Pearl Pointe Nursing Rehab & Care

Based on interview and record review the facility failed to ensure final cooking temperatures were logged to ensure food was cooked to a food-safe temperature before serving. This failure has the potential to affect 64 residents residing in the facility. The findings include:The facility's Data Sheet dated January 20, 2025 shows 65 residents were residing in the facility. Per V9 Corporate staff, there is one resident who does not eat food from the facility kitchen.On January 20, 2026 at 8:40 AM, the kitchen food temperature logs were requested and reviewed. The food temperature logs showed no food temperatures were taken on January 8, 2026 for all three meals, January 9-11, 2026 for breakfast and lunch meals, January 12, 2026 for supper, January 13, 2026 for all three meals, January 14, 2026 for breakfast and lunch, January 15, 2026 for all three meals, and January 16,17, 2026 for breakfast and lunch. Both cooking temperatures and serving temperatures were missing and not documented. On January 20, 2026 at 8:40 AM, V4 Dietary Manager said that food temperatures should be taken when…

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 resident equipment was maintained for two (R3, R4) of five residents reviewed for safe/clean/homelike in the sample of five.The findings include:1 R3's admission Record shows he was admitted to the facility on [DATE] with diagnoses including chronic respiratory failures, venous insufficiency, lymphedema, morbid obesity, fluid overload, cellulitis of right lower limb, bed confinement status, and stage 4 pressure injury of the sacral region.R3 Minimum Data Set (MDS) dated [DATE], shows that he is cognitively intact.On January 20, 2026 at 10:54 AM, R3 said the right siderail on his bed is loose. R3 moved the right siderail and it moved side to side. R3 said he let the facility know about it about a week ago, and they haven't fixed it yet. R3 said he needs to use his side rails in order to roll from side to side. On January 20, 2026 at 11:15 AM, V7 Maintenance Director said the facility does not use work orders. If a resident needs…

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 was free from misappropriation for 1 of 3 residents (R1) reviewed for theft in the sample of 5. The findings include:On 11/24/25 at 9:30 AM, R1 was sitting at the bedside in her room. R1 said she woke up one morning and her ring was missing. R1 pointed to her left hand, ring finger. R1's left hand ring finger had a visible indentation of where a ring had been worn. R1's skin in this area was lighter in color. R1 said it was a tight-fitting ring and it just wouldn't slide off. R1 said she was very upset and told the first person that came in the room when she noticed. R1 said she never took the ring off. R1 said it was a large ring and went from her knuckle to the base of her finger. R1 said it had numerous diamonds with two large diamonds and it was yellow gold. R1 stated I miss it a lot. R2 (R1's room mate) said R1 always wore the ring and both herself and R3 sat with R1 at meals saw R1's ring. R2 said R1 came to…

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

Based on observation, interview, and record review the facility failed to follow their Abuse Policy when a resident reported missing property for 1 of 3 residents (R1) reviewed for abuse in the sample of 5. The findings include:On 11/24/25 at 9:30 AM, R1 was sitting at the bedside in her room. R1 said she woke up one morning and her ring was missing. R1 pointed to her left hand, ring finger. R1's left hand ring finger had a visible indentation of where a ring had been worn. R1's skin in this area was lighter in color. R1 said it was a tight-fitting ring and just wouldn't slide off. R1 said she was very upset and told the first person that came in the room when she noticed. R1 said she never took the ring off. R1 said it was a large ring and went from her knuckle to the base of her finger. R1 said it had numerous diamonds with two large diamonds and it was yellow gold. R1 stated I miss it a lot. R2 (R1's roommate) said R1 always wore the ring and both herself and R3 sat with R1 at meals saw R1's ring. R1 said some staff had helped her look for it. R2 said R1 came to breakfast one day…

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 an allegation of misappropriation of resident property was reported immediately for 1 of 3 residents (R1) reviewed for theft in the sample of 5.The findings include: On 11/24/25 at 9:30 AM, R1 was sitting at the bedside in her room. R1 said she woke up one morning and her ring was missing. R1 pointed to her left hand, ring finger. R1's left hand ring finger had a visible indentation of where a ring had been worn. R1's skin in this area was lighter in color. R1 said it was a tight-fitting ring and just wouldn't slide off. R1 said she was very upset and told the first person that came in the room when she noticed. R1 said she never took the ring off. R1 said it was a large ring and went from her knuckle to the base of her finger. R1 said it had numerous diamonds with two large diamonds and it was yellow gold. R1 stated I miss it a lot. R2 (R1's roommate) said R1 always wore the ring and both herself and R3 sat with R1 at meals saw…

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 hand hygiene was completed to prevent cross-contamination, kitchen equipment was cleaned, sanitized, and covered, and failed to ensure a thermometer was cleaned and sanitized before continued use. This has the potential to effect all residents receiving food from the kitchen. The findings include: Centers for Medicare and Medicaid Services 671 dated 11/17/25 shows there are 68 residents in the facility. Facility provided diet report shows there are 2 residents that are on a nothing by mouth (NPO) diet order and do not receive food from the kitchen. 1. On 11/17/25 at 10:07 AM, V16 (Cook) began removing raw chicken leg quarters from a box and placing them on a full size sheet pan while wearing a pair of gloves. At 10:09 AM, V16 used both gloved hands to handle the raw chicken. Immediately after handling the raw chicken, while wearing the same gloves, V16 grabbed a container of seasoning and began seasoning the chicken. At 10:11 AM, while still wearing the same gloves, V16 proceeded to reach under the prep…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents with new diagnoses of mental health disorders were referred to the state designated authority. This applies to 4 of 4 (R9, R4, R6, R68) residents reviewed for pre-admission screening and resident reviews (PASRRs) in the sample of 18. The findings include:1. R9's Facesheet dated 11/18/25 shows R9 was admitted to the facility on [DATE]. R9's Facesheet shows R9 had the following mental health diagnoses upon admission: anxiety disorder, mild intellectual disabilities, and mild cognitive impairment. R9's OBRA-I (Omnibus Budget Reconciliation Act) Initial Screen dated 10/16/15 shows there were no suspicions of Developmental Disability or Mental Illness for R9. R9's psychiatry progress note dated 4/30/19 shows R9 has the following diagnoses: bipolar disorder (unchanged), generalized anxiety disorder (unchanged), major depressive disorder (unchanged), and insomnia (new). R9's Psychiatry note dated 12/14/19 shows staff report R9 having…

