Community Nursing And Rehabilitation Center

Based on observation, interview, and record review the facility failed to provide oxygen as ordered by the physician and failed to maintain oxygen tubing and humidifier bottle in a sanitary manner for 1 of 1 random observation of oxygen use (Resident F). Review of the clinical record of Resident F on 12/10/25 at 11:08 a.m., indicated the resident's diagnoses included, but were not limited to, heart failure, peripheral vascular disease, diabetes, muscle weakness, anxiety disorder and major depressive disorder. The plan of care for Resident F, dated 8/18/25, indicated the resident had impaired gas exchange and utilized oxygen. The interventions included, but were not limited to, administer oxygen as ordered. The December 2025 physician order for Resident F, indicated she was ordered oxygen 3 liters per nasal cannula every shift and change tubing and humidity every week on Sunday. The quarterly Minimum Data Set (MDS) assessment for Resident F, dated 11/18/25, indicated the resident was cognitively intact for daily decision making. The resident was consistent and reasonable. During 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 interview and record review, the facility failed to ensure a resident's choice was honored pertaining to selection of food items of their choice for 1 of 3 residents reviewed for resident rights. (Resident B) Findings include: The clinical record for Resident B was reviewed on 7/14/25 at 3:50 p.m. The diagnoses included, but were not limited to, encephalopathy (group of conditions that cause brain dysfunction), hemiplegia (loss of strength leading to paralysis on one side of the body), and dysphagia (difficulty swallowing). A Significant Change Minimum Data Set (MDS) assessment, dated 6/3/25, indicated Resident B had moderate cognitive impairment, required substantial/maximal assistance with toileting hygiene, and was always incontinent of bowel and bladder. A care plan, last revised 5/28/25, indicated Resident B required assistance with activities of daily living (ADLs) including eating and toileting. The approach included to provide assistance with eating as needed and assistance with toileting and/or incontinent care as needed related to Resident B being incontinent 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 timely implement a podiatry recommendation for 1 of 3 residents reviewed for foot care (Resident E).Findings include: The clinical record for Resident E was reviewed on 7/14/25 at 2:15 p.m. The resident's diagnosis included, but was not limited to, polyneuropathy (disorder of the nervous system).A physician's order, dated 9/25/24, indicated Resident E could be seen by the Podiatrist.On 7/14/25 at 2:45 p.m., Resident E was observed with the Director of Nursing (DON) in her room. She was lying in her bed, and her feet were observed to have thick, yellowing, crusty toenails on both big toes. Resident E indicated she had been seen by the Podiatrist recently.A Podiatry Group note, dated 6/14/25, indicated she had been seen by the Podiatrist and the nails on both feet had been debrided (reduced in size). There was a recommended new order of urea 40% cream (medication for dry skin and damaged nails) to all toenails daily for sixty days. The clinical record did not contain an order for urea 40% cream to be applied 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.

A. Based on observation, interview, and record review, the facility failed to ensure the kitchen was clean and in good repair, the staff contained their hair in the kitchen, and food was not open to air, labeled, dated and not expired. This had the potential to affect 54 of 54 residents that eat food prepared in the facility kitchen. B. Based on observation, interview, and record review, the facility failed to cover trash cans when not in use in the kitchen with the potential to affect 54 or 54 residents who receive food out of the facility kitchen. Findings include: A. On 4/21/25 at 6:25 p.m., the facility kitchen was observed with Dietary Aide (DA) 15. The walk- in refrigerator was observed to have a metal can of butterscotch pudding with a piece of plastic wrap covering the open can. The can did not contain a date on which it was opened. There was an undated plastic storage container of macaroni and cheese, an undated jar of beef base, an undated bottle of orange juice and grape juice which were half empty, an undated container of ranch and Caesar salad dressing, an undated jar…

