Riverbend Post Acute Rehabilitation

Based on observation, record review, and interviews, the facility failed to ensure a functional call light system for Resident (R) 111 while he was on or in bed, in order to convey his needs to staff. Findings included:- R111's Electronic Medical Record (EMR) showed a diagnosis of generalized muscle weakness, difficulty walking, and unsteadiness on feet.R111's Care Plan dated 08/25/2025 stated R111 was at risk for falls related to occasional bladder incontinence and he required assistance with activities of daily living (ADL)s He was at risk for complications as evidenced by decreased functional mobility and dementia (decline in cognitive functioning The plan directed staff to be sure the call light was within reach and encourage the resident to use it to call for assistance as needed.Observed on 05/05/2026 at 10:25 AM, R111's call light was at the head of his bed. R111 sat on the edge of the bed. R111 stated he was trying to get some help, but no one was coming. A check of the call light within reach of R111's bed revealed the light did not come on at the door or at the monitor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and observation, the facility staff failed to ensure a safe, sanitary, and functional environment on one of the stairwells. Findings included:- Observed on 05/07/2026 at 08:30 AM, one of the stairwells had a white, wet, organic type substance on the walls with a strong musty odor. There was dusty debris, which appeared to be flaked plaster, on the handrail and the floor at the back wall of the stairwell. There were stains which appeared to be water damage on the ceiling inside the stairwell.Interviewed on 05/07/2026 at 08:37 AM, Housekeeping Staff stated that housekeeping staff were responsible for cleaning the floors and handrails in the stairwell, but not the walls and ceilingsInterviewed on 05/07/2026 at 08:40 AM, Maintenance Staff U stated the maintenance department would be responsible for cleaning the walls of the stairwell. He said he would get a plan in place to spray the white substance on the walls with bleach to clean it.During an interview on 05/07/2026 at 08:40…

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.

The facility identified a census of 123 residents. The sample included 25 residents, with seven reviewed for reasonable accommodation of needs related to call lights and wheelchair foot pedals. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 84 had a call light he could functionally activate for staff assistance and ensure R96, R47, and R81 had foot pedals on their wheelchairs while being pushed. The facility additionally failed to provide R10's sensory hand item.Findings Included:- On 11/18/25 at 08:55 AM, R84 (severely cognitively impaired resident) sat in his bed with his bedside table over him. He stated he was done with his breakfast tray and needed staff to assist him. R84's call light was placed inside the dresser next to his bed and out of his reach. R84's low air-loss mattress was set to 200 pounds (lbs). On 11/18/25 at 09:00 AM, R96 (severely cognitively impaired resident) was pushed into the dining room in his wheelchair. His feet slid on the floor as he was pushed from his room to the dining room table. His wheelchair 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 123 residents. The sample included 25 residents, with five residents reviewed for accidents and/or hazards. Based on observation, record review, and interview, the facility failed to secure rooms containing hazardous materials to keep out of reach of 12 cognitively impaired /independently mobile residents. The facility additionally failed to follow Resident (R) 61 and R67's implemented fall interventions per their care plans.Findings Included: - On 11/17/25 at 07:10 AM, a walkthrough was completed in the facility's secured 2nd floor, and the following was observed: An inspection of an unsecured linen closet next to the nurse's station next to the elevator, revealed a container of purple disinfectant wipes on top of the room's counter. An inspection of the dining area revealed a cabinet next to the seating area with a container of purple wipes stored in the upper cabinet. An inspection of an unsecured soiled utility closet next to the rear nurse's station revealed two overfilled…

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 The facility had a census of 123 residents. The sample included 25 residents. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 67 had a physician's order and was assessed for the ability to safely self-administer an inhaler medication.Findings included:- The Electronic Medical Record (EMR) for R67 documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), acute and chronic respiratory failure with hypercapnia (when the body can't effectively get rid of carbon dioxide because of persistent lung disease).The Quarterly Minimum Data Set (MDS) dated [DATE] documented R67 had intact cognition. R67 required supervision with showers, dressing, mobility, transfers, and ambulation. The assessment documented R67 received an antianxiety (a class of medications that calm and relax people), antidepressant (a class of medications used to treat…

