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Based on observation, interview, and record review, the facility failed to implement the plan of care for a cognitively impaired resident at high risk of falling for 1 of 1 residents reviewed for falls. Fall care plan interventions were not in place. (Resident 14)Finding includes:On 1/28/26 at 3:33 P.M., Resident 14's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's disease, dementia without behaviors, and Guillain-Barre syndrome. The most recent quarterly Minimum Data Set (MDS) assessment, dated 1/21/26 indicated Resident 14's cognition was severely impaired, partial to moderate assist from staff (resident performs over half the effort) for bed mobility and transfers, and substantial to maximum assistance of staff (staff performs over half the effort) for toileting and bathing, and the resident has had two or more falls with no injury and 2 or more falls with injury (not major) since the last MDS assessment, dated 11/3/25.A current Fall Care plan, last revised 1/20/26, included, but were not limited to, the following interventions:keep urinal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medications were given as ordered and a discharged resident was sent home with the correct medication for 1 of 3 closed records reviewed. A blood thinner was not given as ordered, and a resident was sent home with another resident's medications at discharge. (Resident B)On 1/30/26 at 4:00 P.M., the Administrator provided an incident form that indicated on 9/19/25 when Resident B was discharged from the facility, medications belonging to another resident had been sent home with them. The form indicated the facility attempted to contact Resident B's representative several times daily until 9/25/25 when contact was made and the medication was brought back to the facility the same day. On 1/29/26 at 11:32 A.M., Resident B's clinical record was reviewed. Resident B was admitted to the facility on [DATE] and discharged on 9/19/25. Diagnosis included, but was not limited to, fracture of the right lower leg. The most recent admission 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.

Based on observation, interview, and record review, the facility failed to ensure a sanitary environment to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents observed for incontinence care. Hand hygiene was not done, gloves were not changed between clean and dirty tasks, and the soiled incontinence pad was laid on the bedsheet. (Resident 45)Finding includes:On 1/29/26 at 8:57 A.M., incontinence care was observed on Resident 45 performed by Certified Nurse Aide (CNA) 14 and CNA 22.CNA 14 used Antibacterial Hand Rub (ABHR) and put gloves on. Then she used the bed control to put the bed down, touched the privacy curtain, grabbed the foot board of the bed, and then grabbed the resident's call light. CNA 22 did not sanitize hands before putting on gloves, used the bed control to lower and raise the bed and moved the call light. Both CNAs pulled down the resident's bed sheets and blanket. CNA 14 unfastened the resident's incontinence pad and held the resident on her left side while CNA 22 grabbed wipes and a clean incontinence pad…

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 medications were stored safely or under proper temperature controls for 2 of 15 residents sampled for medications on the floor, and 2 of 2 medication storage rooms. (Resident D, Resident M, 100 Hall Medication Storage Room, 300/400 Hall Medication Storage Room) Findings include: 1. On 10/15/24 at 9:19 A.M., the 100 Hall Medication Storage Room medication refrigerator log was observed to be missing temperatures. The 100 Hall medication refrigerator log lacked a temperature on days from 10/1/24 through 10/15/24. The 100 Hall medication refrigerator log was missing a temperature for night shift on 10/1/24, 10/2/24, 10/4/24, 10/5/24, 10/6/24, 10/7/24, 10/9/24, 10/10/24, 10/12/24, 10/13/24, and 10/14/24. At that time, QMA (Qualified Medication Aide) 11 indicated that temperatures were taken twice a day and logged for medication refrigerators. The 300-400 Hall medication refrigerator log was observed to be missing temperatures for day shift from 10/2/24 through 10/15/24. The log was observed to be missing 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, observation, and record review, the facility failed to ensure food was stored and prepared safely in accordance with professional standards for food service for 1 of 2 kitchen observations. Foods were not labeled correctly, food was stored uncovered, and the facility failed to dispose of outdated food. Findings include: On 10/15/24 at 9:13 A.M., the following was observed in the kitchen: Freezer in the kitchen: -- 5 undated, uncovered, and unlabeled bowls of pink ice cream -- 5 covered bowls undated and unlabeled. Refrigerator in the kitchen: -- clear container with cheese that had a label printed on 10/2/24 with a discard date of 10/8/24 -- applesauce with an opened date of 10/8/24 and a discard date of 10/14/24 -- clear container of lettuce undated and unlabeled -- 3 trays of fruit with several bowls uncovered on all 3 trays -- silver container with hotdogs and hamburgers undated and unlabeled -- silver container with an unknown substance that was undated and unlabeled Walk in freezer -- apple roasted pork prepared on 9/29/24 with a discard date of 10/1/24…

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 observation, interview, and record review, the facility failed to ensure resident safety during transportation for 1 of 3 residents reviewed for accidents. A resident was improperly loaded onto a transportation vehicle lift causing the resident to fall backwards from a wheelchair onto the lift platform. (Activity Assistant 3, Resident B) Finding includes: During a review of facility reported incidents on 6/19/24 at 10:35 A.M., an incident that occurred on 6/3/24 at 2:45 P.M., indicated that Resident B was being transferred out of the facility transportation van and fell off the lift. Resident B was sent to the emergency room and received eight sutures to the right shin. During an observation and interview on 6/19/24 at 11:00 A.M., Resident B was sitting in her wheelchair in the dining room. Resident B indicated that she had fallen off of the facility transportation vehicle when the vehicle lift was not out properly. Resident B indicated she needed 8 stitches to her right leg and thinks she landed on a metal part of the lift which cut her leg. Resident B indicated the driver…

