Evergreen Crossing And The Lofts

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure insulin was administered in accordance with physician's orders and by manufacturer's instructions for 3 of 3 residents observed for insulin administration (Residents B, H, and T). Findings include:1. A concern brought up during the survey indicated Resident B had complained to the staff daily about his high blood sugar readings, not getting his insulin timely, the physician not being contacted for extra insulin coverage when his blood sugar readings were high, and not receiving the proper diet to help control his diabetes. On 12/30/25 at 12:36 p.m., Resident B was observed returning to his room. The resident indicated his blood sugar readings were always high due to not getting his insulin correctly. That morning at 4:00 a.m., his blood sugar had read high which meant over 600, he had cold sweats, and the staff had responded by turning on the air conditioner but had refused to call the physician and get insulin coverage. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure care plan interventions were personalized, implemented, and updated to include changes to wound management for 1 of 3 residents reviewed for care plans (Resident B). This deficient practice was corrected by 10/31/25 prior to the start of the survey and was therefore Past Noncompliance. Findings include:Resident B's clinical record was reviewed on 11/7/25 at 2:00 p.m. Diagnoses on Resident B's profile included hemiplegia and hemiparesis (paralysis) following a cerebral infarction (stroke - death of brain tissue caused by a lack of blood flow) affecting the left dominant side, type 2 diabetes mellitus with diabetic neuropathy, Parkinson's disease, encephalopathy (disfunction of the brain that caused confusion and memory loss), and dysphagia (difficulty swallowing). A care plan for Resident B, dated 9/5/25, indicated the resident was at risk for altered skin integrity related to impaired mobility, and type 2 diabetes mellitus. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide or document showers for 4 of 11 residents reviewed for bathing preferences (Residents C, K, L, and N). Findings include:During the initial facility tour on 8/6/25 at 10:45 a.m., the following residents complained of not getting showers.a. On 8/6/25 at 11:22 a.m., Resident K was observed lying in bed watching TV. The resident indicated she required assistance with ADL's (activities of daily living) to include bathing, transfers out of the bed, and wheelchair (WC) mobility.On 8/8/25 at 10:52 a.m., electronic shower documentation for Resident K, dated 7/1/25 - 8/6/25, indicated the resident had received a shower on 7/23, 8/4, and 8/6. Licensed Practical Nurse (LPN) 9 indicated, the resident had moved upstairs from Heritage hallway 2 days prior. There was no documentation to indicate Resident K had refused to have a shower.b. On 8/6/25 at 11:37 a.m., Resident L was observed wheeling herself into her room in a manual WC and stopped 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, interview, and record review, the facility failed to provide comfortable water temperatures of more than 100 degrees Fahrenheit (F) and less than 120 degrees F in 16 of the 16 residents' bathrooms on the [NAME] 1 hallway reviewed for comfortable temperatures (Rooms 200, 201, 202, 203, 204, 205, 206, 207, 208, 209, 210, 211, 212, 213, 214, and 215) . Findings include: During the initial tour, on 8/6/25 at 12:03 p.m., Resident N indicated that the water in her bathroom was cold, she could not take a shower in her room, and CNA 8 had to warm up water in a basin at the nurse's station so she could be washed. A visitor observed the water being cold after having been turned on for 5 minutes. The resident indicated she had notified management more than once that her water did not always warm up after being turned on for 20 minutes.Documentation of water temperature monitoring included:a. On 7/7/25, water temperatures were 120 Fahrenheit (F) in the Health hallway nurse's station, Heritage hallway…