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' respect and dignity were maintained for 2 of 3 residents reviewed for dignity, 3 of 8 resident interviews in abuse investigations, and 3 residents randomly observed during dining. (Resident B, D, F, J, K, L, M, and N) Findings include: 1. The clinical record for Resident J was reviewed on [DATE] at 11:30 a.m. The diagnoses included, but were not limited to, cellulitis. The admission Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident J was cognitively intact. An interview was conducted with Resident J on [DATE] at 11:18 a.m. She indicated the staff were disrespectful during care. The staff needed training to not rush during care. They were rushing and jerk you around. It was rough, but not abusive. 2a. The clinical record for Resident D was reviewed on [DATE] at 12:00 p.m. The diagnoses included, but were not limited to, depression. The Quarterly MDS assessment, dated [DATE], indicated Resident D was…

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

Based on observation, interview, and record review, the facility failed to ensure food was served at palatable temperatures for 4 of 4 residents reviewed for food and 14 of 54 residents that attend resident council. (Residents' B, D, 22, J, K, 33, 28, 13, 31, 4, G, H, 25, 23, E, 41, 6, and 48) Findings include: 1. The clinical record for Resident J was reviewed on 4/22/25 at 11:30 a.m. The diagnoses included, but were not limited to, cellulitis. The admission Minimum Data Set (MDS) assessment, dated 3/24/25, indicated Resident J was cognitively intact. An interview was conducted with Resident J on 4/22/25 at 11:18 a.m. She indicated the food was served cold. 2. The April 2025 resident council minutes were provided by the Activities Director on 4/23/25 at 9:31 a.m. The resident attendees were the following: Residents' 6, 23, H, 33, 41, 13, 25, 28, and G. The council indicated the food temperatures were not appropriate. During a resident council meeting on 4/23/25 at 11:05 a.m., the council attendees were the following: Residents' K, 33, 28, 13, 31, 4, G, H, 25, 23, E and 48. 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 interview and record review, the facility failed to follow up on grievances for 2 of 2 residents reviewed for grievances. (Resident B and Resident 41) Findings include: 1. The clinical record for Resident B was reviewed on 4/22/25 at 12:00 p.m. The diagnoses included, but were not limited to, stroke. A Quarterly Minimum Data Set (MDS) assessment, completed 1/20/25, indicated she was cognitively intact. An interview was conducted with Resident B on 4/21/25 at 7:01 p.m. She indicated she had filed grievances and had not heard anything about a follow-up from the facility. Resident B indicated she was missing an arm sling, a backpack, a purse, and a box of crackers. An interview was conducted with the Social Services Consultant on 4/24/25 at 2:32 p.m. The Social Services Consultant indicated she could not find the grievances filled out by Resident B. Social Services Director (SSD) 4 indicated she spoke with Resident B and filled out grievances. SSD 4 indicated she did not know where the original grievances were located. 2. The clinical record for Resident 41 was reviewed 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, interview, and record review, the facility failed to protect a resident's right to be free from abuse for 2 of 3 residents reviewed for abuse. (Resident 37 and Resident 42) Findings include: 1. The clinical record for Resident 42 was reviewed on 4/22/25 at 9:00 a.m. The diagnoses included, but were not limited to, stroke, major depressive disorder, physical debility, unsteadiness on her feet, and anxiety disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 3/16/25, indicated Resident 42 was moderately cognitively impaired. The resident had impairments with her upper and lower extremities on one side. She utilized a walker and wheelchair. She required substantial assistance with dressing but was able to sit to stand independently with no assistance. A behavior care plan, dated 10/4/24, indicated Resident 42 had exhibited verbal aggression towards staff and anxiousness. 2. The clinical record for Resident 37 was reviewed on 4/22/25 at 9:57 a.m. The diagnoses included, but were not limited to, schizoaffective disorder, bipolar disorder, anxiety…

