Bridgeway Senior Living

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the use of a restraint and oxygen therapy.This applies to 2 of 2 residents (R9 and R147) reviewed for accuracy of assessments in a sample of 30. The findings include: 1. R147 was admitted to facility on July 28, 2024, with multiple diagnoses including intervertebral disc degeneration of lumbar region, hypercholesterolemia, hypertension, osteoarthritis of the left hip and knee, dementia, chronic embolism and thrombosis, Alzheimer's disease, anxiety disorders, varicose veins, and osteoporosis.R147's quarterly MDS dated [DATE], show R147 has severe cognitive impairment. Section P of the MDS shows R147 does not utilize a restraint. On January 12, 2026, at 11:36 AM R147 was in the dining room pushed up to a corner table with a secured lap cushion attached to her wheelchair. R147 was not able to move the lap cushion.On January 14, 2026, at 11:04 AM V18 (Licensed Practical Nurse)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to off-load the heels of a resident, who has facility-acquired pressure ulcers. This applies to 1 of 3 residents (R176) reviewed for pressure ulcers in the sample of 30. The findings include:The EMR (Electronic Medical Records) shows R176 was admitted to the facility on [DATE], with multiple diagnoses including, congestive heart failure, other abnormities of gait and mobility, and dementia. R176's MDS (Minimum Data Set) dated December 31, 2025, shows R176 has severe cognitive impairment, requires substantial/maximal assistance for bed mobility and transfers. R176 is frequently incontinent of bowel and bladder. R176's MDS continues to show R176 is at risk of developing a pressure ulcer and did not have any pressure ulcers at the time of the MDS assessment. R176's initial wound evaluation dated January 8, 2026, shows R176 has unstageable DTI (Deep Tissue Injury) with intact skin on both left and right heels. R176's initial wound evaluation…

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 failed to provide adequate care and services to maintain adequate nutritional status by failing to monitor food intake and offer offering meal alternatives similar nutritive value, encourage resident intake of meals, and ordering and providing nutritional supplements as recommended by the dietitian for residents with low body weights and poor oral intake. This failure applies to three of six residents (R18, R49, and R105) reviewed for nutrition in a total sample of 30 residents. Findings include:1. According to the face sheet, R49 was admitted to the facility on [DATE], and had multiple diagnoses, including chronic obstructive pulmonary disease, type 2 diabetes mellitus, abnormalities of gait and mobility, and lack of coordination. R49's MDS (Minimum Data Set) dated December 23, 2025, showed R49 had moderate cognitive impairment and required supervision or touching assistance from the staff for eating. R49's Nutrition care plan 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident received oxygen as prescribed. This applies to 3 of 4 resident (R7, R9, and R81) reviewed for oxygen administration in a sample of 30.The findings include: 1.R7 was admitted to the facility on [DATE], with diagnoses including acute and chronic respiratory failure with hypoxia, other pneumonia, heart failure, and COPD (chronic obstructive pulmonary disease) with acute exacerbation. R7's POS (Physician Order Sheet), dated 01/03/2026 shows an order for oxygen administration as oxygen at 7 LPM (liters per minute) per NC (nasal canula) every shift for COPD. On 1/12/2026 at 10:54 AM, R7 was lying in bed and was receiving between 8 to 8.5 LPM via NC. On 1/13/2026 at 12:15 PM, R7 was receiving between 8.5 to 9 LPM via NC, R7 was irritable and uncomfortable and was using accessory muscles to breathe. V16 (RN-Registered Nurse) verified that R7's oxygen rate was set between 8.5 to 9 LPM. V16 stated the oxygen rate should be set…

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 ensure a resident with complaint of pain was reassessed and provided interventions to relieve pain in accordance with facility policy. This applies to 1 of 1 residents (R8) reviewed for pain management in the sample of 30. The findings include:R8's face sheet showed R8 was admitted to the facility on [DATE], with multiple diagnoses including Parkinson's disease, type 2 diabetes, low back and left hip pain, chronic obstructive pulmonary disease, bipolar disorder, and unsteadiness on feet. R8's MDS dated [DATE], showed R8 was cognitively intact and required assistance with ADLs including set up assistance with eating, personal hygiene and bed mobility, supervision with oral hygiene, dressing and transfer. R8's care plan initiated on November 3, 2025, showed no non pharmacological interventions to address pain. R8's care plan initiated on November 22, 2025, showed R8 developed a behavior of calling 911 due to unrelieved pain with 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.

