Presentation Rehab And Skilled Care Center

Based on observations, record reviews and interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for one Resident (#78) out of a total sample of 27 residents. Specifically, the facility failed to ensure that the MDS assessment for Resident #78 coded for a significant change when the Resident signed onto hospice. Findings include: Resident #78 was admitted to the facility in June 2024 with diagnoses including malignant neoplasm of colon and failure to thrive. Review of Resident #78's most recent Brief Interview for Mental Status (BIMS) score dated 3/19/25, indicated the Resident scored 9 out of 15 indicating moderate cognitive impairment. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/18/24, indicated Resident #78 was receiving hospice care but failed to indicate Resident #78 had a significant change completed upon being signed onto hospice. Review of Resident #78's current physician orders indicated the following: - Hospice services initiated 7/12/24. During an interview on 4/28/25 8:49 A.M., the MDS Nurse said the MDS should…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to implement the care plan of one Resident (#74), out of a total sample of 27 residents. Specifically, the facility failed to ensure alarms and floor mats were in place as per the care plan. Findings include: Review of facility policy titled 'Care Plans, Comprehensive Person-Centered' dated 6/6/22, indicated, but was not limited to, the following: - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Resident #74 was admitted to the facility in April 2025 with diagnoses including repeated falls, mild cognitive impairment and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident scored a 3 out of a total possible 15 on the Brief Interview for Mental Status (BIMS) exam indicating severely impaired cognition. Review of 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 3a. Resident #16 was admitted to the facility in June 2024 with diagnoses including unspecified dementia, dysphagia, adjustment disorder with mixed anxiety and depressed mood, weakness and difficulty walking. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/12/25, indicated that Resident #16 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status score of 10 out of 15. The MDS further indicated Resident #16 was dependent on staff for functional tasks and was at risk of developing pressure ulcers/injuries and required a pressure reducing device for bed and chair. Review of Resident #16's physician order dated 3/24/25 indicated: Air mattress to prevent pressure injuries. Every shift for Pressure sore prevention. Review of Resident #16's care plan dated 6/7/24 indicated he/she had an ADL Self Care Performance Deficit r/t (related to) dementia, impaired mobility, and weakness. Interventions included: I have an air mattress. Date Initiated: 03/24/2025 Review of…

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

Based on record reviews and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLS) for one Resident (#67) out of a total of 27 residents. Specifically, the facility failed to ensure that the Resident was offered and/or provided showers. Findings include: Review of the facility policy titled Activities of Daily Living (ADLs), Supporting, last revised March 2018 indicated the following: - Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLS). - Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. - 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the residents and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care). Resident #67 was admitted 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 Based on observation, record review and interviews, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable mental, and psychosocial well-being for one Resident (#54) out of a total sample of 27 residents. Specifically, the facility failed to ensure recommendations from behavioral health services were relayed to the physician and implemented for Resident #54. Findings include: Review of facility policy titled 'Behavioral Health Services' dated February 2019, indicated the following but not limited to: - Behavioral health services are provided to residents as needed as part of the interdisciplinary person-centered approach to care. Resident #54 was admitted to the facility in April 2024 with diagnoses including adjustment disorder with depressed mood. Review of Resident #54's Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident scored a 12 out of possible 15 on the Brief Interview for Mental Status (BIMS) indicating that the…

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

Based on record review and interviews, the facility failed to ensure a current hospice plan of care was present in the medical record and coordinated with facility staff for one Resident (#78) out of a total sample of 27 residents. Resident #78 was admitted to the facility in June 2024 with diagnoses including malignant neoplasm of colon and failure to thrive. Review of Resident #78's Minimum Data Set (MDS) assessment, dated 9/18/24, indicated the Resident scored a 9 out of possible 15 on the Brief Interview for Mental Status exam, indicating he/she had moderate cognitive impairment. The MDS further indicated that the Resident was receiving hospice services. Review of Resident #78's medical record indicated the following: - A physician's order dated 7/12/24, [facility's contracted] Hospice. - A facility care plan: I have a terminal prognosis related to Colon Cancer, dated 6/13/24. Review of the medical record failed to indicate the hospice agency's plan of care was available to the staff at the facility. During an interview on 4/28/25 at 9:46 A.M., Unit Manager #2 said when 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 Based on observation, record review and interview, the facility failed to meet professional standards of quality for four Residents (#3, #62, #312 and #314), out of a total sample of 35 residents. Specifically, the facility failed to: 1.) For Resident #3, the facility failed to obtain weekly weights as ordered by a physician. 2.) For Resident #62, the facility failed to obtain and document pre and post dialysis weights per the physician orders. 3.) For Resident #312, the facility failed to obtain daily weights as ordered by the physician. 4.) Resident #314 the facility failed to change daily dressing as ordered by the physician. Findings include: 1. For Resident #3, the facility failed to obtain weekly weights as ordered by a physician. Resident #3 was admitted in December 2001 with diagnoses including dementia and unspecified severe protein-calorie malnutrition. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #3 scored a 7 out of a possible 15 on the Brief Interview for Mental Status…

