Harbor Health & Rehab

Based on observation, record review, and interview, the facility failed to ensure adequate supervision was provided related to the serving of hot beverages and thickened liquids as well as a resident using a vape pen in their room for 2 of 3 residents reviewed for accidents. (Residents 2 and 63)Findings include: 1. During a random observation on 12/11/25 at 10:28 a.m., Resident 2 was observed in the Second Floor dining room participating in an activity. The resident received a cup of coffee from the activity aide that was not thickened. As she put the cup of coffee on the table, she told the resident to be careful because the coffee was hot. The resident proceeded to pick up the cup of coffee and it started to spill on the table and his hands due to his tremors. He waited a few seconds and attempted to pick up the cup again. The resident continued to shake but he was able to put the cup to his mouth and drink some of the coffee. There was no lid on the cup and he drank approximately a quarter of the coffee. At 10:33 a.m., a staff member came to the table and removed the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure indwelling Foley (urinary) catheter bags and tubing were kept off of the floor, nephrostomy tube equipment was changed and the site was monitored for 1 of 2 residents reviewed for Foley catheters and 1 of 1 resident reviewed for nephrostomy tubes. (Residents 1 and 6)Findings include:1. During random observations on 12/16/25 at 8:29 a.m., LPN 3 was observed preparing medications for the resident outside of Resident 1's door. The door was wide open and the resident was observed in bed. The resident told the nurse to come back later to give him his medications and to close the door. At that time, the resident's Foley catheter bag and tubing was observed on the floor next to his bed. LPN 3 closed the resident's door and did not pick up the Foley bag off of the floor. During random observations on 12/16/25 at 9:34 a.m. and 11:15 a.m., Resident 1 was observed in bed. At those times, his Foley catheter bag and tubing was observed on the…

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

Based on observation, record review, and interview, the facility failed to check for peg tube (a tube inserted directly into the stomach for nutrition) placement properly prior to medication administration for 1 of 1 resident observed for peg tube medication administration. (Resident 11)Finding includes:During a medication administration observation on 12/16/25 at 8:02 a.m., RN 1 poured and prepared medications for Resident 11 to be administered through his peg tube. She entered the resident's room and placed his enteral tube feeding on hold. The RN removed the connection device and hung it over the pole. She then removed the syringe and placed it into one of the two ports on the peg tube. She poured 30 cubic centimeters (cc) of water down the tube via gravity. She removed the syringe and placed the piston inside and pulled back (checking for residual) the stomach contents. She pulled back less than five cc of fluid from each port. At that time, she indicated she was supposed to be able to pull back 30 cc of residual so she was going to notify the physician. During an interview at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure an implanted port device was assessed and monitored for 1 of 1 resident reviewed for parental/IV fluids. (Resident 63) Finding includes:During a random observation on 12/12/25 at 2:00 p.m., Resident 63 was observed sitting in a wheelchair by the elevator. At that time, her shirt was falling off of her shoulder and an implanted port device was observed with a white bandage over it. The record for Resident 63 was reviewed on 12/12/25 at 2:40 p.m. Diagnoses included, but were not limited to, vulva cancer, adult failure to thrive, chronic obstructive pulmonary disease (COPD), anxiety disorder, heart failure, and high blood pressure. The 9/26/25 Significant Change Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for decision making. A Care Plan, dated 12/14/25, indicated the resident had a right chest port-a-cath (PAC). The approaches were to monitor the port and report changes to the physician. An…

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

Based on observation, record review and interview, the facility failed to ensure proper medication storage related to pre-filled saline syringes used to flush implanted port devices stored in the resident's room for 1 of 6 residents observed during medication pass. (Resident 74)Finding includes:During a medication pass observation on 12/15/25 at 2:12 p.m., LPN 2 entered Resident 74's room with an Intravenous (IV) antibiotic medication and two pre-filled normal saline syringes to flush the resident's line before the IV administration. At that time, inside the resident's room, there was a pre-filled normal saline syringe laying on the resident's over bed table as well as two pre-filled normal saline syringes on top of the night stand. The LPN used the two pre-filled syringes she had brought into the room to flush the resident's port and then placed the other three syringes on top of the night stand before she left the room She informed the resident she would be back in one hour to take the IV down and disconnect the tubing. At 3:28 p.m. LPN 2 entered the resident's room with 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 and interview, the facility failed to ensure food was served at a palatable temperature for one of one meal observation. (Residents 4, 24, and 42)Finding includes:During an interview on 12/11/25 at 11:16 am, Resident 4 indicated the facility's food was bad, and most of the time, he did not want to eat it. During an interview on 12/12/25 at 9:41 a.m., Resident 24 indicated the facility's food was often cold. During a resident council interview on 12/15/25 at 3:09 p.m., Resident 42 indicated food taste and temperature had been a concern brought up in resident council. He indicated the food was often cold when they received it. During a meal observation on 12/16/25 at 11:44 a.m., lunch trays were brought up on a non-insulated cart for the second floor dining room. On 12/16/2025 at 11:53 a.m., the test tray temperatures were checked by the Kitchen Manager as follows: chicken-104 degrees, rice-120 degrees, and black beans-120 degrees via a manual thermometer. The Kitchen Manager indicated she thought there was something wrong with the thermometer. She covered 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 record review and interview, the facility failed to ensure a resident received physical therapy as ordered by the physician for 1 of 1 resident reviewed for rehabilitation services. (Resident 10)Finding includes:During an interview on 12/11/25 at 11:16 a.m., Resident 10 indicated he did not receive therapy and sometimes went many days without it. The record for Resident 10 was reviewed on 12/15/25 at 1:20 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited, chronic kidney disease and post surgical Thoracic 11 thru Lumbar 1 laminectomy (a procedure to remove pressure from the spinal cord). The admission Minimum Data Set (MDS) assessment, dated 11/5/25, indicated the resident was cognitively intact for daily decision making and received speech, occupational, and physical therapy. A Physician's Order, dated 11/1/25, indicated physical therapy was to see the resident for five times a week for 30 days for therapeutic exercises, activity tolerance training, gait…