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 wear personal protective equipment when providing care and failed to remove personal protective equipment prior to exiting the room for residents on Enhanced Barrier Precautions. The facility failed to ensure hand hygiene was performed between resident care to prevent the spread of infection. This applies to 5 of 18 residents (R4, R7, R18, R22 and R59) reviewed for infection control in the sample of 18. The findings include:1. On 11/17/25 at 12:06 PM, V12, Certified Nursing Assistant (CNA) entered R4's room, applied gloves and assisted her to use the restroom. V12 then removed her gloves and transported R4 to the dining room. Once in the dining room, a resident stated that he had R18's meal tray. V12 picked up R18's meal tray and placed it on another table where R18 sits for meals. V12 then exited the dining room and went into R59's room and put gloves on and started providing care to R59. V12 did not perform hand hygiene before or after any of the above. On 11/18/25 at 1:13 PM, V12 said that hand hygiene…

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 resident dignity by not applying a privacy covering to a urinary catheter bag for 1 of 18 residents (R22) reviewed for dignity in the sample of 18. The findings include:On 11/18/25 at 11:09 AM, V22, Certified Nursing Assistant (CNA) and V23 (CNA) got R22 into a chair. R22's urinary catheter bag was hung on the side of R22's wheelchair and it did not have a privacy covering on. R22 was brought to the dining room and placed at a table. There were other residents in the dining room waiting for lunch to be served. On 11/18/25 at 1:04 PM, R22 was lying in bed. R22's urinary catheter bag was hanging on the side of her bed with no privacy covering present and the bag could be seen from the hallway. On 11/18/25 at 1:13 PM, V12 (CNA) said that all urinary catheter bags should have a courtesy (dignity) bag on them for the resident's privacy especially if they are in the dining room or public areas. On 11/19/25 at 12:13 PM, V2 (Director of Nursing) said that all urinary catheter bags should have a dignity bag…

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 was safe to self-administer medications for 1 of 18 residents (R66) reviewed for self-administration in the sample of 18. The findings include:R66's Face Sheet shows that he admitted to the facility on [DATE] with diagnoses of: Alzheimer's disease, dementia, chronic obstructive pulmonary disease, chronic respiratory failure with hypercapnia, schizoaffective disorder, chronic hepatic failure, scoliosis and pneumonia.On 11/17/25 at 9:54 AM, R66 had an albuterol inhaler, fluticasone inhaler, beet root 1000 milligram supplement and diclofenac cream on a table in his room. R66 said that he takes the albuterol inhaler when needed, the fluticasone inhaler twice a day, the beet root daily and uses the diclofenac cream when he has pain in his head and neck. R66's Physician's Order Sheet (POS) printed on 11/17/25 shows an order for albuterol inhaler-2 puffs every 6 hours as needed for shortness of breath, fluticasone inhaler-one…

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 their advanced directives policy by not obtaining an order for Do Not Resuscitate (DNR) for 1 of 18 residents (R66) reviewed for advanced directives in the sample of 18. The findings include:R66's Face Sheet shows that he admitted to the facility on [DATE].R66's Do-Not Resuscitate (DNR)/Practitioner Orders for Life-Sustaining Treatment (POLST) Form dated 4/23/18 shows that he does not want cardiopulmonary resuscitation attempted. R66's Physician's Order Sheet printed on 11/17/25 does not document an order for DNR. On 11/18/25 at 2:45 PM, V11 (Registered Nurse) said that typically social services speaks with the resident upon admission on if they would like to be a full code or DNR. V11 said that if they would like to be a DNR, a form has to be filled out and signed by the resident and physician. V11 said that once the form is signed, an order is placed in the electronic medical record for DNR. V11 said that the resident's code status shows on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that required Preadmission Screening and Resident Review (PASARR) Level I screening reflected a resident's possible/suspected developmental disability. This applies to 1 of 5 residents (R10) reviewed for PASARR in the sample of 18. The findings include:On 11/18/25 at 8:18 AM, R10 was laying in bed. She was very childlike and stated, This is a nursing home, I don't want to stay here forever, I'm only 33. She continued to state, she lived in an apartment by herself and had some health issues which sent her to the hospital. She ended up at the facility. She didn't know why she was there. R10's face sheet shows her diagnoses as dehydration, dizziness and giddiness and adult failure to thrive. Her electronic medical record shows, she has no scheduled medication and is independent with all of her personal care. R10's emergency room documentation dated 9/3/25 shows, [AGE] year old with a reported past medical history of developmental delay…

