Landmark of Itasca Rehabilitation and Nursing Cent

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to identify and assess a pressure wound prior to it becoming a Stage III wound for 1 of 5 residents (R2) reviewed for pressure ulcers in the sample of 15. The findings include:On 1/17/26 at 11:10 AM, V16, Wound Care Nurse, was observed as she provided wound treatment to R2's coccyx. R2 had an open area to his coccyx. R2's buttocks were not reddened and did not have any open areas.On 1/17/26 at 1:19 PM, V16, Wound Care Nurse, said R2's coccyx wound was first identified 12/30/25. The wound was a Stage III pressure wound to his coccyx. V16 said R2's coccyx pressure wound was acquired in the facility. V16 said it had yellow slough and was not sure why it was not found sooner. V16 said it (healing) was difficult at first because R2 did not like his low air loss mattress, and he was only moving when staff moved him.On 1/17/26 at 11:40 AM, V8, Certified Nursing Assistant (CNA) said it's important she informs V16 and the (floor) nurse about any…

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 and/or follow Enhanced Barrier Precautions (EBP) for 2 of 3 residents (R2 and R5) reviewed for infection control in the sample of 15.The findings include:On 1/17/26 at 10:15 AM, V16, Wound Care Nurse, said R2 has a sacral pressure ulcer (Stage III). On 1/17/26 at 11:10 AM, V16 approached R2's room to provide wound treatment. R2's room had no EBP sign nor PPE (Personal Protective Equipment) bin outside his room. V16 did not don a gown prior to entering R2's room. V16 was observed providing wound care to R2's coccyx without a gown.On 1/17/26 at 9:42 AM, V8, Certified Nursing Assistant (CNA), entered R5's room without a gown to change R5's brief. R5's room had an EBP sign on her door and a PPE bin outside her room.On 1/17/26 at 12:50 PM, V2, Director of Nursing (DON), said any resident with wounds or a history of MDROs (multidrug resistant organism) needs to be on EBP. A sign will be placed on their door indicating the type of isolation and the PPE. V2 said the PPE needs to be put on and 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's mail was not opened prior to delivering it to the resident. This applies to 2 of 9 residents (R7 and R13) reviewed for resident rights in the sample of 14. The findings include: On 1/12/26 at 9:10AM (R7) was in his room sitting on his bed. R7 stated, Sometimes my mail is open. I got a check a couple months ago, and V1(Administrator) brought it to me and told me I got a check and had me sign it and then the money went into my account. It was from some State check for some missing/ lost property. It was $88. I don't know who opened it, but (V1) brought it to me.On 1/12/26 at 11:35AM R13 was lying on her bed in her room. R13 stated, I have had my mail opened for me. It was from Social Security. They cashed it and then said the check didn't go through right away. It was for $25. It eventually got put into my account. It was a couple months ago. Activities brought me the open envelope and (V5- Business Office Manager) brought me the check and asked me to sign it and about 2 weeks later it was in my…

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 received yogurt with breakfast per resident preference. This applies to 1 of 8 residents reviewed for dietary services in the sample of 14. The findings include: R1's Facesheet shows R1 has a diagnosis of osteoporosis. On 1/12/26 at 8:45 AM, a case of six bulk 5 pound tubs of yogurt were in the walk in cooler in the kitchen. Five of the tubs were unopened and one was opened. V7 (Interim Food Service Director) said one case of yogurt typically lasts the facility about a week and it is an item that residents must request to receive.R1's Dietary Progress Note from 5/19/23 shows R1 prefers milk and yogurt with meals. R1's breakfast tray ticket for 1/12/26 shows R1 is to receive plain yogurt daily. On 1/12/26 at 9:20 AM, R1 said R1 started ordering yogurt at all meals to encourage optimal calcium levels after R1 was diagnosed with osteoporosis. R1 did not receive yogurt with breakfast. R1 said staff told R1 that they were waiting on a shipment because they were out of yogurt. R1 said most, if 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents who are dependent on the facility for ADLs (Activities of Daily Living) such as feeding, dressing, and incontinence care are provided the necessary assistance in a timely manner.This applies to 5 of 5 residents (R8, R9, R10, R11, and R12) reviewed for ADLs in the sample of 12.The Findings include:On December 6, 2025, 9:53 AM to 12:48 PM, R8, R9, R10, and R11 were continuously observed sitting in dining room. They were not checked for incontinence during this time.1. R9's admission record showed R9 to be [AGE] years old with diagnoses that include chronic obstructive pulmonary disease, type 2 diabetes mellitus, dementia, anemia, major depressive disorder with severe psychotic disturbance, anxiety disorder, and fall. R9's MDS (Minimum Data Set) dated September 25, 2025 showed R9 to be dependent on staff for all ADL care. On December 6, 2025 at 11:26 AM, V25 (R9's family member) stated she is at the facility visiting R9…

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 provide portions as shown on the menu spreadsheet.This applies to all residents that receive foods prepared in the facility kitchen.The findings include: Facility Data sheet dated November 18, 2025, showed there was a census of 126 residents in the facility. Facility provided information there was one resident on NPO (nothing by mouth) status.1. The Week at a glance menu (Week 3) for dinner meal on November 17, 2025, included hot dog with hot dog bun, potato wedges, green peas, baked cookie. The extension spread sheet for the same meal showed to serve pureed potatoes (#12 scoop) for pureed diets. On November 17, 2025, at 4:27 PM, the dinner meal items were on the steam table in the facility kitchen and V3 (Cook) stated they were ready for meal service at 4:45 PM and he has already taken the food temperatures of the meal items. It was noted pureed potatoes or mashed potatoes were not prepared. On enquiry what the residents on pureed diets are getting, V30 (Regional Dietary Director), who was at the steam table,…

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 serve meals at required meal temperatures and appearance/consistency for palatability. This applies to all residents that receive foods prepared in the facility kitchen.The findings include: Facility Data sheet dated November 18, 2025, showed there was a census of 126 residents in the facility. Facility provided information there was one resident on NPO status.1. The Week at a glance menu (Week 3) for dinner meal on November 17, 2025, included hot dog with hot dog bun.On November 17, 2025, at 4:27 PM, the dinner meal items were on the steam table in the facility kitchen and V3 (Cook) stated they were ready for meal service at 4:45 PM and he has already taken the food temperatures of the meal items. On request, V30 (Regional Dietary Director) measured the food temperatures at the steam table and showed as follows in degrees Fahrenheit. Mechanical Soft hot dog=110.4, Pureed hot dog =129.7.2. The Week at a glance menu (Week 3) for breakfast meal on November 18, 2025, included Western egg casserole and hot…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to provide a substantial evening snack when the mealtimes exceed 14 hours per resident.This applies to all residents that receive foods prepared in the facility kitchen.The findings include:Facility Data sheet dated November 18, 2025, showed that there was a census of 126 residents in the facility. Facility provided information that there was one resident on NPO (nothing by mouth) status.Facility Mealtimes chart showed as follows:Breakfast: 2 North Unit -7:45 AM - 8:00 AM, 2 South Unit 8:00 AM - 8:15 AM, 2 Main Unit 8:15 AM -8:25 AM, Main Dining room [ROOM NUMBER]:25 AM - 8:40 AM, 1 South Unit 8:40 AM - 8:55 AM, 1 North Unit 8:55AM-9:10 AM.Dinner: 2 North Unit -4:45 PM - 5:00 PM, 2 South Unit 5:00 PM - 5:15 PM, 2 Main Unit 5:15 PM -5:25 PM, Main Dining room [ROOM NUMBER]:25 PM - 5:35 PM, 1 South Unit 5:35 PM - 5:45 PM, 1 North Unit 5:45 PM-5:55 PM.This showed that there was a 15-hour duration between the dinner and breakfast meal.On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement an effective pest control program and failed to respond to sightings of rodent excrement, and dead and live rodents. The facility failed to take measures to eradicate and contain rodents including patching holes in walls, informing pest control vendor of rodent sightings, provide effective room cleaning, and staff failed to notify the Administrator of any evidence of pest or rodent presence in accordance with facility policy. This has the potential to affect all 126 residents who reside in the facility as reported on the Facility Data Sheet, dated November 18, 2025, completed by V1 (Administrator). The findings include:On November 18, 2024, at 10:34 AM, V24 (Pest Control Vendor Employee) stated he visits the facility weekly. V24 stated mice can enter a structure through a hole the size of a dime or under a door if there is enough space to see light. V24 stated he had instructed V22 (Maintenance Supervisor) to patch all holes 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.