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

Based on record review and interview, the facility failed to ensure the medical record was complete and accurate related to inaccurate tube feeding residual amounts and incorrect resident information in a record for 1 of 21 records reviewed. (Resident 11) Finding includes:The record for Resident 11 was reviewed on 12/16/25 at 1:56 p.m. Diagnoses included, but were not limited to, congestive heart failure (CHF), dysphagia (trouble swallowing), and gastrostomy (a feeding tube inserted through the abdomen). The Significant Change Minimum Data Set (MDS) assessment, dated 11/17/25, indicated the resident had moderate cognitive impairment, required substantial assist with activities of daily living (ADLs), and had an enteral (tube) feeding.A Physician's Order, dated 11/19/25, indicated to verify the enteral feeding residual every shift, if more than 100 milliliters (ml), hold the feeding and notify the physician.The December 2025 Medication Administration Record (MAR) indicated the following enteral tube feeding residual amounts: 12/1 1st shift-300, 12/4 2nd shift-300, 12/8 1st shift-300,…

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

Based on record review and interview, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and a system of monitoring to improve resident outcomes and reduce antibiotic resistance related to a resident remaining on an antibiotic after the organism was determined to be resistant to the medication and prescribing antibiotics for not true infections based on the McGeer Criteria for 1 of 1 resident reviewed for urinary catheters. (Resident 8)Finding includes: During an interview on 12/12/25 at 10:23 a.m., Resident 8 indicated he was having issues with frequent urinary tract infections. The record for Resident 8 was reviewed on 12/16/25 at 10:37 a.m. Diagnoses included, but were not limited to, chronic kidney disease, renal dialysis, and obstructive and reflux uropathy (blockage of urine flow). The Quarterly Minimum Data Set (MDS) assessment, dated 9/10/25, indicated the resident was cognitively intact and had an indwelling catheter. A Care Plan, dated 3/28/24 and reviewed on 9/10/25, indicated the resident had a suprapubic catheter…

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

Based on observation, record review, and interview, the facility failed to ensure oxygen was set at the correct flow rate and signed out on the Medication Administration Record (MAR) for 1 of 3 residents reviewed for respiratory care. (Resident E) Finding includes: On 4/7/25 at 9:08 a.m., Resident E was observed lying in bed. The resident's nasal cannula tubing was sitting under her nose and the oxygen flow rate was set a little above 1.5 liters as the ball was under the 2 liter line. On 4/8/25 at 8:51 a.m., the resident was observed in bed eating breakfast. Resident E was wearing oxygen via nasal cannula and the flow rate was set little over 1.5 liter line. During and interview at the time, LPN 1 indicated the resident was on 2 liters of oxygen. When asked to verify the rate again, LPN 1 verified it was not at 2 liters and moved the ball to the middle line of the 2 liter line. The record for Resident E was reviewed on 4/8/24 at 9:11 a.m. Diagnoses included, but were not limited to, dementia, COPD, high blood pressure, heart failure and anxiety. The 3/3/25 Quarterly Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the residents' environment was in good repair related to marred walls, loose baseboards and missing bolts around the toilet for 1 of 2 floors observed. (First Floor) Findings include: During the Environmental Tour on 8/9/24 at 9:30 a.m. with the Maintenance Director, the following observed: First Floor a. room [ROOM NUMBER] - The cove base was pulling away from the wall near the entrance of the room. The walls were marred under the chair rail. The base of bathroom door was scratched and marred. There were 2 residents who resided in room and 4 residents shared the bathroom. b. room [ROOM NUMBER] - The wall the behind the bed was marred and gouged. There was 1 resident who resided in the room. c. room [ROOM NUMBER] - The door frame was marred by the closet and the cove base was loose in the entry way of the room. The walls in the bathroom were marred. There were 2 residents who resided in the room and shared the bathroom. d. room [ROOM NUMBER]- The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure each resident's dignity was maintained related to a cognitively impaired dependent resident being dressed in a hospital gown during the day for 1 of 1 resident reviewed for dignity. (Resident 58) Finding includes: During random observations on 8/5/24 at 11:30 a.m. and 2:55 p.m., on 8/6/24 at 9:58 a.m.,1:00 p.m., 1:45 p.m., and 2:24 p.m., and on 8/7/24 at 10:30 a.m., Resident 58 was observed in bed wearing a hospital gown. The record for Resident 58 was reviewed on 8/6/24 at 1:20 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, stroke, obesity, dysphagia, type 2 diabetes, high blood pressure, heart disease, peg tube (a tube inserted directly into the stomach for nutrition), restlessness and agitation. The 7/9/24 Significant Change Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making. The resident did not participate in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure dependent residents received assistance with activities of daily living (ADL's) related to the cleaning and cutting of fingernails, oral care, and getting out of bed for 2 of 10 residents reviewed for ADL's. (Residents 45 and 58) Findings include: 1. During random observations on 8/5/24 at 10:25 a.m., on 8/6/24 at 2:45 p.m., and on 8/7/24 at 10:15 a.m., Resident 45 was observed in bed with long and dirty fingernails. During an interview on 8/5/24 at 10:25 a.m., the resident stated I need nail care really bad. The record for Resident 45 was reviewed on 8/7/24 at 11:20 a.m. Diagnoses included, but were not limited to, infarction of the spinal cord, heart disease, high blood pressure, type 2 diabetes, major depressive disorder, anxiety disorder, urine retention, and neuromuscular of the bladder. The 5/30/24 Annual Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and needed…

