Vantage at Lowell LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure staff maintained complete and accurate medical records for 3 Residents (#6, #17 and #45) out of a total sample of 21 residents. Specifically, the facility failed: For Residents #6 and #17, the facility failed to accurately document the implementation of physician orders, and 2. For Resident #45, to ensure behavior monitoring documentation was completed every shift on the Documentation Survey Report (a report showing Certified Nursing Assistant documentation for activities of daily living). 1a. Resident #6 was admitted to the facility in June 2021 with diagnoses including paraplegia, diabetes and chronic non-pressure ulcer of the right foot. Review of Resident 36's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she had intact cognition. On 6/1/26 at 8:05 A.M., Resident #6 was observed lying in bed with…

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

Based on record review and interview, the facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) plan. Specifically, the facility failed to monitor the effectiveness and of a QAPI plan put in place for 1a. falls assessments being completed and 1b. the temperature of the food served to the residents. Findings include: Review of the facility policy titled Quality Assurance Equality Assurance and Performance Improvement, undated, indicated the following:A system must be in place in order to monitor policies using the data gathered, including input from staff, residents, families and others as appropriate. Performance indicators should be used to monitor the continuum of care and outcomes. Findings should be reviewed in the context of established benchmarks and/or targets established by the facility for performance. The Administrator and leaders will evaluate the QAPI program on an ongoing basis to determine if conclusions based on findings are accurate and interventions for improvements have been implemented. 1a. During an interview on 6/4/26 at…

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

Based on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Specifically,1.) For Resident #78, the facility failed to implement enhanced barrier precautions. 2.) For Resident #7, the facility failed to implement enhanced barrier precautions. Findings include: Review of the facility policy titled 'Enhanced Barrier Precautions, undated, indicated, but was not limited to the following:-Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents.-Gloves and gown are applied prior to performing the high contact resident care activity. -Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: bathing/showering, providing hygiene, and wound care.1.) Resident #78 was admitted to the facility in June 2021 with diagnoses including osteoarthritis and diabetes.Review of the most recent Minimum Data Set (MDS)…

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 records reviewed and interviews, for one of three sampled residents (Resident #1) the facility failed to ensure they maintained a complete and accurate medical record related to his/her Activities of Daily Living (ADLs), when daily documentation by Certified Nurse Aides was incomplete, with some ADL's left blank. Findings include:Review of the facility's policy titled Charting and Documentation, undated, indicated the following:-All services provided to the resident shall be documented in the resident's medical record.-Documentation in the medical record will be complete and accurate.Resident #1 was admitted to the facility in July 2025, diagnoses included Chronic Obstructive Pulmonary Disease (COPD-a progressive lung disease that makes it difficult to breathe), Congestive Heart Failure (CHF- a long-term condition that affects the heart's ability to beat well), and Cerebral Vascular Accident (CVA/stroke).Review of Resident #1's Certified Nurse Aide (CNA) Activities of Daily Living (ADL) flow sheet for the month of April 2026 indicated the following:*Bathing, dressing,…

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 records reviewed and interviews, for one of three sampled residents (Resident #1) who had limited mobility, required the use of an air mattress, and was dependent on staff to meet his/her care needs, the facility failed to ensure his/her Activities of Daily Living (ADL) Care Plan was individualized, with interventions that clearly identified the appropriate number of staff assistance required to safely meet his/her needs.Findings include:Review of the facility's policy, titled Comprehensive Person-Centered Care Plans, revision date of 03/2022, included 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. -Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. Review of the facility's policy, titled Activities of Daily Living (ADL),…

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 ensure staff treated residents in a dignified manner during the dining experience for one Resident (#24) out of a total sample of 22 Residents. Specifically, the facility failed to ensure that staff were not operating a cell phone while assisting Resident #24 with eating breakfast. Findings include: Review of the facility policy titled Quality of Life - Dignity, undated, indicated the following: - Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be treated with dignity and respect at all times. Resident #24 was admitted to the facility in November 2024 with diagnoses including Parkinsonism, stage 4 pressure ulcer of sacral region, and unspecified protein calorie malnutrition. Review of Resident #24's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status score of 6 out of 15 indicating severe…

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 ensure residents at risk for developing pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to prevent new ulcers from developing for two Resident (#24 and #53) out of a total of 22 Residents. Specifically, the facility failed to ensure the Resident's air mattress were set at the correct setting according to the physician's order. Findings include: Review of the facility policy titled Prevention of Pressure Injuries, dated and revised April 2020, indicated the following: - Support Surfaces and Pressure Redistribution: Select appropriate support surfaces based on the resident's risk factors, in accordance with current clinical practice. Resident #24 was admitted to the facility in November 2024 with diagnoses including Parkinsonism, stage 4 pressure ulcer of sacral region, and unspecified protein calorie malnutrition. Review of Resident #24's most recent Minimum Data Set (MDS)…