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 The facility had a census of 123 residents. The sample included 25 residents. Based on observation, interview, and record review, the facility failed, due to her posttraumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), to provide only female caregivers that were requested, for Resident (R) 82. Findings included:- The Electronic Medical Record (EMR) for R82 documented diagnoses of PTSD and insomnia (inability to sleep).The Quarterly Minimum Data Set (MDS) dated [DATE] documented R82 had intact cognition. R82 was independent with dressing, personal hygiene, mobility, transfers, and ambulation. The assessment documented R82 had no behaviors and did not receive psychotropic medications.R82's Care Plan dated 09/27/25, initiated on 06/27/25, documented social services to provide psychosocial support as needed. The care plan lacked documentation R82 requested no male caregivers.The Social Services…

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.

The facility identified a census of 123 residents. The sample included 25 residents, with one resident reviewed for the discharge process. Based on record review and interviews, the facility failed to provide a final summary of Resident (R) 128's status at discharge. Findings included:- R128s Electronic Medical Records (EMR) documented diagnoses of unsteadiness on feet, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), weakness, major depressive disorder (major mood disorder that causes persistent feelings of sadness), dependence on renal dialysis (a procedure where impurities or wastes are removed from the blood), acquired absence of left great toe, blindness right eye muscle, and dysphagia (swallowing difficulty).R128's Entry Minimum Data Set (MDS) completed 09/18/25.R128's Care Plan dated 09/18/25 documented:- R128 wanted to be discharged home after his skilled stay in the facility. - R128's plan of care dated 10/03/25 documented a pre-discharge plan would be held with the resident,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 123 residents. The sample included 25 residents. Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for two residents, Resident (R) 67 for smoking, and for R82 for posttraumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress). Findings included:- The Electronic Medical Record (EMR) for R67 documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), acute and chronic respiratory failure with hypercapnia (when the body can't effectively get rid of carbon dioxide because of persistent lung disease).The Quarterly Minimum Data Set (MDS) dated [DATE] documented R67 had intact cognition. R67 required R67 supervision with showers, dressing, mobility, transfers, and ambulation. The assessment…

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 The facility identified a census of 123 residents. The sample included 25 residents, with two residents reviewed for activities of daily living (ADL) care. Based on observation, record review, and interviews, the facility failed to ensure staff assisted Resident (R) 10 with showers as scheduled. Findings Included:- R10's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of cerebrovascular accident (CVA: stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), hypertension (elevated blood pressure), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing, need for assistance), dysphagia (swallowing difficulty), and contracture (abnormal permanent fixation of a joint).R10's Annual Minimum Data Set (MDS) dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of 99, which…

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 The facility identified a census of 123 residents. The sample included 25 residents, with five reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on interviews, observations, and record reviews, the facility failed to ensure Resident (R) 84's pressure-reducing interventions were implemented correctly when R84's low air-loss mattress (specialized air mattress used to prevent pressure related wounds) was not set within his current weight range. The facility additionally failed to float R10's heels as directed by wound treatment. heelsFindings included:- R84's Electronic Medical Records (EMR) included diagnoses of congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), heart disease, and a stage-three (full-thickness pressure injury extending through the skin into the tissue below) pressure injury. R84's admission…