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 maintain evidence that an allegation of abuse was thoroughly investigated for 2 of 3 residents reviewed for abuse (Resident 37 and Resident 42). Findings include: 1. The clinical record for Resident 42 was reviewed on 4/22/25 at 9:00 a.m. The diagnoses included, but were not limited to, stroke, major depressive disorder, physical debility, unsteadiness on her feet, and anxiety disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 3/16/25, indicated Resident 42 was moderately cognitively impaired. The resident had impairments with her upper and lower extremities on one side. She utilized a walker and wheelchair. She did need substantial assistance with dressing but was able to sit to stand independently with no assistance. 2. The clinical record for Resident 37 was reviewed on 4/22/25 at 9:57 a.m. The diagnoses included, but were not limited to, schizoaffective disorder, bipolar disorder, anxiety disorder, and post-traumatic stress disorder. The Quarterly MDS assessment, dated 3/24/25, indicated Resident 37 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 interview and record review, the facility failed to timely refer a resident with a new diagnosis of a psychiatric condition for a Level 2 assessment for 1 of 5 residents reviewed for unnecessary medications and 1 of 1 resident reviewed for Preadmission Screening and Resident Review (Resident 33 and Resident 41). Findings include: 1. The clinical record for Resident 33 was reviewed on 4/22/25 at 2:33 p.m. The diagnoses included, but were not limited to, dementia and schizoaffective disorder. A Psychiatric Progress Note, dated 5/15/24, indicated the Preadmission Screening and Resident Review (PASRR) had no history of serious mental illness, intellectual disability, or developmental disability. A Quarterly Minimum Data Set (MDS) assessment, completed 11/5/24, indicated Resident 33 was cognitively intact. The diagnosis of schizoaffective disorder was not included in the MDS assessment. A Physician's Assistant (PA) progress note, dated 11/4/24, indicated the diagnosis of schizoaffective disorder had an onset date of 10/30/24. The plan was to administer olanzapine (anti-psychotic…

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 timely pull a resident up in bed as requested repeatedly and provide consistent showers for 1 of 7 residents observed during medication administration and 1 of 2 residents reviewed for activities of daily living (ADL) care. (Resident E and Resident B) Findings include: 1. The clinical record for Resident E was reviewed on 4/22/25 at 10:30 a.m. The diagnoses included, but were not limited to, chronic respiratory failure, and stroke resulted in hemiplegia (loss of strength on one side). The Quarterly Minimum Data Set (MDS) assessment, dated 1/17/25, indicated Resident E was moderately cognitively impaired. The resident had upper and lower impairments on one side with substantial maximum assistance by a staff member to roll left and/or right and sit to lying position. An observation was conducted of Resident E during a medication administration with Qualified Medication Aide (QMA) 10 on 4/21/25 at 6:47 p.m. The resident was observed in bed. The resident's head was not positioned at the top of the bed. 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 administer medications and treatments as ordered for 1 of 5 residents reviewed for dignity, 1 of 5 residents reviewed for unnecessary medications, and 1 of 4 residents reviewed for activities of daily living. (Resident G, Resident 42, and Resident E) Findings include: 1. The clinical record for Resident G was reviewed on 4/22/25 at 12:12 p.m. The diagnoses included, but were not limited to, liver transplant and major depressive disorder. A physician's order, dated 10/10/24, indicated Resident G was to receive mycophenolate mofetil (immunosuppressive medication) 500 milligrams (mg) twice daily; to be given one hour prior or two hours after eating. A Quarterly Minimum Data Set (MDS) assessment, dated 3/24/25, indicated Resident G was cognitively intact. During an interview on 4/22/25 at 12:12 p.m., Resident G indicated he had a liver transplant and had gone several days without his immunosuppressive medications. The facility had run out of his medication. He was worried because he did not want to have his…

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

Based on observation, interview, and record review, the facility failed to ensure the resident's oxygen provided was as ordered for 1 of 7 residents observed during medication administration. (Resident E) Findings include: The clinical record for Resident E was reviewed on 4/22/25 at 10:30 a.m. The diagnoses included, but were not limited to, chronic respiratory failure, and stroke resulted in hemiplegia (loss of strength on one side). The Quarterly Minimum Data Set assessment, dated 1/17/25, indicated Resident E was moderately cognitively impaired. A physician order, dated 9/25/24, indicated Resident E was to receive two liters of oxygen via nasal cannula (tubing that delivers oxygen through the nose) every shift. An observation was conducted of Resident E during a medication administration with Qualified Medication Aide (QMA) 10 on 4/21/25 at 6:47 p.m. The resident was observed in bed with her nasal cannula out of her nose lying on her chest. QMA 10 educated the resident at that time; she needed the nasal cannula in her nose to receive the oxygen. QMA 10 assisted the resident with…