Based on observation and record review, the facility failed to serve residents with non-disposable cutlery. This applies to 6 of 6 residents (R5, R37, R38, R39, R40, R41) reviewed for dietary services in the sample of 41.The findings include:On November 19, 2025, at 8:54 AM, during room tray meal observations in the 1 South unit, it was noted that multiple trays only had silverware consisting of forks and knives and had plastic spoons for the cereal. V37 who was passing out food trays out to the residents in 1 South unit from the food cart stated, They (Dietary staff) only give plastic plates in the evening. How can the food stay warm?On November 18, 2025, at 9:10 AM, V11 (Regional Dietary Manager) stated the facility uses plastic disposable utensils and plates as a lot of the utensils and dishes don't come back from the resident's rooms. V11 added, Maybe it's still in the residents room.On November 18, 2025, starting at 12:10 PM, the lunch meal service was observed in the facility kitchen. Towards the at the end of the lunch meal service, the facility ran out of beef stroganoff…

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

Based on observations, interviews and record review, the facility failed to provide meal preference as shown on the meal tickets.This applies to 5 of 5 residents (R13, R21, R31, R32, R33) observed for dietary services in the sample of 41.The findings include:On November 18, 2025, starting at 7:35 AM, the breakfast meal service was observed in the facility kitchen with V33 (Dietary Aide) platting the food and V53 (Dietary Aide) placing the nutritional supplements, thickened drinks and condiments on the tray. V53 stated that the cartons of milk and juice and coffee in pitchers are sent up for CNA's (Certified Nursing Assistants) to pass out. The milk cartons sent up in coolers were noted to be 2% milk. The residents' meal tickets did not show yogurt, pudding nor cottage cheese. (R21, R31, R32, R33) did not receive these. V33 stated that the facility does not have yogurt as they have run out for a while.1. R13's meal ticket included whole milk, fruit yogurt. On November 17, 2025, at 2:19 PM, R13 stated he prefers whole milk and that he only gets 2% milk. On November 18, 2025, at 9:31…

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 serve diets as ordered.This applies to 8 of 8 residents (R1, R21, R22, R23, R24, R25, R26, R27) reviewed for dietary services in the sample of 41. The findings include:On November 18, 2025, starting at 7:35 AM, the breakfast meal service was observed in the facility kitchen with V33 (Dietary Aide) platting the food. The resident meal tickets which showed double portion (R25, R26, R27) received 2 pieces of toasts with one small piece of western omelet and a bowl of cereal. The resident meal tickets that showed yogurt (R1) did not receive the same. V33 stated that it's her understanding that double portion is giving two toasts instead of one. V33 added that the facility does not have yogurt as they have run out for a while. The resident meal tickets that showed superceral (fortified cereal) (R21, R22, R23, R24, R25) received grits or cream of rice.On November 18, 2025, at 9:02 AM, V32 (Cook) stated he did not prepare superceral as they had run out of oatmeal. V32 added that he prepared the grits and cream 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 protect residents from physical abuse. This failure applies to 2 of 5 residents (R4 and R5) reviewed for abuse in a sample of 36.The findings include:Findings include: The Electronic Medical Record (EMR) indicated the following: -R4, a [AGE] year-old female resident admitted on [DATE]. Diagnoses include, but are not limited to major depressive disorder, anxiety disorder, alcohol abuse, bipolar disorder, and a history of falls.-R5, a [AGE] year-old female resident admitted on [DATE]. Diagnoses include chronic obstructive pulmonary disease, iron deficiency anemia, major depressive disorder, history of falls, weakness, need for assistance with personal care, difficulty walking, and dependence on supplemental oxygen.The facility's incident reports documented multiple verbal and physical altercations between R4 and R5:-May 4, 2025, at 9:45 PM: R4 reported to nursing staff that R5 grabbed the back of R4's shirt while R4 was mobilizing in 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.

Based on interview and record review, the facility failed to employ a qualified full time Social Services Director. This applies to all 129 residents residing in the facility. The findings include:Facility Daily Census, dated 11/5/25, shows the facility census was 129 residents.Application for Employment, dated 6/25/21, shows V3 (Director of Social Work) applied for the Social Service Director position. The application shows V3's highest level of education attained was a high school diploma.Employment offer letter, dated 7/2/21, shows the facility offered V3 the position of Social Services Director and V3 accepted the position on 7/2/21.Director of Social Services Job Description, signed by V3 (Director of Social Services) on 1/10/23, shows the education and experience required for the position includes either a bachelor's degree in psychology or sociology; a Bachelors or Master of Arts in Social Work, or a Licensed Clinical Social Worker's Certificate. On 11/13/25 at 10:30 AM with V19 (Consultant) and V2 (Director of Nursing), V1 (Administrator) stated V3 (Social Services Director)…

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 administration failed to provide oversight and leadership to ensure staff is qualified to work as a Social Service Director. The administration also failed to ensure self-harm/suicide risk screening assessments were completed accurately, timely, and individualized and measurable care plan interventions were put in place for residents identified at risk for suicide. This applies to all 130 residents living in the facility.The findings include: The Facility Data sheet dated October 24, 2025, shows the facility census as 130 residents. Concerns were identified regarding the accuracy, timeliness, and individualized care plan interventions for multiple residents screened by V12 (SSD-Social Service Director) for self- harm/suicide risk, including R1, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R17. On October 30, 2025, at 3:00 PM, V12's employment record showed on July 19, 2021, V12 was hired as the facility's full-time Social Service Director. V12's employment record shows V12 has completed four years of high school education. V12 did not have…

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 employ a qualified social worker on a full-time basis. This applies to all 130 residents residing in the facility. The findings include: The Facility Data sheet dated October 24, 2025, shows the facility census as 130 residents. On October 30, 2025, at 3:30 PM, V1 (Administrator) said he is not sure if V12 (SSD- Social Service Director) has all the required qualifications to work as the facility's Social Service Director. On October 30, 2025, at 3:00 PM, V12's employment record shows on July 19, 2021, V12 was hired as the facility's full-time Social Service Director. V12's employment record shows V12 has completed four years of high school education. V12 did not have any college education listed in her employment record. The facility's Job Description for the position title of Director of Social Services shows the education requirements for the position of Director of Social Services as either a bachelor's degree in psychology or sociology, a B.A. (Bachelor of Arts) or M.A. (Master of Arts) in social work, or a Licensed…

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 food portions as shown on the facility menu spreadsheet. This applies to 129 facility residents receiving oral diets. The findings include: The Facility Data Sheet dated September 15, 2025, shows the facility census was 132 residents. The facility's Diet Type Report dated September 15, 2025, shows two residents had diet orders for nothing by mouth and one resident was a vegetarian. On September 15, 2025, at 11:48 AM, during lunch tray line service with V5 (Cook) and V6 (Cook), V5 said the tray line consisted of a tray of cheese tortellini combined with meat sauce, a tray of green beans, a tray of garlic bread slices, a tray of chopped pasta combined with meat sauce, a tray of mashed potatoes, and containers of pureed meat sauce, pureed pasta, and pureed green beans were being served to residents for lunch. The tray line did not show a container of pureed garlic bread. V6 said he was using a 4 oz spoodle for the tray of pasta mixed with meat sauce, a 4 oz spoodle for the green beans, a 4 oz scoop for 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 follow the facility's policy to serve food at a palatable temperature. This applies to 6 of 6 residents (R1, R2, R3, R4, R5, and R6) reviewed for dietary services in the sample 6. The findings include: On September 15, 2025, at 11:48 AM, during lunch tray line service with V5 (Cook) and V6 (Cook), V5 and V6 served resident room meal trays on hard plastic, non-warmed, room temperature plates with lids. V5 and V6 did not use thermal bases or heated plates. On September 15, 2025, at 12:47 PM, V6 prepared a test meal tray. V6 used a hard plastic, non-warmed plate and placed cheese tortellini with meat sauce, green beans, and one piece of a plain breadstick. V6 placed a lid on the plate and placed the plate directly onto a serving tray. The tray was placed on an open-air unit meal cart with the 1 North resident meal trays. At 12:51 PM, the meal cart was delivered to the 1 North resident hallway with the other resident meal trays. At 1:10 PM, when the last resident meal tray was delivered, V5 took the temperatures…