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 maintain a clean and sanitary environment on 4 of 4 hallways (Health Heritage, [NAME] 1, and [NAME] 2 hallways) observed for cleanliness. Findings include:1. A confidential interview during the survey process indicated family members had visited to find the resident's room in complete filth. The resident had multiple sheets with urine and bowel movement, and the mess had been covered up with cloth pads by the staff instead of them changing his sheets. There had been dried bowel movement on the trash can, and someone had removed the trash can liner then put a trash can liner back in on top of the dried bowel movement. There was an occurrence when the resident had a loose bowel movement, could not get staff to respond to his call light, and in attempts to clean up the mess had smeared it from the bed into the bathroom. The resident had an infectious disease, and having his bodily fluids all over the room was not hygienic. On 8/6/25 at 2:38 p.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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident rooms and common areas were free of flying and crawling insects, and subsequently into and landing on open food and drinks in the resident's room on 4 of 4 nursing units during random observation of resident rooms (Health, Heritage, [NAME] 1, and [NAME] 2 hallways). Findings include:On 8/6/25 at 11:16 a.m., a gnat was observed flying outside Resident Z's doorway as Housekeeper 7 mopped the floor.On 8/6/25 at 11:37 a.m., gnats were observed flying in Resident L's room as she was wheeling herself into her room in a manual WC (wheelchair). A protein shake with an expiration date of 6/26/25 and an opened container of coffee with tissue paper stuffed in the top, were sitting next to an opened bottle of wound spray that had a dried dark food substance down the side, all sitting among additional food and personal items on her dresser. There were open containers of powdered vanilla creamer, sugar, and frosted cereal on the shelves…

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 resident food was stored in a safe and sanitary manner when resident and staff food were co-mingled and not labeled in 3 of 4 nurse's station refrigerators observed for resident food storage, and failed to ensure resident food was stored in a safe and sanitary manner when food was left open in residents' rooms (Residents C, L, and Q) with visible gnats. Findings include: 1. During the initial tour, on 8/6/25 at 10:45 a.m., a refrigerator with a combination lock was observed in each nurse's stations. A sign printed on bright pink paper, taped to the front of each refrigerator indicated, This is for the storage of resident's food and drinks only [with name and date]. Any personal items will be thrown away.During an interview on 8/7/25 at 12:19 p.m., Certified Nursing Assistant (CNA) 7 indicated, the nurse's stations refrigerators were for the storage of the residents' food and drinks, but sometimes staff working off hour shifts would put their food…

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

Based on observation, interview, and record review, the facility failed to ensure a comprehensive and individualized care plan was developed for a resident with behaviors related to wandering, adjustment to new living conditions and personal hobbies for 1 of 1 residents reviewed for elopement, (Resident 88) and failed to implement a comprehensive care plan for a resident who admitted to the facility with a trans metatarsal amputation (TMA) ( a surgical procedure that involves the removal of the distal portion of the metatarsal bones in the foot) for 1 of 5 residents reviewed (Resident 196). Findings include: 1. On 2/24/25 at 11:36 a.m., Resident 88 was observed through his open door. He refused to allow entrance and instead of answering questions, he became agitated and demanded that he get his bicycle back. He adamantly declared he was a cyclist, his bicycle had been confiscated from him, that he was being kept against his will, and institutionalized. Resident 88 was observed to wear slick-styled nylon sports pants and wore cleats. A wanderguard bracelet was observed around 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 reassess the effectiveness of interventions and review and revise a resident's care plan (Resident 28 and Resident 241) for 2 of 23 residents reviewed for care plan revision. Findings include: 1. Resident 28's medical record was reviewed. She was a long-term care resident whose diagnoses included, but were not limited to, hemiplegia (paralysis of one side of the body), and dysphagia (difficulty swallowing.). A social service note that was a summary of a care plan meeting, dated 8/2/24, indicated they reviewed dietary concerns and Resident 28 indicated she cannot chew the food. Resident 28 had a care plan with a revision date of 9/16/24 that indicated the Resident was at nutritional risk due to poorly fitting dentures and a mechanically altered diet. The care plan lacked documentation of interventions related to the resident's complaints of chewing or swallowing noted. Resident 28 had an order, dated 9/18/24, that indicated she was on a regular texture diet. Resident 28 had a care plan with a revision date of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent the potential for accidents when call lights were observed out of reach, neurological checks were not completed, for 3 of 3 residents reviewed for accidents (Residents 10, 142, and 15), and failed to ensure medications were not left at bedside for 1 of 3 residents reviewed for accidents (Resident 10). Findings include: 1. On 2/25/25 at 9:23 a.m., Resident 10 was observed. She was reclined in her bed with the head of the bed (HOB) slightly elevated. She held a piece of toast, but her eyes were closed, and she appeared to be asleep. A half-eaten plate of breakfast was observed on her overbed table. Her call light was observed on the floor to the left side of her bed, out of her line of sight, and out of reach. On 2/25/25 at 9:50 a.m., Resident 10's breakfast tray had been removed, but her call light remained on the floor. On 2/26/25 at 9:58 a.m., Resident 10 was observed. She sat on the right edge of her low air loss mattress, her…