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 interview, the facility failed to provide continued therapy services and recommended by the Occupational Therapist for one Resident #24 out of a total sample of 22 Residents. Specifically, the facility failed to ensure that Resident #24 continued to receive Occupational Therapy services as recommended for the use of a hand orthotic while under hospice services. Findings include: Review of the facility policy titled Scheduling Therapy Services, dated and revised July 2013, indicated the following: - Therapy services shall be scheduled in accordance with the resident's treatment plan. - The therapist shall interview the resident and consult with the attending physician as to the type of treatment to be administered. - Therapy is scheduled in coordination with nursing service and is documented in the resident's medical record. - Nursing service shall be responsible for preparing and escorting the resident to the therapy area unless such treatment is scheduled 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 Based on observation, record review and interview, the facility failed to ensure practices to support nutritional needs for one Resident (#48), out of a total sample of 22 residents were implemented in accordance with professional standards of care. Specifically, Resident #48, who was assessed for nutritional risk, experienced a severe weight loss, which was not evaluated by the registered dietitian. Findings include: Review of the facility's policy titled, Weight Assessment and Intervention, revision date March 2022 indicated the following: Residents weights are monitored for undesirable and unintended weight loss or gain. Weight Assessment 1. Residents are weighed upon admission and at intervals established by the interdisciplinary team., 2. Weights are recorded in each unit's weight record or chart and in the individual's medical record. 3. Any wight change of 5% or more since the last weight assessment is retaken the next day for confirmation. a. if the weight is verified, nursing will immediately notify the…

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

Based on observation and interview, the facility failed to ensure standards of practice to prevent the spread infection were implemented. Specifically, a Laboratory Technician providing laboratory services to residents, failed to adhere to infection control practices when she placed her bag, which she uses to store supplies and specimens and uses in other facilities, on top of a resident's bed. Findings include: During an observation on 5/13/25 at 11:36 A.M., a Laboratory Technician was observed in a resident room occupied by two residents. The room was marked by a sign at the door indicating enhanced barrier precautions. The Laboratory Technician's bag with her supplies was on top of the resident's bed and in contact with the linen. The lab technician did the blood draw to the resident in bed 2 and then moved to the bedside table of the resident in bed one to fill out a form and then removed her gloves and placed the specimen in a plastic bag and into the bag that was on the bed. During an interview on 5/13/25, when the Laboratory Technician exited the room, the Laboratory…

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, policy review, and interview, the facility failed to ensure treatment carts on two of two units were locked and secured while not in use. Findings include: Review of the facility policy titled, Storage of Medications, not dated, indicated the following: -Medications and biologicals are stored safely, securely, and properly. The medication supply is accessible only to licensed nursing staff is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. On 5/14/24 from 7:35 A.M. to 8:06 A.M., the surveyor observed the the Left Unit treatment cart unlocked and unsupervised in the hallway. On 5/15/24 at 7:52 A.M., the surveyor observed the the Left Unit treatment cart unlocked and unsupervised in the hallway. On 5/15/24 at 8:08 A.M., the surveyor observed the the Right Unit treatment cart unlocked and unsupervised in the hallway. During an interview on 5/16/24 at 9:11 A.M., Nurse #4 said the expectation is that the treatment carts are always locked unless a nurse is present at the cart. During…

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, resident group meeting, and test tray results, the facility failed to ensure foods provided to residents were prepared by methods that conserve nutritional value, flavor, were palatable and at appetizing temperatures on 2 out of 2 units. Findings include: During the screening portion of the survey, numerous residents expressed concerns about poor food quality, palatability, and temperature. During the resident group meeting on 5/15/24 at 11:00 A.M., 8 out of 8 participating residents said that they did not like the food being served at the facility. Residents described the food as gross or disgusting. Review of the grievances book included two resident grievances regarding the quality of the food, food delivery and accurate meal orders. On 5/15/24 at 1:01 P.M., the left-wing unit food truck arrived. At 1:11 P.M., all resident trays were served, and the surveyors received test trays. The following results were recorded: 1a) -Pureed Chicken: 131 degrees Fahrenheit, no flavor, very bland. Warm to taste, not hot. - Pureed Vegetables: 132 degrees…

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, undated, indicated the following: - Foods shall be received and stored in a manner that complies with safe food handling practices. - Food Services, or other designated staff, will maintain clean food storage areas at all times. - All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) The surveyor made the following observations in the walk-in refrigerator during the initial walk-through of the kitchen on 5/14/24 at 7:10 A.M.: - A pan containing raw chicken was observed covered in plastic wrap with the date 5/7/24 written. The chicken was observed to be covered in slimy, pink juices. - A pan containing a cooked meat product covered with aluminum foil. There was no date or label identifying what the product was. -…