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 observations, interviews, policy review and record review, the facility failed to maintain a safe environment for three Residents (#82, #23, and #90) out of 35 total sampled residents. Specifically: 1. For Resident #82, the facility failed to implement the physician's order for bed alarm and floor mat. 2. For Resident #23, the facility failed to ensure nurse staff maintained 1:1 supervision in accordance with plan of care. 3. For Resident #90, the facility failed to implement the physician's order for floor mat. Findings include: Review of the facility policy titled Fall Prevention and Management, dated 9/1/2017, indicated, but was not limited to: -Prevention strategies to be implemented are listed on the plan of care. 1.) Resident #82 was admitted to the facility in February 2023 with diagnoses including dementia and epilepsy (a seizure disorder). Review of the most recent Minimum Data Set (MDS) assessment, dated 5/8/24, indicated that Resident #82 had severe cognitive impairment as evidenced by a…

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

Based on observation, interviews and policy review the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal laws. Specifically, the facility failed to: 1. Ensure inhalers and medications with shortened expiration dates are dated once opened 2. Ensure orally administered medications are kept separate from externally used medications and treatments such as suppositories, ointments, creams, vaginal products, etc. 3.Ensure medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures and humidity. 4.Ensure only medications of residents residing in the facility were stored in the medication cart. Findings include: Review of the facility policy, titled 'Medication Storage in The Facility', dated 9/1/2013, indicated the following but not limited to: -Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. - Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides)…

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 properly store food items and properly follow sanitation and food handling practices to prevent the risk of foodborne illness in accordance with professional standards for food service safety. Findings include: Review of the facility policy titled, Food Receiving and Storage, dated November 2022, indicated the following: -refrigerated foods are labeled, dated and monitored so they are used in the appropriate time frame. Review of the facility policy titled, Food Preparation and Service, dated November 2022, indicated the following: -food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illnesses. -Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single use items and are discarded after each use. The following observations were made in the kitchen refrigerators on 5/21/24 at 7:00 A.M.: -A bowl of cut up melon not dated or labeled. -A container of ground turkey dated 5/16/24. -A takeout…

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 observations, record reviews and interviews, the facility failed to ensure accurate medical records for three Residents (#3, #106 and #82) out of a total sample of 35 residents. Specifically, 1) for Resident #3 the facility failed to complete accurate skin assessments, 2) for Resident #106 the facility failed to maintain accurate medical records. 3) For Resident #82, the facility failed to accurately document the functioning of a bed alarm and presence of a floor mat 4.) For Resident #88, the facility failed to accurately document the flow rate of oxygen. Findings include: Resident #3 was admitted to the facility in December 2001 with diagnoses including dementia. Review of Resident #3's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 7 out of a possible 15, which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #3 was dependent on staff for all functional tasks. Review of Resident #3's…

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

Based on observations, interviews, and policy review, the facility failed to ensure staff followed standards and transmission-based precautions to prevent the spread of infection. Specifically: 1.) The facility failed to ensure staff wore precaution gowns when required while providing care to residents with contact precautions and enhanced barrier precautions in place on one of four nursing units. 2.) The facility failed to ensure the nurse cleaned the top of an insulin vial prior to drawing up insulin. Findings include: 1.) Review of the facility policy title 'Isolation - Categories of Transmission-Based Precautions', revised September 2022, indicated, but was not limited to: -Transmission-based precautions are additional measures that protect staff, visitors and other residents from becoming infected. These measures are determined by the specific pathogen and how it is spread from person to person. -When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors…

