Sunny View Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to follow document and/or carry out physician orders for 2 of 16 residents reviewed (Resident #2 and Resident #3). Resident #2 had an order to check her oxygen saturation (POx) once per shift. She had a second PRN (as needed order) to apply oxygen if the oxygen saturation was below 90%. There was no documentation of oxygen application for oxygen saturation below 90%. Resident #3 had an order to check Hgb A1c (a test that measures the average blood sugar) every 6 months. This was not done. The facility reported a census of 86 residents. Findings include: 1. A Quarterly Minimum Data Set (MDS) dated [DATE], documented Resident #2's diagnoses included heart failure and non-Alzheimer's dementia. A Brief Interview for Mental Status (BIMS) documented a score of 4 out of 15, which indicated severely impaired cognition. This resident received oxygen treatment. A Treatment Administration Record (TAR) for June 2025 and printed on 6/25/25 at 3:33…

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 doctor's orders for oxygen (O2) were being followed for 3 out of 3 residents reviewed (Residents #2, #8 and #9. Resident #2 had an order for PRN (as needed) oxygen to be placed when her oxygen saturation was below 90%. Documentation showed she had a least 2 occasions when her oxygen saturation read by a pulse oximeter (Pox) was 89% and oxygen was not documented as being applied. Staff reported not knowing there was an order for PRN oxygen, but they were applying oxygen without clarifying the order. Residents #8 and #9 were observed to have oxygen administered at flow rates that differed from their doctor ordered oxygen flow rates. The facility was not documenting what the liter flow was for oxygen saturation readings on an oxygen order that was to be titrated between 2 and 4 liters(L) per Resident #8's needs. The facility reported a census of 86 residents. Findings include: 1. A Quarterly Minimum Data Set (MDS) dated [DATE],…

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 clinical record review, staff interviews and facility policy review, the facility failed to maintain complete and accurate medical records for 2 of 3 residents reviewed for discharge planning (Resident #15 and Resident #16). The facility reported a census of 86. Findings include: 1. The Quarterly Minimum Data Set (MDS) of Resident #15 dated 4/8/25 recorded a Brief Interview for Mental Status (BIMS) Score of 12, which indicated moderate cognitive impairment. The Care Plan, last reviewed on 4/22/25, failed to reflect a discharge plan for Resident #15. The Care Conference Review Notes dated 1/10/25 recorded the presence of the social services representative at the care conference. The Notes revealed Resident #15's daughter requested a referral to be made to another facility in the resident's home town for the resident to move to. The Care Conference Review Notes dated 4/15/25 recorded the presence of the social services representative at the care conference. The Notes revealed Resident #15's daughter…

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 clinical record review, staff interview, and facility policy/procedures the facility failed to clarify a medication when a resident was admitted on [DATE] for which delayed the resident getting the medication as directed until 4/7/25. (Resident #1). The facility reported a census of 82 residents. Finding include: The admission Minimum Data Set (MDS) for Resident #1, with an assessment reference dated 4/7/25, documented diagnoses for which included anemia, hypertension, benign prostate hyperplasia (BPH) and arthritis. The MDS revealed the resident with a Brief Interview for Mental Status (BIMS) score of 15 for which indicated no memory impairments and requiring partial to moderate assistance with Activities of Daily Living (ADL). The MDS documented no mood disorders and able to be understood and understand others. The Plan of Care with an initiated date of 4/4/25, had a focus area of ADL Care-Resident requires assistance with ADL's secondary to lumbar spine fusion procedure. Intervention include:…

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 interview, and facility cleaning procedures, the facility failed to ensure resident rooms were free of odors to create a home-like environment for 1 of 59 resident rooms (Resident #71). The facility reported a census of 82. Findings include: The Minimum Data Set (MDS) dated [DATE] revealed Resident #71 with a Brief Interview for Mental Status score of 14, which indicated intact cognition. Diagnoses on the MDS include anxiety, cerebrovascular accident (stroke), chronic pain syndrome, depression, diabetes, hemiplegia, non-Alzheimer dementia, Parkinsons, and prostate cancer. The MDS noted Resident #17 utilizes either a walker or wheelchair for mobility. The Care Plan with a completion date of 12/2/24 indicated Resident #71 has had falls with minor injury due to poor balance. Interventions included staff to check urinal frequently and empty if needed to prevent spills. During an observation on 2/10/25 at 11:10 AM, an ammonia odor was present in the hallway from Resident #71's room.…