Based on observation, interview, and record review the facility failed to implement infection control practices including hand hygiene during dining and the use of personal protective equipment for residents on isolation and enhanced barrier precautions. This applies to 2 of 4 residents (R74, R92) reviewed for infection control in the sample of 30. The findings include: 1. R92 had multiple diagnoses including, oral phase dysphagia and adult failure to thrive, based on the face sheet. R92's active order summary report showed an order dated December 20, 2025, for a bolus tube feeding four times a day. On January 13, 2026, at 1:38 PM, an EBP (Enhanced Barrier Precaution) sign was posted on the door of R92's room. The EBP sign showed that providers and staff must wear gloves and gown during high-contact resident care activities, including during feeding tube device care or use. Inside the room, R92 was sitting in his reclining wheelchair. V5 (Registered Nurse) was inside the room to administer the bolus feeding of R92 via the gastrostomy tube. V5 administered the ordered initial water…

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

Based on observation, interview, and record review, the facility failed to ensure a safe, clean, and comfortable environment. This applies to 1 of 5 residents (R5) reviewed for environment in a sample of 5. The findings include:R5's face sheet shows multiple diagnoses, including Parkinson's disease, bipolar disorder, paranoid schizophrenia, unspecified dementia, hypertension, and chronic diastolic heart failure. R5's Minimum Data Set (MDS) shows impaired cognition, impaired mobility, poor safety awareness, and increased fall risk.On 12/26/2025 at 11:45 AM, two floor tiles were raised and uneven in the left corner of the R5's room, creating an unstable surface. V10 (Maintenance Director) acknowledged the tiles were uneven and stated they should have been repaired when it was initially identified. V5 added the uneven flooring contributed to instability of furniture placed on top of the tiles.The window in R5's room had rotting wood, peeling paint, and a non-functioning crank, preventing the window from opening or closing. A piece of wood had been placed on the sill as a makeshift…

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 in interview and record review the facility failed to follow its policy to notify resident representative of a change in condition.This applies to 1 of 3 residents (R5) reviewed for notification of change in the sample of 7.The findings include:R5's EMR (Electronic Medical Record) showed R5 was admitted to the facility on [DATE], with multiple diagnoses including type 2 diabetes, diastolic congestive heart failure, gout, chronic kidney disease stage 3, and morbid obesity. R5's MDS (Minimum Data Set) dated July 29, 2025, showed R5 was cognitively intact and required assistance with ADLs including set up assistance with eating and oral hygiene, supervision with personal hygiene, partial assistance with bed mobility, transfer and upper body dressing, substantial assistance with lower body dressing, toileting, and bathing and dependent on staff assistance with footwear.On September 11, 2025, at 3:12 PM, V15 (LPN) stated she was R5's nurse on September 6, 2025, during the night shift. V15 stated at 10:40 PM, R5…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its policy and perform an assessment on a resident who exhibited a change in condition.This applies to 1of 3 residents (R5) reviewed for assessment in the sample of 7.The findings include:R5's EMR (Electronic Medical Record) showed R5 was admitted to the facility on [DATE], with multiple diagnoses including type 2 diabetes, diastolic congestive heart failure, gout, chronic kidney disease stage 3, and morbid obesity. R5's MDS (Minimum Data Set) dated July 29, 2025, showed R5 was cognitively intact and required assistance with ADLs including set up assistance with eating and oral hygiene, supervision with personal hygiene, partial assistance with bed mobility, transfer and upper body dressing, substantial assistance with lower body dressing, toileting, and bathing and dependent on staff assistance with footwear.On September 11, 2025, at 3:40 PM, V16 (RN) stated she was R5's nurse on September 7, 2025, during the 7:00AM to 3:30 PM (day shift), V16…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care timely incontinence care. This applies to 4 of 6 residents (R1, R2, R3, R4) reviewed for incontinence care in the sample of 11. The findings include: 1. R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including unspecified dementia, aphasia, dysphagia with gastrostomy tube status, and conversion disorder with seizures or convulsions.R1's MDS (Minimum Data Set) dated April 29, 2025, showed R1 was severely cognitively impaired and required assistance with ADLs including dependent on staff assistance for bathing, dressing, grooming, toileting, bed mobility, and transfer and was always incontinent of bowel and bladder.R1's incontinence care plan initiated on October 10, 2022, showed to provide R1 with incontinence care every 2 hours or more often as needed.On August 11, 2025, at 4:32 PM, R1 was provided incontinence care by V8 (CNA) and V9 (CNA). R1 had a disposable…