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 observations, policy review, record review and interviews, the facility failed to provide a dignified existence for one Resident (#31) out of a total sample of 35 residents. Findings include: Review of the facility policy titled, Dignity, dated June 2022, indicated the following: -each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. -staff strive to treat residents with dignity and respect. -demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; For example: promptly responding to a resident's request for toileting assistance. Resident #31 was admitted to the facility in August 2016 with diagnoses including dementia. Review of Resident #31's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) of 9 out of a possible 15, 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 Based on observations, record review, policy review and interviews, the facility failed to keep one Resident (#64) free from verbal abuse out of a total sample of 35 residents. Findings include: Review of the facility policy titled, Abuse Prevention Program 2022, last revised November 2022, indicated the following: -Verbal abuse: the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their distance, regardless of their age, ability to comprehend, or disability. Verbal abuse includes but is not limited to threats of harm and/or making statements to frighten a resident. Resident #64 was admitted to the facility in December 2023 with diagnoses including anxiety. Review of Resident most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15, which indicated he/she is cognitively intact. On 5/22/24 at 9:15 A.M., the Admissions Director…

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 observations, record reviews and interviews, the facility failed to implement the plan of care to ensure foot protection booties were in place for two Residents (#1 and #3) out of a total sample of 35 residents. Findings include: 1. Resident #1 was admitted to the facility in December 2021 with diagnoses including traumatic brain injury and hemiplegia. Review of Resident #1's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident was unable to complete the Brief Interview for Mental Status (BIMS) exam and the staff did not assess his/her cognitive level. The MDS also indicated Resident #1 was dependent on staff for all bed mobility/repositioning tasks. On 5/21/24 at 7:57 A.M., Resident #1 was observed lying in bed. Both of his/her feet were directly on the bed. Two heel protection booties were observed on the dresser across from the Resident's bed. On 5/22/24 at 6:39 A.M., Resident #1 was observed lying in bed. Both of his/her feet were directly on the bed. Two heel protection booties…

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 observations, interviews, policy review, and record review, the facility failed to provide the necessary activities of daily living (ADLs) for one Resident (#63) out of 35 total sampled residents. Specifically, the facility failed to provide the needed supervision and assistance with eating. Findings include: Review of the facility policy titled Activities of Daily Living (ADLs), Supporting, revised March 2018, indicated: -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with dining (meals and snacks). Resident #63 was admitted to the facility in July 2023 with diagnoses including dysphagia (difficulty swallowing and left sided hemiparesis (weakness) following a stroke. Review of the most recent Minimum Data Set (MDS) assessment, dated 4/10/24, indicated that Resident #63 was unable to complete the Brief Interview for Mental Status (BIMS) and had a staff assessment that indicated the Resident 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 Based on observations, record review, policy review and interviews, the facility failed to provide an activity program for two Residents (#1 and #69) out of a total sample of 35 residents. Findings include: Review of the facility policy titled, Activity Programs, dated June 2018, indicated the following: -activity programs are designed to meet the interest and of and support the physical, mental and psychosocial well-being of each resident. -The activities program is provided to support the well-being of residents and to encourage both independents and community interaction. -Activities offered are based on the comprehensive resident centered assessment and the preferences of each resident. -the activities program is ongoing and includes facility organized group activities, independent individual activities and assisted individual activities. -Activities are considered any endeavor, other than routine ADLs, in which the resident participates, that is intended to enhance his or her sense of well-being and to…