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

Based on observation, interview, and record review, the facility failed to ensure a resident without teeth or dentures was provided interventions to ensure the resident was able to eat and did not have significant weight loss of 11 percent over 6 months for 1 of 5 residents reviewed for nutrition (Resident 28). Findings include: On 2/24/25 at 10:52 a.m., Resident 28 was observed as she sat up in her bed, she appeared thin and petite in stature. Licensed Practical Nurse (LPN) 12 was in the room checking to see if she had eaten her lunch. LPN 12 indicated Resident 28's family had brought her lunch before she left the resident's room. Resident 28 had her over the bed table in front of her with a Styrofoam tray with several pieces of fried catfish, fried whole chicken wings, and other assorted fried sides on it. Resident 28 indicated she could not eat the food in front of her because it was too hard for her to chew. Resident 28 opened her mouth to show that she had no natural teeth and did not have dentures in place. The resident indicated she had dentures, but she had not had them for…

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

Based on record review and interview, the facility failed to hold medications when a resident's vital signs were outside of the ordered parameters for 3 of 5 residents reviewed for unnecessary medications (Resident 196, 59, and 195). Findings include: 1. On 2/26/25 at 11:27 a.m., a record review was completed for Resident 196. He had the following diagnoses which included, but were not limited to, end stage renal disease, trans metatarsal amputation (TMA), hypertension, left above the knee amputation, and major depressive disorder. He had an order, dated 1/29/25, for metoprolol succinate (a blood pressure medication) extended release oral tablet 24 hour, 25 milligrams (mg) to give 1 tablet in the evening every Monday, Wednesday, and Friday. The medication was to be held for systolic less than 110 and/or pulse less than 60. The Medication Administration Record (MAR) indicated Resident 196 was given the medication on 2/3/25 when his blood pressure was 102/83, on 2/5/25 when his blood pressure was 110/68, and on 2/7/25 when his blood pressure was 93/58. On 2/17/25, 2/19/25, 2/21/25,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to date multi-dose vials of tuberculin serum and failed to remove expired insulins from the medication cart for 2 of 3 refrigerators observed for medication storage and 1 of 3 medication carts observed for medication storage. Findings include: On [DATE] at 10:22 a.m., the Health unit medication room refrigerator was observed. A vial of Aplisol (tuberculin serum) was in the refrigerator with no date to indicate when it was opened. Health unit medication cart number 2 contained 2 insulin pens belonging to Resident 26. One insulin pen Semglee (insulin) 100 unit/ml opened on [DATE] and the other was Lispro (insulin) 100 unit/ml opened on [DATE]. Heritage unit medication room refrigerator had a vial of Tubersol (tuberculin serum) 5 unit/0.1mg with no date to indicate when it was opened. During an interview with Licensed Practical Nurse 7, she indicated the insulin pens were only good for 30 days. A policy titled, Storage of Medications, was provided by the…

