Autumn Lake Healthcare At Homewood

Based on observation, record review, and interview, it was determined that the facility failed to ensure respiratory care was provided in accordance with physician orders. This was evident for 3 (Resident #72, #20 & #73) of 4 residents observed during the recertification survey. The findings include: 1). Observation of resident #72 on 07/13/2026 at 8:31AM revealed that s/he was receiving oxygen at 2 Liters via a nasal cannula connected to a humidifier which helps add moisture to air by decreasing dryness to the nose caused by the supplemental oxygen. The 02 tubing and humidifier were not labelled with a change date. A review of resident #72's physician's order revealed an order written on 5/26/26 that reads: Oxygen at 2L/M as needed for COPD, O2 Concentrator at Bedside. 6/23/26: Oxygen Equipment - Change tubing every 7 days every night shift. 2). On 07/13/2026 at 8:43 AM the surveyor also observed Resident #20 receiving oxygen via nasal canula (a tube that delivers supplemental 02) at 2liters. Further observation failed to reveal a label to indicate when the O2 tubing was last…

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 with staff, it was determined that the primary medical provider failed to review and revise the total program of care. This was found evident for 1 (Resident #28) out of 45 residents reviewed during the survey. The findings include: On 7/13/26, 7/14/26, 7/15/26, 7/16/26 and 7/17/26 the surveyor observed Resident #28 close to the nurses' station at some point in the day with multiple observation of staff utilizing a communication board to communicate with Resident #28. On 7/15/26 at 7:33 AM, the surveyor reviewed Resident #28's medical record. The review revealed that Resident #28 had a urology consultant at the facility on 6/29/26 related to urinary retention. The note stated that urinary retention was noted at the hospital, that the patient was unable to communicate voids, Resident #28 had diapers that were dry on assessment, and that silent retention was a concern. The plan stated to check bladder scan for post void residual (scan bladder to evaluate volume after urination) now and at reasonable intervals to establish a trend. If further…

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 a complaint #3055819, record review and staff interviews, it was determined that the facility failed to provide evidence that accounts for some narcotic drug record use and reconciliation. This was evident for 1 of 3 nursing units reviewed for alleged narcotic misappropriation during the annual survey. The findings includeOn 7/13/2026 at 9:00AM, review of a complaint incident #3055819 alleged that the night supervisor was misappropriating the patient's narcotic and signing out narcotics without administering them to the residents. The residents are stating they did not receive their medications.In an Interview with Resident #75 on 7/13/26 at 9:05 AM, S/he stated that they were not receiving their Suboxone as ordered, for drug dependency and that staff are not renewing their medication timely, when it runs out.Review of Resident #75's Medication orders on 7/13/26 at 9:18AM revealed orders written as: Suboxone Sublingual Film 8-2 MG (Buprenorphine HCl-Naloxone HCl Dihydrate) Controlled Drug Give 2 tablet…

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 reviews and staff interviews, it was determined that the facility failed to carry out Pharmacist recommendations on three different occasions following the monthly medication regimen review (MRR). This was evident for 1(#6) of 5 residents reviewed for unnecessary medications. The findings includeOn 7/14/26 at 9:15 AM The facility was asked to provide the Pharmacist MMR from June 2025 to July 2026 for Resident #6. Review of the document which identifies irregularities discovered by the Pharmacist dated 3/27/25 revealed recommendations to review and change Risperidone to GT or PEG administration in PCC. This was not done by the facility. The same recommendation was noted again on next month's pharmacy review on 4/10/26 but was not acted upon. A 3rd recommendation was noted again regarding the same issue on 6/27/26. The facility still did not act on it or indicate why they did not.Review of the physician order revealed an order written on 11/20/24 that reads: Risperidone Oral Tablet 0.25 MG (Risperidone)Give 1 tablet by mouth two times a day 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 record review and staff interviews, it was determined that the facility failed to ensure that physicians' orders are followed. This was evidenced by staff giving as needed narcotics outside of the recommended parameters for 2 (Resident $42 and #75) of 5 residents reviewed for unnecessary medications during the annual survey. The findings Include. 1). On 07/15/2026 at 4:37 PM Review of the June 2026 Medication administration records (MAR) revealed that Resident #75 was getting their PRN (as needed) narcotic pain medication when their pain level was documented as zero on 6/3, 6/7, and 6/11. The order was to give oxycodone HCL oral tablet 5MG- Give 4 tablets by mouth every 4 hours as needed for severe pain level of 6-10. Further review of July 2026 MAR revealed a second PRN order for narcotic pain medication written as: Oxycodone HCL oral tab 5MG: give 3 tablets by mouth every 4 hours as needed for moderate pain 1-5. This medication was being administered when the resident's pain level was greater than 5. The dates include: 7/2 and 7/5- Pain level was 10. On 7/9- Pain level…