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 who requires assistance with activities of daily living received assistance with showers. This applies to 1 of 18 residents (R54) reviewed for activities of daily living in the sample of 18. The findings include: R54's face sheet shows he was admitted to the facility on [DATE] with diagnoses including history of falling, pneumonia, myocardial infarction type 2, and nonrheumatic aortic valve stenosis. On 11/17/25 at 9:55 AM, R54 was in his room sitting on his bed. R54 said he came here from the hospital with pneumonia and is weak. He is not strong enough to walk and stand on his own. R54's hair was disheveled, unkempt, and oily. R54's facial hair was overgrown and scruffy, he said he has not had a shower since being at the facility and no one has offered him a shower. On 11/18/25 at 9:15 AM, R54 was in his room his hair remained disheveled, unkept and oily. He said he has not been offered a shower yet. On 11/18/25 at 1:10…

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 pressure ulcer prevention interventions were in place for at risk residents for 2 of 4 residents (R22 and R59) reviewed for pressure ulcers in the sample of 18.The findings include:1. R22's Braden Scale dated 10/10/25 shows that she is at risk for developing pressure ulcers. R22's Wound Physician Notes dated 11/17/25 shows that she has pressure ulcers on her right lateral proximal leg measuring 0.3 centimeters (cm) x 0.5 cm x 0.1 cm, left lateral leg/ankle measuring 1.0 cm x 0.5 cm x 0.3 cm and medial 1st metatarsal of left foot measuring 0.9 cm x 0.7 cm x 0.2 cm. R22's November Monthly Weights Report shows that she weighs 144.2 pounds. R22's Physician's Order sheet shows an order dated 9/24/25 for, Apply heel protectors to bilateral heels while in bed for pressure off-loading. On 11/17/25 at 11:09 AM, R22 was lying in bed. R22 had an air mattress. R22's air mattress had a fitting sheet over it. R22's air mattress was set to firm, normal pressure. R22 had a heel protector boot on her left heel. R22 was…

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

Based on observation, interview, and record review the facility failed to ensure a resident's indwelling urinary catheter drainage tubing and drainage bag was positioned to prevent from touching the floor for a resident with a history of urinary tract infection. This applies to 1 of 3 residents (R44) reviewed for indwelling catheters in the sample of 18. The findings include:R44's face sheet shows he has diagnoses including multiple sclerosis, hypertension, neuromuscular dysfunction of bladder and emphysema. On 11/17/25 at 3:50 PM, R44 was in the hallway self-propelling in his wheelchair. R44's indwelling catheter tubing and urinary drainage bag was dragging on the floor underneath his wheelchair. On 11/18/25 at 9:17 AM, R44 was in his room sitting in his wheelchair. R44's dignity bag was loosely secured to the back of his wheelchair with the urinary drainage tubing and drainage bag resting on the floor under his wheelchair. On 11/18/25 at 12:57 PM, V11 (Registered Nurse-RN) said R44 has indwelling catheter and was treated for urinary tract infection this month. On 11/18/25 at 1:10…

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 had orders for oxygen administration and failed to ensure tubing was changed and humidifiers were monitored for 2 of 2 residents (R66 and R50) reviewed for oxygen in sample of 18. The findings include:1. R66's Face Sheet shows that he admitted to the facility on [DATE] with diagnosis of: chronic respiratory failure with hypercapnia and hypoxia, chronic obstructive pulmonary disease and pneumonia. On 11/17/25 at 9:54 AM, R66 was lying in bed with oxygen being administered via a nasal cannula. The oxygen tubing was attached to an oxygen concentrator and set to 2.5 liters. R66's oxygen tubing was dated 10/27/25. R66 had a portable oxygen tank in his room, and the oxygen tubing was dated 11/4/25. On 11/18/25 at 2:45 PM, V11 (Registered Nurse) said that all oxygen administration needs to be ordered by the physician. V11 said that oxygen tubing is changed weekly and is documented on the Medication Administration Record. R66's…

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 appropriately assess a resident experiencing a change in condition. This applies to 1 of 3 residents reviewed for quality of care and the sample of 3. The findings include:R1's admission Record showed he was admitted to the facility on [DATE] with diagnoses to include but not limited to Chronic Obstructive Pulmonary Disorder (COPD, chronic lung disease); Dementia, atrial fibrillation (irregular, rapid heartbeat); Heart Failure; and Diabetes;. R1's 9/19/25 Alert Note from 12:00 PM (Authored by V7 Licensed Practical Nurse, LPN) showed R1 was more lethargic than usual; however, the note showed V7 believed this was due to R1's urinary tract infection, which R1 was being treated for. The note does not document any vital signs, blood sugar, or complete head-to-toe assessment. The note showed R1 was sent out via 911.R1's 9/19/25 at 2:26 PM, Narrative note showed vital signs transcribed from 9/18/25 at 5:34 PM. The note did not show a blood sugar was checked or…

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

Based on observation, interview, and record review the facility failed to provide incontinence care for residents dependent upon staff for assistance. This applies to 3 of 3 residents (R1, R2, R3) reviewed for nursing care in the sample of 5. The findings include: 1. R3's admission Record (Face Sheet) showed an admission date of 2/4/25 with diagnoses to include diarrhea, sacral pressure ulcer (top of buttocks), and diabetes. R3's 2/9/25 Five Day Medicare A Minimum Data Assessment (MDS) showed he was cognitively intact with a Brief Interview for Mental Status score of 13 out of 15. The MDS showed, he required substantial/maximal assistance for toileting hygiene (the ability to clean oneself after voiding or bowel movement). On 3/13/25 at 7:37 AM, V3 and V4 Certified Nursing Assistants (CNAs) stated they were the only CNAs assigned to the first floor. On 3/13/25 at 12:15 PM, R3 was in bed watching television. R3 stated he has had diarrhea since November 2024. During the interview, at 12:17 PM, R3 stated he had a bowel movement and turned on his call light. The interview was stopped.…