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

Based on observation, interview, and record review, the facility failed to provide adequate pain control for 2 of 2 residents reviewed for pain medication. (Resident D and Resident J) Findings include: 1. The clinical record for Resident D was reviewed on 4/24/25 at 4:08 p.m. The diagnoses included, but were not limited to, diabetes mellitus. A Quarterly Minimum Data Set (MDS) assessment, completed on 3/5/25, indicated she was cognitively intact. A physician's order, dated 3/4/25, indicated to administer Tylenol 1000 milligrams (mg) every six hours as needed for pain. During an interview with Resident D on 4/21/25 at 7:07 p.m., she indicated she asked Licensed Practical Nurse 5 (LPN 5) for Tylenol at 3:00 p.m. She indicated she was still waiting for LPN 5 to administer the requested Tylenol. An observation was conducted of an interview with LPN 5 with Nurse Consultant (NC) 13 on 4/21/25 at 8:20 p.m. LPN 5 indicated he had not gotten to Resident D's medication pass at that time. He was in the process of preparing medication for Resident D's roommate. NC 13 requested LPN 5 to stop…

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 timely document behaviors and to initiate new interventions to the plan of care for a resident with dementia with behaviors of wandering and urinating in inappropriate places for 1 of 2 residents reviewed for accidents. (Resident H) Findings include: 1a. The clinical record for Resident H was reviewed on 4/22/25 at 2:40 p.m. The diagnoses included, but were not limited to, dementia with behavioral disturbance, Alzheimer's disease, and anxiety. A Quarterly Minimum Data Set (MDS) assessment, completed 2/24/25, indicated Resident H was severely cognitively impaired, was able to ambulate 150 feet in the corridor with supervision of staff, and was occasionally incontinent of urine. 1b. The clinical record for Resident 41 was reviewed on 4/23/25 at 2:00 p.m. The diagnoses included, but were not limited to, borderline personality disorder. A Quarterly MDS assessment, dated 9/16/24, indicated Resident 41 was cognitively intact. Resident H's clinical record contained a progress note, dated 1/29/25, which indicated Resident H had…

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

Based on interview and record review, the facility failed to timely follow-up on pharmacy recommendations for 1 of 5 residents reviewed for unnecessary medications. (Resident B) Findings include: A. The clinical record for Resident B was reviewed on 4/22/25 at 12:00 p.m. The diagnoses included, but were not limited to, stroke. A Quarterly Minimum Data Set (MDS) assessment, completed 1/20/25, indicated she was cognitively intact. A pharmacy recommendation, dated 2/19/25, indicated the discontinuation of fenofibrate (used together with a proper diet to reduce and treat high cholesterol and triglyceride [fat- like substance] levels in the blood) 54 milligrams (mg) daily. If medication was discontinued a fasting lipid panel was to be collected at the 4-week mark and every 12 months. On 2/29/25 the Doctor of Medicine (MD) signed the pharmacy recommendation in agreement to discontinue fenofibrate and lab recommendations. The MD ordered a fasting lipid panel to be drawn on 3/3/25. A physician's order, dated 2/19/25, was noted for a lipid panel lab draw for 3/3/25. The facility was unable…

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 open and/or expiration dates were on insulin medication for 1 of 3 medication carts observed. (Resident 7, Resident 22, and Resident F) Findings include: 1. The clinical record for Resident 7 was reviewed on 4/22/25 at 11:30 a.m. The diagnoses included, but were not limited to, diabetes mellitus. A physician order, dated 9/4/24, indicated the staff was to administer 18 units of Novolin (intermediate-acting insulin) twice a day. 2. The clinical record for Resident F was reviewed on 4/22/25 at 11:45 a.m. The diagnoses included, but were not limited to, diabetes mellitus. A physician order, dated 3/11/25, indicated the staff was to administer 24 units of Humalog (fast acting insulin) three times a day. 3. The clinical record for Resident 22 was reviewed on 4/22/25 at 12:00 p.m. The diagnoses included, but were not limited to, diabetes mellitus. A physician order, dated 4/18/25, indicated the resident was to receive a sliding scale of lispro insulin (fast acting insulin) three times a day. An observation…