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 reviews and staff interviews, it was determined that the facility failed to 1), store and serve food in a manner that prevents foodborne illness and 2), failed to date and label resident's food stored in the nourishment refrigerator. This was evident during the annual survey.The findings include1). On 07/13/2026 at 06:56 AM an observation of the facilities kitchen refrigerator revealed food stored without a date or labels on them. They include:A container with diced carrots in an aluminum container covered with a transparent film.A Big jar of Sysco reliance Barbecue sauce 3/4 empty-not datedThree one-liter water jugs, filled with pink juice and four one-liter jugs, filled with lemon juice- not dated.Further review of the Food temp log on 07/13/2026 at 7:23 AM revealed that: on 7/3/26, breakfast food temperature was not taken or documented. on 7/6/26 breakfast and lunch food temperature was not taken or documented.In an Interview with the district manager (CDM)#35 on 07/15/2026 at 8:23 AM, he was asked about their Policy for food storage, and he said that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a complaint #3055819, record review and staff interviews, it was determined that the facility failed to employ a Registered Nurse (RN) in accordance with Maryland State laws. This was evident for 1 (Staff #2) of 3 employee files reviewed during the annual survey. The findings include On [DATE] at 9:30 AM review of a complaint incident #3055819 alleged that the Director of Nursing's (DON) RN license was supposed to be from Florida and her MD LPN License was inactive with the MD Board of Nursing. The surveyor requested Staff #2's employee files. Review of staff #2's employee files verified that the employee has a valid compact RN license from Florida and that she resides in Maryland. However, the surveyor was unable to verify staff #2's Maryland license from the MBON website, and there were no copies of their MD license on file. In an Interview with the Human Resources (HR) Director #30 on [DATE] at 12:01PM the HR director was asked about their process for verifying the validity of a nurse's license. She…

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 and interview, it was determined that the facility failed to separate the clean and soiled laundry areas with a closed barrier to prevent the potential for cross-contamination and failed to maintain a process to identify residents who required Enhanced Barrier Precaution (EBP). This was evident in the laundry room and 3 (#40, #44, and #54) out of 10 rooms observed for precaution signage.The findings include:1) On 07/14/2026 at 10:25 AM, the surveyor observed an opening between the clean and dirty areas of the laundry. Staff #9 stated that the opening needs to be there for maintenance of the dryer area and there was no way to close the opening.On 07/14/2026 at 10:35 AM, the Administrator acknowledged the concern and stated the facility would explore solutions. 2) On 07/14/2026 at 10:40 AM, the survey observed 10 rooms with Enhanced Barrier Precaution (EBP) signage. Orange dots were found on 7 rooms identifying which bed the precautions were needed. Rooms #40, #44, and #54 did not have an…

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, it was determined that the facility failed to ensure that there was an effective pest control program in place at the facility to be free from pests. This was evident for several observations throughout the annual survey.The findings include:On 07/13/2026 at 11:34 AM, during an interview with Resident #9, a fly was flying around the room. Resident #9 swatted the fly away. At the same time, Resident #9 indicated that he/she had seen flies frequently in their room and that they had landed in their food and on objects around the room. On 07/13/2026 at 1:00 PM, an observation revealed a gnat (small fly) in the surveyor conference room. On 07/14/2026 at 7:30 AM, an observation revealed fly in the surveyor conference room.On 07/14/2026 at 8:05 AM, the surveyor caught and disposed of the fly. On 07/14/2026 at 10:50 AM, an observation revealed a fly in the surveyor conference room. On 07/15/2026 at 10:15 AM, an observation revealed a fly in a fresh cup of coffee in the surveyor conference room.On 07/15/2026 at 1:24 PM, an observation revealed a fly 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 reviews of clinical records, all pertinent facility administrative records, and interviews with the facility staff, it was determined that the facility nursing staff failed to 1) follow the physician's specific pulse and blood pressure parameters before administering cardiac medications to residents, and 2) failed to document an associated blood pressure before administering the cardiac medication. This was evident for 1 (Residents #6) of 9 residents reviewed during a complaint survey. The findings include: On 06/10/26 at 3 pm, a review of the facility policy Medication Administration, Section 7.1, under the heading of Policy Explanation and Compliance Guidelines: under #8, indicated the nursing staff must obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. A review of Resident #6's clinical record on 06/10/26 revealed that Resident #6 was admitted to the facility on [DATE] 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to provide the resident or representative with an outcome and/or resolution following the conclusion of a grievance investigation for 1 (R#12) of 6 sampled residents reviewed for grievances.Findings included:A review conducted on 5/14/2026 at 10:02 AM, of a facility policy titled, Resident and Family Grievances, dated 11/3/2025 revealed . Procedure: This facility will not retaliate or discriminate against anyone who files a grievance or participates in the investigation of grievance. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form. Take any immediate action needed to prevent further potential violations of any resident rights. Report any allegations involving neglect, abuse, injuries of unknown source, and/or misappropriation of resident property immediately to the administrator and follow procedures for those…