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 the necessary services to maintain good personal hygiene for 1 of 3 residents (R9) reviewed for activities of daily living in a sample of 3. Findings include: On 1/21/25 at 11:10 AM, observed R9 lying in a bariatric bed. R9 was alert, oriented x 3. R9 had disheveled hair, nails were overgrown in both hands and both feet and the nails had brownish debris underneath them. R9 stated, one day last week, no one provided her perineal care and she was left wet the whole shift. R9 could not remember the date. R9 stated, at the moment, her brief, bedsheet and her blanket were wet. R9 lifted her gown. Observed that R9 had a wet disposable brief. R9 stated, she had been wet for almost an hour. R9 stated, either she had to wait until someone comes in to check on her or she has to holler because her call light was not working. R9 stated, probably the CNAs (Certified Nursing Assistants) were on lunch break. R9's face-sheet showed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident's call light was in working condition and the resident receives services within a reasonable timeframe. This applies to 1 of 3 residents (R9) reviewed for call lights in the sample of 9. Findings include: On 1/21/25 at 11:10 AM, observed R9 lying in a bariatric bed. R9 was alert, oriented x 3. R9 stated, her brief, bedsheet and blanket were wet. R9 lifted her gown. Observed that R9 had a wet disposable brief. R9 stated, she had been wet for almost an hour. R9 stated, her call light was broken since the previous day. No one had fixed it. R9 stated, either she had to wait until someone comes in to check on her or she had to holler. Observed R9 press the call light and it didn't work. Observed that R9 did not have any other alternative method to call the nursing staff. On 1/22/25 at 9:00 AM, V16 (CNA) and V17 (CNA) were transferring R9 to her wheelchair. Asked them if R9's call light was working, and they stated it 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 observation, interview, and record review, the facility failed to follow recipes as instructed for palatability. This applies to all residents that receive regular diets, regular or pureed texture, prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 12/10/24 documents that the total census was 159 residents. On 12/10/24 at 4:15 PM, V2 (Director of Nursing) said the facility has 3 NPO (Nothing by Mouth) residents and the facility provided resident diet list showed 137 residents receive regular diets of regular or pureed textures. R101's MDS (Minimum Data Set) dated 10/22/24 shows her cognition is intact. R101's POS (Physician Order Set) shows an order dated 6/8/24 for regular diet, regular texture. On 12/10/24 at 11:05 AM, R101 said the food is poor and it usually comes salty. R101 said she has her family bring her cans of soup and that is what she eats instead of…

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

Based on observation, interview, and record review, the facility failed to properly label/date/seal/store items, wear hair restraints, and maintain safe food storage temperature of walk-in cooler in kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 12/10/24 documents that the total census was 159 residents. On 12/10/24 at 4:15 PM, V2 (Director of Nursing) said the facility has 3 NPO (Nothing by Mouth) residents. On 12/10/24 starting at 9:43 AM, the facility kitchen was toured in the presence of V23 (Dietary Manager). For the entirety of the tour, V23 did not wear a beard restraint in the facility kitchen. During the kitchen tour, the following was found: In the walk-in cooler: 1. The temperature inside the cooler on thermometer was reading 58 degrees Fahrenheit and inside the cooler did not feel cold enough. 2. A staff lunch of tortillas and what appeared to 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 observation, interview, and record review, the facility failed to maintain the kitchen walk-in cooler in safe operating condition. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 12/10/24 documents that the total census was 159 residents. On 12/10/24 at 4:15 PM, V2 (Director of Nursing) said the facility has 3 NPO (Nothing by Mouth) residents. On 12/10/24 at 10:08 AM during a kitchen tour with V23 (Dietary Manager), the walk-in cooler in the facility kitchen was noted to be 58 degrees Fahrenheit per the in unit thermometer and inside the cooler did not feel cold. On 12/11/24 at 10:32 AM during a return of kitchen tour with V23 (Dietary Manager), the walk-in cooler outside unit thermometer was showing 53 degrees Fahrenheit. V23 said he removed all of the food from the walk-in cooler on 12/10/24. V23 and surveyor then walked into walk-in cooler and surveyor 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a resident and/or their family/POA (POA/Power of Attorney) in writing for the reason of transfer to the hospital. The facility also failed to notify the ombudsman of the transfer. This applies to 5 of 5 residents (R9, R25 R58, R63, and R84) reviewed for discharge in a sample of 32. The findings include: 1. R63's After Visit Summary shows that R63 was admitted to the hospital from [DATE] to 9/16/24 with the diagnosis of acute cystitis without hematuria. R63's progress notes of 9/13/24 at 9:36 PM states that resident was observed sitting in her recliner chair with head and body jerking/shaking; resident's vitals were taken, and resident noted with elevated blood pressure of 242/108. Resident was sent to the hospital/emergency room via 911. 2. R58's After Visit Summary shows that R58 was admitted to the hospital from [DATE] to 10/18/24 with the diagnosis of wound infection. R58's progress notes of 10/11/24 states that resident was seen by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide in writing to the residents and/or their POA (POA/Power of Attorney) information regarding bed hold and return at the time of discharge to the hospital. This applies to 5 of 5 residents (R9, R25 R58, R63, and R84) reviewed for discharge in a sample of 32. The findings include: 1. R63's After Visit Summary shows that R63 was admitted to the hospital from [DATE] to 9/16/24 with the diagnosis of acute cystitis without hematuria. R63's progress notes of 9/13/24 at 9:36 PM states that resident was observed sitting in her recliner chair with head and body jerking/shaking; resident's vitals were taken, and resident noted with elevated blood pressure of 242/108. Resident was sent to the hospital/emergency room via 911. No bed hold documentation uploaded into the medical record. The facility was unable to provide documentation of bed hold given to the resident and/or the POA. 2. R58's After Visit Summary shows that R58 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 observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) care for 5 residents (R34, R5, R151, R139, & R38) who are dependent on care for activities of daily living in a sample of 32. The findings include: 1. On 12/10/24 at 11:29 AM, R5 was observed with facial hair on her chin and around her mouth. R5 said that she was not aware that she had any facial hair on her face because she is not able to hold a mirror and the staff has never offered her one. R5 said that she had never been shaved and after touching her face and feeling the facial hair, R5 said that having the facial hair makes her feel bad and it is not a good feeling. On 12/11/24 at 11:12 AM, R5 was observed in her bed with facial hair on her chin and around her mouth. R5's EHR (Electronic Health Record) showed that she is a [AGE] year old female admitted on [DATE] with diagnoses including MS (multiple sclerosis) and osteoarthritis. R5's 11/4/24 MDS (Minimum Data Set) section GG showed that R5…