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 accurately transcribe a resident hospital discharge medication list, failed to follow a physician medication order for narcotics, and failed to follow their policy for controlled substances. This applies to 1 of 3 residents (R1) reviewed for medications in the sample of 5. The findings include: 1. R1's admission Record (Face Sheet) shows he was admitted on [DATE] with diagnoses to include chronic obstructive pulmonary disease (COPD, a lung disease which leads to decreased lung function and decreased lung capacity). R1's 2/25/25 admission Minimum Data Set (MDS) showed he was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. R1's Hospital Medication list printed on 2/20/25 at 8:42 AM says TAKE these medications: . albuterol sulfate (a medication which dilates the bronchi, the air tubes leading to the lungs) 2.5MG (milligrams)/0.5ML milliliters Nebulizer: 2.5 mg by nebulization route 4 times daily as…

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

Based on observation, interview, and record review the facility failed to follow their menu. This has the potential to affect all residents receiving a regular diet at the lunch meal. The findings include: The Facility Data Sheet dated 2/19/2025 shows a total in-house census of 68 residents. The facility provided Diet Type Report dated 2/19/2025 lists 58 of 68 or 83.8% of residents within the facility diet texture as Regular. On 2/19/2025 at 12:04PM, the burgers were observed sitting on the steam table ready for plating. The burgers appeared small and shrunken. On 2/19/2025 at 12:02PM, V5 (Registered Dietition) said the hamburgers looked a little small to me when I walked by a minute ago. V5 said lunch should include 2oz of protein. On 2/19/2025 at 12:05PM, V4 Certified Dietary Manager (CDM) said the burgers should be 2oz. V4 said the burgers should be measured on a scale to make sure they are the correct size/portion. V4 said [V6-Cook] made the burgers today for lunch. On 2/19/2025 at 12:07PM, V6 said he patted out the burgers for lunch today. V6 said he estimated the size of the…

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

Based on observation, interview, and record review the facility failed to serve the correct menu items for residents receiving a mechanical soft and pureed diet, and failed to provide the correct portion size of food for all residents. These failures have the potential to affect 63 of the 64 residents residing in the facility. The findings include: The facility's resident roster provided on 11/12/24 showed 64 residents residing in the building with 1 resident receiving tube feedings. On 11/12/24 at 9:04AM, V4 (Dietary Manager) stated, For lunch today we are serving oven herb roasted turkey with gravy, baked sweet potato, capri mixed vegetables, and frosted white cake. The facility's daily spreadsheet printed 5/14/24 showed, Oven herb roasted turkey General diet: 2oz Mechanical Soft: #16 scoop Pureed: 2, #24 scoops. Baked sweet potato Mechanical soft: baked sweet potato no skin Pureed #8 scoop pureed baked sweet potato no skin. On 11/12/24 at 11:07 AM, V4 removed the cooked turkey from the oven and began slicing it in random portions. V4 stated they will serve the residents an equal…

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 proper dishwasher sanitizer levels, failed to maintain overall kitchen cleanliness, failed to ensure foods were stored in a manner to prevent pests and rodents, and failed to store bulk dry foods in a manner to prevent cross contamination. These failures have the potential to affect 63 of the 64 residents residing in the building. The findings include: The facility roster printed on 11/12/24 showed 64 total residents in the building with 1 resident receiving tube feedings. On 11/12/24 at 9:04AM, the initial tour of the kitchen showed the following: a bulk sized bag of sugar split open, beef base and chicken base containers with dried substance crusted on top of both lids and sides of containers, scoops located inside of the beef and chicken base, floors underneath the dry storage filled with crumbs and cereal, a bulk bag of pinto beans ripped open, bulk bread crumbs opened, and an opened bag of cheese puffs with a large hole in it. All 3 exposed cooler doors had dried, crusted substances on them. The…

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

Based on observation, interview, and record review, the facility failed to provide a homelike environment during dining for 5 of 5 residents (R3, R7, R13, R22, R53) in the sample of 20 and 5 residents outside of the sample (R4, R21, R29, R40, R164). The findings include: On 11/13/24 at 12:10PM, R3, R4, R7, R13, R21, R22, R29, R40, R53 and R164 were being served their noon meal trays in the dining room. V14 and V15 (Certified Nursing Assistants) served all residents their meal on trays and did not remove any items onto the table. R13 stated, It feels like I'm in an institution or still in grade school when they serve our meals on a tray. I don't mind if they bring it to the table on the tray, but they should take everything off the tray and put it on the table to make it feel more like home. We are already stuck in a facility, but it should feel like home, not an institution. R40 and R53 agreed with R13's statement and stated if they had a choice, they wouldn't be served meals on a tray. On 11/14/24 at 10:57AM, V14 stated, We don't take the plates and cups or anything else off the…

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

Based on observation, interview, and record review, the facility failed to prepare and serve residents a mechanical soft diet. This applies to 3 residents in the sample of 20 (R22, R23, R45) and 7 residents (R4, R12, R19, R24, R28, R40, R41) outside of the sample reviewed for mechanical soft diets. The findings include: The facility's document titled, Diet Type Report printed on 11/12/24 showed R4, R12, R19, R22, R23, R24, R28, R40, R41, and R45 receive mechanical soft diets. The facility's document titled, Recipe preparation: Ground herb roasted turkey with gravy showed, Place portion of prepared turkey in food processor and grind to appropriate consistency. Serve 2oz ground protein portion with #16 scoop. Top with 1oz hot gravy to keep moist. On 11/12/24 at 11:54AM, V6 (cook) stated, I didn't prepare any mechanical soft food because they are getting mashed potatoes and the turkey I will just shred with my hands. The turkey is basically mechanical soft already, it's just not ground up. On 11/12/24 at 12:16PM, V6 served all residents their noon meal. All 10 residents on a mechanical…