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, family and staff interviews, and clinical record review, the facility failed to follow the physician's orders for 1 of 20 residents (#32). The facility reported a census of 82 residents. Findings include: 1. On 2/10/25 at 3:56 PM, Resident #32's visitor stated the resident missed several doses of Calcium Carbonate (Tums) during the last week of October 2024. She also stated there were several occasions when the resident's Voltaren External gel (topical analgesic used to treat pain and inflammation) was not given until after the prescribed time. On 2/10/25 at 5:29 PM, the resident's relative stated the resident received the Tums to provide calcium for a previously fractured T12 vertebrae. She also stated the Volteran gel was to be applied for the same reason. The Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #32 revealed a Brief Interview for Mental Status (BIMS) score was not obtained because the resident was rarely/never understood. It included diagnoses of Heart Failure,…

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 health record review, facility document review, and staff interviews, the facility failed to communicate throughout departments current resident staff assistance level for 1 of 5 residents reviewed for nursing supervision (Resident #71). The facility reported a census of 82. Findings include: The Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #71 with a Brief Interview for Mental Status score of 14, which indicated intact cognition. Diagnoses on the MDS include anxiety, cerebrovascular accident (stroke), chronic pain syndrome, depression, diabetes, hemiplegia, non-Alzheimer dementia, and Parkinsons. The MDS noted Resident #17 utilizes either a walker or wheelchair for mobility. The MDS revealed Resident #71 is independent with chair/bed-to-chair transfers, toilet transfers, and walk 10 feet. The MDS recorded no falls since prior assessment. The Care Plan with a completion date of 12/2/24 indicated Resident #71 has a self-care performance deficit related to stroke with left-sided…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and resident and staff interviews, the facility failed to provide resident assistance or follow-up with medical equipment for 1 of 2 residents reviewed for respiratory care (Resident #235). The facility reported a census of 82. Findings include: The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #235 with a Brief Interview for Mental Status score of 15, which indicated intact cognition. Diagnoses on the MDS include anemia, atrial fibrillation, hip fracture, obstruction sleep apnea, and osteoporosis. The facility admission date documented as 1/28/25. The Care Plan revised on 2/11/25, indicated Resident #235 had a self-care performance deficit due to right shoulder fracture and left femur fracture. Interventions include staff assist of 1 with a hemi-walker for transfer inside the room, weight-bearing as tolerated to left lower extremity, and staff assist of 1 to turn and reposition in bed. The Care Plan indicated Resident #235 is a fall risk due to weakness, decreased…

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 policy review, the facility failed to ensure a yearly psychotropic medication (a medication that affects a person's mental state) gradual dose reduction (GDR) was attempted or appropriately declined for 3 of 3 resident (#32, #44, & #66). The facility reported a census of 82. Findings included 1. On 2/11/25 at 11:00 AM, Resident #32 was identified as a resident who received psychotropic medications. The Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #32 revealed a Brief Interview for Mental Status (BIMS) score was not obtained because the resident was rarely/never understood. It included diagnoses of Heart Failure, Chronic Kidney Disease (CKD), Diabetes Mellitus (DM), chronic pain, anxiety, and spinal stenosis (narrowed spinal canal). It also revealed the resident required setup assistance with eating, supervision with oral and personal hygiene, maximal assistance with toileting hygiene and bathing, and was dependent with all other aspects of Activities 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 clinical record review, staff interviews and policy review, the facility failed to provide care and services according to accepted standards of clinical practice for 1 of 1 resident reviewed (Resident #5) for weight monitoring. The facility failed to obtain weights per physician order. The facility reported a census of 82 residents. Findings includes: Resident #5's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS identified Resident #5 was dependent on staff for bed mobility. The MDS documented Resident #5 did not get out of bed during the assessment period. The MDS revealed Resident #5 had an indwelling catheter and was always incontinent of bowel. Resident #5's MDS included diagnoses of neurogenic bladder (urinary bladder problems due to disease or injury to the central nervous system), septicemia (blood infection), urinary tract infection (UTI) in the last 30 days, quadriplegia (paralysis that…