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 plan and serve resident menus and food portions per facility policy. This applies to all 128 facility residents receiving oral diets. The findings include:Facility resident roster, provided 7/10/25, shows the facility census was 129 residents. Facility document, dated 7/15/25, shows one resident had physician diet orders for NPO (nothing by mouth.)1. On 7/10/25, the following residents expressed concerns:- R7 stated the facility serves only small portions of meat and vegetables.- R5 stated the facility never served fresh fruits even in the summer when fruits are available. R5 stated the residents were rarely served vegetables.- R2 stated the facility only provided menus for review the day of service and not prior. R2 stated she and other residents asked for weekly planned menus but the facility will not provide menus in advance because they often serve something different than the planned menu. R2 stated the facility served small portions of vegetables.Review of the facility four-week menu cycle, dated 6/22/25…

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 palatable meals per facility policy. This applies to all 128 facility residents receiving oral diets. The findings include:Facility resident roster, provided 7/10/25, shows the facility census was 129 residents. Facility document, dated 7/15/25, shows one resident had physician diet orders for NPO (nothing by mouth.)1.On 7/10/25 at 11:57 AM during lunch tray service in the kitchen, the broccoli in the steamtable pan on the steamtable looked very pale green/gray and consisted mostly of cut broccoli stems and few broccoli florets. The pureed meatloaf was in a steamtable pan being served to residents. The pureed meatloaf appeared to be separated from a reddish-brown greasy-looking liquid floating at the top of the pureed meatloaf. V10 (Corporate Food Service Manager) stated the product needed further pureeing. V10 removed the product from the steamtable, strained the greasy-looking liquid from the product, re-pureed the product, and placed the product back on the steamtable. The re-pureed and strained…

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 meals on time to residents per the facility meal schedule. This applies to all 128 facility residents receiving oral diets. The findings include: Facility resident roster, provided 7/10/25, shows the facility census was 129 residents. Facility document, dated 7/15/25, shows one resident had physician diet orders for NPO (nothing by mouth.) On 7/10/25 at 1:13 PM, the last lunch tray was served to residents on 1 South. Facility mealtime document, undated, shows the 1 South unit was to be served their lunch meals between 12:25 to 12:35 PM. The document shows the facility was to serve breakfast between 7:45 AM and 9:10 AM, lunch between 11:30 AM and 12:45 PM, and dinner between 4:45 PM and 5:55 PM. On 7/10/25 during resident interviews, R2, R5, R6, and R8 all stated the facility meals were often served late. On 7/10/25 at 3:21 PM, R2 stated her dinner was sometimes served at 7:00 PM. 0n 7/10/25 at 3:32 PM, R6 stated he sometimes received his dinner after 7:00 PM. On 7/14/25 at 1:58 PM, V9 (Corporate Food…

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 perform hand hygiene after touching soiled dishes and failed to store foods to prevent cross contamination. The facility also failed to sanitize equipment prior to use and failed to utilize food service supplies to avoid potential chemical contamination of foods. This applies to all 128 facility residents receiving oral diets.The findings include:Facility resident roster, provided 7/10/25, shows the facility census was 129 residents.Facility document, dated 7/15/25, shows one resident had physician diet orders for NPO (nothing by mouth.)1. On 7/10/25 at 10:56 PM, a white bouffant hairnet was located in the coffee brew basket of the coffee machine and had wet coffee grounds in the hairnet. There were white coffee filters on top of the coffee machine in packages. V6 (Dietary Aide) stated the staff had used the white bouffant hairnets in the coffee machine to brew resident coffee for approximately two weeks because they felt the coffee filters being provided were too small to brew enough coffee. V5 (Dietitian)…

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 were free of physical abuse. This applies to 4 of 4 residents (R10, R15, R21, and R24) reviewed for abuse in a sample of 25.The findings include: 1. Face sheet, dated 7/15/25, shows R10's diagnoses included major depressive disorder, anxiety disorder, alcohol abuse, and bipolar disorder. MDS (Minimum Data Sheet), dated 7/1/25, shows R10 was cognitively intact.Face sheet, dated 7/22/25, shows R17's diagnoses included chronic obstructive pulmonary disease, acute and chronic respiratory failure, and major depression. MDS, dated [DATE], shows R17 was cognitively intact.On 7/22/25 at 2:48 PM, R10 stated she and R17 got into a fight when R10 was sitting outside the facility front door and R17 appeared with sunglasses that R10 stated were glasses R10 was offering for sale in her personal store at the facility. R10 stated she told R17 that R17 owed her two dollars for the sunglasses and R17 replied, Come and get them! R10 stated she grabbed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to provide dementia care and behavioral interventions to a resident who had chronic dementia-related behaviors. This applies to 1 of 3 residents (R25) reviewed for behavior management in a sample of 25. The findings include:Face sheet, dated 7/22/25, shows R25's diagnoses included alcohol use with alcohol-induced persisting dementia, psychosis, cerebrovascular disease, unsteadiness on feet, weakness, and major depressive disorder. The face sheet shows R25 was admitted to the facility on [DATE].MDS, dated [DATE], shows R25's cognition was moderately impaired. Pre-admission paperwork, dated 7/1/25, shows R25 showed agitation with combative behavior towards at the prior facility. The paperwork shows R25 fought with staff and hit, punched, cursed and threatened other residents at the prior facility. The paperwork showed R25 banged and punched walls and was sent to the hospital for the behaviors.Alzheimer's Special Care Unit Review, dated 7/22/25, shows R25…

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 food prepared for residents were nutritive, palatable, and attractive. This applies to all 119 residents who receive food from the kitchen. Findings include: On 6/30/2025 at 1:32 PM, V3 (ADON, Assistant Director of Nurses) stated 119 residents out of 130 received food prepared in facility's kitchen. The menu for 6/25/2025 showed the main entree for lunch was Skillet Lasagna. On 06/25/2025, during lunchtime, staff delivered lunch trays to many residents including R8, R10, and R14. R8 called the writer and showed the meal card and skillet Lasagna that was served, and asked the writer if it looked like Lasagna. R10 asked the staff who served her tray what was on her plate, and the staff said it was Lasagna. R10 said, It didn't look like Lasagna. R14 went outside the room with her lunch plate, with anger and frustration, in front of V1 (Administrator), V3 (Assistant Director of Nursing), and V7 (Licensed Practical Nurse), who were 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.

Based on interview, and record review, the facility failed to implement their abuse policy to conduct background checks on employees prior to working in the facility. This applies to all 125 residents residing in the facility. The findings include: The facility's Long-term Care Application for Medicare and Medicaid dated April 28, 2025, showed the facility's census was 125 residents. 1. On October 2, 2024, V9 (Facility Bus Driver) submitted an application for employment and checked yes to Have you been convicted of or pled guilty or no contest to a felony or misdemeanor other than a minor traffic related infraction? The facility does not have documentation to show a criminal background check was performed or V9 was sent for fingerprinting. V9's personnel file did not show the Health Care Work Registry was checked prior to V9 being employed in the facility. V9's Health Care Worker Registry dated April 29, 2025, at 11:38 AM, showed Worker Eligibility: Not Yet Determined. On April 29, 2025, at 2:18 PM, V9 said his most recent conviction was in 2020 for possession of a weapon by 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 plan and serve the facility menu per facility policy. This applies to all 123 residents receiving oral diets in the facility. The findings include: 1. Facility Long-Term Care Facility Application for Medicare and Medicaid document, dated April 28, 2025, shows the facility census was 125 residents. Facility Diet Spreadsheet, dated Week 3 Day 17 Tuesday, shows all facility resident diets were to be served one portion of chicken pot pie except those residents on a Heart Healthy, 2 gram Sodium, and Finger Foods diets. The spreadsheet shows the Finger Foods diet was to receive 3 ounces of edible protein from chicken tenders. Facility Diet Type Report, dated April 29, 2025, shows no residents had physician orders for Heart Healthy Diets, 2 gram Sodium diets, or Finger Foods diets. The report shows there were two residents who had diet orders of NPO (Nothing by Mouth). On April 29, 2025 at 11:52 AM during lunch tray line observations, one individual chicken pot pie was served on resident plates during lunch service.…