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 6. On 12/10/24 at 11:01 AM, R109 was in her room and there were 10 Pills in a medication cup on her bedside table. R109 said that the nurse gave the medicine to her and then the nurse walked away. R109 said that she was not going to take her medications until her stomach felt better. R109 said that she had been throwing up since early morning and every time she drinks water she throws up. On 12/12/24 at 12:45 PM V2 (Director of Nursing) said that all residents need an assessment to self-medicate, and they also need an order from the physician. V2 then looks at R109 EHR (Electronic Health Record) and said that R109 did not have an order to self-medicate or an assessment. V2 said that the medications should not have been left there because the resident could throw away the medications and there is no guarantee the resident is taking the medications. V2 said she was not aware of the facility's policy on storage of medications. R109's EHR showed that she is a [AGE] year old female admitted on [DATE] with 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.

Based on observation, interview and record review the facility failed to maintain temperature logs, properly store and label food items, and discard potentially spoiled food items. This applies to 5 residents (R153, R5, R16, R8, and R109) reviewed for personal food storage in a sample of 32 residents. The Findings include: 1. On 12/10/24 at 10:45 AM 153's personal refrigerator did not have a temperature log on it and there was no thermometer in the refrigerator. Inside of the refrigerator were 4 supplement drinks, 1 yogurt, several cups of jello, water and puddings. 2. On 12/10/24 at 11:29 AM, R5's personal refrigerator did not have a temperature log on it and there were 10 Peanut Butter and Jelly sandwiches in it, 3 cups of ice cream that was in a liquid form, 2 cups of sherbet that had also turned into a liquid form and the sherbert had separated, 1 of the sherbert cups was open without a lid and half full. 3. On 12/10/24 at 01:09 PM, R8's personal refrigerator was observed without having a temperature log and did not have a thermometer in it. In the freezer was ice cream and in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow infection control practices. This applies to all 159 residents residing in the facility. The findings include: 1. On December 10, 2024, at 11:30 AM, R161's room did not have any EBP (Enhanced Barrier Precautions) signage or isolation bin with PPE (Personal Protective Equipment) outside of her room. On December 11, 2024, at 12:25 PM, V10 (Wound Care Coordinator/RN-Registered Nurse) and V31 (CNA/Certified Nurse Assistant) went to R161's room and only applied gloves before starting wound care treatment. At 12:31 PM, V10 and V31 touched R161's urinary catheter bag and placed it onto the bed. At 12:33 PM, V31 lowered R161's bed and the urinary catheter bag was resting on the ground. At 1:57 PM, V10 entered R161's room with only gloves on and began moving the urinary catheter bag and placed onto the bed. On December 12, 2024, at 9:29 AM, V10 and V11 (LPN/Licensed Practical Nurse) went to R161's room to provide wound care and only had…

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 provide care with dignity to 1 resident (R139) reviewed for resident rights in a sample of 32. The findings include: On 12/10/24 at 12:19 PM, V9 (Nurse) was observed standing over R139 while feeding her. V9 was observed telling R139 eat, eat. in a demeaning tone. R139 is an [AGE] year old female admitted to the facility on [DATE] with diagnoses including hemiplegia, spinal stenosis, contracture of muscle, muscular degeneration, & vascular dementia. R139's 10/22/24 MDS (Minimum Data Set) section C showed that R139's mental cognition is severely impaired. R139's 10/22/24 MDS section GG showed that R139 needs substantial/maximal assistance for eating. On 12/12/24 12:32 PM V2 (Director of Nursing) said that staff should not be standing over R139 when feeding her, they should be sitting down next to her, so they are at the same level for dignity. The facility's Resident Rights Statement dated December 2023 showed that all residents have a…

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

Based on observation, interview, and record review, the facility failed to have call lights accessible to dependent residents. This applies to 1of 1 residents (R63) reviewed for accommodation of needs in a sample of 32. The findings include: On 12/10/24 at 11:48 AM, R63 was sitting in recliner chair in her room. R63's call light was attached to her bed by the side rail. R63's bed was by the window, while R63 was sitting closer to door. When asked about her call light, R63 said, I cannot reach it from here, I do use it and it irritates me when it does not follow me across the room. I do need it; I can use it. Surveyor pushed R63's call light at 11:51 AM, V7 (Minimum Data Set/MDS Coordinator) came to R63's room. V7 said the call light should be close to the residents and within their reach all the time so they can us it when they need assistance. R63's MDS of 10/8/24 shows that R63's cognition is moderately impaired; R63 is dependent on staff for toileting hygiene and partial/moderate assistance with personal hygiene. R63's care plan (initiated 12/27/22) shows that R63 is at risk 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.