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

Based on observation, interview, and record review, the facility failed to ensure infection control was maintained by utilizing hand hygiene prior to administering eye drop medications and to follow infection control practices by not timely removing feces and urine from a bedside table, and failure to wear a gown while disposing of bodily fluids for a resident in Enhanced Barrier Precautions for 2 of 7 residents observed during medication administration and 1 of 1 resident observed for Enhanced Barrier Precautions. (Resident H, Resident 29 and Resident 27) Findings include: 1. The clinical record for Resident H was reviewed on 4/21/25 at 6:30 p.m. The diagnoses included, but were not limited to, glaucoma (eye condition that damages optic nerve). A physician order, dated 4/17/25, indicated the resident was to receive one drop of timolol eye drops in both eyes twice a day. An observation was conducted of eye drop administration to Resident H with Qualified Medication Aide (QMA) 10 on 4/21/25 at 6:35 p.m. QMA 10 was observed at the medication cart pulling the medications for 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, interview, and record review, the facility failed to promote a homelike environment for 3 of 5 residents reviewed for environment (Residents L, 9, and 17). Findings include: An observation was made on 4/21/25 at 7:49 p.m. The blinds in Resident L's room were broken. An observation was made on 4/22/25 at 9:41 a.m. Resident 9's room smelled strongly like urine and there was an area of scraped paint on the wall behind the bed. An observation was made on 4/22/25 at 10:14 a.m. The blinds in Resident 17's room were broken. In an interview with Resident 17, on 4/25/25 at 1:18 p.m., he indicated the broken blinds bothered him, especially when he had company, and they had been that way for three years. A walk-through tour was conducted with the Maintenance Supervisor (MS) and Housekeeping Supervisor (HS) on 04/25/25 at 1:10 p.m. During the tour, Resident L and Resident 17's blinds were broken. Resident 9's room smelled like urine and the paint on the wall was scraped. The MS was interviewed on 4/25/25 at 1:14 p.m. He indicated he was aware of the broken blinds 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, interview, and record review, the facility failed to serve breakfast at safe and palatable temperatures with the potential to affect 54 of 55 residents residing at the facility. Findings include: During a Resident Council meeting on 4/16/24 at 3:00 p.m., 8 of 10 residents who attended indicated that breakfast was often served cold. During an interview on 4/17/24 at 11:06 a.m., Resident 43 indicated that breakfast was served cold most days. A grievance form, dated 4/10/24, indicated that Resident B had a concern that the food was sometimes cold. On 4/18/24 at 8:25 a.m., breakfast service was observed in the facility kitchen. Three plates of fried eggs and 1 plate of scrambled eggs were observed sitting on the counter in back of the steam table. Seven plates of fried eggs were observed sitting on the shelf above the stove. FC (Facility Cook) 5 was observed taking a plate of fried eggs from the counter behind the steam table and placing them on a tray to be served. The tray was taken from the serving area and served to a resident. At 8:35 a.m., the DM (Dietary…

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 the first-floor shower room in good condition and to timely repair a leaking pipe for the pot filler in the kitchen with the potential to affect 55 of 55 residents residing at the facility. Findings include: 1. On 4/16/24 at 12:00 p.m., the facility kitchen was observed with the RD (Registered Dietician) and the (DM) Dietary Manager A pipe located to the side of the stove was observed to have a clear pasty substance present at the joints and rusted joint clamps. The copper pipe had a heavy patinated appearance. There was a puddle of water present under the pipe. The DM indicated the water on the floor was because the pipe of the pot filler was leaking and believed a work order had been done. The RD indicated that due to the appearance of the pipe and the rust present on the pipe clamps, the pipe had been leaking for a while. On 4/18/24 at 2:03 p.m., the Executive Director provided a service request, dated 4/16/24, requesting service to the water leak in the kitchen. 2. During an interview on 4/17/24 at 11:04 a.m.,…