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 The facility had a census of 123 residents. The sample included 25 residents. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 82 received trauma-informed care to eliminate or mitigate triggers that may cause traumatization related to a diagnosis of post-traumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress). Findings included:- The Electronic Medical Record (EMR) for R82 documented diagnoses of PTSD and insomnia (inability to sleep).The Quarterly Minimum Data Set (MDS) dated [DATE] documented R82 had intact cognition. R82 was independent with dressing, personal hygiene, mobility, transfers, and ambulation. The assessment documented R82 had no behaviors and did not receive psychotropic medications.R82's Care Plan dated 09/27/25, initiated on 06/27/25, documented social services to provide psychosocial support as needed. The EMR lacked documentation of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 123 residents. The sample included 25 residents, with seven residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to hold Midodrine (a medication for low blood pressure) for Resident (R) 26 and R97 and failed to hold insulin (controls the amount of sugar in the blood by moving into the cells) as the physician ordered for R67. Findings included:- The Electronic Medical Record (EMR) for R26 documented diagnoses of hyperlipidemia (condition of elevated blood lipid levels) and hypotension (low blood pressure).The Annual Minimum Data Set (MDS) dated [DATE] documented R26 had intact cognition. R26 required supervision from staff for toileting hygiene, upper body dressing, personal hygiene, mobility, and transfers. The assessment further documented R26 received insulin, opioid (moderate to severe pain medication), and antiplatelet (medication that prevents platelets from sticking together and decreases your body's ability to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 123 residents. The sample included 25 residents, with two reviewed for Hospice (specialized care that mainly aims to provide comfort and dignity to the patients, by providing physical comfort and emotional, social, and spiritual support for people nearing the end of life) services. Based on observation, interview, and record review, the facility failed to ensure a communication process between the hospice provider and the facility for Resident (R) 34, which included a plan of care and a description of the services provided, which included visit frequency for certified nurse aides, chaplain, medications, and medical equipment provided.Findings included:- The Electronic Medical Record (EMR) for R34 documented diagnoses of Huntington's disease (a rare abnormal hereditary condition characterized by progressive mental deterioration, a disabling central nervous system movement disorder), neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do…

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 - R5's Electronic Health Record (EHR) revealed diagnoses of diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), major depressive disorder (major mood disorder that causes persistent feelings of sadness), hyperthyroidism (a condition characterized by hyperactivity of the thyroid gland), muscle weakness, and contracture right ankle. R5's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R5 had a Brief Interview for Mental Status (BIMS) of 15 indicating intact cognition. The MDS recorded he required moderate staff assistance with transfers and activities of daily living (ADL). The MDS documented the resident propelled independently with a wheelchair and received insulin (a hormone that lowers the level of glucose in the blood), opioid (a class of controlled drugs used to treat pain) medications, and antidepressant (a class of medications used to treat mood disorders) medications. The Care Area Assessment (CAA), dated 01/10/25,…

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 The facility had a census of 113 residents. The sample included 24 residents. Based on observation, interview, and record review, the facility failed to label Resident (R) 35s, R5s, R88s, R17s, R59s, R13s, R6s, R110s, R10s, R16s, and R64s insulin (a hormone that lowers the level of glucose in the blood) flex pens and vials with the opened date and when expired. This deficient practice placed the affected residents at risk for ineffective medications. Findings included: - On [DATE] at 09:00 AM, observation of the facility's South Hall medication cart revealed the following: R35's Insulin Aspart (fast-acting) flex pen was not labeled with the date opened or the date expired. R5's Lispro (fast-acting) insulin vial was not labeled with the date opened or the date expired. R88's Lantus Solostar (long-acting) insulin was not labeled with the date opened or the date expired, and Lispro Kwik pen was not labeled with the date opened or the date expired. R17's Glargine (long-acting) insulin flex pen was not labeled 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.

The facility had a census of 113 residents. The sample included 24 residents. Based on observation, record review, and interview, the facility failed to adhere to infection control for enhanced barrier precautions (EBP - an infection control intervention designated to reduce transmission of resistant organisms that employs targeted gown and glove used during high contact resident care activities) for Resident (R) 5 who had a diabetic neuropathy ulcer (wound on the skin, typically the feet, that develops due to nerve damage (neuropathy) and decreased sensation caused by diabetes) on his right great toe and right second toe. This placed the resident at risk for possible exposure to infection. Findings included: - On 05/20/25 at 08:00 AM, observation revealed License Nurse (LN) G entered the room of R5, who was lying in bed in his room with both feet under the covers. Observation revealed LN G removed the covers from his right lower leg. Observation revealed LN G washed her hands, donned gloves but no gown, and removed R5's dressings on his right great toe, and right second toe.…