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, record review, and interview, the facility failed to provide a personalized activity program for cognitively impaired and dependent residents related to ongoing stimulation and being invited to activities for 2 of 2 residents reviewed for activities. (Residents 24 and 58) Findings include: 1. On 8/6/24 at 12:58 p.m., 2:10 p.m., and 3:03 p.m., Resident 24 was observed in his room in bed. The resident's eyes were closed and no television or radio were present in the resident's room. On 8/7/24 at 9:05 a.m., 10:05 a.m., 11:39 a.m., and 1:28 p.m., the resident was observed in his room in bed. His eyes were closed and there was no television or radio present in his room. On 8/8/24 at 11:00 a.m. and 1:10 p.m., the resident was observed in his room in bed. His eyes were closed and there was no television or radio present in his room. On 8/9/24 at 8:47 a.m., the resident was observed in his room in bed. His eyes were closed and there was no television or radio present in his room. The record for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure areas of discoloration and treatments for non-pressure areas were completed and/or ordered for 2 of 2 residents reviewed for non-pressure related skin conditions (Residents 13 and 57) Findings include: 1. During a random observation on 8/5/24 at 2:40 p.m., Resident 13 was observed in bed. At that time, her feet were very dry and flaky with peeling skin. The resident had an open area on her right ring finger that was uncovered. During an interview at that time, the resident indicated the treatment to the finger was last done on Friday 8/2/24, and it was done every Monday, Wednesday and Friday. She indicated staff did not put any special lotion on her feet. During an interview on 8/7/24 at 1:50 p.m., the resident indicated she had seen the wound physician today and the treatment to her finger was not completed yesterday (8/6/24). The record for Resident 13 was reviewed on 8/7/24 at 2:30 p.m. Diagnoses included, but were not limited…

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, record review, and interview, the facility failed to ensure glasses were received as ordered and a follow up audiology (a physician who treats hearing issues) appointment was completed for 3 of 4 residents reviewed for vision and hearing. (Residents 2, 45, and 34) Findings include: 1. During an interview on 8/5/24 at 1:32 p.m., Resident 2 indicated he needed new glasses and he had told the staff. The resident was not wearing glasses at the time of the interview. The record for Resident 2 was reviewed on 8/9/24 at 9:00 a.m. Diagnoses included, but were not limited to, type 2 diabetes and end stage renal disease. The Annual Minimum Data Set (MDS) assessment, dated 6/11/24, indicated the resident was cognitively intact. The resident was identified as having adequate vision with corrective lenses. A Care Plan, dated 9/7/21 and reviewed on 6/17/24, indicated the resident's vision was adequate with the use of glasses, which he utilized mainly for reading. Interventions included, but were 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, record review, and interview, the facility failed to ensure a resident with a pressure sore received the necessary treatment and services to promote healing related to providing a treatment as ordered by the physician for 1 of 2 residents reviewed for pressure ulcers. (Resident 58) Finding includes: During a random observation on 8/6/24 at 2:24 p.m., CNA 1 and CNA 3 were observed in Resident 58's room. At that time, they were asked to reposition the resident onto his left side so the bandage on the pressure ulcer could be observed. CNA 3 removed the resident's bed linens and the peg tube was disconnected from the enteral feeding as there was feeding all over his gown. CNA 1 left the room to get the nurse to reconnect the tube feeding. Once CNA 1 was back, accompanied by LPN 2, they rolled the resident over and removed his brief. At that time, there was no bandage covering the pressure ulcer. The resident had several ulcers observed on his buttocks and sacral area. The areas were pink, red…

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, record review, and interview, the facility failed to ensure a resident with a suprapubic foley (urinary) catheter received foley catheter care for 1 of 1 resident reviewed for catheters. (Resident 45) Finding includes: During a random observation on 8/5/24 at 10:31 a.m., Resident 45 was observed in bed. At that time, the resident was asked to lift his gown so his the stoma for his suprapubic catheter could be seen. The bandage around the stoma was dated 8/2/24 and had dried brown blood on it. The record for Resident 45 was reviewed on 8/7/24 at 11:20 a.m. Diagnoses included, but were not limited to, infarction of the spinal cord, heart disease, high blood pressure, type 2 diabetes, major depressive disorder, anxiety disorder, urine retention, and neuromuscular of the bladder. The 5/30/24 Annual Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and needed partial to moderate assistance with personal hygiene. The resident had a suprapubic catheter. A Care Plan, revised on 7/9/24, indicated the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a resident was positioned upright at least 45 degrees while an enteral feeding was infusing into a peg tube (a tube inserted directly into the stomach to provide nutrition) for 1 of 1 resident reviewed for tube feeding. (Resident 58) Finding includes: During a random observation on 8/6/24 at 2:24 p.m., CNA 1 and CNA 3 were observed in Resident 58's room. At that time, they were asked to reposition the resident onto his left side so the bandage on the pressure ulcer could be observed. CNA 3 took the bed remote and started to lower the resident's head of the bed to 5 degrees. At that time, she was asked to stop due since the enteral tube feeding was currently infusing into the peg tube. The CNA stated You are absolutely right. Can I put the peg tube on hold? She was asked if she was allowed to do that and the CNA stated Yes, the nurses let us do that all the time. The CNA walked over to the enteral feeding pump and put the feeding on…

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

Based on observation, record review, and interview, the facility failed to ensure oxygen was set at the correct flow rate for 1 of 3 residents reviewed for respiratory care. (Resident 13) Finding includes: During random observations on 8/5/24 at 10:40 a.m. and 2:41 p.m., and on 8/6/24 at 10:00 a.m., Resident 13 was observed in bed wearing oxygen per nasal cannula at 1.5 liters. The record for Resident 13 was reviewed on 8/7/24 at 2:30 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, type 2 diabetes, major depressive disorder, chronic kidney disease, heart disease, heart failure, atrial fibrillation, and anxiety disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 7/12/24, indicated the resident was cognitively intact for daily decision making. The resident did not wear oxygen. A Care Plan, revised on 4/12/24, indicated the resident had complications of shortness of breath when lying flat in bed. The approaches were to encourage the use of supplemental oxygen at 2 liters. A Care Plan, revised on…