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

Based on observation and interview, the facility failed to provide a dignified dining experience for Residents on the Right Wing unit. Findings include: The surveyor made the following observations: - On 5/14/24 at 8:19 A.M., a Certified Nursing Assistant (CNA) was observed feeding a resident in bed while standing over him/her, not at eye level. - On 5/14/24 at 11:47 A.M., a resident was observed sitting at a table in the dining room with a second resident. The first resident received his/her tray at 12:08 P.M. and was being assisted by staff. At 12:08 P.M., the staff assisting the resident told the other resident Your food is in the next truck. The second resident received his/her meal at 12:42 P.M., 55 minutes after the first resident had begun eating. - On 5/15/24 at 8:13 A.M., a resident was observed sitting in a Broda chair at a dining room table with another resident who was being assisted with breakfast. At 8:17 A.M., a CNA was observed leaning on the initial resident's Broda chair talking to another CNA at a different table. At 8:27 A.M., a CNA sat down with the resident 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 Based on observation, record review, and interview, the facility failed to protect one Resident (#54) from abuse out of a total of 22 sampled residents. Specifically, Occupational Therapist (OT) #1 yelled at Resident #54 in the presence of other residents and staff for not following his/her directions. Findings include: Review of the facility's Abuse Prohibition policy dated 2/20/23 indicated: *The facility prohibits the mistreatment, neglect and abuse of residents/patients and misappropriation of resident/patient property by anyone including staff, family, friends, etc. Each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. Residents will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers and staff of other agencies serving the resident. *Types of abuse: Verbal: oral, written or gestured language, that willfully includes disparaging and derogatory terms, to the resident/patient or their families,…

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 ensure one Resident (#13) was free from restraints by locking the remote control for the bed, preventing the Resident to reposition him/herself in bed, out of a total sample of 22 residents. Findings include: Review of the facility policy titled, Physical Restraints, dated 1/1/17, indicated the following: -The facility recognizes each resident's right to be treated with respect and dignity including the right to be free from any physical restraint imposed for the purposes of discipline or convenience and not required to treat the resident's medical condition. -The policy includes an interdisciplinary process of assessment and reassessment in order to ensure that when a restraint is necessary to treat a resident's medical condition the least restrictive is utilized for the least amount of time to treat the resident's medical condition with the plan for continued assessment and reduction. -Components of constraint use:…

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 ensure staff followed its abuse policies and procedures for one Resident (#54) out of a total of 22 sampled residents. Specifically, staff who were present when Occupational Therapist (OT) #1 yelled at Resident #54 did not intervene or remove OT #1 from the unit per policy. Findings include: Review of the facility's Abuse Prohibition policy dated 2/20/23 indicated: *The facility prohibits the mistreatment, neglect and abuse of residents/patients and misappropriation of resident/patient property by anyone including staff, family, friends, etc. Each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. Residents will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers and staff of other agencies serving the resident. *Types of abuse: Verbal: oral, written or gestured language, that willfully includes disparaging and derogatory…

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

Based on record review and interview, the facility failed to report an allegation of neglect to the state agency as required for one Resident (#285) out of a total of 22 sampled residents. Findings include: Review of the facility's Abuse Prohibition policy, dated 2/20/23 indicated: The Administrator is responsible for ensuring that there has been notification [to] local law enforcement and the State Survey Agency within two hours of allegation after identification of alleged/suspected incident. All alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of an unknown source and misappropriation of resident property are reported immediately but not later than two hours after the allegation is made. Review of the grievance book included a grievance dated 6/13/23 which indicated that Resident #285's family member had found Resident #285 in his/her room not wearing oxygen (02). The grievance indicated that nurse staff then took Resident #285's 02 saturation level and he/she was at an Oxygen saturation of 81 percent. The family member documented on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews, the facility failed to ensure resident centered care plans were implemented for three Residents (#64, #182, #23) to ensure aspiration risk precautions were followed, out of a total sample of 22 residents. Findings include: Review of the facility policy titled Activities of Daily Living (ADLs), dated December 2022, indicated To provide support, assistance, and encouragement to remain as independent as possible with activities of daily living, including hygiene, mobility, elimination, dining, and communication; and that the care and services provided are person-centered, and honor and support each resident's preferences, choices, values, and beliefs. A resident who is unable to carry out activities of daily living will receive the services to maintain good nutrition, grooming, and personal and oral hygiene. 1. Resident #64 was admitted to the facility in June 2023 with diagnoses including dysphagia, type 2 diabetes, and chronic obstructive pulmonary disease…

