Review of the Agreement to Resolve Disputes by Binding Arbitration revealed under section C. Who Will Conduct Arbitration. The Arbitration shall be conducted by the American Health Lawyers Association ( AHLA) through its Alternative Dispute Resolution (ADR) service. If the AHLA process is no longer in existence at the time of the dispute, or AHLA is unwilling or unable to conduct the arbitration, then facility shall choose another independent entity that is regularly engaged in providing ADR services to conduct the mediation or arbitration.The form was signed by Resident #19 on 7/27/25.The form was signed by Resident #117 on 8/6/25.The form was signed by Resident #215 on 8/25/25.During an interview on 08/28/2025 at 5:42 p.m. with the admission Coordinator (AC), stated the agreement does not appear to give the resident a choice for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure an effective infection control program was implemented related to: a) improper use of Personal Protective Equipment (PPE); b) contact/isolation signs not posted and precautions not followed by staff; and c) hand hygiene practices were not conducted properly in four of four wings observed.Findings included: 1) On 08/25/2025 Observed room [ROOM NUMBER] to have Special Contact/Droplet isolation sign posted at the door. PPE caddy was present at the door Resident from room observed wheeling herself through the hallways and interacting with staff, resident was not wearing any mask. Interviewed Staff AA, unit clerk on 08/25/2025 at 10:25AM. She stated the resident was on Special Contact/Droplet precautions for the wound on her foot. Voiced resident had a wound vac requiring the isolation precaution. Interview with Staff Y, RN manager on 08/26/2025 about resident's precaution and she stated the resident was exposed to covid because her…

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 clean and sanitary resident spaces, to include resident rooms and bathrooms and clean and safe resident equipment, during three of four days observed (8/25/2025, 8/26/2025, and 8/28/2025) and in four of four units (A, B Memory Unit, C, and D).Findings included: 1. During a facility tour on 8/25/2025 at 9:50 a.m., 8/26/2025 at 8:10 a.m. and on 8/28/2025 at 8:20 a.m. the following was observed: Resident room [ROOM NUMBER] was observed with a sliding glass door that is not unlockable. The bottom track of the door was observed with a very large water logged white and with rusted spots clogging what appeared to be a water leak. The towel which was heavily water logged, appeared to be in this position for a long period of time. Photographic evidence was taken. Resident room [ROOM NUMBER] bathroom shower stall observed with bio growth on shower tiles and grouting. Photographic evidence was taken. The cubby sitting area in between…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility did not ensure grievances were documented and/or resolved for the Resident Council, the Food Committee, and six residents (#8, #171, #172, #213, #169, #125) out of thirty-eight residents sampled. Findings included: 1. On 8/25/25 at 10:12 a.m., an observation of Resident #171 revealed she was laying down in bed. She said she wanted choices with meals. She said she received chicken on most days of the week. She said she does not get the option of choosing a substitute for the main meal. Resident #171 stated she has told staff and, “Nothing happens.” She said she would like a hot dog or hamburger. She confirmed that staff have talked to her about her food preferences and dislikes. On 8/25/25 at 12:05 p.m., an observation of Resident #171’s lunch meal was conducted. The resident said she received gravy when her meal ticket indicated a dislike of gravy. She opened the Styrofoam to-go-box which had mashed potato and gravy on top. The meal ticket revealed gravy under…