Based on interview and record review, the facility failed to invite a resident to the care plan meetings. This applies to 1 of 1 resident (R146) reviewed for care plan meetings in a sample of 32. The findings include: On December 10, 2024 at 11:01 AM, R146 said he wished somebody would tell him what he needed to do to go home. R146 said he was not told what the goals were or what he needed to do to be discharged home. R146 said he had never heard of a care plan meeting and had never been invited to one. R146 said he made his own goals up. On December 12, 2024 at 11:31 AM, V20 (Social Services Director) said R146 does not attend his meetings because he had never chosen to. V20 said she did not have documentation or progress notes to show she had invited R146 to the care plan meetings. V20 said R146's family was never there and had never scheduled to come to the meetings. V20 said she did not have documentation, including progress notes, to show the facility staff had invited the family to the care plan meetings. R146's Care Plan Meeting Attendance forms dated November 12, 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.

Based on observation, interview and record review, the facility failed to obtain residents' blood glucose levels appropriately and failed to follow physician order for administering insulin. This applies to 2 of 2 residents (R100 and R121) reviewed for blood glucose monitoring and insulin. The findings include: 1. On 12/10/24 at 10:38 AM, V6 (Agency Registered Nurse/RN) checked R100's blood glucose level. R100's glucose level was 221. V6 said that R100 gets insulin per sliding scale. At 10:49 AM, V6 returned to R100's room and administered 4 units of insulin Aspart to R100's left upper arm. R100 said he had breakfast around 8:00 AM. The lunch trays were passed at 12:18 PM. Review of R120's Electronic Medical Record (EMR) shows the following diagnoses of chronic kidney disease, disorder of kidney and ureter and Type 2 diabetes mellitus without complication. R100 has a physician order for accucheck four times a day, Insulin Aspart injection solution 100 unit/ml, inject as per sliding scale. On 12/11/24 at 9:13 AM, V6 (Agency RN) said she took R100's 11 AM blood glucose level yesterday…

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 implement a physician's order. This applies to 1 resident (R77) reviewed for quality of care in a sample of 32. The findings include: On 12/10/24 at 12:39 PM R77 was in her room eating her lunch. The diet slip on her tray showed No Straws. At 12:54 PM V14 CNA (Certified Nurse's Assistant) brought a cup of water with a straw in the cup and placed it on R77's table and removed her lunch tray. On 12/12/24 at 01:09 PM V15 (CNA) said that she put a straw on R77's lunch tray and was bringing the tray to R77's room when V13 SLP (Speech Language Pathologist) took R77's tray from V15 and brought it into R77 room herself. On 12/12/24 at 01:15 PM V13 said that she did a bedside swallow study on R77 at that time, and she used the straw. V13 said that her evaluation determined that R77 is still not to use straws. V13 said that R77 last evaluation was in June of 2023, and it was determined that she was not to use straws, was to be on mechanical soft…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide restorative services to a resident as recommended per ADL (Activities of Daily Living) Restorative Assessment. This applies to 1 resident (R128) reviewed for restorative services in a sample of 32. The findings include: R128's Face Sheet shows he is a [AGE] year old male with a history of Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side, aphasia following cerebral infarction, dysphagia following cerebral infarction, and repeated falls. R128's MDS (Minimum Data Set) dated 10/15/24 shows he has impairments on one side of both upper and lower extremities, and he uses a wheelchair for mobility. On 12/10/24 at 11:38 AM, R128 was interviewed by surveyor while sitting in his bed. R128 is unable to speak due to history of stroke and aphasia, but he was able to respond to yes or no questions by moving his head up and down and side to side. R128 said the facility staff did offer him a communication board, but he did…

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 properly position resident's indwelling catheter bag/drainage bag during wound care dressing change and incontinent care. This applies to 3 of 3 residents (R5, R84 and R155) reviewed for indwelling catheters and incontinent care in a sample of 32. The findings include: 1. On 12/11/24 at 8:37 AM, R84 was observed sitting in her motorized wheelchair going down the hallway. R84's indwelling catheter drainage bag was hanging on the arm rest of the motorized wheelchair above the bladder line. There was back flow of urine noted. On 12/12/24 at 10:30 AM, V10 (Wound Care Nurse) and V11 (Licensed Practical Nurse/LPN) completed wound care for R84. V10 informed R84 of her dressing change; at 10:34 AM, V11 approached R84's left side of the bed and unhooked her catheter drainage bag from the side of the bed, lifted it up and placed it on the bed, back flow of urine was noted in the tubing. V11 moved to right side of the bed and turned R84 on her right…