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 contact isolation precautions as ordered (R214), failed to follow enhanced barrier precautions (R57) and failed to implement enhanced barrier precautions (R38, R52 and R17). This applies to five (R214, R57, R38, R52, and R17) of six residents reviewed for infection control in the sample of 20. The findings include: 1. The facility face sheet for R214 shows he was admitted to the facility with a diagnosis of enterocolitis due to clostridium difficile (C-diff) (inflammation of the colon caused by the bacteria C-diff). The Physician Order Sheet (POS) shows an order dated 10/16/2024 to maintain contact precautions for C-diff. On 11/12/2024 at 8:47 AM, at the entrance conference, V2 Director of Nursing (DON) said R214 is on isolation for C-diff. On 11/12/2024 at 10:54 AM, the door leading into R214's room had a sign stating R214 was on enhanced barrier precaution and to see the nurse before entering. The bin for PPE (personal protective…

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 daily dressing changes, assess a resident for a change in condition, and notify the physician and family of a change in condition for 2 of 2 residents (R52 & R23) reviewed for quality of care in the sample of 20. The findings include: 1. The Medication Review Report dated 11/13/24 for R52 showed, order date 11/8/24, santyl external ointment. Apply to right ankle topically every day shift every Monday, Wednesday, and Friday for wound care. Clean area with Wound Cleanser, pat dry, apply santyl, cover with ABD (abdominal pad dressing) and secure with kerlix. The Wound Care Physician's Note dated 11/11/24 for R52 showed, arterial wound of the right, medial ankle - full thickness. Wound size (Length x Width x Diameter): 1.9 x 1.0 x 0.3 cm. Dressing treatment plan: Primary Dressing - apply santyl once daily for 30 days. Secondary dressing - gauze roll (kerlix) 3.4 apply once daily for 16 days. Tubigrip apply once daily for 16 days: low pressure. Periwound treatment - skin prep apply once daily for 16 days.…

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 transfer a resident in a safe manner (R25) and failed to supervise a resident walking unassisted down the hallway and update their care plan after a fall (R52). This applies to two of three residents reviewed for safety/supervision in the sample of 20. The findings include: 1. The face sheet for R25 shows she was admitted to the facility with diagnoses to include type 2 Diabetes Mellitus, chronic obstructive pulmonary disease and hypertension. The facility assessment dated [DATE] shows R25 to have moderate cognitive impairment and requires substantial assistance with transferring from bed to chair. On 11/13/24 at 12:02 PM, V14 and V15 both CNA's (Certified Nursing Assistants) were assisting R25 out of bed for lunch. V14 pulled R25 up to a sitting position and applied a gait belt around the waist of R25. V14 and V15 then put their arms under R25's arms and lifted R25 up. R25 was not completely bearing weight and she was lowered back 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.

Based on observation, interview, and record review the facility failed to provide catheter care daily, change suprapubic catheter dressing change daily and ensure catheter tubing secure device was in place for 1 of 4 residents (R38) reviewed for catheters in the sample of 20. The findings include: On 11/12/24 at 10:21 AM, R38 was sitting in bed, on top of his blankets, with his head of the bed elevated while watching TV. R38 had a thin 4 x 4 with a ragged cut in it that was placed around his suprapubic catheter. The dressing was sticking up and not secured with tape. R38 stated his dressing around the suprapubic catheter was just changed by the nurse before the surveyor entered the room. R38 stated the nurse changes the dressing once a week. R38 pointed to a white paper back next to his bed and stated there are dressings in there for him to put around the catheter himself. R38 stated his catheter tubing gets cleaned once a week. The catheter tubing secure device was sitting in it's package on the table next to his bed. R38 stated he didn't think they put the catheter secure device…

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 dietary interventions were implemented for a resident with weight loss for 1 of 1 residents (R3) reviewed for weight loss in the sample of 20. The findings include: R3's admission record shows she was admitted on [DATE] with multiple diagnoses including paranoid schizophrenia, schizoid personality disorder and mood disorder. The November medication review report shows she has a weekly weight for weight monitoring, super cereal with breakfast for supplement, and a general diet with fortified potatoes with lunch daily. The monthly weight report shows a steady decline in R3's weight from 215.8 pounds in January 2024 to 173.6 in November. A 42 pound weight loss over 11 months. The 11/13/24 nutrition weight review notes R3 trigger for a significant weight loss for 6 months and has supplements ordered including fortified potatoes with lunch, ready care twice daily and supercereal. At the nutrition meeting staff reported R3 spends a lot 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 observation, interview, and record review the facility failed to ensure oxygen equipment was clean, filters were intact, bubblers had fluid, oxygen tubing was not too long or kinked, and changed for 2 of 2 residents (R39 & R22) reviewed for oxygen in the sample of 20. The findings include: On 11/12/24 at 9:30 AM, R39 was sitting up on the side of her bed with oxygen on via nasal canula. R39's oxygen tubing was extremely long, tangled up and kinked in several spots. The oxygen tubing was attached to an oxygen concentrator that had an empty humidification bubbler. The oxygen concentrator was covered in a thick layer of dust. The back of the concentrator where there is grate was occluded by a thick layer of gray-white dust. On 11/12/24 at 9:34 AM, V3 LPN (Licensed Practical Nurse) went into R39's room and stated, they should be checking the oxygen concentrator and cleaning it weekly. Obviously it has not been done. V3 stated the humidification bubbler should be full so the nose doesn't dry out. V3 stated…