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 oxygen was administered per physician orders for four residents (#179, #117, #65, and #6) out of six reviewed for oxygen therapy. Findings included: 1. An observation and interview was conducted on 8/25/25 at 10:47 a.m. of Resident #117. Resident #117 was in bed resting with a nasal cannula (n/c) in place. The oxygen (O2) concentrator was observed to be running at 4 liters/minute (L/min). The resident said she does not mess with the oxygen; the nurse does that. Review of admission Records showed Resident #117 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD) and dependence on supplemental oxygen. Review of Resident #117 Brief Interview for Mental Status (BIMS), dated 8/6/25, showed a score of 15 indicating she was cognitively intact. Review of Resident #117’s Care Plan showed a focus area of oxygen therapy as needed related to ineffective gas exchange, dated 8/25/25. Interventions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure medications were stored and secured in accordance with guidelines related to 1) medications improperly labeled and stored in resident rooms (#316 and #416); 2) medications left out in an unlocked office; 3) glucose test strips undated in a medication cart; 4) personal items stored with medications; and 5) improper disposal of a medication observed during three of four days of survey. Findings included: An audit of the A-wing Mid medication cart was conducted on 8/28/2025 at 11:40 a.m. Narcotics were stored in a separate locked compartment; hearing aids and a hearing aid charger were observed stored in the drawer with the medications. Staff KK, Licensed Practical Nurse (LPN) stated those should not be in there. An observation was conducted on 8/25/25 at 11:39 p.m. of a prescription tube of Triamcinolone Cream 0.1 sitting on the bathroom counter of room [ROOM NUMBER]. An observation was conducted on 8/25/25 at 4:39 p.m. of 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 interviews and record review, the facility failed to offer a nourishing evening snack for seven residents (Resident #3, #131, #33, #181, #108, #60, and #10) out of seven residents sampled for dining.Findings included: During a Resident Council meeting on 08/27/2025 at 11:15 a.m., Resident #131 stated residents were not offered evening snacks. She stated she was aware snacks were available on the floors, just not being offered by the staff. Also, stated she'd asked for an evening snack from staff more than once and was told they were out of snacks or didn't have any left. During Resident Council meeting on 08/27/2025 at 11:15 a.m., Resident's #33, #3, #181, and #108 voiced concerns regarding the snacks. Resident #33 stated she had been told more than once snacks were not available at night. Resident #3 stated only one CNA (Certified Nursing Assistant) regularly offered snacks, usually offered cookies, on nights he worked. Residents #33, #3, #108, and #181 all agreed stating they would enjoy an evening snack as there is a large time gap between dinner and breakfast. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide Quality Assurance and Performance Improvement (QAPI) practice that demonstrated identification, monitoring and implementation of an effective Action Plan to improve findings of deficient practice on the recertification survey conducted 8/25/25 -8/28/25 regarding medication storage, infection control, food safety and sanitation, and arbitration agreements. Findings included: A. The facility plan of correction completion (POC) date was 9/28/25. The plan of correction for F761 showed: The hearing aids and hearing aid charger were removed from the A wing middle narcotic drawer. Triamcinolone cream was removed from resident room # 416 with resident's permission. Ammonium Lactate and medication cups were removed from resident room # 316 with resident's permission. The wound care office door and treatment cart were locked. Loose pills were removed from the D wing medication cart. Glucose test strips were discarded. A new bottle of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure a functioning call light system for four residents (#169, #125, #147, and #84) out of four residents sampled for call lights. Findings included: An interview was conducted on 8/25/25 at 11:03 a.m. with Resident #169. He/she said after admission it was discovered the call light didn’t work and it was reported. Residen#169 said it took until the next day until the call light was fixed, and he/she was not provided a hand bell or anything to get staff’s attention. Review of admission Records showed Resident #169 was admitted on [DATE]. Review of Resident #169 admission Minimum Data Set (MDS), dated [DATE], Section C, Cognitive Patterns, showed a brief Interview for mental (BIMS) score of 15, indicating she was cognitively intact. An interview was conducted on 8/25/25 at 5:00 p.m. with Resident #125. Resident #125 stated the call light was not working. He/she was unsure of when it worked last but notified staff early that morning 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.