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 perform hand hygiene and utilize chemical sanitizing solution in a three compartment sink per facility policy. This applies to all 123 residents residing in the facility and receiving oral diets. The findings include: Facility Long-Term Care Facility Application for Medicare and Medicaid document, dated April 28, 2025, shows the facility census was 125 residents. Facility Diet Type Report, dated April 29, 2025, shows there were two residents who had diet orders of NPO (Nothing by Mouth). On April 28, 2025 at 9:45 AM in the dish room, V3 (Food Service Aide) was loading dirty trays into the dish machine and, without changing gloves or washing hands, walked to the clean side of the dish machine. V3 then removed clean/sanitized food trays from the clean side of the dish machine wearing his soiled gloves. V3 walked back to the dirty side of the dish machine and, without changing gloves or washing hands, and placed soiled plate lids onto a dish rack and into the dish machine. Without changing gloves or washing…

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 administration failed to ensure healthcare worker background checks were being completed for newly hired staff. This applies to all 125 residents residing in the facility. The findings include: The facility's Long-term Care Application for Medicare and Medicaid dated April 28, 2025, showed the facility's census was 125 residents. On October 2, 2024, V9 (Facility Bus Driver) submitted an application for employment and checked yes to Have you been convicted of or pled guilty or no contest to a felony or misdemeanor other than a minor traffic related infraction? The facility does not have documentation to show a criminal background check was performed or V9 was sent for fingerprinting. V9's personnel file did not show the Health Care Work Registry was checked prior to V9 being employed in the facility. V9's Health Care Worker Registry dated April 29, 2025, at 11:38 AM, showed Worker Eligibility: Not Yet Determined. On April 29, 2025, at 11:20 AM, V8 (Human Resources) said she was unaware V9 was Not Yet Determined on the Health Care Worker…

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 include the Medical Director in attendance at facility QAPI (Quality Assurance Performance Improvement) meetings per facility policy. This applies to all 125 residents residing in the facility. The findings include: Facility Long-Term Care Facility Application for Medicare and Medicaid document, dated April 28, 2025, shows the facility census was 125 residents. Review of QAPI Committee Meeting Sign-In Sheets, dated April 30, 2024 to 3/27/25, shows the facility medical director attended the following meetings: April 30, 2024 - no attendance May 28, 2024 - Medical Director attended October 29, 2024 - no attendance November 27, 2024 - no attendance February 4, 2025 - no attendance February 28, 2025 - no attendance March 27, 2025 - no attendance On April 30, 2025 at 1:06 PM V1 (Administrator) stated the Medical Director has not joined the QAPI meetings lately. V1 stated the medical director attended approximately one QAPI meeting in the last year and was absent more than present. V1 stated the medical director is invited 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. R67's admission record showed R67 was admitted to the facility on [DATE], with multiple diagnoses including type 2 diabetes mellitus, schizophrenia, hypertensive heart disease and conversion disorder with seizures or convulsions. R67's physician orders showed R67's scheduled medication for 9:00 AM included Probiotic Oral Capsule 250 MG (Saccharomyces boulardii) give 1 capsule by mouth one time a day, Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium) give 500 mg by mouth two times a day, Metoprolol Tartrate Oral Tablet 50 MG give 1 tablet by mouth two times a day, and diltiazem HCl Oral Tablet 60 MG give 1 tablet by mouth four times a day. On April 29, 2025, at 9:16 AM, V7 (LPN) was preparing R67's medications. V7 had long artificial nails, painted with white polish and did not perform hand hygiene prior to putting R67's medications into the cup. V7 used her bare hands to place metoprolol tab into the cup, and to open 4 capsules of Depakote, to prepare to administer 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 ensure expired medications were removed from the active medication cart and discarded. The facility also failed to label, and date opened eye drops to determine the expiration date. This applies to 7 of 7 residents (R72, R90, R48, R69, R37, R9, and R24) reviewed for medication labeling and storage in the sample of 25. The findings include: On April 30, 2025 at 10:31 AM, while checking an active medication cart with V16 (Registered Nurse/RN), residents' insulin and eye drops were stored in see-through pouches. 1. R72's opened Insulin Lantus pen was labeled with an open date of March 27, 2025 and an expiration date of April 25, 2025. V16 stated that the Insulin Lantus should have been thrown out when it expired on April 25, 2025. V16 stated that insulin is good for 28 days after it has been opened. 2. R90's opened Insulin Lantus pen had an open date of March 19, 2025 and an expiration date of April 18, 2025. On April 30, 2025 at 10:56 AM while checking a medication cart with V7 (Licensed Practical Nurse/LPN)…

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 accurate and timely accounting of controlled medications. This applies to 8 of 8 residents (R54, R116, R73, R9, R15, R97, R37 and R78) reviewed for controlled medications in the sample of 25. The findings include: On April 30, 2025, at 10:31 AM, the controlled medication was counted with V16 (Registered Nurse/RN), and the following was observed: 1. R54's controlled drug receipt/record/disposition form showed there was 19.5 milliliters of Lorazepam oral concentrate 2 milligrams/milliliters (mg/ml) remaining in the vial. The vial of Lorazepam 2mg/ml that was in the refrigerator only had 16 ml remaining in the vial. V16 stated she had done a count of the narcotics with another nurse at shift change. Review of the shift change Narcotic Count showed that 2 nurses had signed off on the narcotic count. V16 stated there was about 18 ml of Lorazepam in the vial in the morning during the count and maybe there is only 16 ml in there now because the vial is cold. V16 said she did not administer any of this…

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 perform monitoring on a resident after an incident. This applies to 1 of 1 resident (R37) reviewed for accidents in the sample of 25. The findings include: The EMR (Electronic Medical Record) showed R37 was admitted to the facility on [DATE], with multiple diagnoses including major depressive disorder, anxiety disorder, and history of falling. R37's MDS (Minimum Data Set) dated April 1, 2025, showed R37 was cognitively intact. On April 28, 2025, at 11:11 AM, R37 said she was hit by a car in July 2024 when she was out on community pass. R37 said she had a bad ankle sprain and a scrape on her right knee. A progress note dated July 15, 2024, at 3:28 PM, V16 (RN/Registered Nurse) showed, The administrator informed the writer that the resident in the hospital for she flipped out from her wheelchair when she was going to town. Police took her in [local hospital]. On April 30, 2025, at 9:57 AM, V2 (DON/Director of Nursing) said on July 15, 2024, R37 was hit…