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

Based on observations, interviews, policy review, and record review, the facility failed to provide appropriate treatment and services related to hearing for one Resident (#88) out of a total of 35 sampled residents. Specifically, the facility failed to assist Resident #88 in maintaining hearing abilities and making an appointment to replace a lost and/or broken hearing aid. Findings include: Review of the facility policy titled Hearing Impaired Resident, Care of, revised February 2018, indicated: -Staff will assist hearing impaired residents to maintain effective communication with clinicians, caregivers, other residents, and visitors. -Staff will assist the resident (or representative) with locating available resources, scheduling appointments and arranging transportation to obtain needed services. -Staff will help residents who have lost or damaged hearing devices in obtaining services to replace devices. -When interacting with the hearing impaired or deaf resident, staff will: evaluate and address avoidable obstacles to effective communication. Resident #88 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to follow a physician's order for air mattress settings for pressure ulcer prevention for 2 Residents (#91 and #102), out of a total sample of 35 residents. Findings include: Review of the facility policy titled Support Surface Guidelines, revised September 2013, indicated the following: - Redistributing support surfaces are to promote comfort for all bed- or chairbound residents, prevent skin breakdown, promote circulation and provide pressure relief or reduction. - Support surfaces are modifiable. Individual resident needs differ. 1. Resident #91 was admitted in January 2022 with diagnoses including depression and pressure ulcers of the left and right heel. Review of the Minimum Data Set (MDS), dated [DATE], indicated that the Resident did not score on the Brief Interview for Mental Status (BIMS), but is severely cognitively impaired. Review of the MDS indicated that Resident #91 is dependent with all activities of daily living. Review 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 observations, record review and interviews, the facility failed to implement interventions to prevent increased contractures for two Residents (#30 and #69) out of a total sample of 35 residents. Findings include: 1. Resident #30 was admitted to the facility in October 2014 with diagnoses including hemiplegia with hemiparesis after a stroke. Review of Resident #30's most recent Minimum Data Set (MDS), dated [DATE], indicated Resident #30 had a Brief Interview of Mental Status Exam score of 9 out of a possible 15, which indicated the Resident had moderate cognitive impairment. The MDS also indicated Resident #30 is dependent on staff for all functional tasks with the exception of eating. On 5/21/24 at 8:15 A.M., Resident #30 was observed lying in bed. The Resident was observed to have a left-hand contracture and was not observed to be wearing a splint. At this time, Resident #30 said he/she had not worn a splint in a long time. On 5/21/24 at 12:18 P.M., Resident #30 was observed lying in bed. The…

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

Based on observations, interviews, policy review, and record review, the facility failed to provide respiratory care services in accordance with professional standards of practice one Resident (#88) out of a total sample of 35 residents. Specifically, the facility failed to follow Resident #88's physician's orders to implement the correct oxygen flow rate. Findings include: Review of the facility policy titled Oxygen Administration, revised October 2010, indicated: -Preparation: Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. -Reporting: Notify the supervisor if the resident refuses to procedure. Resident #88 was admitted to the facility in October 2023 with diagnoses including chronic obstructive pulmonary disease (COPD) and emphysema, both which are common lung disease causing restricted airflow and breathing problems. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/1/24, indicated that Resident #88 had moderate cognitive impairment as evidenced by a Brief Interview 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 interviews and record review the facility failed to provide the dietary preference for one Resident (#312) out of a total sample of 35 residents. Specifically, the facility failed to honor no pork products per resident preference. Findings include: Review of facility policy titled 'Resident Food Preference' revised July 2017 indicated the following but was not limited to: -Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modification to diet will only be ordered with the residents' or representative's consent. -Upon the resident's admission (or within 24 hours after his/her admission) the Dietician or nursing staff will identify a resident's food preferences. -When possible, staff will interview the residents directly to determine current food preferences based on history and life patterns related to food and mealtimes. Resident #312 was admitted to the facility in May 2024 with diagnoses including acute systolic congestive heart failure, fluid overload and chronic kidney disease stage four. Review of the Brief…

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 observations, record review, policy review and interviews the facility failed to ensure infection control standards of practice for the prevention of infections were implemented. Specifically, the facility failed to: 1.) Ensure housekeeping staff performed hand hygiene upon removal of gloves and followed manufactures guidelines for disinfectant contact time. 2.) Ensure a transmission based precaution sign was posted for one COVID-19 positive Resident (#1), out of a total sample of five Residents. Findings include: 1.) The facility failed to ensure housekeeping staff performed hand hygiene upon removal of gloves and followed manufactures guidelines for disinfectant contact time. Review of the facility policy titled, Cleaning and Disinfection of Environmental Surfaces, dated as revised August 2019, indicated environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Bloodborne Pathogens Standard. 2. Non-critical surfaces will be disinfected with an EPA-registered intermediate or…

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.