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 clinical record review, staff interview and policy review the facility failed to provide bathing assistance for 1 of 4 residents reviewed for bathing (Resident #1). The facility reported a census of 82 residents. Findings include: Resident #1's admission Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. The MDS identified Resident #1 required substantial/maximal assistance shower or bathing. Resident #1's MDS included diagnoses of cancer, anemia, coronary artery disease (CAD) hypertension (high blood pressure), cirrhosis of the liver, and right humerus fracture. The Progress Note dated 7/16/24 revealed Resident #1 was admitted to the facility from the hospital. The Care Plan with a revised date of 07/18/24 identified Resident #1 required assistance of 1 staff member to provide showering tasks at least twice weekly and as necessary. The facility form titled Shower/Bath for July and August 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 clinical record review, staff interviews, and policy review the facility failed to provide interventions necessary for the care and services, to maintain the residents' highest practical physical well- being for 1 of 6 resident reviewed (Resident #2). The facility failed to complete and document nursing assessments including neurological assessments after a report that a resident had hit his head on a wall. The facility reported a census of 82 residents. Findings include: Resident #2's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 05, indicating severe cognitive impairment. The MDS identified Resident #2 required substantial/maximal assistance with bed mobility, transfers, and toileting. Resident #2 ' s MDS included diagnoses of anemia, coronary artery disease (CAD) hypertension (high blood pressure), renal disease (kidney), diabetes mellitus, non-Alzheimer's dementia, anxiety, and depression. The Care Plan with initiated date of [DATE]…

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 clinical record reviews, observations, staff interviews and policy review, the facility failed to provide adequate nursing supervision to prevent accident and injuries for 1 of 1 residents reviewed (Resident #2). The facility reported a census of 82 residents. Findings include: Resident #2's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 05, indicating severe cognitive impairment. The MDS identified Resident #2 required substantial/maximal assistance with bed mobility, transfers, and toileting. Resident #2 ' s MDS included diagnoses of anemia, coronary artery disease (CAD) hypertension (high blood pressure), renal disease (kidney), diabetes mellitus, non-Alzheimer ' s dementia, anxiety, and depression. The Care Plan with initiated date of 12/5/23 revealed Resident #2 required total care in all activities of daily living (ADLs) secondary to decreased mobility related to right hip fracture, chronic pain and dementia. The care plan also…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, and clinical record review the facility failed to monitor and provide appropriate urinary assessment after a indwelling catheter was removed for 1 of 4 residents reviewed (Resident #4) for catheters. The facility also failed to document accurate urine output and follow a physician order when inserting an indwelling catheter. The facility reported a census of 82 residents. Findings include: Resident #4's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) was not able to be completed. A Staff Assessment for Mental Status indicated Resident #4 had severe cognitive impairment. The MDS identified Resident #4 was dependent on staff for bed mobility, transfers and toileting. The MDS revealed Resident #4 had an indwelling catheter, and was always incontinent of bowel. Resident #4's MDS included diagnoses of down syndrome, anxiety, depression, and non-Alzheimer's dementia. The Care Plan dated 6/27/24 revealed Resident #4 had a urinary 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, clinical record review, staff interviews, and policy review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 2 of 4 resident reviewed for catheter care (Resident #5 and #3). The facility reported a census of 82 residents. Findings include: 1. Resident #5's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS identified Resident #5 was dependent on staff for bed mobility. The MDS documented Resident #5 did not get out of bed during the assessment period. The MDS revealed Resident #5 had an indwelling catheter and was always incontinent of bowel. Resident #5's MDS included diagnoses of neurogenic bladder (urinary bladder problems due to disease or injury to the central nervous system), septicemia (blood infection), urinary tract infection (UTI) in the last 30 days, and quadriplegia…

