Lighthouse Rehabilitation And Healthcare Center

Based on staff interview and record review, the facility failed to ensure the Nursing staff completed the required 12 hours (no less than ) of annual training, which at minimum includes dementia training for 4 out of 5 employee records reviewed. Findings include: The facility policy titled Staff Education and Competency, undated, indicated the following: -Education is a key component to ensuring that our residents receive quality care. Education is provided to staff in various formats. We use Relias© as an online training resource. In addition, we provide both individual and group training sessions. -Education begins at orientation which includes job specific training. All new staff receive a general orientation to core facility processes, policies, and procedures. Orientation training topics include, but are not limited to, hand hygiene, infection control, bloodborne pathogens, resident rights, abuse and neglect, HIPAA, dementia and behavior management, fire safety, disaster preparedness, emergency response, workplace safety, and additional topics as required by the State 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 observation, record review and interview the facility failed to provide a dignified existence for one Resident (#110) out of a total sample of 30 residents. Specifically: For Resident #110, who is dependent on staff for feeding, the staff stood beside the bed, looking down at Resident #110, rather than seated at eye level while feeding him/her meals. Findings include: The facility policy titled Dignity, dated February 2021, indicates 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 ad self-esteem. -5. When assisting with care, residents are supported in exercising their rights. For example, residents are: e. provided with a dignified dining experience. Resident #110 was admitted to the facility in February 2024 and has diagnoses that include Alzheimer's disease, history of falling and hemiplegia affecting right dominant side. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/18/24, indicated that on the 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 observations and interviews, the facility failed to ensure resident protected health information (PHI) was secure and not visible to others on two of three nursing units. Findings include: Review of the facility policy titled Confidentiality of Information and Personal Privacy, dated as revised February 2021, indicated the following: 1. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. 2. The facility will strive to protect the resident's privacy regarding his or her: b. medical treatment 4. Access to resident personal and medical records will be limited to authorized staff and business associates. On 2/11/25 at 8:28 A.M., the surveyor observed an unattended medication cart on the third-floor unit. The computer on top of the cart was open, displaying a resident's name and a list of his/her medications. During an interview on 2/11/25 at 8:31 A.M., with Nurse #5 said that the screen on her computer, displaying a resident's medical information, should be privatized and not left open when unattended. On 2/11/25 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to complete an assessment for an air mattress with bolsters for one Resident #87 out of a sample of 30 Residents. Specifically, the facility failed to complete a restraints assessment before applying an air mattress with bolsters in the Resident's bed. Findings include: A review of the facility policy titled 'Use of Restraints' with a revision date of April 2017 indicated the following: - Physical Restraints are defined as any manual method or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. -The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition (i.e., side rails are put back down, rather than climbed over), 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 record review and interviews, the facility failed to report injuries of unknown origin to facility administration for two Residents (#87 and #118) out of a sample of 30 Residents. Specifically: 1. For Resident #87, the facility failed to report an X-ray (X-radiation-images created inside of a body by passing beams of radiation through the body) positive for a fracture from an unknown origin. 2. For Resident #118 the facility failed to implement their abuse policy and notify facility administration of a new fracture (an acute right intertrochanteric [thigh bone] fracture) of unknown origin. Findings include: A review of the facility policy titled, 'Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating' with a revision date of September 2022 indicated the following: -All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation are reported to local, state and federal agencies (as required by current regulations) 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.

Based on record review and interviews, the facility failed to thoroughly investigate an injury of unknown origin (a fracture), for one Resident (#118) out of a total sample of 30 residents. Specifically for Resident #118 who on 1/4/25 experienced pain which was new and on 1/5/25 Resident #118 was found to have an acute right intertrochanteric (thigh bone) fracture, the facility failed to conduct interviews from staff members (on all shifts) who had contact with the resident during the period of the alleged incident. Findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated as revised September 2022, indicated that all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/ misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. - Investigating Allegations 7. The individual…

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 meet professional standards of practice for one Resident (#113) out of a total of sample of 30 residents. Specifically, for Resident #113, the facility failed to ensure nursing clarified a physician's orders for two different suprapubic (SPT) catheter flushes. Findings include: Resident #113 was admitted to the facility in April 2024 with diagnoses including neuromuscular dysfunction of the bladder, diabetes, and depression. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/8/25, indicated that Resident #113 was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 15 out of 15. The MDS further indicated Resident #113 required an indwelling catheter. Review of Resident #113's active physician's order, dated 12/7/24, indicated: -Flush SPT three times daily (3x/day) by using 50 cc catheter tip syringe and normal saline and injecting through yellow port of the SPT into the bladder and aspirating to ensure drainage, three times a day. Scheduled three times daily at 6:00 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.