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

Based on record review and interview, the facility failed to establish and/or maintain a system that accounted for, periodically reconciled, and ensured the disposition of all controlled drugs, related to inaccurate documentation of narcotic medications for 1 of 1 resident reviewed for narcotics. (Resident 33) Finding includes: On 8/5/23 at 11:18 a.m., an investigation of a narcotic diversion regarding a previously employed nurse was reviewed. The file folder was full of old narcotic sheets from a resident for whom the narcotic diversion was suspected. During the investigation, there was a discrepancy noted earlier on the narcotic log than what was reported on 7/31/24. The record for Resident 33 was reviewed on 8/07/24 at 3:16 p.m. The diagnoses included, but were not limited to, hemiplegia (paralysis on one side of the body), stage 4 sacral wound, anemia, anxiety, hypertension (high blood pressure), depression, and colostomy status. The Significant Change Minimum Data Set (MDS) assessment, dated 7/8/24, indicated the resident was cognitively intact. The resident used hospice…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to appropriately monitor blood pressures (BP) related to medications with BP parameters for 1 of 5 residents reviewed for unnecessary medications. (Resident 58) Finding includes: The record for Resident 58 was reviewed on 8/6/24 at 1:20 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, stroke, obesity, dysphagia, type 2 diabetes, high blood pressure, heart disease, peg tube (a tube inserted directly into the stomach for nutrition), restlessness and agitation. The 7/9/24 Significant Change Minimum Data Set (MDS) assessment, indicated the resident was moderately impaired for daily decision making. The resident was dependent on staff to roll to the right and the left, transfer out of bed, personal hygiene and oral care. Physician's Orders, dated 7/20/24, indicated Hydralazine (a medication used to lower the blood pressure) 50 milligrams (mg), 1 tablet three times a day and hold for systolic blood pressure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure an adequate indication for the use of an antipsychotic medication was documented in the clinical record for 1 of 5 residents reviewed for unnecessary medication. (Resident 5) Finding includes: The record for Resident 57 was reviewed on 8/8/24 at 8:40 a.m. Diagnoses included, but were not limited to, Alzheimer's disease (dementia), high blood pressure, anemia, and osteoarthritis. The resident was admitted to the facility on [DATE]. The Modification of the admission Minimum Data Set (MDS) assessment, dated 5/23/24, indicated the resident was moderately impaired for daily decision making and had the behavior of wandering which occurred 4 to 6 times during the reference period. The resident received an antipsychotic medication which was scheduled and no gradual dose reduction (GDR) had been attempted. A Care Plan, dated 5/21/24, indicated the resident received an antipsychotic medication for behavior management. A Nurses' Note, dated 5/17/24 at 8:57…

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, record review, and interview, the facility failed to ensure a resident received routine dental services related to decayed and broken teeth for 1 of 2 residents reviewed for dental services. (Resident 45) Finding includes: During an interview on 8/5/24 at 10:28 a.m., Resident 45 indicated he had seen the dentist about 5 months ago, and the dentist indicated they were going to pull his teeth as they were bad, but he has heard nothing more of it. Resident 45 indicated it was hard to eat with his teeth as they were brittle. During an observation at that time, the resident had obvious broken, loose and decayed teeth. The record for Resident 45 was reviewed on 8/7/24 at 11:20 a.m. Diagnoses included, but were not limited to, infarction of the spinal cord, heart disease, high blood pressure, type 2 diabetes, major depressive disorder, anxiety disorder, urine retention, and neuromuscular of the bladder. The 5/30/24 Annual Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and needed partial to moderate assistance…

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, record review, and interview, the facility failed to ensure food was prepared in a form to meet individual needs related to not following the pureed recipe. This had the potential to affect 2 residents who received a pureed diet. (Cook 1) On 8/7/24 at 11:37 a.m., a pureed demonstration of barbeque chicken was observed with [NAME] 1. The pureed barbeque chicken was precooked and 2 servings were measured out from the mechanical barbeque chicken mixture and added to the blender. There were no additional ingredients that were added to the mixture. The barbeque chicken puree was pudding thick, and the mixture was even with no clumps. [NAME] 1 measured out 2 servings and placed them in 2 serving bowls. On 8/7/24 at 11:45 a.m., [NAME] 1 measured out 2 servings of precooked broccoli and added to the blender. There were no additional ingredients added to the mixture. The consistency was even with no lumps or clumps. [NAME] 1 then measured out 2 servings and placed them in 2 serving bowls. During an interview on 8/7/24 at 11:37 a.m., [NAME] 1 indicated she did not use…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to maintain clinical records that were complete and accurately documented related to documentation of a dialysis access site for 1 of 1 resident reviewed for dialysis (Resident 2) and the correct medication administration route for 1 of 1 resident reviewed for unnecessary medications (Resident 58). Findings include: 1. The record for Resident 2 was reviewed on 8/9/24 at 9:00 a.m. Diagnoses included, but were not limited to, type 2 diabetes and end stage renal disease. The Annual Minimum Data Set (MDS) assessment, dated 6/11/24, indicated the resident was cognitively intact. The resident was receiving dialysis services. A Care Plan, reviewed on 6/17/24, indicated the resident had a right permacath (a flexible, soft plastic tube used for short term dialysis treatment) in place. Interventions included, but were not limited to, keep catheter site clean and dry, observe for redness, swelling, any discharge, increased pain or warmth due to infection. 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 record review and interview, the facility failed to identify unresolved quality deficiencies, which had been cited on previous surveys, and ensure actions were developed and implemented to attempt to correct the deficiencies through the quality assessment and assurance (QAA) process, as evidenced by the number of repeated deficiencies cited for pest control related to gnats in resident rooms. This deficient practice had the potential to affect 60 of 60 residents residing in the facility. Finding includes: During an interview on 8/9/24 at 11:30 a.m., the Administrator indicated the Quality Assessment and Assurance (QAA) Committee had a meeting on 7/18/24 and the committee consisted of the Medical Director, the Administrator, the Director of Nursing (DON), the Assistant Director of Nursing (ADON), the Minimum Data Set (MDS) Nurse, the Food Sanitation Supervisor, the Social Service Director, the Activity Director, Housekeeping and Maintenance Directors. The committee met on the third Thursday of the month. The Quality Assurance and Performance Improvement (QAPI) plan was 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, record review, and interview, the facility failed to ensure the residents' environment was free of pests related to gnats for 1 of 1 residents observed with gnats in their room. (Resident 33) Finding includes: On 8/5/24 at 10:12 a.m., Resident 33 was observed lying in bed with gnats flying in the room and landing on her bed linen and right lower leg wound dressing. On 8/5/24 at 11:04 a.m., the Wound Nurse was observed entering the resident's room and attempting to complete wound care. There were gnats observed in the air, on the resident's gown, and on the wound dressing. The wound nurse removed several layers of the bandages and several gnats were observed inside the bandages and on the resident's open ulcerations to the right lower leg. During an interview at that time, the Wound Nurse indicated they were attempting to get rid of the gnats and had put a work order in for treatment. There were gnat strips hanging in the room, and she was aware the gnats were flying on and around the wound during the treatment. The Wound Nurse indicated the Director of Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure fall interventions were care planned for a resident with a history of falls for 1 of 5 care plans reviewed. (Resident E) Finding includes: During an observation on 6/19/24 at 9:54 a.m., Resident E was observed in bed. The bed was in low position and there was a mat on the floor next to him. During observations on 6/20/24 at 9:05 and 9:55, the resident was observed in bed in the low position with a mat on the floor next to him. The resident's record was reviewed on 6/20/24 at 9:40 a.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to, dysphagia (difficulty swallowing), Diabetes Mellitus and hypertension. The admission Minimum Data Set assessment was in progress. The Brief Interview for Mental Status, dated 6/12/24, indicated the resident was cognitively intact. The Baseline Care Plan, dated 6/7/24, indicated the resident was two person assist for bed mobility. A Post Fall Observation, dated 6/8/24,…