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

Based on interview and record review the facility failed to ensure the Quality Assessment and Assurance committee met quarterly with the required members. This failure has effects all the residents in the facility. The findings include: The Facility Data Sheet dated 6/20/24 showed there were 163 residents residing in the facility. On 7/1/24 at 10:00 AM, V3 (DON - Director of Nursing) provided a monthly QA (Quality Assurance) Committee sign-in sheet dated 4/23/24. This form showed the meeting was attended by Restorative, MDS Coordinator, Infection Control Preventionist, Business Office Manager, Admissions, Laundry/Housekeeping, Human Resources, ADON, and DON. The Administrator and Medical Director were not in attendance. (There were no monthly sign-in sheets for May or June 2024). The last QAPI (Quality Assurance and Performance Improvement) sign-in sheet was 12/23/23. The Administrator, Medical Director, and other required staff were present for this meeting. (There was no QAPI sign in sheet since 12/23/23 provided). On 7/1/24 at 2:11 PM, V13 (Social Services Director) said she…

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

Based on observations, interview, and record review the facility failed to ensure the resident hallway was safe, sanitary and comfortable for 7 residents (R12, R13, R14, R15, R16, R17, R18) reviewed for safe, sanitary, comfortable environment in the sample of 18. The findings include: The facility census report dated 6/19/24 showed R12, R13, R14, R15, R16, R17, and R18 resident in the rooms affected. On 6/20/24 at 10:25 AM, near the B-wing nurses' station and the beginning of the 2401-2408 hallway there were ceiling tiles missing and water steadily dripping. The carpet in a 5 foot radius of this area was saturated and caused a sloshing sound when the surveyor attempted to walk past the area. There was a large, gray, round, wheeled trash can under the missing tiles, but water was still dripping onto the carpet and surrounding area. There were 4 pink, personal care basins at the base of the trash can and two towels, with a light brown discoloration, spread out on the floor. The missing tiles exposed pluming and the air ducts. The water appeared to be steadily dripping from the duct…

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

Based on observation, interview and record review, the facility failed to provide incontinence care to a resident dependent on staff for ADLs (Activities of Daily Living). This applies to 1 of 4 residents (R4) reviewed for ADLs. The findings include: On February 29, 2024, at 11:22 AM, R4's bedding had a stain visible on the flat sheet underneath him. R4 said he had not been changed since the night before and was wet. R4 then said the staff said they could change him after lunch. R4 said the staff usually change him when they can and have the time, and he felt they probably did not have the time this morning. R4 said he was dependent on staff for everything. On February 29, 2024 at 11:41 AM, V7 (CNA) said she had not rounded on R4 because she was waiting for the wound nurse to change him. V7 said she normally changed him two times a day. V7 said she was going to clean him after she passed the lunch trays. At 12:28 PM, V7 (CNA/Certified Nurse Assistant) came to R4's room to provide incontinence care. V7 turned R4 to his right side and the sheet under R4 was made visible, showing a 2.5…

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. R11 is 80 years-old with multiple medical diagnoses which include dementia, needs assistance with personal care, generalized muscle weakness, and abnormalities of gait and mobility. R11's Minimum Data Set (MDS) dated [DATE] shows that R1 is total dependent on staff for toileting and hygiene. On January 22, 2024, at 11:47 AM, V13 (Certified Nursing Assistant/CNA) was providing care to R11. There was a pervasive urine odor in the bedroom. R11's linen sheet was heavily saturated with urine, there were layers of brown ring stain in the linen which showed the different drying stages of the urine in the linen. R1's wound dressing to his sacral area was wet with urine. V13 stated that the last time she changed R11's incontinence brief was at 7:00 AM On January 24, 2024, at 2:58 PM, V3 (Assistant Director of Nursing/ADON) stated that the residents are to be checked and changed for incontinence every 2 hours and as needed to prevent skin breakdown, urinary tract infection, and promote comfort. Based on observation,…

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 peri-care in a manner that would prevent urinary tract infection. In addition, the facility failed to ensure that an indwelling urinary catheter bag is not touching the floor. This applies to 5 of the 7 residents (R14, R38, R114, R160, R163) reviewed for peri-care and indwelling urinary care in the sample of 34. The findings include: 1. Face sheet shows that R14 is an [AGE] year-old who has multiple medical diagnoses which include Parkinson's disease, muscle weakness, and urinary tract infection (UTI). On January 22, 2024, at 11:13 AM, V16 (Certified Nursing Assistant/CNA) assisted R14 to the toilet who voided. After R14 voided, V16 assisted R14 to get up and cleaned R14's back perineum. Then V16 pulled the incontinence brief up and assisted R14 back to the bedroom without cleaning her frontal perineum. 2. Face sheet shows that R160 is 85 years-old with multiple medical diagnoses which include need assistance for personal care,…