Based on observations, interviews, and record review, the facility failed to ensure dignity was maintained for residents during dining related to serving residents at a single table meals at the same time in one out of four dining rooms observed. Findings included:An observation was conducted on 08/25/2025 at 12:25 p.m. in the D-unit dining room, two tables were pushed together with six residents seated. Four of the residents had their meals and were eating while the fifth and sixth residents did not have any food or drink. Staff V, Certified Nursing Assistant (CNA) was sitting in a chair at the far end of the table, looking at her hands while holding an electronic device. During an interview on 08/25/2025 at 12:53 p.m. Staff V, CNA stated staff were still passing the trays and the staff pass the trays in room order only. Staff V, CNA stated all residents should be served at the same time at one table, but I am only to watch them. An observation was conducted on 08/28/2025 at 8:00 a.m. in the D-unit dining room, five residents were seated around a table. Three residents had empty…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure Preadmission Screening and Resident Review (PASRR) assessments were accurate and failed to submit a Level II PASRR for one resident (#8) out of three residents sampled.Findings included:Review of Resident #8's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses to include mood disorder, insomnia, dementia and bipolar disorder.Review of the Level I PASRR, dated 7/04/2024, showed in Section II: Other Indications for PASRR Screen Decision-Making, questions 1 through 7 were marked No. A level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder (including Alzheimer's disease), and a suspicion or diagnosis of a Serious Mental Illness. Section IV: PASRR Screen Completion, Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to 1) provide adequate catheter care for Resident # 10, and 2) ensure documentation of catheter care was completed for Resident #125, out of three residents sampled for catheter care.Findings Included: 1) During an interview with Resident #10 on 08/25/2025 at 9:45a.m., the resident voiced concerns regarding lack of care for her suprapubic catheter. The resident stated no one had cleaned the site or changed the dressing on her catheter for three days. Resident #10 voiced a concern of her catheter care not being done correctly since a nurse who previously did most of her care resigned from the facility. A follow-up interview was conducted on 08/26/2025 at 10:20 a.m. where the resident stated she had still not received care for her catheter. Resident #10 stated she did ask a nurse if the catheter was going to be replaced as previously it had been replaced every 30 days, but the nurse told her there was no order for that. Resident #10 was admitted to 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, interviews, and record review, the facility failed to provide effective pain management in a timely manner for one resident (#179) out of one resident sampled for pain management. Findings included:An interview was conducted on 8/25/2025 at 9:30 a.m. with Resident #179. The resident stated she/he was not receiving adequate pain medication and had to wait for hospice. The resident was observed in a wheelchair, dressed in appropriate clothes. The resident stated she/he has a lot of back pain. The resident stated staff can't give anything else, she/he is waiting for hospice. The resident appeared to be wincing in pain.An observation and interview were conducted on 8/27/2025 at 10:41 a.m. The resident was observed in a wheelchair next to the bed, dressed in appropriate clothes. The resident is still reporting a lot of pain in the back. The resident stated she/he wakes up and gets into the wheelchair and doesn't go back to bed because she/he is in so much pain. The resident was observed wincing…

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 ensure sufficient staff were available to meet the needs of the residents on four units (A, B, C and D) out of four units in the facility. Findings included: An interview was conducted on 8/25/25 at 10:42 a.m. with Resident #216. He/she said when the call light is pressed it can be an hour to an hour and half before someone comes to assist. Resident #216 said he/she had to call the receptionist at the front desk and ask them to call the nurses’ station to get help. The resident said even then, it took another 20 minutes before a staff member made it to the room to assist. The resident said he/she is unable to do anything without assistance. Review of admission Records showed Resident #216 was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction. Review of Resident #216’s Brief Interview for Mental Status (BIMS), dated 8/25/25, showed a score of 15, indicating he/she was cognitively…