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

Based on record review and interview, the facility failed to ensure resident received the necessary care and services related to lack of blood glucose parameters in place and Physician notification of elevated blood glucose levels for 1 of 3 residents reviewed for diabetic care. (Resident B) Finding includes: Resident B's record was reviewed on 6/19/24 at 1:45 p.m. Diagnoses included, but were not limited to, Diabetes Mellitus, heart failure and hypertension. The Quarterly Minimum Data Set assessment, dated 4/12/24, indicated the resident was cognitively intact and received insulin. Current Physician Orders indicated the resident was to receive Insulin lispro, 8 units, three times a day and Lantus (long acting insulin) 20 units at bedtime. There were no parameters in place when to notify the Physician of low or high blood glucose levels. A Progress Note, dated 5/31/24, indicated the resident's blood glucose level was 422 (milligrams per deciliter). The resident received an additional 8 units of lispro. A Progress Note, dated 6/10/24, indicated the resident's blood glucose level was…

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

Based on record review and interview, the facility failed to ensure treatment orders were obtained timely for a newly developed pressure ulcer for 1 of 3 residents reviewed for pressure ulcers. (Resident B) Finding includes: The closed record for Resident B was reviewed on 1/25/24 at 9:22 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, type 2 diabetes, adult failure to thrive, anorexia, and dementia without behavior disturbance. The admission Minimum Data Set (MDS) assessment, dated 7/26/23, indicated the resident was cognitively impaired for daily decision making. They required extensive assistance with bed mobility and were totally dependent on staff for transfers. No pressure ulcers were noted during the assessment reference period. A Care Plan, dated 9/20/23 and revised on 9/26/23, indicated the resident had impaired skin integrity to the left heel related to immobility. Interventions included, but were not limited to, administer treatments as ordered and monitor for effectiveness. A Change in Condition Evaluation, dated 9/20/23 at 2:39 p.m., indicated 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 record review, and interview, the facility failed to ensure residents with pressure ulcers received the necessary care and services to treat and improve the wounds related to the lack of documentation and obtaining orders for the treatment of pressure ulcers and following the dietician's recommendations for healing for 2 of 3 residents reviewed for pressure ulcers. (Residents E and B) Findings include: 1. The record for Resident E was reviewed on 9/13/23 at 3:30 p.m. Diagnoses included, but were not limited to acute spinal cord infarction, chronic ischemic heart disease, high blood pressure, type 2 diabetes, major depressive disorder, anxiety disorder, panic disorder, stroke with no residual, and coronary artery bypass graft. The 8/30/23 Quarterly Minimum Data Set (MDS) assessment, indicated the resident was cognitively intact and had 1 Stage 4 pressure ulcer. The Care Plan, revised on 7/26/23, indicated the resident was at risk for impaired skin integrity and the current area of impairment included 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 and interview, the facility failed to store and prepare food under sanitary conditions related to built up grease on the stove top, open food containers, and uncovered food in the freezer for 1 of 1 kitchens observed. This had the potential to affect the 64 residents who received food from the kitchen. (The Main Kitchen) Findings include: During the initial kitchen tour on 7/24/23 at 8:50 a.m., with the Dietary Manager, the following was observed: a. The stove top and fire irons had a build up of grease. b. The dry food storage area had an open container of dry oats on the floor and an open container of grape jelly on the counter. c. The freezer had a block of cheese uncovered sitting on the counter. Interview with the Dietary Food Manager on 7/24/23 at 9:00 a.m., indicated the stove should have been cleaned and the food items in the dry storage and freezer should not have been left open. 3.1-21(i)(3)