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, record review, review of the facility-reported incident, review of the facility's Abuse Prevention Policy, and review of the facility's investigative documentation, the facility failed to ensure Resident #5 was free from verbal and mental abuse when a staff member yelled at the resident and threatened to have a family member come to the facility to 'take care' of the resident, for 1 of 3 sampled residents reviewed for abuse.Review conducted on 5/14/2026 at 10.15 AM. The Abuse Prevention Policy revealed that the facility policy prohibited verbal and mental abuse toward residents. The policy further indicated residents were to be free from verbal threats, intimidation, harassment, and abusive language by facility staff.Review conducted on 5/14/2026 at 10:23 AM of the facility-reported incident dated 12/24/2025 revealed that Resident #5 reported that the GNA entered the resident's room yelling and threatened to have the GNA's father come to the facility to take care of him. Facility…

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 medical record review and staff interviews, it was determined that the facility failed to ensure staff implemented interventions to prevent a resident from falling from bed during an incontinence change for 1 of 3 sampled residents for accidents. (R#6) The findings include:R#6 was admitted to the facility on [DATE] with diagnoses including unspecified injury at C5 level of cervical spinal cord. The quarterly Minimum Data Set (MDS) dated [DATE] identified R#6 as cognitively intact and dependent on staff for activities of daily living. The care plan dated 4/24/2026 identified a focus related to bed mobility and indicated the resident required the assistance of one staff member to reposition and turn in bed.On 5/11/2026 at 1:56 PM review of a change in condition note dated 2/19/2026 revealed a witnessed fall. Geriatric Nursing Assistant (GNA3) called for assistance. Upon entering the room, the resident was observed sitting on the floor next to her bed. The Resident denied pain or discomfort and vital signs…

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 it was determined that the facility failed to ensure that residents were free of significant medication errors as evidenced by facility staff failing to administer medications in accordance with professional standards. This was evident for 1 (#5) of 8 resident reviewed for medication administration.The findings include:Medication is to be administered according to the five rights of medication administration: right person, right medication, right route, right dosage, and right time. On 1/9/2026 at 9AM, a review of Complaint #2695708 revealed that Resident # 5 medication was not given as prescribed by the physician.A record review of Resident # 5's medication administration audit for 12/6/25 revealed Resident # 5 had received medication that was not prescribed by the physician for a urinary track infection.On 12/6/25 at 6PM, the following medication was administered meropenem which is a broad-spectrum carbapenem antibiotic used to treat severe bacterial infections instead of cefepime, a potent, broad-spectrum, fourth-generation…

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 medical record review and interview, facility nursing staff failed to follow a physician's order for an upper right quadrant ultrasound for a resident (Resident #6). This was evident for 1 of 7 residents reviewed during a complaint survey. The findings include:On 1/12/26, the State of Maryland's Office of Health Care Quality received a complaint which alleged the facility failed to monitor Resident #6's status and well-being during his/her stay in the facility. Review of Resident #6's medical record on 1/12/26 at 8:46 AM revealed that Resident #6's labs in 9/2025 found elevated liver enzymes. The physician ordered a right upper quadrant ultrasound on 9/18/2025. Further review of Resident #6's medical records revealed no evidence of the results from the right upper quadrant ultrasound. Interview with the Director of Nursing on 1/12/25 10:40 AM revealed that the facility's nursing staff failed to complete the physician ordered right upper quadrant ultrasound. The surveyor explained that this is a concern due to failure to follow a physician's order.