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, clinical record review, a photograph and facility policy review, the facility failed to properly provide perineal cares for 2 of 3 residents reviewed (Resident #2 and #3 ). The facility identified a census of 88 residents. Findings include: 1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. Resident #2 required substantial/maximal assistance with toilet use, personal hygiene, and ambulation. The listed Resident #2 as frequently incontinent of bowel and bladder. The MDS included diagnoses of renal insufficiency (inadequate functioning kidneys), polyneuropathy (multiple areas of nerve damage that causes numbness, pain, and tingling), anxiety, and non Alzheimer's dementia. The Care Plan Focus revised 6/20/23 indicated Resident #2 had an activities of daily living (ADL) self care performance deficit related to (r/t) weakness, shortness of breath, an unsteady gait, and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on family interview, resident interview, staff interview, Ombudsman email, Resident Council Minutes, and facility policy review the facility failed to answer resident call lights within 15 minutes for 2 of 3 residents reviewed (Residents #2 and #5). The facility identified a census of 88 residents. Findings include: 1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. Resident #2 required substantial/maximal assistance with toilet use, personal hygiene, and ambulation. The listed Resident #2 as frequently incontinent of bowel and bladder. The MDS included diagnoses of renal insufficiency (inadequate functioning kidneys), polyneuropathy (multiple areas of nerve damage that causes numbness, pain, and tingling), anxiety, and non Alzheimer's dementia. On 5/22/24 at 12:36 PM Resident #2's family member reported she timed Resident #2's activated call light for 30 45 plus minutes. On a couple…

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 clinical record review, staff interview and facility policy review, the facility failed to maintain a complete and accurate Care Plan for 1 of 3 resident's reviewed (Resident #2). The facility identified a census of 88 residents. Findings included Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. Resident #2 required substantial/maximal assistance with toilet use, personal hygiene, and ambulation. The listed Resident #2 as frequently incontinent of bowel and bladder. The MDS included diagnoses of renal insufficiency (inadequate functioning kidneys), polyneuropathy (multiple areas of nerve damage that causes numbness, pain, and tingling), anxiety, and non Alzheimer's dementia. Resident #2's Care Plan failed to address her continence status. An email dated 6/4/24 at 12:30 PM, from the Director of Clinical Services confirmed Resident #2's Care Plan didn't address incontinence. The Care Plan…

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, clinical record review, resident interview and staff interview, the facility failed to follow physician's orders for 1 of 3 residents reviewed (Resident #13). In addition, the facility failed to properly administer medications according to the nursing standards of practice for 2 of 3 residents (Residents #12 and #11). The facility identified a census of 88 residents. Findings include: 1. Resident #13's Medication Administration Audit Report dated 5/22/24 at 11:16 AM directed the facility staff to administer the following medications at 6 AM. The documentation reflected Staff G, Certified Medication Aide (CMA), administered the medications at 8:48 AM a. Apixaban (blood thinner) oral tablet 5 milligrams (mg) one (1) tablet by mouth (po) two (2) times a day (BID). b. Famotidine (prostate health) oral tablet 20 mg po in the morning (AM). c. Losartan Potassium (blood pressure) oral tablet 25 mg po in the AM. d. Baclofen (muscle relaxer) oral tablet po BID. e. Spironolactone (water pill) oral…

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 clinical record review, staff interview and facility policy review, the facility failed to assess and implement interventions for a 1 of 3 residents following a fall (Resident #3). The facility identified a census of 88 residents. Findings include: Resident #3's MDS assessment form dated 4/16/24 identified a BIMS score of 4, indicating severely impaired cognition. Resident #3 required substantial/maximal assistance with toilet hygiene. The assessment listed Resident #3 as always incontinent of bowel and bladder. The MDS included diagnoses of fractures, non Alzheimer's dementia, bell's palsy and weakness. The Progress Note dated 5/13/24 at 10:29 AM indicated Resident #3 sustained an unwitnessed fall without injury in her room at 7:30 AM. Resident #3's clinical record lacked follow-up assessments following the fall on 5/13/24. According to an email dated 6/5/24 at 1:51 PM the Director of Clinical Services confirmed they expected the staff to perform follow-up assessments following a fall for 72-hours.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, and policy review the facility failed to answer call lights in a timely manner within 15 minutes for one of two nursing units reviewed. The facility reported a census of 85 residents. Findings include: 1. Resident interviews revealed the following: On 3/4/23 at 11:19 AM, Resident #84 reported it took staff 45 minutes to respond to his call light. The resident reported he had a clock on the wall to know the time and how long it took staff. The resident reported he required the assistance of two staff and it took longer to find staff to help. On 3/4/24 at 11:53 AM, Resident #139 reported the facility didn't have enough help. The resident reported he waited 30-40 minutes for staff to come and assist him. The resident stated he didn't want to have an incontinence episode. He has had staff tell him to go in pants but he wasn't brought up that way. The resident reported he fell on 3/3/24 around 9 PM. He had his call light on, he had to go to the bathroom and couldn't…