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

Based on observation, interview, and record review, the facility failed to ensure the physician was notified of a change in a reesident's condition related to the development of new impairments to their skin for 2 of 3 residents reviewed for pressure ulcers (Resident B and D). Findings include: 1. On 11/15/24 at 10:35 a.m., Resident B's medial record was reviewed. She was a long-term care resident with diagnoses which included, but were not limited to, unspecified dementia (a degenerative brain disease which affects memory and cognitive functioning), chronic obstructive pulmonary disease (COPD, a lung disease which makes it hard to breath), and hypertensive (high blood pressure) heart disease. Resident B had a discharge Minimum Data Set (MDS) assessment, dated 11/1/24, which indicated she discharged with a new unstageable (full-thickness pressure injuries in which the base is obscured by slough and/or eschar) pressure ulcer. A nursing progress note, dated 10/18/24 at 4:27 p.m., indicated a CNA notified the nurse of a new wound. The nurse assessed and cleansed the area, then notified…

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 prevent the development of a new pressure ulcer for a resident with a history of pressure ulcers and ensure timely assessment and treatment of the new pressure ulcer for 1 of 3 residents reviewed for pressure ulcers (Resident B) . Findings include: On 11/15/24 at 9:55 a.m., Resident B was observed in her room. She was in her bed with the head of her bed (HOB) elevated at approximately a 45-degree angle, and she was positioned on her left side with pillows propped under her right hip/buttock area. She was awake and alert to herself only as she was pleasantly confused and unable to engage in conversation or answer yes/no questions. During an interview on 11/15/24 at 10:00 a.m., Licensed Practical Nurse (LPN) 67 indicated, Resident B had recently returned from the hospital after she had been sent out for the wound. LPN 67 indicated she had not worked with Resident B for a while since she had been off work and the resident was in the hospital, but LPN 67 was surprised to learn that her wound had gotten bad so…

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 residents' discharge instructions accurately reflected their reconciled medications to ensure residents were sent home with an accurate quantity of medications for 2 of 3 residents reviewed for discharge (Resident B and D). Findings include: 1. On 3/6/24 at 11:00 a.m., a comprehensive record review was completed for Resident B. He had the following diagnoses which included but not limited to peripheral vascular disease (PVD, a slow and progressive circulation disorder), type 2 diabetes, hyperlipidemia (HLD), morbid obesity, right above knee amputation (AKA), and polyneuropathy (a condition in which a person's peripheral nerves are damaged). Resident discharged from the facility on 2/1/24. He was discharged to the community. A medication discharge form was present in the record. Three medications lacked a quantity of the medication that was sent with him. The medications were 1. Ozempic (a medication used weekly to treat diabetes), 2. NovoLog pen (insulin), and 3. insulin glargine solution (used to treat diabetes).…

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 grievances that had been filed on behalf of a resident were documented, followed up with, and resolved for 1 of 1 resident reviewed for grievances (Resident D). Findings include: During a confidential interview, it was indicated, Resident D's family had voiced their concerns related to Resident D's care many times and to many staff members. On 2/6/24 at 10:35 a.m., Resident D's medical record was reviewed. The record lacked documentation of Grievance Forms being filed regarding the resident. On 2/7/24 at 8:13 a.m., grievances related to Resident D were requested. On 2/7/24 at 12:05 p.m., the Executive Director (ED) provided 1 Grievance Form dated 1/5/24. The ED indicated the Director of Nursing kept separate documentation in nurses' notes related to her direct follow up with Resident D and his family. The family provided a copy of a grievance filed on 11/7/23 which indicated, .[Resident D] was found in the bed completely saturated in urine up to the middle of his back (t-shirt) as well as stool (loose)…