Based on record review and staff interview, the facility failed to document the recapitulation of the Resident's stay that included his/her course of illness/treatment for one Resident (#123), of two closed records Findings include: Review of the facility policy titled Discharge Summary and Plan, dated as revised October 2022, indicated the following: -When a resident's discharge is anticipated, a discharge summary and post discharge plan is developed to assist the resident with discharge. 1. The discharge summary includes a recapitulation of the resident's stay at the facility and a final summary of the resident's stats at the time of discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The discharge summary shall include a description of the resident's: 1. current diagnosis; b. medical history; c. current illness, treatment and/or therapy since entering the facility; d. current laboratory, radiology, consultation and diagnostic test results; e. physical and mental functional status; f. ability to perform…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide assistance with activities of daily living (ADLs) for three dependent Residents (#61, #15 and #48) out of a total sample of 30 residents. Specifically, the facility failed to: 1) Provide assistance with grooming for Resident #61. 2) Provide supervision with meals for Resident #15. 3) Provide assistance with grooming for Resident #48. Findings Include: Review of the undated facility policy, titled Activities of Daily Living (ADL), Supporting, revised in March 2018, indicated, but was not limited to, 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. 1) Resident #61 was admitted to the facility in October 2024 with a diagnosis…

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 records reviewed, the facility failed to provide the necessary services to ensure one Resident (#15) out of a total sample of 30 Residents, was able to effectively communicate his/her needs. Findings include: Review of the facility policy titled Translation and/or Interpretation Services, dated 2021, indicated the following: -This facility will ensure that individuals who are non-English speaking or have a communication disability will have access to translation and/or interpretation methods. Policy Interpretation and Implementation 1. The facility will determine a means to communicate with any resident admitted who is non-English speaking and/or has a communication disability. 2. The facility utilizes Interactive Voice Response (IVR) to connect to an interpreter for limited Englich proficient residents. 3. The facility uses Cue Cards (Communication Boards) to assist health professionals and residents who have English language difficulties or communication difficulties 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 observation, record review and interview the facility failed to ensure interventions to treat contracture management were implemented for one Resident (#26) out of a total sample of 30 residents. Specifically, the facility failed to ensure palm protectors were in place. Findings include; The facility policy titled titled Resident Mobility and Range of Motion, dated July 2017, indicated the following: 2. Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM (range of motion). 5. The care plan will include specific interventions, exercises and therapies to maintain, \prevent avoidable decline in, and/or improve mobility and range of motion. Resident #26 was admitted to the facility in August 2021 and has diagnoses that include Alzheimer's disease and unspecified lack of coordination. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/27/24, indicated Resident #26 was dependent on staff for all Activities of Daily Living (ADLs). Review of the Occupational Therapy (OT) treatment note,…

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 implement a physician ordered intervention to mitigate injury from an accident for one Resident (#110) out of a total sample of 30 residents. Specifically, the facility failed to ensure a fall mat was in place when Resident #110 was in bed. Findings include: The facility policy titled Falls-Clinical Protocol, dated as revised September 2012, indicated the following: -Treatment/Management: 1. Based on preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. The facility policy titled Care Plans, Comprehensive Person-Centered, dated as revised March 2022, indicated the following: 9. 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. Resident #110 was admitted to the facility in February 2024 and has diagnoses that include…

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 professional standards of practice for Foley catheter care for two residents (#38 and #133) out of a total sample of 30 residents. Specifically: 1. For Resident #38, the facility failed to ensure they obtained physician's orders for the correct indwelling catheter size. 2. For Resident #133, the facility failed to ensure Nurse #8 inserted the correct size suprapubic tube (SPT) into his/her bladder. Finding include: Review of the facility policy titled Catheter Care, Urinary, dated as revised August 2022, indicated that the purpose of this procedure is to prevent urinary catheter- associated complications, including urinary tract infections. Changing Catheters 2. Change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. 1.) Resident #38 was admitted to the facility in September 2024 with diagnoses including atrial fibrillation, low back pain, and chronic…

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 for one Resident (#375) of a total sample of 30 residents, the facility failed to provide sufficient fluid intake as ordered by the physician. Specifically, for Resident #375 the facility failed to ensure nursing provided free water bolus' (FWB) consistently as ordered by the physician. Findings include: Review of the facility policy titled, Enteral Nutrition dated as revised November 2018, indicated that adequate nutritional support through enteral nutrition is provided to residents as ordered. 3. The dietitian, with input from the provider and nurse: d. calculates fluids to be provided (beyond free fluids in formula). Resident #375 was admitted to the facility in February 2025 with diagnoses including vascular dementia, diabetes, and chronic kidney disease. Review of Resident #375's hospital Discharge summary, dated [DATE], indicated the following: - Nutrition following, Jevity 1.5 tube feeding rate of 100 milliliters (mL) per hour from 10:00 P.M., to 10:00 A.M., with 175…