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 two residents (#23, #90) were offered the COVID-19 vaccine out of 5 residents sampled for COVID-19 immunizations.Findings included:1. A review of Resident #23's admission Record revealed the resident was admitted to the facility on [DATE].Further review of the medical record revealed Resident #23 was sent to the Emergency Department on 8/15/2025. The resident tested positive for COVID-19 at the Emergency Department and was re-admitted to the facility on [DATE].A COVID-19 vaccine consent or refusal was not found in the medical record prior to 8/15/2025.2. A review of Resident #90's admission Record revealed Resident #90 was admitted to the facility on [DATE].Further review of the medical record revealed the resident was sent to the Emergency Department on 08/17/2025 and was diagnosed with COVID-19. The resident was re-admitted to the facility on [DATE].A COVID-19 vaccine consent or refusal was not found in the medical record prior 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 interviews, record review, and facility policy review, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for six employees (Staff C, Licensed Practical Nurse and Unit Manager, Staff G, Registered Nurse, Staff H, Certified Nursing Assistant, Staff I, Certified Nursing Assistance, Staff J, Licensed Practical Nurse, and Staff K, Certified Nursing Assistant) of six employee files reviewed. Findings included: Record review of the facility's undated policy titled, Resident Rights to Freedom from Abuse, Neglect, and Exploitation, showed the facility had no procedure for screening of employees or verifying prior employment. During an interview with the Nursing Home Administrator (NHA) on 2/17/25 at 2:00 p.m., the NHA stated the only policy and procedure they have is the one titled, Resident Rights to Freedom from Abuse, Neglect, and Exploitation. Review of Staff C, Licensed Practical Nurse's (LPN's) employee file revealed: Date of Hire (DOH) 12/3/24, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility did not ensure preferences were honored and dignity maintained for one resident (#8) out of eight sampled residents. Findings included: An interview was conducted on 2/17/25 at 12:03 p.m. with Resident #8. The resident stated on several occasions she requested to only have female care givers for incontinence care. She said there were some male caregivers she did not want to care for her, and they were often assigned to her. Review of the admission Record showed Resident #8 was admitted [DATE] and re-admitted on [DATE] with diagnoses including fracture of left lower leg, major depressive disorder, and morbid obesity. Review of Resident #8's care plan showed a Focus area: I need assistance with activities of daily living related to atrial fibrillation, fibromyalgia, hyperlipidemia, hypertension, diabetes mellitus type 2, and left lower leg fracture, initiated 6/6/24. Interventions included resident prefers female care givers, updated on 9/3/24. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to act upon resident's concerns and grievances for two residents (#3 and #8) of seven residents reviewed for grievances. Findings included: 1. During an observation and interview conducted on 2/16/25 at 12:05 p.m., Resident #3 stated she had concerns and filed several grievances related to call lights not being answered timely and her meal tray not always being set up in a way where she could reach it. She reported her concerns to the SSD (Social Services Director). The resident stated the SSD did not come to her with any feedback. She also stated there was a problem with medications, she does not receive her medications in a timely manner, and sometimes they are not available. She stated most recently last week, she did not receive her sleeping pill and it was not re-ordered. The ARNP (Advanced Registered Nurse Practitioner) ordered it the next day. The resident stated she filed a grievance about this. She stated there was a problem with staffing.…

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 care and treatment was provided in accordance with professional standard of practice related to 1. Failure to ensure repositioning, skin integrity checks, and incontinence care was provided timely for one resident (#3) of three residents sampled, 2. Failure to ensure a lift transfer was conducted per facility protocol for one resident (#3) of three residents sampled, 3. Failure to ensure a call light was within reach for one resident (#7) of seven residents sampled, and 4. Failure to ensure medications were administered per physician orders for one resident (#3) of three residents sampled. Findings included: 1. During an observation and interview conducted on 2/16/25 at 12:05 p.m., Resident#3 stated she was not repositioned timely and she was afraid her wound on her bottom was going to reopen due to lack of repositioning. The resident stated today the CNA (Certified Nursing Assistant) was here last about 10 a.m. Resident #3…