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 have policy and procedures in place for the care of a dialysis resident for 1 of 2 residents (R13) reviewed for dialysis in the sample of 20. The findings include: R13's admission record shows she was admitted on [DATE] with multiple diagnoses including dependence on renal dialysis and end stage renal disease. The 10/11/24 admission assessment of R13 shows she is cognitively intact. The November medication review report shows her dialysis days to be Tuesday, Thursday, and Saturday at a local dialysis center. The orders show she has an access site located in her right arm and the site is to be checked daily for a bruit and thrill (potency). The November MAR (Medication Administration Record) was reviewed and showed no order for the access site assessment for bruit or thrill. R13 did not have a TAR (Treatment Administration Record). R13's diet slip was observed to show an order for a low concentrated sweet diet and no added salt. The slip…

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 medications were taken by residents at the time of administration for 2 of 2 residents (R18, R13) reviewed for medications in the sample of 20. The findings include: 1. R18's admission record shows she was admitted on [DATE] with multiple diagnoses including osteomyelitis, diabetes, congestive hear failure, pressure ulcers, and gastroparesis. The facility's 8/13/24 resident assessment and care screening for R18 shows she has moderate cognitive impairment with behaviors including rejection of care and verbal behaviors towards others. On 11/12/24 at 9:30 AM, R18 was observed lying on her right side in bed. On the bedside table next to the bed was a medication cup about half full of multiple pills. R18 was alert and was able to speak clearly. She said the nurse had delivered her medications to her this morning, but she was nauseous at the time, so the nurse just left them on the bedside table. R18 said the pills were from 8:00 AM, and…

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

Based on observation, interview, and record review, the facility failed to administer medications at ordered times. There were 32 opportunities with 2 errors resulting in a 28.5% medication error rate. This applies to 1 of 3 residents (R16) observed in the medication pass. The findings include: R16's physician's orders for November 2024 showed R16 is to receive apixaban 5mg (milligrams) at 9am and 5pm and baclofen 10mg at 9am, 1pm, and 5pm. On 11/12/24 at 10:20AM, V7 (Licensed Practical Nurse) administered R16's apixaban 5mg and baclofen 10mg. (1 hour and 20minutes past the scheduled administration time). V7 stated she is a new nurse and is trying her best to keep up with learning all the residents. V8 (Registered Nurse) was training beside V7 and stated she should have stepped in to help V7, but she was trying to get her to learn her own routine. V7 and V8 both stated medications are to be given within 1 hour before or 1 hour after the scheduled administration time. On 11/14/24 at 10:52AM, V2 (Director of Nursing) stated, All medications should be given within 1 hour before or…

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

Based on observation, interview, and record review, the facility failed to ensure safe storage of narcotic medications, failed to ensure medications were stored in their original packaging, and failed to monitor the temperature of a medication refrigerator. This applies to 1 of 2 medication rooms and 1 of 2 medication carts reviewed for medication storage. The findings include: On 11/13/24 at 1:41PM, The facility's medication refrigerator had a temperature log dated April 2024 located on the outside of it. The refrigerator had a lock on it that was not locked and was hanging open. Upon review of the refrigerator, 2 bottles of liquid lorazepam were located inside. V9 (Licensed Practical Nurse) stated, We don't usually have the medication fridge unlocked but we have 2 nurses' up here today and we don't have 2 sets of keys. We are supposed to be checking the medication and resident refrigerator temperature, but it looks like we haven't had it done since April according to the sheet on both refrigerators. On 11/13/24 at 1:52PM, One of the facility's medication carts were reviewed and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a shower or bath and/or hair care were provided for 3 of 3 residents (R1, R2, & R6) reviewed for activities of daily living in a sample of 6. The findings include: 1. The hospital emergency room Nurse's Note dated 9/18/24 for R1 showed, Patient arrived from facility with poor hygiene care. Patients hair was matted with food in it. Indwelling urinary catheter bag clogged with large sediment, exterior catheter visibly dirty. Patient had a pungent smell. The nurse bed bathed patient, applied shower cap, changed indwelling urinary catheter. This nurse made provider aware of patient status. On 9/26/24 R1 could not be observed at the facility; R1 was still in the hospital. On 9/26/24 at 11:42 AM, V6 CNA (Certified Nursing Assistant) stated, residents' showers are on a schedule and are done at least once a week. If a resident refuses a shower they are supposed to ask the resident three times and then get the nurse who will ask 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 ensure a residents wound dressings were being changed for 1 of 3 residents (R3) reviewed for wounds in the sample of 6. The findings include: On 9/26/24 at 10:48 AM, R3 was in therapy and had gauze wrapped around his right elbow that was secured with tape. The dressing was not dated. V5 (R3's daughter) was present and stated, R3 came here last Tuesday (9/17/24) evening; he was in the hospital. R3 has a wound to his elbow and swelling. The wound drains and has packing in it. One day it was draining and I had to keep asking them to change it (dressing) and they never did. V8 (R3's son) asked them three times that day and they did not change it. When I came the next day the dressing had dirty, crusty drainage. On 9/26/24 at 3:24 PM, V7 LPN (Licensed Practical Nurse/Wound Nurse) stated, R3 had silver rope ordered as a packing for the right elbow when he was admitted to the facility and they were waiting for it to come in because they did not…