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, policy review, and staff interviews, the facility failed to provide a clean and sanitary environment when they failed to clean shower chairs between residents. The facility also failed to create and implement a water control plan to protect the facility from legionella and other water borne illnesses. The facility reported a census of 85 residents. Findings include: 1. A direct observation of a PVC bariatric shower chair on 03/05/2024 at 11:33 AM showed the inner rim of the shower chair seat had a visible smear of brown debride that appeared to be feces. A second surveyor confirmed the smear on the shower chair appeared to be feces. At 11:51 AM, Staff F, Universal worker took the soiled shower chair into Resident # 40's room to prepare her for a shower. A direct observation on 03/05/24 at 12:40 PM of a standard shower chair in use by Staff I for various residents without sanitizing between residents. The standard shower chair was placed in the hallway still visibly wet without being disinfected. A second direct observation of a PVC bariatric shower chair on…

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 clinical record review, policy review, and staff interviews, the facility failed to notify residents families of falls for 1 of 3 residents reviewed for falls (Resident #40). The facility reported a census of 85. Findings include: The Progress Notes for Resident #40 documented the following: On 12/24/23 at 06:40 AM witnessed fall at 04:50 AM standing with her walker in front of the toilet due to resident's knees gave out. Assist with walker to her recliner. Family/Physician notification not done due to resident self aware. In an interview on 03/06/24 at 12:00 PM Staff E stated staff are advised to inform the physician and call the resident's family if the resident has had a fall, even if the fall was unwitnessed or if there was no injury. Only if the resident was their own guardian would they not be required to call. In an interview on 03/06/24 at 12:05 PM, the Assistant Director of Nursing (ADON), stated she expected the resident's responsible party be notified after an incident involving a resident. These notes documented in the electronic health record (EHR) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and facility policy review the facility failed to update the comprehensive care plans when a resident had a change in advanced directives for one of twenty-four residents reviewed (Residents #10). The facility reported a census of 85 residents. Findings include: The significant change minimum data set (MDS) assessment dated [DATE] revealed Resident #10 had diagnoses that included respiratory failure and obstructive sleep apnea. The MDS indicated the resident had shortness of breath with exertion, at rest, and when lying flat. The MDS documented the resident on hospice and had a condition that may result in a life expectancy of less than 6 months. The Care Plan initiated [DATE] revealed the resident desired CPR (cardiopulmonary resuscitation) performed if he was found without a pulse. The Care Plan also revealed the resident on hospice services for end of life care. The Bio sheet dated [DATE] revealed Resident #10's code status as DNR (do not resuscitate). 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 3. The MDS assessment dated [DATE] revealed Resident #74 has diagnoses of frontal temporal neurocognitive disorder, PICK's disease (a form of dementia that affects behavior, personality, and speech), aphasia, and receiving hospice care. The Care Plan dated 2/19/24 revealed Resident #74 is nonverbal, staff must anticipate resident's needs, including the need to be fed meals. The resident had an unavoidable weight loss. Staff directives included to encourage oral fluids and supplements as ordered by the physician. Review of resident #74's physician orders indicated: 6/16/23 new order to start house supplement, 4 ounces three times daily 8/3/23 new order to increase house supplement to 6 ounces three times daily 8/28/23 new order to increase supplement to 8 ounces three times daily 10/2/23 new order to increase supplement to 8 ounces four times daily 11/3/23 new order for warm pack to right hand 5-10 minutes four times daily as needed for pain. These orders reviewed and processed per facilities triple check…

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 clinical record review, observation, family interview, staff interview, and policy review, the facility failed to assist a dependent resident with dining assistance when the resident demonstrated an inability to feed themselves for 1 of 3 residents reviewed for feeding assistance. The facility reported a census of 85 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #74 had diagnoses of frontal temporal neurocognitive disorder, PICK's disease (a form of dementia that affects behavior, personality, and speech), and aphasia (trouble speaking). The MDS assessment indicated the resident on hospice and dependent for all cares. The Care Plan dated 2/19/24 revealed Resident #74 required assistance with ADL's (activities of daily living) and nonverbal. The staff directives included: anticipate the resident's needs including the need to be fed meals by staff, encourage oral fluids and nutrition as tolerated, and allow extra time for feeding. The Care Plan 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, staff interviews, and facility policy review, the facility failed to provide proper supervision as it relates to a resident at risk for choking in 1 of 4 sampled residents (Resident #40), and failed to ensure a resident's bed left in low position and the equipment in safe operating condition for 1 of 4 residents reviewed for falls (Resident #10). The facility reported a census of 85 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment of Resident #40 dated, 12/06/2023, identified a Brief Interview of Mental Status (BIMS) score of 14 out of 15 which indicated intact cognition. It noted the need for a mechanically altered diet, but contained no information regarding poor fitting dentures or a diagnosis of dysphagia. The Care Plan for Resident # 40 dated 12/08/2023 noted: 1. Difficulty chewing due to lack of dentition and poor fitting dentures. 2. A diagnosis of dysphagia related to a cerebrovascular event (stroke). 3. A need to be observed…