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 a safe, clean, and homelike environment was maintained, to include resident rooms, resident bathrooms, and doors, on four of four resident units, during five of five days observed during survey. Findings included: The following observations were made between 10/21/24 and 10/25/24 during survey activities: - Resident rooms 216 & 217 did not have access to a sink and the bathroom door was locked with a padlock from both sides. - Resident room [ROOM NUMBER] - at the entrance way to the corridor a ceiling tile was missing, and a large hole was in the ceiling above the bathroom door, - Resident room [ROOM NUMBER] - the ceiling above the bathroom door, near the air conditioner intake vent, the paint appeared to be bubbling away from the ceiling, and black/brownish color is in a circular pattern near the area. - Resident common area, Sunroom on the D unit had an orange colored, cloth sofa which emanated an offensive urine spell…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure all alleged violations involving abuse or neglect were reported immediately, but not later than two hours after the allegation was made, to the administrator of the facility and required state agencies in accordance with state law through established procedures for three residents (#3, #8, and #12) of three sampled residents. Findings Include: Review of Resident #3's progress note, dated 6/22/24 at 9:48 a.m., authored by Staff M, Licensed Practical Nurse (LPN) showed the following: Upon arriving on the unit and doing rounds the resident was observed sitting in wheelchair by resident's room door chanting but not outside of her normal behavior. Another nurse came and informed the nurse that the resident posture was not looking normal and if I would assess her. Upon walking up to the resident, the posture was abnormal, and her leg was twisted. When approaching the resident to touch her she begin screaming. Wheelchair was in locked position. 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, interviews, and record review, the facility failed to provide assistance with Activities of Daily Living (ADL's) related to showers, incontinence care, and assistance with meals for six residents (#16, #18, #7, #17, #24, and #25) out of six reviewed for Activities of Daily Living. Findings included: 1. On 10/21/2024 at 10:15 a.m. during an observation and interview, Resident #16 was observed in bed, dressed in a facility gown watching television. Resident #16 was observed partially covered by a bed sheet and his face had food from breakfast on it. Resident #16 said the care in facility was not great. He said he had not had a shower or a bed bath in a long time. He stated it had been about two weeks. Resident #16 said he had asked several times for a shower or bed bath, but was told by staff they were too busy, and he would have to wait. He said he does not like to feel dirty. Review of Resident #16's admission Record showed he was admitted to the facility on [DATE] with medical diagnoses…