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 timely provide assistance with dressing for 1 of 1 resident reviewed for ADL (Acts of Daily Living) care (Resident 6). Findings include: The clinical record for Resident 6 was reviewed on 4/16/24 at 3:21 p.m. The Resident's diagnosis included, but were not limited to, dementia and heart failure. A care plan, initiated 6/16/2020, indicated Resident 6 required assistance with ADL care related to his dementia, heart failure and muscle weakness. The goal was for him to improve current functional status. The interventions included, but were not limited to, assist with toileting and/or incontinent care, start date 6/16/2020, and assist with dressing, grooming, and hygiene as needed. Encourage him to do as much for self as possible, start date 6/16/2020. A Quarterly MDS (Minimum Data Set) Assessment, completed 3/4/24, indicated he had moderately impaired cognition and needed cues and supervision with dressing. On 4/16/24 at 3:21 p.m., Resident 6 was observed sitting in his wheelchair in his room. He was wearing 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 interview and record review, the facility failed to assess a resident's skin condition; timely clarify the dosage and administration time of a resident's antipsychotic medication; administer insulin as ordered; and monitor frequency of bowel movements for a resident with constipation for 1 of 1 resident review for constipation, 1 of 5 residents reviewed for unnecessary medications, and 1 of 1 resident reviewed for skin conditions. (Residents B and 27) Findings include: 1a. The clinical record for Resident B was reviewed on 4/17/24 at 9:00 a.m. The diagnoses for Resident B included, but were not limited to, type 2 diabetes mellitus, borderline personality disorder, somatization disorder, post-traumatic stress disorder and bipolar disorder. A care plan dated 4/17/24 indicated .Resident is at risk for adverse effects of hyperglycemia or hypoglycemia related to use of glucose lowering medication and/or diagnosis of diabetes mellitus .Approach .medications as ordered .Monitor blood sugars as ordered . A physician order dated 4/1/24 indicated Resident B was to receive 10 units 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 provide oral care, as ordered by the physician, and to timely obtain a physician's order to provide gastrostomy tube site care for 1 of 1 resident reviewed for tube feeding (Resident 23). Findings include: The clinical record for Resident 23 was reviewed on 4/16/24 at 2:40 p.m. The Resident's diagnosis included, but were not limited to, dysphagia (inability to swallow), aphasia (inability to speak), and gastrostomy (g-tube). A care plan, initiated 11/8/2018, indicated Resident 23 was at risk for complications related to enteral feedings. The goal was for him to be free from complications related to enteral feeding. The approaches included, but were not limited to, cleanse around site as ordered, initiated 11/8/2018, and elevate head of bead, initiated 11/08/2018. A physician's order, dated 1/28/2021, indicated to provide oral care every shift. A Quarterly MDS (Minimum Data Set) Assessment, completed 3/28/24, indicated his long- and short-term memory was intact. He was independent with decision making and 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 interview and record review, the facility failed to adequately monitor and document behaviors for 1 of 1 resident reviewed for mood and behaviors and 2 of 5 residents reviewed for unnecessary medications. (Residents 38 and 45) Findings include: 1. The clinical record for Resident 45 was reviewed on 4/17/24 at 1:43 p.m. His diagnoses included, but were not limited to: schizoaffective disorder, bipolar disorder, insomnia, neurocognitive disorder, encephalopathy, and extrapyramidal and movement disorder. He was admitted to the facility on [DATE] from another skilled nursing facility. The 1/14/24 New/Worsening Behavior Communication Event indicated Resident 45 grabbed a female staff's breast/buttocks inappropriately. The intervention attempted in response to the behavior was to explain that it was inappropriate and encouraged not to do it again. The effectiveness of the interventions were somewhat effective, but Resident 45 did it again after the first action. The interventions put into place to prevent…

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 medication error rate of less than 5 percent for 1 of 5 residents observed during medication pass. There were 34 opportunities with 2 errors resulting in a 5.88% medications error rate. The errors involved 1 resident (Resident 43) in the sample of 5. Findings include: The clinical record for Resident 43 was reviewed on 4/17/24 at 1:00 p.m. The diagnosis for Resident 43 included, but was not limited to, type 2 diabetes mellitus. A care plan dated 2/27/24 indicated staff was to obtain blood sugars as ordered. The Annual MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 43 was cognitively intact. A physician order dated 1/9/24 indicated the staff was to obtain blood sugars four times a day. The scheduled times were 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. A physician order dated 4/16/24 indicated the resident was to receive 22 units of lantus insulin. A physician order dated 4/17/24 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.