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 residents with pressure ulcers had pressure reducing/preventative measures in place for 2 of 3 residents (R2 and R3) reviewed for pressure injuries in the sample of 6. The findings include: 1. On Thursday, 9/26/24 at 11:09 AM, R2 was laying on his bed in his room wearing an incontinence brief. R2 has an amputation of his right lower leg. R2's left heel was lying directly on his bed and not offloaded. R2 had one pillow in his bed behind his head and none at his foot level. R2 did not have an off-loading boot visible in his room. On 9/26/24 at 11:42 AM, V6 CNA (Certified Nursing Assistant) stated, R2 did not have any pressure ulcers; she did not notice anything the other night when providing care. At 11:52 PM, V6 went to R2's room with the surveyor and R2's left heel was laying on the bed. V6 lifted R2's left heel and there was a small black area the size of a pencil eraser on his heel with some redness around it. V6 looked in R2's room for an off- loading boot and said she could not find one. R2 stated…

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 catheter care was being provided, the drainage bag was kept off the floor, the drainage bag was maintained below the level of the bladder, and catheters were changed as needed for 2 of 3 residents (R1 & R5) reviewed for catheters in the sample of 6. The findings include: 1. On 9/26/24 at 11:38 AM, R5 was sitting up in bed with his catheter tubing and drainage bag visible. R5's catheter tubing had sediment in it. R5's drainage bag was covered on the sides but not the bottom and was attached to a small garbage can with the bottom of the bag on the floor. On 9/26/24 at 11:42 AM, V6 CNA (Certified Nursing Assistant) stated R5 has a catheter and does his own catheter care including emptying the drainage bag. V6 stated when catheter care is done it should be done every shift and included cleaning around the tubing, cleaning the tubing and emptying the drainage bag. On 9/27/24 at 8:27 AM, V2 DON (Director of Nursing) went to R5's room with the surveyor to observe his catheter. R5 was sitting up in bed wearing…

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 refund a resident's funds within 30 days of discharge for 1 of 3 residents (R1) reviewed for resident funds in the sample of 6. Findings include: R1's Facesheet printed 5/23/24 showed she was admitted to the facility on [DATE] and discharged from the facility on 4/3/24. This document showed R1 had diagnoses including: chronic obstructive pulmonary disease, diabetes, bipolar disorder, obesity, fibromyalgia, obstructive sleep apnea, nicotine dependence, hypertension, and localized swelling of bilateral lower extremities. R1's facility assessment dated [DATE] showed she was cognitively intact. R1's Progress Notes showed R1 left the facility AMA (Against Medical Advice) and was demanding her money. The progress notes showed on 4/3/24 at 5 PM, R1 was unhappy with the $60 paid to her. This note showed HR (Human Resources) spoke with her on 4/2/24 to explain how Social Security works and the trust account. R1's progress notes showed R1 or someone on R1's…

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 document a resident's non-pressure (venous) wounds. The facility also failed to follow up with the resident's physician after a visit at his office and failed to follow physician orders written during that visit. This failure resulted in R1 having no wound assessments since January 2024 for 4 venous wounds on her legs, R1 having exposed open and bleeding wounds to the backs of her thighs, and R1experiencing an 18 day delay in increasing her pain medication. This applies to 1 of 3 residents (R1) reviewed for quality of care in the sample of 7. The findings include: R1's EMR (Electronic Medical Record) shows that R1 was admitted to the facility on [DATE] with diagnoses including Morbid Obesity, Mood Disorder, Chronic Kidney Disease, Stage 4 and non-pressure chronic ulcers of the left and right leg. R1's last wound assessment is dated 1/15/2024 on a document entitled Specialty Physician Wound Evaluation and Management Summary shows…

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 care plan and interventions were developed and implemented to prevent pressure ulcers, failed to provide pressure ulcer treatment, and failed to update interventions to the care plan and update the skin risk assessment once pressure ulcers developed for 2 of 3 residents (R1, R3) reviewed for pressure ulcers on the sample list of 6. The findings include: 1. R1's Face Sheet shows his diagnoses to include acute respiratory failure with double lung transplant, protein-calorie malnutrition, pneumonia, and type 2 diabetes mellitus. On 4/2/24 at 10:00 AM, R1 was in his bed with the bed pan under his bottom. When R1 was finished he was rolled by the CNA (Certified Nursing Assistant) and there was no dressing on his pressure wound on his buttocks. The old dressing was not on the pad beneath R1 or in the bed pan. On 4/2/24 at 1:00 PM, V4 and V5 both CNAs said, R1 is alert and oriented. V4 and V5 said, if a dressing falls off or gets…

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

Based on observation, interview and record review the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This failure affects all 65 residents who currently reside in the facility. Findings include: On 12/12/23 at 9:07 AM, the entry door into the kitchen has thick raised layers of dust, dirt and grim. The sides of the door from the hinges down to the floor has raised grayish dust. On the pipes in the ceiling throughout the kitchen and the air-conditioner (AC) and vents has raised thick layers of grayish dust. On 12/12/23 at 11:30 AM, V5 (Dietary Manager) DM said, we deep clean 2 times a week. On 12/12/23 at 12:20 PM, V5 DM said, the dust comes from the AC (air conditioner). If it shoots out and blows into the food. They (residents) could get sick. The food could get contaminated. V5 said, this is a kitchen that should be very clean. The dust could blow into the food and yes, they could get sick. I see that around the entry door, the floor has dust, dirt and grim on it. Around the edges of the floor is dirt and debris, and on the pipes in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident was treated in a dignified way for 1 of 3 residents (R14) reviewed for dignity in the sample of 20. The findings include: R14's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease with acute exacerbation, hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, acute on chronic diastolic (congestive) heart failure, acute and chronic respiratory failure with hypoxia, chronic kidney disease, secondary hyperparathyroidism, morbid obesity, Type 2 Diabetes, anemia in chronic kidney disease, acquired absence of right leg below knee, acquired absence of left leg above knee, major depressive disorder, and anxiety disorder. On 12/14/23 at 9:25 AM, R14 said, It happened again last night. I don't get much notice when I need to have a bowel movement. I tried to get into my bed to get onto the bed pan but I didn't make…