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 proper wound care to prevent the development of complications for four residents (#19, #21, #22, and #20) of four reviewed for wound care. Finding included: 1. An observation was conducted on 10/21/24 at 10:11 a.m. of Resident #19 in bed with the head of the bed elevated. He had a bandage on his right anterior forearm. The bandage was approximately 6 by 4 and clearly visible. The bandage had a faded date of 10/8/24 written on it. The same bandage remained in place on 10/22/24 and 10/23/24. Review of admission Records showed Resident #19 was admitted on [DATE] with diagnoses including severe protein-calorie malnutrition and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of Resident #19's orders showed an order for Skin Check: Complete weekly body assessment every evening shift every Monday for skin integrity, dated 9/25/24. There were no additional orders related to wound care.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to provide medication administration per physician orders for three residents (#1, #13, #15) of three reviewed for medication administration. Findings included: 1. Review of Resident #1's admission Record showed he was admitted to the facility on [DATE] with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, chronic pain syndrome, and polyneuropathy. Review of Resident #1's active physician orders revealed the following orders: -Flomax Capsule 0.4 mg. [milligram] Give 1 capsule by mouth at bedtime. Dated 9/25/24. -Lyrica Oral Capsule 25 mg. (Pregabalin). Give 1 capsule by mouth two times. Dated 9/25/24. Review of Resident #1's October Medication Administration Record (MAR) revealed Flomax was not administered on 10/05/24, 10/07/24, 10/08/24, 10/09/24, 10/11/24, and 10/12/24, and Lyrica was not given on 10/11/24. A review of Resident #1's complete medical record revealed no documentation for the reason as to why 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 interview, record review, and policy review the facility failed to provide laboratory services as ordered for three residents (#14, #13, and #10) out of three reviewed for laboratory orders. Findings included: 1. Review of admission Record showed Resident #14 was admitted on [DATE] with diagnoses including acute respiratory failure with hypoxia, heart failure, chronic kidney disease, and Type II Diabetes mellitus. Review of Resident #14's physician orders showed: - Please check Vitamin D level, BMP, iron level, B12 level, CBC, A1C, Lipids. One time only for 1 Day. Ordered 8/26/2024. - Please check Vitamin D level, iron level, B12 level, BMP, CBC, A1C, Lipids. Every night shift for LABS for 1 Day. Ordered 9/4/2024. Discontinued 9/5/24. - Please check Vitamin D level, iron level, B12 level, BMP, CBC, A1C, Lipids. Every night shift for LABS for 1 Day. Ordered 9/5/2024. Review of Resident #14's August 2024 MAR showed the lab test was signed off as completed on 8/26/24. Review of Resident #14's Lab Reports…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to provide follow-up notification for critical radiology results for one resident (#9) of one reviewed for imaging. Findings included: Review of admission Records showed Resident #9 was admitted on [DATE] with diagnoses including anemia, Type 2 Diabetes Mellitus, dementia, and acquired absence of left great toe. Review of Resident #9's wound care provider notes dated 8/19/24 showed the following: The patient is an [AGE] year-old female who I have been asked to see regarding an ulcer on her left foot .The area needs continued aggressive offloading. Measurements of the left foot ulcer are 2.6 cm long, 2.7 cm wide, and 0.5 cm deep with moderate serosanguineous drainage. Notes showed a wound culture and arterial and venous doppler ultrasound were ordered. Review of Resident #9's physician orders revealed an order dated 8/19/24 for Complete ultrasound to left foot due to open wound. The computer showed it was ordered by Staff A, [NAME] Clerk. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure infection control practices were implemented to provide a safe, sanitary, and comfortable environment for residents on three out of four units in the facility related to hand hygiene, soiled linens, housekeeping carts during mealtime, personal protective equipment (PPE) carts, and isolation precautions. Findings included: On 10/21/24 at 10:00 a.m. an observation was made of a staff member entering room [ROOM NUMBER], removing tape from a call light button, turning the light off, and exiting the room with no hand hygiene performed. On 10/21/24 at 10:05 a.m. an observation was made of a used exam glove on the floor inside the entrance to room [ROOM NUMBER], a room on enhanced barrier precautions. On 10/21/24 at 10:25 a.m. an observation was made in the A Unit shower room of multiple soiled towels and bath clothes in the shower and on the floor of the shower room. Bags of soiled linen were observed in the shower room. On 10/21/24 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 observations, interviews, and record review, the facility failed to store medications properly on one out of four units and in three out of four medication carts. Findings include: On 10/21/24 at 10:03 a.m. observed a treatment cart sitting in an alcove outside a resident room unlocked. No staff were within sight. The cart remained unlocked at 10:45 a.m. On 10/21/24 at 10:15 a.m. observed a medication cup containing a pill sitting on the bedside table in room [ROOM NUMBER] window bed. On 10/21/2024 at 10:15 a.m. observed a lidocaine pain relief patch on the resident's over bed table in room [ROOM NUMBER] window bed. On 10/21/2024 at 10:26 a.m. observed Fluticasone Propionate Nasal Spray and a container of A&D+E ointment located on the resident's nightstand in room [ROOM NUMBER] door bed. On 10/21/24 at 10:28 a.m. observed a bottle of Nystatin topical power with a prescription label attached on the bedside table in room [ROOM NUMBER] window bed. On 10/21/24 at 4:03 p.m. observed a medication cart on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to have sufficient nursing staff to provide nursing and related services in a timely manner in relation to call lights for three residents (#173, #57, and #117) out of 53 sampled residents with the potential to affect all residents in the faciltiy. Findings included: 1. A grievance was filed on 01/17/24 related to call lights not being answered in a timely manner. The resolution showed staff were educated on answering call lights promptly. The In-Service Sign in Sheet, dated 01/19/24, for the 11-7 shift showed a topic of answering call lights in a timely fashion. A grievance was filed on 03/18/24 related to call lights not being answered. The resolution showed the resident was offered a facility change, but the family declined. A call light audit was completed through maintenance. A work history report showed a test was conducted on the nurse call system once a month from 05/31/23 to 04/30/24 and was completed by maintenance. A grievance…

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 environment was maintained in a clean and comfortable manner in two hallways (100 hall and 200 hall) out of four hallways in the facility serving as resident living areas. Findings included: 1. Observations during the initial tour of the 200 hall, a secured unit, on 05/06/24 from 10:26 AM to 11:47 AM revealed the following: -room [ROOM NUMBER], A privacy curtain and a toilet bowel noted to be soiled with a brown substance. The bedroom floor was noted to be dirty and the bathroom had missing tile. (Photographic evidence obtained) -room [ROOM NUMBER], The bathroom ceiling was noted to be peeling. (Photographic evidence obtained) -room [ROOM NUMBER], The bathroom ceiling was noted with peeling paint with area noted with black/brown bio-growth. (Photographic evidence obtained) -room [ROOM NUMBER], Directly outside the door was noted to have peeling paint, and two nails were noted to be protruding out of the door frame on the left…