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, staff interviews and policy review, the facility failed to ensure the medication cart remained locked in a resident care area when not under staff supervision. The facility reported a census of 85 residents. Findings include: During an observation 3/05/24 at 2:25 PM, the medication cart in the central hallway next to the staff break room noted to be unlocked with staff not present. Further observations revealed the following: a. 2:25 PM Housekeeper cleaning the dining room floor across from the unlocked medication cart. b. 2:26 PM- a guest walked past the unlocked medication cart. c.2:28 PM- staff member walked into the break room, a housekeeper and guest walked past the unlocked medication cart, and a staff member exited the break room. d. 2:30 PM- 2 staff members exited the break room and walked past the unlocked medication cart. e. 2:31 PM- a guest walked past the unlocked medication cart. f. 2:32 PM- a resident in a wheelchair with a family member walked past the unlocked medication cart. g. 2:33 PM- 3 staff members walked past the unlocked medication cart.…

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, clinical record review, staff interviews, resident interview and facility policy review, the facility failed to properly provide perineal cares for 1 of 3 residents reviewed (Resident #6), failed to provide oral cares to 3 of 3 residents reviewed (Resident #6, #11, #12), failed to provide dining assistance for 1 of 3 residents reviewed (Resident #9 ) and failed to provide toileting assistance for 1 of 3 residents reviewed. (Resident #5). The facility identified a census of 86 residents. Findings include: 1. A Minimum Data Set assessment dated [DATE] indicated Resident #6 had diagnoses that included aphasia, dementia, frontotemporal neurocognitive disorder and osteoarthritis. The assessment indicated the resident had severely impaired cognitive skills, fluctuating inattention and disorganized thinking, always incontinent of her bowels and bladder and required extensive assistance of two (2) staff with toilet use. An observation on 10/26/23 at time unknown revealed Staff A, Certified Nursing…

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, clinical record review, staff interview and resident interview, the facility failed to assure resident belongings were returned to one (1) resident and/or family post discharge from the facility (Resident #3). The facility identified a census of 86 residents. Findings include: The Progress Notes for Resident #3 documented the following: On [DATE] at 9:55 p.m. the resident expired at 9:15 p.m., Hospice notifed. On [DATE] at 10:27 p.m. resident expired at 9:15 p.m. with family member present. Hospice notified and body carried to the funeral home. On [DATE] at 12:07 a.m. removed client medications from med cart, resident dentures and glasses sent with resident to funeral home. During an interview on [DATE] at 1:14 p.m. the Administrator confirmed the facility packed up Resident #3's belongings and there had been a missing teddy bear the family wanted placed into the resident's casket. During an interview on [DATE] at 1:25 p.m. Staff D, housekeeping confirmed there had also been fresh flowers…

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, clinical record review and facility policy review the facility failed to provide the necessary assessments for 1 of 3 residents reviewed with a skin condition and/or a condition change. (Resident #4) The facility identified a census of 86 residents. Findings include: A Minimum Data Set (MDS) assessment form dated 8/11/23 indicated Resident #4 had diagnoses that included septicemia, diabetes mellitus, infection in/on her right hip prosthesis post right hip replacement, muscle weakness, unsteadiness on her feet and difficulty walking. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 (moderately impaired cognitive skills), no behaviors or delirium, dependent on two (2) staff with ambulation in her room and required extensive assistance of 2 staff with bed mobility, transfers, toileting and one (1) staff assistance with personal hygiene. The assessment indicated the resident as at a fall risk and with 1 fall without injury since admission or reentry to the facility. A Care Plan with a Focus area initiated…

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.