Based on review of employee records and interview with facility staff, it was determined that the facility failed to 1) conduct annual performance reviews of Geriatric Nursing Assistants (GNAs) and 2) provide regular, in-service education based on the outcome of those individual performance reviews. This was evident for 5 (GNA #49, GNA #50, GNA #1, GNA #51, GNA #52) of 5 randomly selected GNAs' records reviewed during the facility's recertification survey. The findings include:Performance reviews are to be completed for every GNA at least every 12 months to identify specific in-service education based on the outcome of those individual performance reviews. On 7/22/25 at 9:15 AM in an interview with the Director of Nursing (DON) when asked who conducted performance reviews for the GNAs and nurses, she stated the Unit Managers. When asked where they were stored, she stated, We were in the process of getting them done when you came in. Additionally, she stated, From my understanding, they have not been done for quite some time. On 7/22/25 at 1:02 PM, a review of 5 GNAs' randomly…

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 and interviews, it was determined the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was evident on 2 of 3 nursing units observed during the recertification/complaint survey. The findings include:The following environmental concerns were observed during the initial entrance rounds in the facility on 7/15/25 at 7:45 AM and throughout the survey until 7/25/24.room [ROOM NUMBER] - in the bathroom there were 4 ceiling tiles with brown stains/water marks.room [ROOM NUMBER] - there was no toilet paperroom [ROOM NUMBER]A - the laminate was peeling on the headboard and footboard of the bed. There was peeling paint on the entire front edge of the window sill down to the bare wood. There was no string for the over-the-bed light.room [ROOM NUMBER] - The frame on the over the toilet riser was rusted in the front and on the legs room [ROOM NUMBER] - There was approximately 3 feet of molding by the window…

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 review of facility reported incidents, record review, and interview, it was determined the facility failed to report allegations of abuse within 2 hours of the allegation and misappropriation of property within 24 hours to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 8 (#120, #107, #117, #67, #81, #103, #104, #122) residents reviewed for 21 facility reported incidents during the recertification/complaint survey. The findings include: 1) On 7/16/25 at 8:23 AM a review of facility reported incident 326126 was conducted and revealed Resident #120 alleged that on 3/21/23 at 12:30 PM the phlebotomist came to draw the resident’s blood while the resident was in the middle of prayer. The resident alleged the phlebotomist punched him/her in the chest and wrestled his/her arms and said, “listen to me. Review of the facility’s investigation failed to produce an email confirmation as to when the initial report was submitted to OHCQ. Review of the Comprehensive and Extended…

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 review of facility reported incidents, medical records, and staff interview, it was determined the facility failed to provide documentation that allegations of abuse and misappropriation of property were thoroughly investigated. This was evident for 7 (#120, #127, #117, #101, #81, #103, #126) of 21 residents reviewed for facility reported incidents during the recertification/complaint survey. The findings include: 1) On 7/16/25 at 8:23 AM a review of facility reported incident 326126 was conducted and revealed Resident #120 alleged that on 3/21/23 at 12:30 PM the phlebotomist came to draw the resident’s blood while the resident was in the middle of prayer. The resident alleged the phlebotomist punched him/her in the chest and wrestled his/her arms and said, “listen to me.” Review of Resident #120’s medical record revealed a 3/24/23 change in condition note that documented the resident filed a grievance related to the incident. Review of the facility’s investigation revealed (13) staff interviews and an…

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 medical record review and interview, it was determined the facility staff failed to hold care plan meetings to include the interdisciplinary team, resident and resident's representative for residents. This was evident for 5 (Resident #1, #4, #9, #67, and #75) of 64 residents reviewed during a recertification/complaint survey. The findings include: Once the facility staff completes an in-depth assessment (MDS) of the resident, the interdisciplinary team meet and develop care plans. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the resident's specific needs. The care plan is a means of communicating and organizing the actions and assure the resident's needs are attended to. The care plan is to be reviewed and revised at each assessment time of the resident to ensure the interventions on the care plan is accurate and appropriate for the resident. Care plan meetings are held each quarter and as needed. 1)On 7/16/25 at 1:23 PM a review of Resident #67’s medical…

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 medical record review and interview, it was determined the facility staff failed to provide treatment and care in accordance with professional standards of practice for residents (Resident #40, # 75, #106 and #113). This was evident for 4 of 64 residents reviewed during a recertification/complaint survey. The findings include:1.The facility staff failed to follow the nurse practitioner's instructions for Resident #40. Review of Resident #40's medical record on 7/22/25 revealed the Resident was admitted to the facility in March 2024 with a diagnosis to include hypertension. Hypertension (high blood pressure) is when the pressure in your blood vessels is too high. a) Further review of Resident #40's medical record revealed the Resident was seen by the Nurse Practitioner (NP) (Staff #47) on 7/7/25. Review of the NP's 7/7/25 note revealed the Resident was seen for a follow-up lab review. The NP documented the Resident continues on Lasix 20 mg daily for bilateral lower extremity edema and to monitor weights…