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

Based on observation, interview, and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for one Resident (#38), out of a total sample of 30 residents. Specifically, for Resident #38, the facility failed to ensure that nursing changed Resident #38's oxygen tubing as ordered by the physician. Findings include: Review of the facility policy titled, Oxygen Administration, dated as revised October 2010, indicated the purpose of this procedure is to provide guidelines for safe oxygen administration. 1. Verify that there is a physician's order for this procedure. Review physician's orders or facility protocol for oxygen administration. Resident #38 was admitted to the facility in September 2024 with diagnoses including atrial fibrillation, low back pain, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment, dated 12/18/24, indicated that Resident #38 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This…

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 ensure nursing was competent and had the required skill set to provide necessary care for residents' needs. Specifically, for Resident #60, the facility failed to ensure that nursing prepared medications in a safe manner. Findings include: Review of the facility policy titled, Administering Medications, dated as revised April 2019, indicated that medications are administered in a safe and timely manner, and as prescribed. 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 22. The individual administering the medication initials the resident's Medication Administration Record (MAR) on the appropriate line after giving each medication and before administering the next ones. Resident #60 was admitted to the facility in June 2023 with diagnosis including epilepsy, diabetes, and heart failure. On 2/12/25 at 9:39 A.M. until 9:40 A.M., 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, record review and interview the facility failed to ensure accuracy of the medical record for two Residents (#110 and #13) out of a total sample of 30 residents. Specifically: 1. For Resident #110 the staff inaccurately documented in the Treatment Administration Record (TAR) regarding a resident fall mat. 2. For Resident #13 staff inaccurately documented that blood pressure readings were taken using the Resident's left arm when they were not. Findings include: 1. Resident #110 was admitted to the facility in February 2024 and has diagnoses that include Alzheimer's disease, history of falling and hemiplegia affecting right dominant side. Review of the most recent Minimum Data Se (MDS) assessment, dated 12/18/24, indicated that on the Brief Interview for Mental Status exam Resident #110 scored a 3 out of a possible 15, indicating severely impaired cognition. The MDS further indicated Resident #110 had no behavior of rejecting care and was dependent on staff for all Activities of Daily Living (ADLs). Review of the falls report for Resident #110, dated 8/11/24,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, and interview the facility failed to provide a dignified dining experience in the dining room of the third floor unit, and for three Residents (#36, #96, and #102) out of a total sample of 28 residents. Specifically, the facility failed to ensure that residents seated at the same table were served meals at the same time, that staff did not refer to residents as feeds or feeders in the presence of residents, that staff did not refer to clothing protectors as bibs, and that staff did not stand while providing feeding assistance to three Residents (#36, #96, and #102). Findings include: Review of the facility policy, titled Dignity, initiated November 2023, indicated the following: -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 independence and dignity will be promoted while dinning, such as avoiding: a. Daily use of disposable…

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 store and prepare food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure food was labeled, unpasteurized eggs were cooked thoroughly, and that ready to eat food was not handled using contaminated gloves. Findings include: Review of the undated facility's policy titled General Food Preparation and Handling, indicated, but was not limited to, the following: -Food items will be prepared to conserve maximum nutritive value, develop and enhance flavor and keep free of injurious organisms and substances. -The kitchen and equipment are clean and sanitized as appropriate. -No raw eggs are to be served. They must be cooked. Pasteurized eggs are the exception (these may be served soft cooked). -Leftovers must be dated, labeled, covered, cooled, and stored (within ½ hour after cooking or service) in a refrigerator. -All food service equipment should be cleaned, sanitized, dried, and reassembled after each use. -Use tongs or other serving utensils to serve…

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, policy review, and interviews the facility failed to ensure infection control standards of practice for the prevention of infections were implemented. Specifically: 1. The facility failed to ensure nursing staff appropriately discarded contaminated personal protective equipment (PPE) and performed hand hygiene after caring for a Resident on contact precautions. 2. For the Director of Housekeeping, the facility failed to ensure he wore gloves and cleaned his hands after handling soiled clothing. Findings include: 1. Review of the facility policy 'Transmission-Based Precautions', dated 3/2023, indicated, but was not limited to: - Contact precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. - Gloves will be removed and hand hygiene performed before leaving the room. - Staff will avoid touching potentially contaminated environmental surfaces or items 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.