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 positioning devices for hands that had contractures and limited range of motion. This applies to 2 of 2 residents (R18 and R20) reviewed for limited range of motion in the sample of 25. The findings include: 1, R18 was admitted to the facility on [DATE], with multiple diagnoses including cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, vascular dementia, aphasia, unspecified osteoarthritis, peripheral vascular disease, and essential hypertension. R18's Restorative Nursing assessment dated [DATE], showed R18's right wrist and fingers had a 50 % or moderate loss of range of motion. R18's physician order dated April 29, 2025, showed Assistance with right hand soft pro [NAME] resting hand splints 4-6 hours per day on in AM off in PM as tolerated initiated on February 27, 2024. On April 28, 2025, at 10:33 AM, R18 was not wearing any splint or positioning device to her right hand. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to assess a resident for PTSD (Post-Traumatic Stress Disorder), identify their PTSD triggers, and develop interventions to aid in the management of the residents PTSD. This applies to 1 of 2 residents (R63) in the sample of 25. The findings include: Face sheet, dated April 30, 2025, shows R63's diagnoses included PTSD, major depressive disorder, schizoaffective disorder, alcohol dependence, anxiety disorder, and obsessive-compulsive disorder. PASRR (Preadmission Screening and Resident Review) II document, dated May 18, 2024, shows, You forget often and stated you have Post Traumatic Stress Disorder due to many deaths among friends and family, and from work as a 911 dispatcher. You have unwanted thought, possibly due to obsessive compulsive disorder and you are taking Paroxetine. You do not have documentation to support these diagnosis, you could benefit from neuropsychic evaluation and cognitive testing. You have a mental health diagnosis 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 administer medications as prescribed. There were 27 opportunities with 4 errors resulting in a medication error rate of 14.81%. This applies to 2 of 6 residents (R9, R69) residents reviewed for medication administration in the sample of 25. The findings include: 1. R9's admission record showed R9 was [AGE] years old and was admitted to the facility on [DATE], with multiple diagnosis including cerebral palsy, type 1 diabetes mellitus, chronic obstructive pulmonary disease, schizophrenia, bipolar disorder, and unspecified glaucoma. On April 28, 2025, at 4:24 PM, V6 (LPN) performed blood glucose check and result was 179. V6 administered 1 unit of Admelog SoloStar solution via pen to R9's abdomen, right upper quadrant. V6 then administered haloperidol 2mg tablet, Depakote sprinkles capsules and gabapentin capsule. V6 did not administer Insulin Glargine solution 40 units. R9's physician order summary showed R9's scheduled medication for 5:00…

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 5 of 5 residents (R1, R2, R3, R4 and R5) reviewed for ADLs (activities of daily living) in a sample of 9. The findings include: 1. On 11/12/24 at 11:15 AM, observed R1 in semi-Fowler's position in bed. R1 stated he is doing alright. Alert, oriented X 3. Observed R1's finger nails on both hands are over-grown with brown debris underneath the nails. R1 stated, nobody had offered to clip his nails for him. Observed R1's beard is overgrown and untidy. On 11/13/24 at 9:25 AM, observed R1 dozing in semi-Fowler's position. Observed his finger nails on both hands are over-grown with brown debris underneath the nails. Observed R1's beard is unkempt. On 11/13/24 at 9:45 AM, observed R1's beard is unkempt. R1's MDS (Minimum Data Set) dated 10/17/24 showed, R1 was [AGE] years old, admitted to the facility on [DATE] and needed extensive assist for ADLs. 2. On 11/12/24 at 11:40 AM,…

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 a call light accessible to dependent residents. This applies to 3 of 3 residents (R1, R2 and R3) reviewed for accommodation of needs in a sample of 9. The findings include: 1. On 11/12/24 at 11:15 AM, observed R1 in semi-Fowler's position in bed. R1 stated he is doing alright. Alert, oriented X 3. Observed R1's call light is on the floor at his head end of the bed. R1 stated, call lights don't always work. R1 stated, he just yells out or knocks hard on the wall for the CNA (Certified Nursing Assistant) to come. R1 stated, he usually cannot reach the call light because it is not long enough. On 11/13/24, at 9:25 AM, observed R1's call light hanging over his bed, out of reach of the R1. On 11/14/24 at 9:45 AM, observed R1's call light is lying on the floor at the head end of the bed. V9 (LPN-Licensed Practical Nurse) verified the observation and stated, the call light should be within resident's reach. R1's MDS (Minimum Data Set) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were assisted to reposition in bed. This applies to 3 of 6 residents (R3, R4 and R5) reviewed for ADLs (activities of daily living) in the sample of 6. Findings include: 1. On 10/24/24 at 10:00 AM, R3 is observed to be in supine position. R3 is alert, oriented X 3. On 10/24/24 at 11:30 AM, R3 is observed to be in supine position. On 10/24/24 at 12:30 PM, R3 is in supine position. R3 stated he does not get re-positioned on his side at any time. R3 stated he is always lying on his back and that he is turned only to change his incontinent brief or linen. R3 stated he would love to lie on his side for some time. R3's face-sheet showed R3 was admitted on [DATE] with diagnoses to include Parkinson's Disease, depression and difficulty in walking. R3's MDS (Minimum Data Set) dated 10/4/24 showed R3 had no cognitive impairment. R3's Care plan dated 10/9/24 showed he is at increased risk for alteration of skin integrity and 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's medical records included complete documentation of a resident's death. This applies to 1 of 3 residents (R12) reviewed for medical records in the sample of 15. The findings include: R12's face sheet shows he was a [AGE] year-old male, initial admission date 7/29/20 and readmitted on [DATE]. R12's diagnoses including COPD, weakness, unspecified dementia, aphasia, dysphagia, heart disease, and unspecified psychosis. R12's discharge date showed 9/9/24; discharged to is left blank. R12's nurses note dated 9/8/24 at 4:28 PM, documents R12 seen by hospice nurse .R12 remained with audible crackles, respirations of 20, and oxygen 91% on 4 Liters via nasal cannula. No fluids or food intake, oral care provided, repositioned and kept comfortable. No pain or discomfort observed, cool to touch and mottling on bilateral lower extremities, family visited this afternoon. R12's electronic medical records showed no documentation regarding his death.…

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 protect residents' privacy, as staff took photographs of residents, with a mobile device, without the resident's consent. This applies to 4 of 4 (R6, R9, R10, R11) residents reviewed for resident privacy. On September 10, 2024, at 4:20 PM, V33 (CNA) stated she had taken photos of residents in the facility on May 19, 2023, May 21, 2023, and June 1, 2023, on the dementia unit. V33 stated she had shared the photos with V46 (CNA). On September 11, 2023, at 1:22 PM, V38 (CNA) stated V46 showed the photographs V33 sent to her via cell phone, to both herself and V24 (CNA). On September 12, 2024, at 1:05 PM, V1 (Administrator) and V2 (Director of Nursing) reviewed photos that V1 stated she had received from V46 that were identified as having been taken by V33. There were 7 photos, 4 depicting 2 different unknown female residents (R10, R11) seated in a wheelchair with what appeared to be a sheet tied around the waist, taken in the dining room. There were 2 photos of a female resident (R9) lying in the bed clothed with the bed…

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 staff failed to immediately report suspicions of abuse in accordance with their policy. This applies to 4 of 4 (R6, R9, R10, R11) residents reviewed for allegations of abuse. The findings include: On September 10, 2024, at 4:20 PM, V33 (Certified Nursing Assistant-CNA) stated she had taken photos of residents in the facility on May 19, 2023, May 21, 2023, and June 1, 2023, on the dementia unit. V33 stated she had shared the photos with V46 (CNA). V33 was unable to positively identify any of the residents in the photos she took except for R6. V33 stated she did not report the alleged abuse depicted in the photos at any time to either the previous administrator, V1 (Administrator, who was not the Administrator at the time the photos were taken), or V2 (Director of Nursing, who was DON at the time of the pictures were taken). Review of the facility's incident reports of abuse from May of 2023, until September 18, 2024, showed there were no incident reports regarding abuse for the dates of May 19, 2023, May 21, 2023, or June 1, 2023,…

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 medications were administered with licensed nurse supervision. This applies to 1 of 3 residents (R3) reviewed for pharmacy services in a sample of 13. The findings include: On September 5, 2024 at 12:30 PM, V54 (Family Member) said R3 was given her 5 PM and 9 PM medications at the same time. V54 said R3 was told to take the 5 PM medications and then later take the 9 PM medications. On September 6, 2024 at 11:50 AM, R3 said a nurse came in and gave her the 5 PM and 9 PM medications and told her to take it. On September 17, 2024 at 9:43 AM, V7 (Social Services Assistant-SSA) translated to Spanish for R3, and when asked about the medication, said V10 (LPN/Licensed Practical Nurse) gave her two cups of medications, one for now, and one for later. On September 6, 2024 at 11:20 AM, V7 (SSA) said she was in R3's room earlier in the week and saw a cup with four to five pills sitting on the bedside table. V7 said she was not sure why it was in there and was not sure who the nurse was who did that. V7 said she asked R3 about…