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 review and revise a care plan to reflect the nonuse of a secure door safety banner stop sign for one resident (# 54) out of ten residents sampled. Findings included: During an observations made on 05/07/24 at 9:47 a.m. and 1: 30 p.m., and on 5/8/2024 at 9: 00 a.m. and 3:00 p.m., Resident # 54 was observed sitting on the side of her bed with her call light within reach. Observation showed no stop sign across Resident # 54's room door. Review of the admission Record Resident # 54 was admitted on [DATE] with diagnoses to include Chronic Kidney Disease, Stage 3 unspecified, need for assistance with personal care, unspecified dementia, unspecified severity, with psychotic disturbance, and unspecified mood affective disorder. Review of a Minimum Data Set (MDS), dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 03 indicating Resident # 54 was severely cognitively impaired. Review of Resident # 54's care plan, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide two residents (#3 and #9), who were dependent for Activities of Daily Living (ADLs), personal grooming related to shaving and nail care. Findings included: 1. On 05/06/24 at 11:05 a.m., Resident #3 was observed in bed in her room. Facial hair was observed above the resident's lip. On 05/08/24 at 12:32 p.m., Resident #3 was observed in bed in her room. Facial hair was observed above the resident's lip. The admission Record showed Resident #3 was initially admitted to the facility on [DATE] with a diagnosis to include unspecified intracranial injury with loss of consciousness of unspecified duration. A review of the Minimum Data Set (MDS), dated [DATE], showed in Section C- Cognitive Patterns Resident #3 was rarely/never understood. In Section GG- Functional Abilities and Goals Resident #3 was totally dependent for personal hygiene (shaving). The care plan related to ADLS, initiated on 05/30/19, showed a focus area that revealed…

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

Based on observations, interviews, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice related to unlabeled dressings for one resident (#294) out of two residents sampled for skin conditions. Findings included: An observation of Resident #294 on 05/06/24 at 03:19 PM revealed the resident was lying on his bed with his legs uncovered. The resident had a large white dressing covering his left calf below the knee and above the ankle. The dressing revealed no staff initial or a date listed on the dressing. An observations of the Resident #294 on 05/07/24 at 09:02 AM revealed the resident was lying on his bed with his legs uncovered. Resident #294 had a large white dressing covering his left calf. The dressing had no staff initial or a date listed on the dressing. Review of the residents orders revealed the following: -Cleanse L [left] medial calf with NS [normal saline], pat dry, apply oil emulsion and cover with foam dressing daily/prn [as needed], every day shift for wound care AND as needed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility 1) failed to ensure a resident who cares for his laryngectomy tube was assessed and deemed competent, 2) failed to ensure necessary supplies were available, and 3) failed to ensure follow-up with a specialty physician related to his laryngectomy tube was coordinated for one resident (#154) out of one resident sampled with a laryngectomy tube. Findings included: Review of Resident #154's admission Record revealed he was admitted to the facility from an acute care hospital on 6/21/23 with diagnoses of respiratory failure, chronic obstructive pulmonary disease (COPD), tracheostomy status, malignant neoplasm of the mouth, malignant neoplasm of the larynx, and shortness of breath. An interview and observation were conducted on 05/06/24 at 09:59 AM with Resident #154. Resident #154 was observed to have a laryngectomy tube in place, with clean trach ties. He communicated well by whispering and writing his requests on paper. He said he needs an ear nose…