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

Based on observation, interview, and record review, the facility failed to administer medications as ordered by the physician. There were 31 medication opportunities with 4 errors, resulting in an 12.9% medication error rate. This applies to 4 of 6 residents (R8, R13, R36, R39) reviewed for medication administration in the sample of 34. The findings include: 1. On January 22, 2024, at 4:57 PM, V19 (Nurse) administered Ferrous Sulfate (Fe SO4) Elixir medication to R39. V19 poured the medication in the medicine cup and stated that she will administer the medication to R39. V19 also said that the order is to give 6.8 milliliter (ml) of the Fe SO4 Elixir. Upon inspection, it was noted that there was 7.5 ml of the Ferrous Sulfate in the medicine cup. V19 then re-check how much medication was in the cup, she poured some of the Ferrous Sulfate in the garbage can. It was noted that there was only 5ml of medication in the cup. The order is for 6.8 ml. R89's Medication Administration Record (MAR) dated January 2024, shows Ferrous Sulfate (Fe SO4) Elixir 220 milligram (mg)/5 ml. 2. On January…

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 label and date medications after opening to determine expiration dates. In addition, facility also failed to refrigerate an insulin that is unopened. This applies to 6 of 6 residents (R14, R15, R22, R31, R47, R151) reviewed for medication storage. The findings include: On [DATE], at 2:55 PM, the A-Unit Team 1 cart was observed with V27 (Nurse), and the following was noted: 1. R14's Arnuity Ellipta (fluticasone furoate inhalation powder) 100 mcg (micrograms) and Fluticasone Propionate and Salmeterol 250/50 mcg opened and not dated. 2. R47's Fluticasone Furoate 100 mcg/25 mcg opened and not dated. The Recommended Minimum Medication Storage Parameters based on manufacturer's guidance of the Fluticasone Furoate shows Date product when opened and discard in 6 weeks after opening the foil tray or when the counter reads 0. Whichever comes first. 3. R151's Breo Ellipta 200/25 opened and not dated. 4. R31's Breo Ellipta 200/25 open and not 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.

Based on observation, interview and record review, the facility failed to provide fortified foods as ordered by the physician. This applies to 5 of 5 (R27, R33, R137, R146, R152) residents reviewed for dining in the sample of 34. The findings include: On January 22, 2024, at 9:20 AM, during initial tour of the kitchen, V7 (Cook) stated that she is preparing barbecue pulled pork, carrots and mashed potato for the lunch meal service. On January 22, 2024, starting at 11:13 AM, V7 was platting the meal for the lunch service. V7 was noted to serve the mashed potatoes she had prepared for the meal to the residents that showed fortified mashed potato on the diet card. R27, R33, R137, R146, R152 received regular mashed potatoes instead of fortified potatoes. When asked, V7 stated that she used hot water and chicken base powder and a little butter to prepare the mashed potato. Recipe for Fortified Mashed Potatoes listed ingredients as Potato, Mashed Instant (complete); 2% milk; milk (nonfat dry); sour cream; margarine; iodized salt. On January 22, 2024, at 11:50 PM, V6 (Food Service Manager)…

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

Based on observation, interview, and record review, the facility failed to follow standard infection control processes in regards to hand hygiene and gloving during provisions of peri-care and medication administration. In addition, the facility failed to ensure that items were not stored under the medication room sink. This applies to 4 of the 34 residents (R13, R14, R38, R160) reviewed for infection control in the sample of 34. The findings include: 1. On January 22, 2024, at 5:10 PM, V17 (Nurse) administered medications to R13. During the preparation of medications, V17 was wearing gloves. V17 popped each medication from the bingo card medication container to her gloved hands, then V17 would put the medications in the medicine cup. V17 opened the drawers of the medication cart to gather the additional items she needed for R13. When V17 completed the preparation of R13's medications, V17 proceeded to administer the medications to R13 including the Dorzolamide HCL and Timolol Maleate eye drops while wearing the same gloves and without hand hygiene. 2. On January 22, 2024, at 11:13…