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 The facility had a census of 113 residents. The sample included 24 residents. Based on observation, record review, and interview, the facility failed to revise the care plan to include resident-centered functional abilities for Resident (R) 41 and R69. This placed the residents at risk for unmet care needs. Findings included: - R41's Electronic Medical Record (EMR) included diagnoses of chronic respiratory failure with hypoxia (inadequate supply of oxygen), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), obstructive sleep apnea (a disorder of sleep characterized by periods without respirations), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, major depressive disorder (major mood disorder that causes persistent feelings of sadness), and diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The Quarterly Minimum…

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 The facility had a census of 113 residents. The sample included 24 residents, with one reviewed for activities of daily living (ADL). Based on observation, record review, and interview, the facility failed to provide consistent bathing and grooming for one resident, Resident (R) 43. This placed the resident at risk for complications related to poor hygiene and impaired dignity. Findings included: - The Electronic Medical Record (EMR) recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hypertension (high blood pressure), atrial fibrillation (rapid heart rate), cognitive communication deficit (an impairment in organization, sequencing attention, memory planning, problem-solving, and safety awareness), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). R43's Quarterly Minimum Data Set (MDS), dated [DATE],…

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 The facility had a census of 113 residents. The sample included 24 residents, with four reviewed for dementia (a progressive mental deterioration characterized by confusion and memory failure) care. Based on observation, record review, and interview, the facility failed to address one resident, Resident (R) 36's dementia care needs, when R36 continued to go through staff members' belongings that were kept at the nurse's station. This placed R36 at risk for decreased quality of life and accidents. Findings included: - The Electronic Medical Record (EMR) recorded diagnoses of Wernicke's encephalopathy (a degenerative brain disorder caused by the lack of vitamin B1), alcohol-induced persisting amnestic disorder (a cognitive disorder characterized by significant memory impairment), alcohol dementia (a progressive mental disorder characterized by failing memory and confusion), schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, 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 The facility had a census of 113 residents. The sample included 24 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to hold blood pressure medication per the physician-ordered parameters for Resident (R) 13. This placed the resident at risk for physical decline and other related complications. Findings included: - The Electronic Medical Record (EMR) for R13 documented diagnoses of hypotension (low blood pressure), cognitive communication deficit (an impairment in organization, sequencing attention, memory planning, problem-solving, and safety awareness), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R13's Quarterly Minimum Data Set (MDS), dated [DATE], documented R13 had severely impaired cognition. R13 required partial staff assistance for showers, dressing, personal hygiene,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 113 residents. The sample included 24 residents. Based on observation, record review, and interview, the facility failed to prevent a medication administration error for Resident (R) 13, whose blood pressure was out of the physician's ordered parameters, and she received her blood pressure medication. This placed the resident at risk for physical decline and other related complications. Findings included: - The Electronic Medical Record (EMR) for R13 documented diagnoses of hypotension (low blood pressure), cognitive communication deficit (an impairment in organization, sequencing attention, memory planning, problem-solving, and safety awareness), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R13's Quarterly Minimum Data Set (MDS), dated [DATE], documented R13 had severely impaired cognition. R13 required partial staff assistance…

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

The facility had a census of 112 residents. The sample included 23 residents with five residents reviewed for accidents and/or hazards. Based on observation, record review, and interview the facility failed to secure areas containing hazardous materials out of reach of seven cognitively impaired /independently mobile residents in the secured unit. This deficient practice placed the affected residents at risk for preventable injuries and accidents. Findings Included: - The facility identified Residents (R) 14, R45, R47, R63, R103, R105, and R110 were cognitively impaired residents within the secured 2nd-floor. On 01/21/25 at 07:30 AM, an inspection of the 2nd-floor nursing station revealed an alcohol-based disinfectant container of alcohol-based disinfectant wipes on the outside counter of the nurse's station. A shelf next to the sensory room, behind the nurse's station revealed two more disinfectant containers on the top shelf. The wipe's containers contained the warning, Keep out of reach of children, hazardous to humans can cause eye irritation, harmful if swallowed. On 01/21/25…

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.