Based on record review and interview, the facility failed to identify unresolved quality deficiencies, some of which had been cited on previous surveys, and ensure actions were developed and implemented to attempt to correct the deficiencies through the quality assessment and assurance (QAA) process, as evidenced by the number of repeated deficiencies cited for quality of care related to follow up documentation and assessment after a fall. This deficient practice had the potential to affect 64 of 64 residents residing in the facility. Finding includes: Interview with the Administrator in Training (AIT) and the Medical Record/Human Resource Director on 7/28/23 at 12:45 p.m., indicated the Quality Assessment and Assurance (QAA) Committee had a meeting on 7/11/23 and the committee consisted of the Medical Director, the Administrator, the DON, Infection Control Nurse, the Minimum Data Set (MDS) Nurse, the Food Sanitation Supervisor, the Social Service Director, the Activity Director and Maintenance. The Department Heads also met on a monthly basis. The Quality Assurance and Performance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide documentation of care conferences held with the resident or resident's family and facility staff for 7 of 7 residents reviewed for care planning decisions. (Residents 60, 12, 46, 52, 18, 16, and 10) Findings include: 1. During an interview on 7/24/23 at 9:59 a.m., Resident 60 indicated he had not been invited or attended a care conference with facility staff since he had been living at the facility. The record for Resident 60 was reviewed on 7/26/23 at 9:40 a.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to acute spinal cord infarction, chronic ischemic heart disease, high blood pressure, type 2 diabetes, major depressive disorder, anxiety disorder, panic disorder, stroke with no residual, and coronary artery bypass graft. The 5/30/23 Significant Change Minimum Data Set (MDS) assessment, indicated the resident was cognitively intact for daily decision making. There was no documentation of a care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the residents' environment, as well as the kitchen area, was clean and in good repair related to dirty floors, marred walls, loose baseboards and lime build up in for 1 of 2 floors and the Main Kitchen. (Second Floor and the Main Kitchen) Findings include: 1. During the Environmental tour with the Environmental Manager on 7/27/23 at 2:54 p.m., the following was observed: Second Floor: a. In room [ROOM NUMBER], the walls were marred behind and on the sides of beds one and two. Two residents resided in the room. b. In room [ROOM NUMBER], the walls outside of the bathroom door were marred. Two residents resided in the room. c. In room [ROOM NUMBER], the walls behind the bed were marred. The headboard was missing on bed one. Two residents resided in the room. Interview with the Environmental Manager at that time indicated that he was working on getting all areas together. 2. During the follow up tour in the kitchen on 7/23/23 at 3:18 p.m. with 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, record review, and interview, the facility failed to ensure the resident's preference was honored for the number of medications received for 1 of 1 residents reviewed for choices. (Resident C) Finding includes: On 7/24/23 at 10:08 a.m., Resident C was observed sitting up in bed and indicated she had asked the nurses numerous times to spread out her medications because she takes too many pills at one time. The record for Resident C was reviewed on 7/25/23 at 9:44 p.m. Diagnoses included, but were not limited to, heart failure, hypertension (high blood pressure), hemiplegia left side (left side paralysis), hyperlipidemia (high cholesterol), seizure disorder, acid reflux, and overactive bladder. The Quarterly Minimum Data Set (MDS) assessment, dated 5/6/23, indicated the resident was cognitively intact. A Care Plan, dated 6/6/23, indicated the resident had a behavior of being non-compliant with medication. Approaches included, nursing to educate resident on any medications that she may not be familiar with or any new medications prescribed, resident would vocalize…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure appropriate documentation, such as a discharge summary, was completed prior to transferring a resident to the hospital for 1 of 3 residents reviewed for hospitalization (Resident D). Finding includes: Resident D's record was reviewed on 7/26/23 at 9:15 a.m. The resident was admitted to the facility on [DATE] and discharged on 2/24/23. Diagnoses included, but were not limited to, one sided weakness/paralysis affecting the right dominant side following a stroke, type 2 diabetes mellitus, and bipolar disorder. The Discharge - Return Anticipated Minimum Data Set (MDS) assessment, dated 2/24/23, indicated the resident had a memory problem and required modified independence for daily decision making. She required extensive assistance with one person physical assist for bed mobility, transfers, dressing, toilet use, and personal hygiene. She was totally dependent with one person physical assist for bathing. A Progress Note, dated 2/24/2023 at 7:45…

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

Based on record review and interview, the facility failed to ensure a Care Plan was developed for a resident who had a new Schizophrenia diagnosis for 1 of 19 residents reviewed for Care Plan development. (Resident 10) Finding includes: Resident 10's record was reviewed on 7/27/23 at 2:43 p.m. Diagnoses included, but were not limited to, hypotensive (low blood pressure), depression, bipolar, schizophrenia, restlessness and agitation, and stroke. The Quarterly Minimum Data Set (MDS) assessment, dated 5/4/23, indicated the resident was cognitively intact. A Significant Change Minimum Data Set (MDS) assessment, dated 11/28/22, was completed after emergency detention stay at the hospital. The After-Visit Summary from the hospital, dated 11/21/22, indicated the resident was started on an antipsychotic medication Seroquel (Quetiapine Fumarate) for Schizophrenia. A Physician's Order, dated 11/22/22, indicated Quetiapine Fumarate (Antipsychotic) tablet 50 mg one time a day. A Physician's Order, dated 5/11/23, indicated Quetiapine Fumarate (Antipsychotic) tablet 150 mg every evening. 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 record review and interview, the facility failed to ensure documentation of discharge planning was completed for 1 of 1 closed records reviewed for discharge. (Resident 70) Finding includes: The closed record for Resident 70 was reviewed on 7/28/23 at 10:34 a.m. Diagnoses included, but were not limited to, nontraumatic intracerebral hemorrhage, hypertensive encephalopathy, high blood pressure, gastrostomy, anemia, stroke and hemiplegia on the right side. The Quarterly Minimum Data Set (MDS) assessment, dated 6/16/23, indicated the resident was alert and oriented. There was no documentation related to the resident's discharge in the clinical record. Interview with the Nurse Consultant on 7/28/23 at 12:44 p.m., indicated she was not able to locate the discharge instructions. A facility policy, titled Discharge Planning, received from the Nurse Consultant as current, indicated, .6. The facility will involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final goal. 7. The facility…