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 showers for one Resident (#62) out of a total sample of 22 residents. Findings include: Review of the facility policy titled, Activities of Daily Living, dated 12/22/21, indicated the following: -the resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Resident #62 was admitted to the facility in January 2024 with diagnoses including heart failure. Review of Resident #62's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15, which indicated Resident #62 had moderate cognitive impairment. The MDS also indicated Resident #63 required substantial assistance from staff for bathing tasks. During an interview on 5/14/24 at 7:44 A.M., Resident #62 said he/she had not received a shower in a long time and would…

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, record review and interview, the facility failed to provide vision services as requested for one Resident (#60) out of a total sample of 22 residents. Specifically, the facility failed to follow up with the Resident's and physician's request to schedule an appointment for glasses for Resident #60. Findings include: Review of the facility policy titled Vision and Hearing, dated and revised 12/21/21, indicated the following: - The facility will provide from an outside source ophthalmology and audiology services to meet the needs of the residents. - The facility will, if necessary or requested, assist the resident with: making appointments, arranging transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision of hearing assistive devices. - Assistive devices to maintain vision include, but are not limited to, glasses During an interview on 5/14/24 at 7:49 A.M., Resident #60 told the surveyor that he/she cannot see and he/she needs…

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 record review, observations, and interviews, the facility failed to ensure that a resident admitted with an indwelling catheter is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates continued catheter use is necessary for one Resident (#23) in a total sample of 22 residents. Findings include: Review of the facility policy which is according to the Resident Assessment Instrument (RAI), indicated the following: -Indwelling catheters should not be used unless there is valid medical justification. Assessment should include consideration of the risk and benefits of an indwelling catheter, the anticipated duration of use, and consideration of complications resulting from the use of an indwelling catheter. Complications can include an increased risk of urinary tract infection, blockage of the catheter with associated bypassing of urine, expulsion of the catheter, pain, discomfort, and bleeding. Resident # 23 was admitted to the facility in 04/18/2021…

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 address the nutritional status in a timely manner for one Resident (#19) out of a total sample of 22 residents. Specifically, the facility failed to address a significant weight loss in a timely manner for Resident #19. Findings include: Review of the facility policy titled Weight Monitoring, revised and dated 12/22/21, indicated the following: - Any weight change of 5% or more since the last weight assessment will be retaken within 24 hours for confirmation. If the weight is verified, nursing will notify the Dietitian, Physician and the resident/responsible party. - The Dietitian will review the weights monthly to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. The plan of care will be updated as needed. - The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1…

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 interview, the facility failed to provide respiratory care services in accordance with professional standards of practice one Resident (#8) out of a total sample of 22 residents. Specifically, the facility failed to follow Resident #8's physician's orders to implement the correct oxygen flow rate and ensure the external filter was clean. Findings include: Review of the facility policy titled Equipment Change/Disinfection, undated, indicated the following: - Oxygen Concentrators: Rinse and dry the external filter weekly and PRN (as needed) when visibly dusty. Resident #8 was admitted to the facility in March 2023 with diagnoses including chronic heart failure, type 2 diabetes mellitus and pneumonia. Review of Resident #8's most recent Minimum Data Set Assessment (MDS) dated [DATE], indicated that the Resident had a Brief Interview for Mental Status score of 13 out of a possible 15 indicating intact cognition. Further review of the MDS indicated that Resident #8 requires…

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 and record review, the facility failed to provide food in a form to meet the needs of three Resident (#64, #13, and #23) out of a sample of 22 residents. Specifically, for Residents #64 and #24, the facility to provide the correct diet texture during meals. For Resident #13, the facility failed to provide the correct diet during meals and failed to prevent the Resident from consuming food that was of a texture not ordered by the physician. Findings include: 1. Resident #64 was admitted to the facility in June 2023 with diagnoses including dysphagia, type 2 diabetes, and COPD chronic obstructive pulmonary disease. Review of Resident #64's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 4 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident has severe cognitive impairments. On 5/14/24 from 11:53 A.M. to 12:01 P.M., the surveyor observed Resident #64 in the hallway with his/her lunch tray. The Residents' tray was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to accurately document one Resident's (#2) skin assessment out of a total sample of 22 residents. Findings include: Resident #2 was admitted to the facility in June 2021 with diagnoses including multiple sclerosis. Review of Resident #2's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15, which indicated the Resident was cognitively intact. Review of the wound documentation dated 5/7/24 and 5/14/24 indicated Resident #2 had a stage 2 pressure wound to his/her right buttock, which first appeared on 5/5/24. Review of Resident #2's skin assessment dated [DATE] failed to indicate a right buttock pressure wound. During an interview on 5/16/24 at 8:41 A.M., Nurse #4 said all residents receive a skin assessment weekly and all skin issues are documented on those assessments regardless of the wound doctor documentation. During an interview on 5/16/24 at 8:51 A.M…

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