The facility identified a census of 112 residents. The sample included 23 residents with three residents reviewed for dignity. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 32's right to be treated with respect, and dignity when her privacy curtain or door was closed when she was uncovered and exposed from the waist down. This deficient practice placed R32 at risk for negative psychosocial outcomes and decreased dignity. Findings included: - R32's Electronic Medical Record (EMR) documented diagnoses of major depressive disorder (major mood disorder that causes persistent feelings of sadness), type 2 diabetes mellitus (a chronic disease that occurs when the body is unable to use insulin properly, resulting in high blood sugar levels), and congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid). R32's admission Minimum Data Set (MDS) dated 02/27/24 documented she had a Brief Interview for Mental Status (BIMS) score of 14 which indicated an intact cognition. R32 required substantial…

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.

The facility had a census of 112 residents. The sample included 23 residents with five reviewed for accommodation of needs related assistive devices. Based on observation, record review, and interview the facility failed to utilize wheelchair foot pedals for Resident (R) 14, R47, and R82. This placed the resident at risk for preventable accidents and injuries. Findings Included: - On 01/21/25 at 07:45 AM, R14 (a severely cognitively impaired resident) was wheeled to the small dining room for breakfast. Her wheelchair had no foot pedals and her feet slid on the ground as she was pushed. On 01/21/25 at 09:20 AM, R14 was pushed by staff from the second-floor small dining room to her room. R14's wheelchair lacked foot pedals as her feet slid on the ground multiple times while being pushed to her room. On 01/22/25 at 08:09 AM, R82 (a severely cognitively impaired resident) was pushed by staff out of his room and to the main second-floor dining room for breakfast. R82's feet touched the ground multiple times while being pushed while being pushed. Staff verbally reminded him to raise 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.

The facility identified a census of 112 residents. The sample included 23 residents with one reviewed for notification of changes. Based on observation, record review, and interviews, the facility failed to notify Resident (R) 13's physician with refused daily weights. This deficient practice placed R13 at risk for unmet needs. Findings included: - R13's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (high blood pressure), rheumatoid arthritis (chronic inflammatory disease that affects joints and other organ systems), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), obesity (excessive body fat), absence of right leg below the knee, wheelchair weakness, sleep apnea (a disorder of sleep characterized by periods without respirations), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), need for assistance with personal care, and contracture (abnormal permanent fixation of a joint or muscle) of right hand.…

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 The facility identified a census of 112 residents. The sample included 23 residents with four residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure pressure reducing heel supportive device was in place for Resident (R) 51 who had a pressure-related injury on his right buttocks. This deficient practice placed R51 at risk for complications related to further skin breakdown. Findings included: - R51's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of foot drop in right foot (inability or difficulty in moving the ankle and toes upward), pressure ulcer of right buttocks, need for assistance with personal care, muscle weakness, weakness, reduced mobility, contractures (abnormal permanent fixation of a joint or muscle) of the right shoulder, left shoulder, right…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 112 residents. The sample included 23 residents with five residents reviewed for positioning and mobility. Based on observation, record review, and interviews, the facility failed to ensure Resident (R)26's orthotic (support or brace for limbs) was in place. This deficient practice placed the resident at risk for discomfort and decreased range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension). Findings Included: - R26's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), hypertension (high blood pressure), colostomy (surgical creation of an artificial opening on the stomach wall to excrete feces from the body), hyperlipidemia (condition of elevated blood lipid levels), anemia (an inadequate number of healthy red blood cells to carry…

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 The facility identified a census of 112 residents. The sample included 23 residents with two residents reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 27's continuous positive airway pressure (CPAP - ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) mask was stored in a sanitary manner. This deficient practice placed R27 at an increased risk for respiratory infection and complications. Findings included: - R27's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (high blood pressure), dependence on dialysis (a procedure where impurities or wastes are removed from the blood), hyperlipidemia (condition of elevated blood lipid levels), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), unsteadiness of feet, cognitive…