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 all medications and wound treatment solutions were secured in the public hallway and in the resident rooms (Resident 11, 18, 5, and 21). Findings include: 1. On 12/11/23 at 9:40 a.m., Dakin's solution (denatures protein, loosening slough and rendering it more easily removed from the wound .improves the mechanical debridement due to the desiccative nature of Dakin's solution and adhesion of tissue to each gauze used) bottle was observed on her bedside table. On 12/12/23 at 2:44 p.m., Resident 18's record was reviewed. She was admitted on [DATE]. Her diagnoses included, but were not limited to, stage four (bone exposed) pressure ulcer of the sacral region, it was present on admission. A physician order, dated 7/26/23, indicated to cleanse her sacrum with wound cleanser or normal saline (NS) and pat dry. Apply collagen particles to wound bed, cover with calcium alginate AG and cover with bordered foam daily and as needed (PRN) 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 A. Based on observation and interview, the facility failed to distribute food under sanitary conditions by performing proper hand hygiene during meal service for 9 of 9 residents in the Lofts dining room (several unidentified residents and Resident 64). B. Based on observation and interview, the facility failed to distribute, serve food, and store used room trays under sanitary conditions and perform proper hand hygiene during meal service for 13 of 13 residents receiving meal tray in their room on the Lofts 2 hallway. C. Based on observation and interview, the facility failed to maintain sanitary conditions for use of an ice chest on the Lofts 2 hallway for 1 of 1 random observation (Resident 13). Findings include: A. On 12/11/23, during a continuous observation, from 12:44 p.m. to 12:59 p.m., Certified Nursing Aide (CNA) 89 was observed. At 12:44 p.m., she pulled up the sleeves on her clinical jacket. She did not gel or wash her hands. She was waiting for Dietary Aide (DA) 35 to fill a resident's plate. She…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to care for a resident in a manner that preserved the resident's dignity when she did not receive incontinence care in a timely manner for 1 of 5 residents reviewed for quality of care (Resident F). Findings include, During a random observation on [DATE] at 11:52 a.m., Resident F was observed lying in bed, head of the bed in high position, the resident had slid down, pink silk-like nightgown bunched around her waist, and covers over her lower legs. The resident was observed wearing a saturated adult brief, and there was a strong smell of urine permeating the room. The resident indicated she had used her call light to summons staff at 8:30 a.m. before breakfast was served to assist her as she was incontinent of both urine and stool, but she was still waiting to be changed. The television (tv) remote was observed on the floor on the back side of the bed with the back off and batteries on the floor, she was holding the remote to the bed, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY A. Based on observation, interview, and record review, the facility failed to ensure effective interventions were in place to prevent a resident, (Resident E) from developing new pressure ulcers for 1 of 3 resident reviewed for pressure ulcers. B. Based on observation, interview, and record review, the facility failed to ensure appropriate hand hygiene and application of the correct treatment were provided during a wound treatment observation (Resident 18) for 1 of 3 resident reviewed for pressure ulcers. Findings include: A. An anonymous complaint indicated, .Resident E admitted to the facility with no skin issues and left with 5 wounds. On 12/13/23 at 10:08 a.m., Resident E's medical record was reviewed. She admitted to the facility on [DATE] with diagnoses which included, but were not limited to, end stage hypertensive kidney disease and heart failure. An admission nursing assessment dated [DATE] indicated, Resident E did not have and open areas, but was at risk for the development of pressure ulcers.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident (Resident 41) who had a history of weight loss was provided with the appropriate supplemental health shake and was served meals according to her preferences for 1 of 3 residents reviewed for nutrition. Findings include: On 12/11/23 at 10:09 a.m., Resident 41 was observed in her room. She sat of the edge of her bed with an over-bed table in front of her. Resident 41 indicated she did not like breakfasts because she always got eggs, or stuff with gravy and she did not like gravy. She was supposed to get a milkshake twice a day, but sometimes she didn't and did not like the flavor they had. She would prefer strawberry, or banana flavored. No supplement shake or banana was observed at that time. On 12/11/23 at 12:06 p.m., Resident 41 had a visitor, and she indicated she had offered her lunch since she did not like what it was. Resident 41 and her visitor indicated she had not been offered an alternative when she complained…

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.