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

Based on record review and interview, the facility failed to complete the recapitulation of the resident's stay prior to discharge for 1 of 1 closed records reviewed for discharge. (Resident 70) Finding includes: The closed record for Resident 70 was reviewed on 7/28/23 at 10:34 a.m. Diagnoses included, but were not limited to, nontraumatic intracerebral hemorrhage, hypertensive encephalopathy, high blood pressure, gastrostomy, anemia, stroke and hemiplegia on the right side. The Quarterly Minimum Data Set (MDS) assessment, dated 6/16/23, indicated the resident was alert and oriented There was no documentation related to the recapitulation of stay for the resident prior to discharge. Interview with the Nurse Consultant on 7/28/23 at 12:44 p.m., indicated she was not able to locate the recapitulation of the resident's stay at the facility. A facility policy, titled Discharge Planning, received from the Nurse Consultant as current, indicated, .13. Document, completed on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents had access to receive services for impaired vision for 1 of 1 residents reviewed for vision and hearing. (Resident 60) Finding includes: During an interview with Resident 60 on 7/24/23 at 10:02 a.m., he indicated he had complaints of not being able to see very well. His eyes were bad and he had told staff he wanted to see the eye doctor, but had not seen one since admission. The record for Resident 60 was reviewed on 7/26/23 at 9:40 a.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to acute spinal cord infarction, chronic ischemic heart disease, high blood pressure, type 2 diabetes, major depressive disorder, anxiety disorder, panic disorder, stroke with no residual, and coronary artery bypass graft. The 5/30/23 Significant Change Minimum Data Set (MDS) assessment, indicated the resident was cognitively intact for daily decision making and no vision impairment or corrective lens. There was no Care Plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a resident with a Stage 4 pressure ulcer received the necessary care and services to treat and improve the wound related to not providing a wound vac in a timely manner for 1 of 3 residents reviewed for pressure ulcers. (Resident 60) Finding includes: On 7/27/23 at 9:06 a.m. the Wound Nurse was observed changing Resident 60's bandage to his pressure ulcer on the sacrum. After the bandage was removed, the wound bed was pink with some slough (necrotic tissue) and undermining (tunneling). The record for Resident 60 was reviewed on 7/26/23 at 9:40 a.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to acute spinal cord infarction, chronic ischemic heart disease, high blood pressure, type 2 diabetes, major depressive disorder, anxiety disorder, panic disorder, stroke with no residual, and coronary artery bypass graft. The 5/30/23 Significant Change Minimum Data Set (MDS) assessment, indicated the resident…

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

Based on observation, record review, and interview, the facility failed to ensure splints were applied as ordered for 1 of 1 residents reviewed for limited range of motion (ROM). (Resident 46) Finding includes: On 7/24/23 at 10:56 a.m., Resident 46 indicated he was in need of therapy for his left side and did not wear any type of splinting devices. There was no splinting device noted to his left hand/wrist at the time of interview. On 7/27/23 at 11:26 a.m., Resident 46 was observed in bed with no splint noted to his left hand/wrist. On 7/28/23 at 10:38 a.m., Resident 46 was observed in bed with no splint noted to his left hand/wrist. He indicated he never wore one and no one ever offered to help him put one on. Resident 46's record was reviewed on 7/26/23 at 9:43 a.m. Diagnoses included, but were not limited to, left-sided weakness/paralysis following a stroke and lack of coordination. The Quarterly Minimum Data Set (MDS) assessment, dated 5/30/23, indicated the resident was cognitively intact for daily decision making. He required extensive assistance with two persons physical…

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, record review, and interview, the facility failed to ensure a resident with a history of falls had fall interventions in place to prevent further injury related to not wearing non-skid socks for 1 of 2 residents reviewed for falls. (Resident E) Finding includes: On 7/24/23 at 10:00 a.m., Resident E was observed in bed with her eyes closed. At that time, she was wearing plain white socks to both of her feet. On 07/25/23 8:33 a.m., and 8:50 a.m., the resident was observed in bed. At that time, she was wearing plain white socks. The record for Resident E was reviewed on 7/27/23 at 10:00 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, metabolic encephalopathy, type 2 diabetes, diabetic neuropathy, high blood pressure, anxiety disorder, heart failure, and convulsions. The 6/22/23 Significant Change Minimum Data Set (MDS) assessment, indicated the resident was not cognitively intact for daily decision making. The resident needed extensive…

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, record review, and interview, the facility failed to ensure residents with complex urinary tract infections were seen by the urologist and residents with suprapubic (inserted through the abdomen) foley (urinary) catheters had them changed on a monthly basis for 2 of 3 residents reviewed for catheters. (Residents 60 and 2) Findings include: 1. During an interview on 7/24/23 at 10:05 a.m., Resident 60 indicated staff did not perform catheter care for him every shift or every day. At that time, he was observed with an indwelling foley catheter. The record for Resident 60 was reviewed on 7/26/23 at 9:40 a.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to acute spinal cord infarction, chronic ischemic heart disease, high blood pressure, type 2 diabetes, major depressive disorder, anxiety disorder, panic disorder, stroke with no residual, and coronary artery bypass graft. The resident was admitted to the hospital on [DATE] returning on 2/21/23, on 4/22/23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure residents maintained acceptable parameters of nutritional status related to meal consumption records not completed and dietary supplements not given to the resident for 1 of 4 residents reviewed for nutrition. (Resident 60) Finding includes: During an interview on 7/24/23 at 10:01 a.m., Resident 60 indicated he was supposed to get Glucerna or something like that, however, he had not received it in a long time. The Registered Dietitian (RD) told him he was supposed to receive it. The record for Resident 60 was reviewed on 7/26/23 at 9:40 a.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to acute spinal cord infarction, chronic ischemic heart disease, high blood pressure, type 2 diabetes, major depressive disorder, anxiety disorder, panic disorder, stroke with no residual, and coronary artery bypass graft. The 5/30/23 Significant Change Minimum Data Set (MDS) assessment indicated the resident was…

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

Based on observation, record review, and interview, the facility failed to ensure lung sounds were assessed prior to administering nebulizer treatments and staff remained with the resident during the treatment for 1 of 1 nebulizer treatments observed. (Resident 271) Finding includes: On 7/27/23 at 9:46 a.m., LPN 2 was preparing to administer an Ipratropium-Albuterol nebulizer treatment to Resident 271. The LPN placed the vial of solution in the nebulizer canister and placed the mask over the resident's face. She did not assess his lung sounds prior to administering the treatment. The LPN indicated she would return to the resident's room in about 15 minutes to remove the mask once the nebulizer treatment was completed. The record for Resident 271 was reviewed on 7/27/23 at 3:48 p.m. Diagnoses included, but were not limited to, shortness of breath, chronic obstructive pulmonary disease (COPD), and stroke. The admission Minimum Data Set (MDS) assessment, dated 7/26/23, indicated the resident was cognitively intact. A Physician's Order, dated 7/19/23, indicated the resident was to…