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 prevent a resident from being served food that was spoiled. This applies to 1 of 3 residents (R2) reviewed for spoiled food in a sample of 13. The findings include: On September 5, 2024 at 12:30 PM, V54 (Family Member) said R2 complained about mold all over her hamburger bun. On September 5, 2024 at 3:58 PM, R2 said she had mold on the bottom of her bun. R2 said she had not eaten any of the mold. On September 5, 2024 at 3:22 PM, V16 (Cook) said R2 had complained a few days ago about there being mold on the bread. V16 said the dietary staff had taken a picture of the burger bun with the mold, and when asked, showed the surveyor a picture of R2's food, which was observed to be the bottom slice of a hamburger bun with about a quarter to half dollar sized amount of a green, fuzzy substance. On September 17, 2024 at 9:22 AM, V6 (Social Services Director) said a CNA (Certified Nurse Assistant) had shown her R2's food, which had a quarter to half dollar coin sized amount of mold on it. V6 said she informed V1 (Administrator), 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 provide timely incontinent care to dependent residents. This applies to 2 of 4 residents (R1, R2) reviewed for activities of daily (ADL) care in a sample of 7. The Findings Include: 1. R1 is a [AGE] year-old male admitted with severe cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. R1 is dependent on toileting hygiene. On 8/20/24 at 10:07 AM, R1 was in his bed and upon the surveyor's request V4 (Licensed Practical Nurse) checked on R1 for incontinence. R1 was observed with double diaper with the inner diaper soaked in urine with blackish discoloration. On 8/20/24 at 10:10 AM, V4 stated, R1's certified nursing assistant (CNA) is changing another resident and I will change R1. We are supposed to check on residents every two hours as needed and shouldn't put a double incontinent brief on residents. On 8/20/24 at 10:30 AM, V2 (Director of Nursing / DON) stated, We have couple of residents who prefers to have double diaper…

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 successfully notify the resident's legal representative regarding a significant change in condition for R3 who was sent out to the hospital. This applies to 1 of 4 residents (R3) reviewed for significant change in condition. The findings include: The EMR (Electronic Medical Record) showed R3, a [AGE] year-old, with diagnoses includes dementia, schizophrenia, Alzheimer's disease, bipolar disorder, psychosis, anxiety disorder and COPD (chronic obstructive pulmonary disease). R3 was admitted to the facility on [DATE]. The MDS (Minimum Data Set) dated 4/19/2024 showed R3 was moderately impaired with cognition with BIMS (Brief Interview Mental Status) with a score of 9/15. The MDS also showed R3 was identified with history of fall prior to admission to the facility. The progress notes dated 6/4/2024 showed R3 was noted with the following: -3:15 A.M., R3 was restless and had a near fall scenario as staff assisted R3 to the floor by bedside. The notes showed…

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 provide privacy and confidentiality for a resident by posting her photo on social media without her permission. This applies to 1 of 3 residents (R1) reviewed for privacy and photography in a sample of 3. The findings include: R1's face sheet shows an admission date 7/16/21. R1's face sheet includes the following diagnoses: multiple sclerosis and major depressive disorder. R1's MDS (Minimum Data Set) dated 4/5/24 shows a BIMS (Brief Interview for Mental Status) score of 15 which means she is cognitively intact. R1's Photographic Authorization and Release form dated 3/5/24 shows R1 circled 'no' for having her photo and/or image posted on the facility's website and social media. The form was also signed off by her. On 5/21/24 at 3:43 PM, telephone interview was completed with V5 (R1's family member). R5 stated, I was looking at the facility's web page on social media. I saw (R1's) picture on there with other residents. They are supposed to get my consent first before they do anything like this because I'm the POA (Power 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, and store food items in the 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 4/9/24 documents that the total census was 118 residents. On 4/10/24 at 11:14 AM, V5 (Dietary Manager) said there are 3 residents that do not eat food from the facility kitchen. On 4/9/24 starting at 9:37 AM, the facility kitchen was toured in the presence of V4 (Dietary Manager), and the following was found: In the walk-in cooler: 1. Unlabeled and undated medium-sized silver bin of what V4 said was ground ham. 2. Undated and unsealed and opened processed oven-roasted turkey breast. 3. Unlabeled and undated sliced cheese. In the dry storage: 4. Opened, not sealed 32-ounce bag of sundried raisins with expiration date 8/25/23. V4 said, I have to throw these out because the bag wasn't closed…

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 catheter cares for residents with indwelling urinary catheters, and failed to ensure a catheter collection bag was placed below the level of the bladder. This applies to 4 of 4 (R33, R39, R68, and R122) reviewed for catheters in a sample of 32. The findings included: 1. The EMR (Electronic Medical Record) showed R122 had multiple diagnoses including sepsis, urinary tract infection, and pressure ulcer of sacral region stage 4. The MDS (Minimum Data Set) dated 2/27/2024 showed R122 was incontinent of bowel and had a urinary indwelling catheter. The MDS showed R122 was dependent on facility staff with toileting hygiene and bed mobility. On 4/10/2024 at 1:38 PM, V15 (Certified Nurse Assistant/CNA) was rendering incontinence care to R122. R122's catheter anchoring device was detached and located in her right inner groin area and had a soiled incontinence brief with fecal material. V15 wiped R122's groin and perineal areas from front 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to obtain physician orders for resident medications to be at the bedside. The facility also failed to complete self-administration of medication assessments for residents. This applies to 3 of 10 residents (R29, R45, R106) reviewed for medications in a sample of 32. The findings include: 1. On 4/9/24 at 10:14 AM, during initial tour, on top of R106's end table, there were two Albuterol Sulfate inhalers. R106 stated the inhalers are always in his room and prefers them in his room because it takes forever for the nurses to administer it to him. R106 stated that the nurses did not teach him how to do it. R106 stated he already knows how to use it. R106's face sheet shows a diagnosis of acute respiratory failure with hypoxia. R106's POS shows an order for Ventolin HFA Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate HFA)-2 puffs inhale orally every 6 hours as needed for wheezing. R106's MDS (Minimum Data Set) dated 2/6/24 shows a BIMS…

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 linens were handled in a manner to prevent transmission of micro-organisms and failed to cleanse and sanitize hands to prevent cross-contamination. This applies to 3 of 3 residents (R114, R97 and R122) reviewed for infection control in the sample of 32. Findings include: 1) On 4/9/24 at 11:20 AM, R114 was in wheelchair and V11(CNA-Certified Nursing Assistant) made his bed. In the process, V11 threw a soiled sheet on the floor. 2) On 4/10/24 at 12:45 PM, V11 gave perineal care to R97. When V11 had finished wiping the anal area of R97, V11 did not do hand hygiene or change gloves. With same gloves, V11 touched other surfaces when she put R97's clean brief on, repositioned R97, and changed the bed linen. When V11 was making the bed for R97, V11 threw a soiled sheet on the floor. On 4/10/24 at 12:55 PM, V11 stated she should have changed her gloves and done hand hygiene after providing perineal care to R97 to prevent potential cross-contamination. V11 stated throwing the linen on the floor is her usual…

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 protect the resident's right to be free from mental abuse and mistreatment by V6 (CNA-Certified Nursing Assistant). This applies to 1 of 3 residents (R1) reviewed for mental abuse in the sample of 4. The findings include: The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. R1 has multiple diagnoses including, chronic kidney disease, atrial fibrillation, Type 2 diabetes, acute kidney failure, UTI (Urinary Tract Infection), adult failure to thrive, anxiety, and psychosis. R1's MDS (Minimum Data Set) dated February 12, 2024 shows R1 is cognitively intact, requires setup assistance with eating and oral hygiene, partial/moderate assistance with toilet hygiene, bed mobility, and transfers between surfaces, and substantial/maximum assistance with showering, lower body dressing, and personal hygiene. R1 is frequently incontinent of urine and always continent of stool. On March 21, 2024 at 12:23 PM, R1 was sitting up in her room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure elevators were maintained in safe, operating condition. This applies to 1 of 3 residents (R1) reviewed for furnishings/equipment not maintained in the sample of 4. The findings include: On March 25, 2024 at 9:25 AM, on the first floor of the facility, the elevator located at the north end of the building had a sign posted on the outside. The sign showed the elevator was out of order and directed people to the elevator located on the south end of the building. On the first floor of the facility, the front elevator doors of the south elevator were open. No staff were present. A flatbed, four-wheeled cart was blocking the front door access to the elevator. Half of the flatbed cart was inside the south elevator, and half of the flatbed cart was outside of the elevator. The flatbed cart was holding the front doors to the elevator open and preventing people from entering the front access door to the elevator and preventing the elevator from moving 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 ensure a resident's right to receive mail for 1 of 3 residents (R2) reviewed for resident rights in the sample of 8. The findings include: On 1/25/24 at 12:24 PM, R2 was lying in bed. R2 said the facility was not delivering his mail. R2 said he was having his Social Security checks and most of his mail sent to pay his rent. R2 said he lived in the same apartment for 20 years and was still paying rent because he thought he would have returned there by now. R2 said the facility had provided him with a bill and he appealed the bill. R2 said he was understood that he did not owe any money for the first 3 months of his therapy but would have to pay for any continued therapy after those 3 months. R2 said the facility withheld mail from him. R2 said his insurance carrier changed without his knowledge and the facility changed his address for his Social Security payment. R2 stated, How can they do that without my consent? The business office lady came and spoke to me about it a few weeks ago. She told me that because I…