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 2. R4's admission Record (Face Sheet) showed an original admission date of 11/16/23 with diagnoses to include contracture left hand, paranoid schizophrenia, and mood disorder. R4's 11/22/23 admission Minimum Data Set (MDS) showed moderate cognitive impairment with a brief interview for mental status score of 11 out of 15. The MDS showed she required supervision or touching assistance for personal hygiene. On 12/12/23 at 12:19 PM R4's left hand was contracted. On three of the fingers of her left hand (thumb, middle, and pinky) the nails were 1/4 long and dirty. R4 stated, I wish they would cut them. I would prefer it [if the staff cut the nails]. They never cut my nails. I only get one shower a week. On 12/13/23 at 4:05 PM, R4 stated, I would like my nails trimmed they are too long. I do need help to trim my nails, I can't do it myself. I would let them trim my nails if they asked. Some of them are too long and some are not. They should have been trimmed a while ago. Sometimes they offer to trim my nails but not…

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 administer medication to prevent cross contamination, failed to administer insulin per manufacturer's instructions, and failed to monitor a resident during medication administration. This applies to 2 of 4 residents reviewed for medication administration in the sample of 20. The findings include: 1. R14's admission Record (Face Sheet) showed a current admission date of 6/15/22 with diagnoses to include diabetes, morbid obesity, and long term insulin use. R14's December 2023 Medication Administration Record showed an order for two types of insulin. The first insulin order is for 35 units of a long-acting insulin to be given twice daily via a preloaded syringe. The second insulin order is for 20 units of a rapid acting insulin to be given at breakfast time via a multi-use vial. The manufacturer's instructions for the long-acting insulin state, prior to applying a new needle, Wipe the Rubber Seal with an alcohol swab. The instructions showed when the medication is injected into the resident the button should be held…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain resident equipment in a clean and sanitary manner for 1 of 1 resident (R14) reviewed for equipment on the sample list of 20. Findings include: R14's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease with acute exacerbation, hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, acute on chronic diastolic (congestive) heart failure, acute and chronic respiratory failure with hypoxia, chronic kidney disease, secondary hyperparathyroidism, morbid obesity, Type 2 Diabetes, anemia in chronic kidney disease, acquired absence of right leg below knee, acquired absence of left leg above knee, major depressive disorder, and anxiety disorder. On 12/11/23 at 9:45 AM and 12/14/23 at 12:10 PM, R14 was in his room sitting in his wheelchair. There were feces all across the back of his wheelchair, on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the failed to identify and implement resident centered fall prevention interventions for a resident with a history of falls. This applies to 1 of 5 residents (R1) reviewed for safety in the sample of 5. Findings include: R1's face sheet shows she is [AGE] year-old female admitted to the facility on [DATE] with diagnosis including type 2 diabetes with diabetic neuropathy, morbid obesity, cardiomyopathy, muscle weakness, history of falling, and fibromyalgia. R1's Fall Risk assessment dated [DATE] shows she is a high risk for falls. The assessment shows R1 exhibits loss of balance while walking, balance problem while walking and has decreased muscle function. R1's Minimum Data Set assessment dated [DATE] shows her cognition is impaired, requires substantial/maximum assistance for chair to bed transfers and toilet transfers not attempted due to medical conditions or safety concerns. On 11/2/23 at 6:15 AM, V13 (CNA- Certified Nursing Assistant) said she was R1's aide on 10/13/23,…

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 protect a resident's dignity by announcing a resident's weight in front of other residents and having conversations about a resident's incontinence episodes in the hallway. These failures affect 1 of 3 residents (R1) in the sample of 5. Findings include: R1's admission record documents a current admission date of 6/15/22 with diagnoses including: chronic obstructive pulmonary disorder (COPD); diabetes type 2; and congestive heart failure. R1's 6/16/23 Annual Minimum Data Set (MDS) documents he is cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 out of 15. The MDS documents he requires extensive assistance of one person for cleaning after elimination and personal hygiene. The MDS documents he is frequently incontinent of bowels. On 8/16/23 at 8:37 AM, R1 stated he is supposed to have his weight measured daily due to his congestive heart failure. R1 stated the scale is on the second-floor east hallway wing and after he is weighed the Certified Nursing Assistant (CNA's) will yell his…

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 for a resident dependent upon staff for care. This applies to 1 of 3 (R1) residents reviewed for incontinence care in the sample of 5. The findings include: R1's admission record showed a current admission date of 6/15/22 with diagnoses to include: chronic obstructive pulmonary disorder (COPD); diabetes type 2; and congestive heart failure. R1's 6/16/23 Annual Minimum Data Set (MDS) documents he is cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 out of 15. The MDS documents he requires extensive assistance of one person for cleaning after elimination and personal hygiene. The MDS documents he is frequently incontinent of bowels. R1's Care Plan from 8/3/22 showed, The resident has incontinence of bladder and/or bowel .Administer appropriate cleansing and peri-care (perineal care) after each incontinent episode . On 8/16/23 at 9:20 AM, R1 was in his wheelchair in his room. R1 was using oxygen from an oxygen concentrator. R1 had a partial amputation to both…

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.