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

Based on record review and interview, the facility failed to ensure ongoing communication with the dialysis center was completed with each dialysis session for 1 of 1 residents reviewed for dialysis. (Resident 12) Finding includes: Resident 12's record was reviewed on 7/26/23 at 11:29 a.m. Diagnoses included, but were not limited to, end stage renal disease, dependence on renal dialysis, and type 2 diabetes mellitus. The Quarterly Minimum Data Set (MDS) assessment, dated 6/27/23, indicated the resident was cognitively intact for daily decision making. He received insulin injections and dialysis treatments. A Care Plan, dated 7/24/23, indicated the resident was at risk for adverse effects related to end stage renal disease with dependence on hemodialysis. Interventions included, but were not limited to, check and change dressing daily at access site and encourage resident to go for the scheduled dialysis appointments on Monday, Wednesday, and Friday each week. The Dialysis Communication binder included communication forms that had information for the facility to fill out prior to the…

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

Based on record review and interview, the facility failed to ensure medications were managed appropriately related to missed insulin doses and medication not held as ordered for 1 of 6 residents reviewed for unnecessary medications (Resident 12). Finding includes: The record for Resident 12 was reviewed on 7/26/23 at 11:29 a.m. Diagnoses included, but were not limited to end stage renal disease, dependence on renal dialysis, and type 2 diabetes mellitus. The Quarterly Minimum Data Set (MDS) assessment, dated 6/27/23, indicated the resident was cognitively intact for daily decision making. The resident received insulin injections and dialysis treatments. A Care Plan, dated 7/24/23, indicated the resident was at risk for adverse effects related to end stage renal disease with dependence on hemodialysis. Interventions included, but were not limited to, check and change dressing daily at access site and encourage resident to go for the scheduled dialysis appointments on Monday, Wednesday, and Friday each week. A Physician's Order, dated 4/6/22, indicated amlodipine (blood pressure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents did not receive unnecessary medications related to PRN (as needed) anti-anxiety medication only administered after non-pharmaceutical interventions were attempted for 1 of 6 residents reviewed for unnecessary medications. (Resident E) Finding includes: The record for Resident E was reviewed on 7/27/23 at 10:00 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, metabolic encephalopathy, type 2 diabetes, diabetic neuropathy, high blood pressure, anxiety disorder, heart failure, and convulsions. The 6/22/23 Significant Change Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making. In the last 7 days, the resident had received an antipsychotic medication 7 times and an antidepressant 7 times. Physician's Orders, dated 6/26/23 and discontinued on 7/13/23, indicated Ativan tablet 0.5 milligrams (mg), give 1 tablet by mouth every 4 hours…

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, record review, and interview, the facility failed to ensure a medication error rate of less than 5% for 2 of 5 residents observed during medication pass. Three errors were observed during 30 opportunities for errors during medication administration. This resulted in a medication error rate of 10%. (Residents 34 and 5) Findings include: 1. During observation of medication administration on 7/25/23 at 9:26 a.m., LPN 4 was preparing Resident 34's medications. She dispensed one Seroquel (an antipsychotic medication) 25 milligram (mg) tablet in the med cup. She then proceeded to dispense one Zoloft (an antidepressant) 100 mg tablet in the med cup. The resident also received one Norco (a narcotic pain medication) and one Xanax (an anti-anxiety medication). There were a total of 4 pills in the medication cup. The LPN proceeded to the resident's room to administer the medications. The record for Resident 34 was reviewed on 7/25/23 at 10:30 a.m. Diagnoses included, but were not limited to, schizoaffective disorder, major depressive disorder, and anxiety. A Physician's…

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

Based on observation, record review, and interview, the facility failed to ensure medications were labeled and stored correctly for 1 of 5 residents observed during medication administration. (Resident 5) Finding includes: Observation of medication pass on 7/26/23 at 4:05 p.m., with RN 1, indicated Resident 5's insulin pen was on top of the medication cart. The RN entered the resident's room to check her blood sugar. He closed the door behind him and the medication cart was out of his view. At 4:27 p.m., the RN administered the resident's oral medications. The insulin pen remained on top of the medication cart. The medication cart remained out of the RN's view while he administered the medications. At 5:28 p.m., the RN was preparing to administer the resident's insulin. The insulin pen had remained on top of the medication cart. The RN indicated the resident was to receive 30 units of Humalog (fast acting) insulin based on the order. The label on the insulin pen indicated the resident was to receive 20 units. The RN proceeded to the medication room to look for another insulin pen…

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

Based on interview and record review, the facility failed to ensure the resident's medical record was complete and accurate related to dialysis fistula monitoring for 1 of 1 residents reviewed for dialysis. (Resident 12) Finding includes: Resident 12's record was reviewed on 7/26/23 at 11:29 a.m. Diagnoses included, but were not limited to, end stage renal disease, dependence on renal dialysis, and type 2 diabetes mellitus. The Quarterly Minimum Data Set (MDS) assessment, dated 6/27/23, indicated the resident was cognitively intact for daily decision making. He received insulin injections and dialysis treatments. A Care Plan, dated 7/24/23, indicated the resident was at risk for adverse effects related to end stage renal disease with dependence on hemodialysis. Interventions included, but were not limited to, check and change dressing daily at access site and encourage resident to go for the scheduled dialysis appointments on Monday, Wednesday, and Friday each week. A Physician's Order, dated 8/25/21, indicated assess dialysis access site for redness, swelling, pain, drainage and…

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

Based on observation and interview, the facility failed to maintain an effective pest control program to ensure the facility was free from pests related to live gnats and flies for 2 of 2 residents observed with gnats in their rooms. (Residents G and F) Finding includes: During the survey period, 7/24/23 through 7/28/23, the following was observed: During a random observation on 7/24/23 at 10:44 a.m., Resident G was observed lying in bed. He indicated he had a problem with flies, and he wanted a fly sticker since he can't use his hands due to being a paraplegic. There were flies observed flying around the resident's face. During a random observation on 7/26/23 at 9:39 a.m., Resident F was observed lying in bed with a sheet over her legs. There were several gnats on her bed sheet and a couple were flying around the resident's head. There were 2 residents who resided in the room. During a random observation on 7/26/23 2:46 p.m., Resident F was observed asleep in bed. A sheet covered the resident and there were 3 gnats on the sheet by the residents legs. There were 2 residents in the…

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