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 received an antibiotic ear medication in a timely manner for 1 of 3 residents (R1) reviewed for medications in the sample of 8. The findings include: The Nurses Notes for R1 showed: 1/16/24 - The resident complained of pain/pressure on her left ear, inspection of ear done, no redness, swelling and visible earwax observed. Afebrile, temperature 97.5, no colds and cough, NP was informed. No new order and told this writer that the other NP would be here tomorrow and will evaluate the resident. 1/17/24 at 7:56 AM - Resident slept well. When asked if there's any discomfort of left ear, resident stated, No but the pressure is still there. No swelling noted. The Nurse Practitioner's Note dated 1/17/24 for R1 showed, Patient is sitting in her wheelchair, R1 stated her left ear is painful and she feels pressure in it. Otitis externa/left ear pain: R1 stated she had a shower two days ago. Erythema noted in left ear. Start Ciprofloxacin ear drop…

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 the risk for developing a pressure ulcer, failed to identify and assess a facility acquired pressure ulcer and failed to follow physician's orders for treatment. This applies to 3 of 3 residents (R3, R4, R5) reviewed for pressure ulcer in the sample of 8. The findings include: 1). R3's EMR (Electronic Medical Record) showed R3 was admitted to the facility on [DATE], and discharged from the facility on February 23, 2022. R3 had multiple diagnoses including Parkinson's disease, heart failure, morbid obesity, osteoarthritis of the knees, lymphedema, fracture of the left humerus, and weakness. R3's MDS (Minimum Data Set) dated December 30, 2021, showed R3 to be cognitively intact, and required extensive assistance with ADLs including, bed mobility, transfer, dressing, eating and toilet use. R3's EMR showed R3 had one Braden skin risk assessment on 12/23/21, the day of admission, with a risk score of 19 (meaning R3 was at no risk 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 have menus and serve portion servings to meet nutrient needs that are approved in advance by a licensed Dietitian. This applies to all 123 residents that receive oral diets prepared in the facility kitchen. The findings include: Facility Resident Census and Conditions of Residents form (CMS Form 672) dated 5/22/23 showed that the facility census is 125. Facility provided information that two residents are NPO (nothing by mouth status). 1. Facility Week at a Glance (Week 3) showed that the original menu for General/Regular consistency for Monday (5/22/23) was Stir Fried Chicken over Steamed Rice, Seasoned Broccoli, Fresh Orange, Bread. Meal prepared in the facility kitchen for the day included Chicken Fajitas, Corn or Peas, Fruit Mix. On 05/22/23 11:58 AM, during the lunch meal service in the facility kitchen the residents on Regular diets were noted to receive 1 (one) tortilla topped with one #8 scoop (4 ounce/scoop) of diced chicken with green pepper and onions mixture along with #8 scoop of corn and mixed…

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 timely incontinence care, hygiene, and grooming for residents who require staff assistance for activities of daily living (ADL) care. This applies to 4 of 7 residents (R71, R90, R47, R84) reviewed for ADL care in the sample of 26. The findings include: 1. The EMR (Electronic Medical Record) shows R71 was admitted to the facility on [DATE], with multiple diagnoses including dementia, heart disease, and diabetes. The MDS (Minimum Data Set) dated April 21, 2023, shows R71 has severely impaired cognitive skills for daily decision making. The MDS continues to show R71 requires extensive assistance of facility staff for toilet use and is always incontinent of bowel and bladder. R71's bowel and bladder care plan revised on August 8, 2022, shows, The resident is incontinent of bladder, bowel. This problem is related to poor cognitive skills, inability to communicate need for toileting. The problem is related to type 2 diabetes, weakness,…

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 perform quarterly activity assessments and failed to provide residents with activities that promote their sense of well-being and meet their interests. This applies to 4 of 4 residents (R11, R20, R48, R87) reviewed for activities in a sample of 26. The findings include: 1. R11's admission record shows R11 is [AGE] years old with diagnoses that include hypertensive chronic kidney disease, diabetes, weakness, osteoarthritis of the right shoulder, and adult failure to thrive. R11's MDS (Minimum Data Set) dated April 11, 2023 shows R11 is cognitively intact, requires the use of a wheelchair for mobility and extensive assistance with ADLs (activities of daily living). The MDS shows that to keep up with the news, to do favorite activities, to be around animals, to do things with groups of people and to go outside to get fresh air when the weather is good are important to R11. On May 22, 2023 at 11:35 AM, R11 stated she wants to go outside as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide perineal and catheter care in a manner that would prevent urinary tract infection (UTI). This applies to 4 of 6 residents (R20, R21, R82, R220) reviewed for incontinence and catheter care in the sample of 26. The findings include: 1. R20's electronic medical record (EMR) shows that R20 is 58 years-old who has multiple medical diagnoses which include multiple sclerosis, ataxia, and stage 2 chronic kidney disease. MDS (minimum data sheet) dated 4/7/23 shows that R20 requires extensive assistance for toileting and hygiene. On 5/23/23 at 1:47 PM, V29 (CNA) rendered incontinence care to R20 who was heavily saturated with urine. V29 cleaned R20 from front to back, such as the pubic area, groins, outer labia, rectum, and buttocks. However, she did not separate labia to clean the inner folds. 2. R21's EMR shows that R21 is 92 years-old who has multiple medical diagnoses which include vascular dementia. MDS dated [DATE] shows that R21…

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 label medication of when it was opened to determine the expiration date. This applies to 5 of 6 residents (R12, R31, R86, R88, R221) reviewed during medication storage and labeling inspection. The findings include: On 5/23/23 at 3:25 PM, the 2 South medication cart was inspected with V32 (Nurse). There were multiple medications that were opened and there was no date/label on the container to show when it was opened to determine the expiry date. 1. R12's two bottles of Latanoprost Solution 0.005% and Incruse Ellipta 62.5 mcg were open and not dated. 2. R221's two multi dose vials of Haldol 5mg/ml were open and not dated. 3. R86's Humalog Kwik Pen was opened on 3/11/23. 4. R88's Breo Ellipta was open and not dated. 5. R31's Advair Diskus was open and not dated. On 5/24/23 at 2:05 PM, V12 (Assistant Director of Nursing/ADON) stated when insulin vials or pens, eye drops, and inhalers are opened the staff should date or label the day it was opened because it would determine the expiration date. On 5/24/23 at 4:00…

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 yogurt for food preference as shown on diet cards. This applies to 4 of 4 residents (R26, R39, R46, R63) observed for dining in the sample of 26. The findings include: On 05/22/23 starting at 12:48 PM, R26, R39 and R63's lunch meal served in their rooms were observed. R26 received a lunch room tray of regular consistency diet. R26's Diet Card showed, yogurt per request and did not receive the same. R39 received a lunch room tray of regular consistency diet. Diet card showed yogurt with all meals but did not receive the same. R39 stated that she really likes yogurt and does not know why she did not receive it. R63 received a lunch room tray of regular consistency diet. R63's diet card showed yogurt-preference but did not receive the same. On 05/22/23 at around 1:28 PM, the above information was relayed to V26 (Certified Nursing Assistant) and V25 (Registered Dietitian) who were in the vicinity. V26 stated that she was informed that the facility ran out of yogurt. On 05/23/23 starting at 09:06 AM, during…