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 interviews and record review, the facility failed to ensure the drug regimen review was completed monthly, the pharmacist's report was documented in the medical record, and the pharmacist's recommendations were acted upon for one resident (#135) of nine residents reviewed for unnecessary medications. Findings included: A review of the medical record for Resident #135 revealed diagnoses to include: unspecified dementia, unspecified severity, with other behavioral disturbance, psychotic disorder with hallucinations due to known physiological condition, age-related cognitive decline, mood disorder due to known physiological condition specified, anxiety disorder, unspecified. A review of the Physician Orders, dated May 2024, revealed the following: -Dulaglutide Subcutaneous Solution Pen-injector 0.75 MG (milligrams)/0.5 ML (milliliters) Inject 0.5 ml subcutaneously every evening shift every Sunday for glucose control. Start date 8/27/23. -Glucagon Emergency Kit 1 MG. Inject 1 mg intramuscularly as needed for Hypoglycemia of less than or equal to 70 mg/dl (deciliter) who are…

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 maintain an effect pest control program for two units out of four units in the facility. Findings included: 1. An observation was conducted on 05/06/24 at 10:39 AM. The shower in room [ROOM NUMBER] was had a spider web with a live spider in it. An observation was conducted on 05/06/24 at 10:47 AM of room [ROOM NUMBER] and 110's shared shower. Five small live roaches were crawling on the shower floor. An interview was conducted on 05/06/24 at 11:49 AM with Staff D, Certified Nursing Assistant (CNA). She said out of the four residents who share the shower, one of them uses the shower. The other three residents use the shower room down the hall. She went into the shower room and confirmed there were five roaches in the shower and she said, There is a guy who comes and sprays for pests and housekeeping also sprays for the bugs but it seems the more they spray the more roaches come out. Sometimes there will be flying roaches. An observation 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, interviews, and record reviews the facility failed to ensure Narcotic Cards/ Bottles Reconciliation logs were completed on 4 out 4 resident wings (A, B, C, D) and failed to document controlled narcotics in sufficient detail to enable an accurate reconciliation for 3 residents (Resident #5, Resident #6, and Resident# 11) of 3 residents reviewed on Wing B, for 2 of 2 medication carts located on Wing B. Findings included: 1. Review of the facility's Wing D Narcotic Cards\ Bottles Reconciliation log revealed between 09/07/23 and 09/25/23, there were eight shifts missing oncoming and off going nurse signatures. Review the facility's Wing B Narcotic Cards\ Bottles Reconciliation log revealed between 09/02/23 and 09/25/23, there were 29 shifts missing oncoming and off going nurse signatures. Review the facility's Wing C Narcotic Cards\ Bottles Reconciliation log revealed between 09/01/23 and 09/25/23, there were 21 shifts missing oncoming and off going nurse signatures. Review the facility's Wing…

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 submit a timely report to the required state agencies for 1 resident (#6) out of 3 residents reviewed. The facility failed to submit a timely report to the required state agencies for misappropriation of Resident #6's missing narcotic medication. Findings included: Review of admission records revealed Resident #6 was admitted on [DATE] with diagnoses to include dementia, sacral fracture, and osteoarthritis of the hand. Review of a physician order dated 05/15/23 revealed Morphine Sulfate 100mg/5ml give 0.25 ml by mouth every 4 hours as needed for pain/dyspnea. Review of Resident #6's Medication Administration Record (MAR) and the Controlled Substance Use log for Morphine Sulfate100 mg/5ml for August 2023 and September 2023 revealed the following two entries were medications signed out as given to the resident but not recorded on the log: 1. 09/03/23 at 6:20 p.m. Morphine Sulfate 0.25 milliliters for pain level 3 of 10 was administered 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 interviews and review of facility and resident's record, the facility did not ensure supervision was provided to prevent a fall for 1 of 3 residents reviewed, Resident #3 and the facility did not ensure documentation and follow up were completed after the fall. Findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses to include other intervertebral disc degeneration Lumbar, Unspecified dementia, history of falling, primary insomnia, major depressive disorder, and mood disorder. Review of an annual MDS (Minimum Data Set) for Resident #3 dated 08/05/23 showed Resident #3 had a BIMS (Brief Interview for Mental Status) score of 3, indicating severe impairment. Section G showed Resident #3 required extensive assistance with two plus person's physical assistance for transfers. The resident required extensive assistance with one-person physical assistance for locomotion on and off unit. A care plan for Resident #3 initiated on 04/13/23 showed, the staff have identified that I am 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.