Based on record review, policy review, and interview, the facility failed to ensure that concerns addressed by the Resident Council Group ha sufficient follow-up to address and prevent recurrence. Findings include: Review of the facility's policy titled Grievances/Complaints: Residents, Resident Representatives, Family Members or Resident Advocates, last revised 12/21, indicated the following: -Our facility will assist residents, their representatives, family members, or resident advocates in filing grievances or complaints when concerns are expressed, which may not be able to be handled immediately by facility staff, requires further investigation or requires consultation with other facility staff, the attending physician or outside service providers. -Any resident, his/her representative, family member or advocate may file a grievance or complaint concerning treatment, facility services, medical care, behavior of other residents or staff members, theft or damage of property, etc., without fear of threat or reprisal in any form, missing items should be reported on the missing item…

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 homelike environment on one out of three units. Specifically, the facility served meals on plastic trays and did not use table linens during mealtimes in the dining room of the third floor unit. Findings include: On 2/14/24 at 8:57 A.M., the surveyor observed 15 residents eating breakfast in the dining room of the third-floor unit. All meals were served on top of plastic trays and there were no tablecloths or linens set on the tables. On 2/15/24 at 9:04 A.M., the surveyor observed 18 residents eating breakfast in the dining room of the third-floor unit. All meals were served on top of plastic trays and there were no tablecloths or linens set on the tables. On 2/16/24 at 8:43 A.M., the surveyor observed 10 residents eating breakfast in the dining room of the third-floor unit. All meals were served on top of plastic trays and there were no tablecloths or linens set on the tables. On 2/16/24 at 12:44 P.M., the surveyor observed 12 residents eating lunch in the dining room of the third-floor unit. All meals were served…

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 for two Residents (#92 and #24) out of a total sample of 28 residents, the facility failed to provide assistance with Activities of Daily Living. Specifically: 1. For Resident #92, the facility failed to provide the needed supervision and assistance with eating. 2. For Resident #24, the facility failed to assist with grooming, specifically removal of chin hair. Findings include: The facility policy titled 'Activities of Daily Living (ADLs)' dated March 2022, indicated 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. 1. Resident #92 was admitted to the facility in June 2022 and has diagnoses that include dysphagia (difficulty chewing and swallowing) and dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/20/23, indicated Resident #92 scored a 0 out of 15 on the Brief Interview for Mental…

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, policy review, record review and interview, the facility failed to offer services to maintain vision for one Resident (#42) out of a total of 28 sampled residents. Findings include: Review of the facility policy titled, Optometric Services, dated April 2022, indicated the following: -The facility will assist residents to obtain regular and emergency optometric care. -The facility will maintain a service agreement with an outside organization to provide all optometric care required by residents of the facility. The service agreement will ensure that all residents may have a comprehensive eye exam as regulated by the state and federal law, prescriptive eyewear, optical aids, and other optometric care required by the residents of the facility. Resident #42 was admitted to the facility in August 2021 with diagnoses including dementia, cerebral infarct, and hypertension. Review of Resident #42's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident had a 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, interviews, policy review, and records reviewed for one Resident (#27), out of 28 total sampled residents, the facility failed to provide the necessary treatment and services to prevent the development and promote healing of pressure ulcers. Specifically, the facility failed to implement a physician's order to offload the heels of Resident #27, who was assessed by nursing to be at high risk for skin breakdown. Findings include: Review of the facility policy titled 'Pressure Injury Management Program Evaluating Risk, Prevention, Support Planning, Treatment, and Monitoring', dated March 2022, indicated, but was not limited to: -It is important to recognize and evaluate each resident's risk factors and to identify and evaluate all areas at risk of constant pressure. -Pressure Points and Tissue Tolerance: ii. Heels -Interventions may include: -Redistribute pressure (such as repositioning, protecting heels, etc.) -The facility is expected to document and address the resident's concerns and offer relevant alternatives if the resident has refused specific treatments.…

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, policy review, records reviewed and interviews for two Residents (#72 and #21) of 28 sampled residents, the facility failed to ensure oxygen was administered according to the physicians' orders. Specifically: 1. For Resident #72, the facility failed to obtain a physician's order for the continuous use of oxygen. 2. For Resident #21, the facility failed to administer the correct amount of oxygen, based on the physician's order. Findings include: Review of the facility policy 'Oxygen Administration by Nasal Cannula and Mask', dated as revised March 2022, indicated the following: Residents who require oxygen will have a physician order which includes the following: - Oxygen flow rate. - How the oxygen is administered i.e.; nasal cannula or mask. - Oxygen tubing will be changed weekly. 1. Resident #72 was admitted to the facility in January 2024 with diagnoses including congestive heart failure and chronic obstructive pulmonary disease (COPD) with dependence on supplemental oxygen. Review of the Minimum Data Set assessment, dated 1/23/24, indicated Resident #72…

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.