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

Based on observation, and interview, the facility failed to follow standard infection control practices related to hand hygiene and gloving during provision of incontinence care. This applies to 5 of the 26 residents (R20, R21, R47, R82, R220) reviewed for infection control in the sample of 26. The findings include: 1. On 5/23/23 at 12:02 PM, V29 (Certified Nursing Assistant/CNA) provided bed bath and peri-care to R220. After completing the bed bath and peri-care, V29 applied Aquaphor ointment, and new incontinence brief, adjusted bed position, removed soiled or old linen, touched call lights and bed control, and assisted to dress R220, while wearing the same soiled gloves all throughout the care. 2. On 5/23/23 at 1:45 PM, V29 and V30 (Both CNA) transferred R20 to bed via mechanical lift. At 1:47 PM, while wearing same gloves. V29 proceeded to render incontinence care. V29 wiped R20 from front to back, applied new incontinence brief, pulled pants up, adjusted R20's clothes and transferred R20 back to the wheelchair via mechanical lift while wearing the same soiled gloves. 3. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident had a POLST (Physician Ordered Life Sustaining Treatment) form signed by the physician before designating a resident as a DNR (Do Not Resuscitate) status. This applies to 1 of 2 residents (R109) reviewed for advanced directives in the sample of 26. The findings include: The EMR (Electronic Medical Record) shows R109 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease, dementia, depression, and urinary tract infection. The MDS (Minimum Data Set) dated May 5, 2023, shows R109 has severe cognitive impairment. On May 23, 2023, at 1:04 PM, V16 (RN/Registered Nurse) said I know a resident's code status by looking at the order in the computer. On May 24, 2023, at 11:20 AM, V12 (ADON/Assistant Director of Nursing) said to make a resident a valid DNR it must be signed by the physician and then the DNR can be ordered in the EMR. V12 continued to say a DNR cannot be ordered in the EMR until the POLST…

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 that a resident receives foot care and treatment for overgrown, thick and painful toenails. This applies to 1 of 1 resident (R84) reviewed for foot care in the sample of 26. The findings include: R84 has multiple diagnoses which includes idiopathic peripheral autonomic neuropathy, weakness and need for assistance with personal hygiene, based on the face sheet. R84's quarterly MDS (minimum data set) dated May 1, 2023 shows that the resident is severely impaired with cognition and requires extensive assistance from the staff with most of his ADLs (activities of daily living) including dressing and personal hygiene. The same MDS shows that R84 has functional limitation in range of motion affecting one side of both upper and lower extremities. On May 22, 2023 at 11:59 AM, R84 was sitting in his wheelchair inside the first floor dining/activity room. R84 was alert and verbally responsive. R84 complained that his toe nails are long and causes him pain. V3 (Nurse) was present when R84 made this comment. V3…

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 adaptive equipment and services to residents to prevent further reduction in mobility and ROM (range of motion). This applies to 2 of 9 residents (R80, R84) reviewed for mobility and range of motion in the sample of 26. The findings include: 1. R84 has multiple diagnoses which includes idiopathic peripheral autonomic neuropathy, weakness and need for assistance with personal hygiene, based on the face sheet. R84's quarterly MDS dated [DATE] shows that the resident is severely impaired with cognition and requires extensive assistance from the staff with most of his ADLs (activities of daily living). The same MDS shows that R84 has functional limitation in range of motion affecting one side of both upper and lower extremities. On May 22, 2023 at 11:59 AM, R84 was sitting in his wheelchair inside the first floor dining/activity room. R84 was alert and verbally responsive. R84 had weakness to his right hand and he was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their policy for a resident identified as a high elopement risk. This applies to 1 of 3 residents (R370) reviewed for elopement in the sample of 26. The findings include: The EMR (Electronic Medical Record) shows R370 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease and major depressive disorder. On May 22, 2023, at 3:10 PM, R370 was self-ambulating in the hallway and was attempting to follow a facility staff member off the unit. On May 24, 2023, at 2:35 PM, R370 was wandering near the exit door of the unit. On May 24, 2023, at 2:37 PM, R370 was attempting to follow this surveyor out the exit door of the unit, and no staff were aware or attempted to stop R370. This surveyor had to alert staff to keep R370 from exiting the unit. On May 22, 2023, at 11:16 AM, V34 (LPN/Licensed Practical Nurse) said R370 is always trying to leave the unit. V34 continued to say R370 tried to escape one time…

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 verify placement of gastrostomy tube (g-tube) prior to flushing the g-tube with water and administering medications through the g-tube. This applies to 2 of 2 residents (R25, R47) reviewed for gastrostomy tube (g-tube) in the sample of 26. The findings include: 1. R25's electronic medical record (EMR) shows that R25 is 82 years-old who has multiple medical diagnoses which include hemiplegia affecting left non-dominant side, aphasia, dysphagia, vascular dementia, gastrostomy status, and gastro-esophageal reflux disease without esophagitis On 5/23/23 at 4:40 PM, R25 was resting in bed. V22 (Nurse) flushed the g-tube with 60 ml (milliliters) of water without checking the placement of g-tube. On 5/23/23 at 5:24 PM, V22 administered medications to R25 through the g-tube. V22 again, did not check the placement of the g-tube prior to medication administration. 2. R47's EMR shows that R47 is 85 years-old who has multiple medical diagnoses which include Alzheimer's disease, dysphagia, encounter for attention 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident did not receive unnecessary psychotropic medications. This applies to 3 of 5 residents (R109, R370, and R72) reviewed for unnecessary psychotropic medications in the sample of 26. The findings include: 1. The EMR (Electronic Medical Record) shows R109 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease, dementia, depression, and urinary tract infection. The MDS (Minimum Data Set) dated May 5, 2023, shows R109 has severe cognitive impairment. On May 22, 2023, at 10:47 AM, R109 was sitting in her wheelchair in the dining room. R109 was slumped over and not participating in the group activity. On May 22, 2023, at 12:26 PM, R109 was sitting in her wheelchair in the dining room. R109 was resting her head on a pillow on the table. On May 24, 2023, at 2:35 PM, R109 was sitting in her wheelchair in the dining room. R109 was resting her head on a pillow on the table. R109's Order Summary…

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 diet consistency for residents that have swallowing problems. This applies to 2 of 2 residents (R22, R60) reviewed for dining in the sample of 26. The findings include: On 05/23/23 at 12:05 PM, during lunch meal service R60 received pureed foods with nectar thick liquids juice and regular coffee, 4 oz/ounce carton of health shake and was fed by V27 (Certified Nursing Assistant) in the dining room. Diet card showed nectar thick liquids. When asked if coffee is thickened, V27 stated that R60 likes her coffee diluted with hot water and it is not thickened. V27 remarked, She has her juice that is thickened. V27 was made aware that the diet card showed nectar thick liquids. R60's face sheet included diagnoses of Pneumonia due to other specified bacteria and Dementia of unspecified severity. On 05/23/23 at 12:31 PM, R22 received a lunch meal tray with thickened fluids and fruited gelatin for dessert. R22's diet card showed nectar thick liquids. Staff present in the area were not aware of diet specifications 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 assess and provide appropriate assistive eating device to maintain ability to eat independently for a resident identified with limited ROM (range of motion) of the upper extremities. This applies to 1 of 1 resident (R84) reviewed for assistive eating device in the sample of 26. The findings include: R84 has multiple diagnoses which includes idiopathic peripheral autonomic neuropathy, weakness and need for assistance with personal hygiene, based on the face sheet. R84's quarterly MDS (minimum data set) dated May 1, 2023 shows that the resident is severely impaired with cognition and requires supervision from the staff when eating. The same MDS shows that R84 has functional limitation in range of motion affecting one side of both upper and lower extremities. On May 22, 2023 at 12:38 PM, R84 was inside the first floor dining/activity room. R84 was alert and verbally responsive. R84 had weakness on his right hand, and he was not able to open his right-hand fingers due to contracture. R84 was served pureed food in 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.