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 The facility identified a census of 112 residents. The sample included 23 residents with five residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to ensure that Resident (R) 51 had a documented risk assessment for the use of side rails, consent for the use of the side rails, and failed to ensure the resident and/or responsible party were advised of the risks and/or benefits of the use of the side rails. This placed the R51 at risk for uninformed decision and impaired safety related to the risks associated with the use of side rails. Findings included: - R51's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of foot drop in right foot (inability or difficulty in moving the ankle and toes upward), pressure ulcer of right buttocks, need for assistance with personal care, muscle weakness, weakness, reduced mobility, contractures (abnormal permanent fixation of a joint or muscle) of the right shoulder, left shoulder, right knee, left…

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 The facility identified a census of 112 residents. The sample included 23 residents with four residents reviewed for frequency of physician visits. Based on observation, record review, and interviews, the facility failed to ensure the attending physician conducted the required visits for Resident (R) 51. This deficient practice placed R51 at risk of unrealized changes in condition leading to unnecessary complications in his wellbeing. Findings included: - R51's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of foot drop in right foot (inability or difficulty in moving the ankle and toes upward), pressure ulcer of right buttocks (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), need for assistance with personal care, muscle weakness, weakness, reduced mobility, and contractures (abnormal permanent fixation of a joint or muscle) of the right shoulder, left shoulder,…

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.

The facility identified a census of 112 residents. The sample included 23 residents with four reviewed for dementia (a progressive mental disorder characterized by failing memory, and confusion) care. Based on interviews, record review, and observations, the facility failed to provide dementia-related behavioral services for Resident (R) 14 to promote her highest practicable level of well-being. This deficient practice placed R14 at risk for decreased quality of life, isolation, and impaired dignity. Findings Included: - The Medical Diagnosis section within R14's Electronic Medical Records (EMR) included diagnoses of dementia, cognitive-communication disorder, repeated falls, muscle weakness, need for assistance with personal care, and scoliosis (curvature of the spine). R14's admission Minimum Data Set (MDS) completed 11/27/24 documented a Brief Interview for Mental Status (BIMS) score of three indicating severe cognitive impairment. The MDS noted a history of hallucinations (sensing things while awake that appear to be real, but the mind created). The MDS indicated she required…

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.

The facility identified a census of 112 residents. The sample included 23 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 27's continuous positive airway pressure (CPAP - a machine that uses mild air pressure to keep breathing airways open while you sleep) mask was stored appropriately when not in use. The facility failed to ensure R315's tracheal (a surgical procedure that creates an open in the neck and windpipe to help a person breathe) tubing was stored appropriately when not in use. The facility failed to ensure R48's nasal cannula (a hollow tube device used to provide supplemental oxygen) was appropriately stored when not in use. These deficient practices placed R27, R315, and R48 at risk of infection development and possible respiratory complications. Findings included: - On 01/21/25 at 08:33 AM, R27 laid in his bed. R27's CPAP mask laid directly on the bedside table. On 01/22/25 at 08:22 AM, R315 laid in her bed on her back, R315's tracheal tubing was disconnected from her trachea, and placed in a drawer in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 110 residents. The sample included three residents. Based on record review, interview, and observation, the facility failed to ensure staff implemented nursing services consistent with standards of care when staff failed to follow a physician's order to notify emergency medical services (EMS) when Resident (R) 1 had chest pain and required a second dose of nitroglycerine (NTG-medication used to relieve an angina attack that is already occurring) and failed to assess vital signs to monitor resident status. This deficient practice placed R1 at risk for delayed emergency care and complications related to the use of NTG. Findings included: - R1's Electronic Medical Record (EMR) under the Diagnosis tab listed diagnoses of atrial fibrillation (rapid, irregular heartbeat), atherosclerotic heart disease (a condition where the arteries become narrowed and hardened due to buildup of plaque (fats) in the artery wall), cerebral infarction (stroke), and hypertension (elevated blood…

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.