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 plan of care was implemented for 1 of 3 residents reviewed for ADL (activities of daily living) care provided. A resident was not assisted by two staff members during a transfer during incontinence care per the resident's plan of care. (Resident D, Resident C) Finding includes: During an interview on 2/6/24 at 10:35 A.M., Resident D indicated that they had reported CNA 9 for punching her in the stomach while providing care. Resident D indicated that CNA 9 transferred her from her wheelchair to her bed using a Hoyer mechanical lift prior to providing incontinence care. Resident D indicated that CNA 9 slipped and accidentally hit her stomach while providing care. During record review on 2/6/24 at 11:30 A.M., Resident D's diagnoses included, but were not limited to unspecified multiple injuries, person injured in unspecified motor vehicle accident, chronic pain, displaced commuted fracture of right patella, fracture of sternum, fracture of unspecified forearm, and fracture of right lower leg. Resident D's most…

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 develop resident specific care plans and implement interventions for 4 of 4 residents reviewed for care plans. A resident's care plan indicated to encourage fluids when the resident was NPO (nothing by mouth). Two residents had orders that did not match care plans for dental services. A resident with falls did not have interventions in place. (Resident 6, Resident 49, Resident 51, Resident 62) Findings include: 1. On 8/8/23 at 10:05 A.M., Resident 62 was observed lying in bed with the head of her bed elevated 30 degrees, on her right side,eyes closed, moving her right arm around. Her tube feeding was infusing at 45 ml/hr (milliters/hour) per pump. An oxygen mask, dated 8/8/23, was over the tracheostomy. High flow humidified oxygen was on at 6 L/min (Liters per minute). Foley catheter was hanging on the right side of the bed covered with a bag and draining yellow urine with sediment. Suction machine was sitting on the bedside cabinet. Call…

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 the resident's right of dignity was promoted and protected for 2 of 3 residents reviewed for dignity. A visibly soiled resident was not stopped by staff on his way to the dining room and a resident receiving incontinence care was told the staff was going to change his diaper. (Resident 35, Resident 40) Findings include: 1. On 8/7/23 at 3:09 P.M., Resident 35 was laying in bed with a urinary catheter hanging on the right side of his bed. On 8/9/23 at 1:30 P.M., Resident 35's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus type II, prostate cancer, stroke, and hemiplegia on left side. The most recent admission MDS (Minimum Data Set) Assessment, dated 7/7/23, indicated the resident was moderately cognitively impaired, an extensive assist of 2 staff for bed mobility and toileting, and had a urinary catheter but was incontinent of bowel movements. On 8/10/23 at 2:55 P.M., incontinence care given by CNA (Certified Nurse Aide) 14 and CNA 28 was observed on Resident 35. During that…

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

Based on observation, interview, and record review, the facility failed to ensure residents that were self-administering medications were assessed for capability to self administer medications for 1 of 2 residents reviewed for accidents and 1 of 5 residents reviewed for medication administration. Resident clinical records lacked a self administration of medication assessment. (Resident 6, Resident 65) Findings include: 1. On 8/11/23 at 8:29 A.M., Resident 6 was observed sitting in his room in his wheelchair. At that time, there was a medicine cup sitting on his bedside table with 1 white, circular pill in it. On 8/10/23 at 9:03 A.M., Resident 6's clinical record was reviewed. Diagnoses included, but were not limited to, dementia with behaviors and diabetes mellitus type II. The most current significant change MDS (Minimum Data Set) Assessment, dated 7/17/23, indicated resident was severely cognitively impaired and was an extensive assist of 2 staff members for bed mobility, transferring, and toileting. Resident 6's clinical record lacked a physician's order for self administering…

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 assessments were conducted and completed following an emergency room visit where all insulin medications were discontinued for a diabetic resident for 1 of 3 residents reviewed for change of condition. (Resident 31) Findings include: On 8/7/23 at 2:25 P.M., Resident 31 was observed sitting in a wheelchair in the dining room. At that time, he was observed sweating, with a yellow substance in the outer corner of the left eye, and a built up white substance on his teeth at the gum line. On 8/9/23 at 9:57 A.M., Resident 31's clinical record was reviewed. Diagnosis included, but were not limited to, heart failure and diabetes. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 7/26/23, indicated no cognitive impairment, no behaviors, required extensive assistance of two staff with bed mobility and toileting, supervision of one staff with eating, and was totally dependent of two staff with transferring and bathing. Resident 31 did not receive insulin in the 7-day look back period. Physician…

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 medications were administered free of error for 1 of 5 residents reviewed for medication administration. A resident was administered the wrong dose of (2) medications, resulting in an error rate of 8%. (Resident 65) Findings include: On 8/10/23 at 7:11 A.M., Qualified Nurse Aide (QMA) 9 was observed to administer medications to Resident 65 that included, but were not limited to, the following: Auryxia (an iron supplement medication) 210mg (milligram) tablet (one tablet) hydralazine (a blood pressure medication) 100mg tablet (one tablet) Breakfast was not provided at the time of the medication administration. On 8/11/23 at 1:51 P.M., Resident 65's clinical record was reviewed. Diagnosis included, but were not limited to, diabetes and anxiety. The most recent admission MDS (minimal data set) Assessment, dated 7/26/23, indicated no cognitive impairment. Resident 65 required extensive assistance of two staff with bed mobility, transfers, and toileting. Current physician orders 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.