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 and interview the facility failed to place residents' indwelling catheter urinary drainage bags into a privacy bag. This applies to 2 of 5 residents (R51, R114) reviewed for dignity. The findings include: 1. R51's EMR (Electronic Medical Record) showed R51 was admitted to the facility on [DATE], with diagnoses that included neuromuscular dysfunction of bladder, dementia, and benign prostatic hyperplasia. R51's MDS (Minimum Data Set) dated November 21, 2023, showed R51 had moderately impaired cognition. On January 23, 2024, at 9:39 AM, R51's indwelling urinary catheter bag was hanging on the side of the bed facing the door and was visible from the hallway. R51's drainage bag was not in a privacy bag. 2. R114's EMR showed R114 was admitted to the facility on [DATE], with diagnoses that included obstructive and reflux uropathy acute benign prostatic hyperplasia, and kidney failure. R114's MDS dated [DATE], showed R114 was cognitively intact. On January 22, 2024, at 10:04 AM, R114's indwelling…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to include a plan of care for pain management in the Comprehensive Care Plan for residents experiencing pain. This applies to 2 residents (R102 and R132) reviewed for care planning in the sample of 34. 1. R132's face sheet showed R132 has resided in the facility since January 2023 and has diagnoses that include but are not limited to rheumatoid arthritis, Parkinson disease, and myasthenia gravis. R132's comprehensive care plan was reviewed and there was no plan identified or interventions for pain management found in R132's comprehensive care plan. On January 22, 2024, at 10:02, R132 stated she has pain in both knees that makes it very difficult for her to stand. R132 stated there is a prescription for lidocaine pain patches to be placed on each knee daily. On January 24, 2024, at 11:01 AM, V2 (Director of Nursing) stated the comprehensive care plan for R132 should include a plan and interventions for pain management. 2. R102's face sheet documents 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 observation, interview, and record review, the facility failed to obtain prescriber's orders for holding a dose of insulin and for a formulary exchange of insulin; and failed to assess for medication self -administration and provide a secure bedside storage for self administered medications. This applies to 3 of 3 (R8, R22, R83) residents reviewed for medication administration and medication storage in a sample of 34. 1.R8's EMR (Electronic Medical Record) showed R8 admitted to the facility on [DATE], with multiple diagnoses including type 2 diabetes mellitus with diabetic neuropathy, unspecified, type 2 diabetes mellitus with hyperglycemia, unspecified diastolic congestive heart failure, and cerebral infarction unspecified. R8's MDS (Minimum Data Set) dated January 2, 2024, showed R8 with severe cognitive impairment, and required partial assistance from staff for bed mobility, transfer, toileting and lower body dressing, putting on and taking off shoes, moderate assistance for bathing and set up…

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

Based on observation, interview, and record review, the facility failed to provide wound care as ordered by physician and failed to ensure that a resident with a sacral pressure injury was kept clean and dry to promote wound healing per plan of care. This applies to 1 of 8 residents (R11) reviewed for pressure ulcer in the sample of 34. The findings include: R11 is 80 years-old with multiple medical diagnoses which include unstageable pressure ulcer in the sacral region, dementia, generalized weakness, and need assistance with personal care. On January 22, 2024, at 11:47 AM, V13 (Certified Nursing Assistant/CNA) was providing care to R11. There was a pervasive urine odor in the bedroom. R11's linen sheet was heavily saturated with urine, there were layers of brown ring stain in the linen. R1's wound dressing to his sacral area was wet. The label date of the dressing change was faded and illegible. The surrounding skin of the wound was macerated. V13 stated that the last time she changed R11's incontinence brief was at 7:00 AM. On January 24, 2024, at 10:58 AM, V22 (Wound Care Nurse)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to assess and provide interventions for R150's left hand contracture. This applies to 1 of 5 (R150) residents reviewed for range of motion and positioning in a sample of 34. R150's EMR (Electronic Medical Record) showed R150 was admitted to the facility on [DATE], with multiple diagnoses including spastic hemiplegia affecting left non dominant side, weakness, spinal stenosis lumber region, chronic viral hepatitis, vascular dementia, osteoarthritis of left, and contracture of muscle left forearm. R150's MDS (Minimum Data Set) dated October 17, 2023, showed R150 with moderate cognitive impairment and impairment of upper extremity range of motion on one side, and substantial assistance from staff for bathing, dressing, bed mobility, dependent on staff for transfer and assistance with eating. R150's care plan ADL (Activity of Daily Living) dated July 10, 2023, identifies limited ROM (Range of Motion), but does not include an intervention 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 observation, interview, and record review the facility failed to ensure effective treatment and interventions for a resident's pain. The facility also failed to provide pain relief patches for one resident per physician orders. This applies to 2 of 6 residents (R102 and R132) reviewed for pain in the sample of 34. Findings include: 1. R102's face sheet documents a [AGE] year old female admitted to the facility last on May 19, 2022, with diagnoses that include Fracture of one rib, Fracture of shaft of Femur, Dementia, Anxiety, Depressive Disorder, History of falling, and Schizoaffective disorder. On January 22, 2024, at 10:41 AM, R102 stated she was scared and in pain. R102 stated her neck, legs, back and head hurt. R102 stated her pain level was an 8 out of 10. R102 stated she had pain medication about an hour ago and the nurse said she would give her more pain medication after 12:00 PM. R102 stated, I can't bear the pain. On January 22, 2024, at 10:47 AM, R102 told V4 (LPN/Licensed Practical Nurse) 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.