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 medical record review, observation, and interview, it was determined the facility failed to 1) ensure that fall precautions were in place, per the physician's orders, for a resident with a history of falls from the bed, 2) follow the resident's smoking plan of care, and 3) provide supervision for residents requiring supervision while smoking. This was evident for 4 (Resident #4, #1, #83, and #97) of 64 residents reviewed during the recertification/complaint survey.The findings include: 1)On 7/16/25 at 11:15 AM Resident #4’s medical record was reviewed and revealed Resident #4 was admitted to the facility in July 2023 with diagnoses that included cerebral infarction, symptoms and signs involving cognitive function following cerebral infarction, osteoarthritis of the right knee, and bipolar disorder. A 6/11/25 at 19:30 (7:30 PM) change in condition note documented Resident #4 had an unwitnessed fall from the fall from the bed. There were no visible injuries noted other than a skin tear on the right forearm. A 6/24/25 at 4:05 AM change in condition note documented Resident #4…

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 review of complaints, medical record review, and staff interview, it was determined the facility failed to 1) provide timely medication to meet the needs of the residents, and 2) ensure that narcotic medications were consistently reconciled by two nurses at change of shift. This was evident for 3 (#67, #108, #111) of 64 residents reviewed, and 4 halls ([NAME], [NAME], [NAME], and [NAME]) of 4 halls of narcotic and controlled substance log binders reviewed for accuracy and completeness of controlled medication storage and documentation during the recertification/complaint survey. The findings included: Narcotic (controlled) medication, due to its potential for abuse and addiction, is required to be thoroughly tracked and accounted for by the facility. This includes but is not limited to an accounting of all narcotics in storage whenever a change of shift among nursing staff occurs. This medication count must be performed by two nursing staff at the same time to verify the counts being conducted. Any…

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 a tour of the kitchen, staff interview and observation, it was determined that the facility staff failed to 1) ensure proper disposal of foods no longer safe to consume, and 2) store food in accordance with professional standards for food service safety. This was evident for 2 out of 3 kitchen tours and observation of a nourishment room during the recertification/complaint survey. The findings include: 1)During the initial tour of the kitchen on 7/15/25 at 7:34 AM these items were found in the walk-in cooler: 4 - 4 packs of yogurt (2 strawberry yogurt cups and 2 vanilla yogurt cups per pack), 2 loose containers of strawberry yogurt, and 1 loose container of vanilla yogurt that had best by dates of 7/2/25. The Dietary Manager (Staff #53) was interviewed on 7/15/25 at 7:40 AM. This surveyor showed her the yogurts and their dates. She replied by saying that they needed to be thrown out. She then took the items off of the shelf to be discarded. During a tour of the kitchen on 7/22/25 at 8:10 AM 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of a complaint, observation of resident rooms, common shared areas, interviews, and documentation review, it was determined that the facility staff failed to 1)follow infection control practices and guidelines to prevent the development and transmission of infection and disease, 2) ensure staff donned appropriate personal protective equipment (PPE) for enhanced barrier precautions during medication administration to resident with a Gastrostomy tube and post appropriate Enhanced Barrier Precautions (EBP) signage, 3) place order for contact precaution and care plan for a resident with an infectious disease, 4) place precaution order and signage on the door for EBP residents. This was evident on 3 of 3 hallways observed, 5 (Residents #11, #128, #12, #27, and #44) of 7 residents reviewed for Infection Control during the recertification/complaint survey.The findings include: TBP definitions: Transmission Based Precautions (TBPS) (a set of infection control measures used in addition to standard…

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 of restrooms for residents and visitors, a nursing station, a public shower room, and facility staff offices, it was determined that the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, visitors, and staff as identified. This was evident in 2 staff bathrooms observed on 2 nursing units, 2 of 2 shower rooms, and 2 staff offices observed during the recertification/complaint survey. The findings include:On 7/15/25 at 9:03 AM observation was made in the Human Resources Director's (HR) office of black specs which appeared to be a moldlike substance on the window blinds and covering the slats of the air conditioning unit which also had condensation around the unit. An interview was conducted with Staff #5 who confirmed there was mold growing in the office and that she had reported it to administration. On 7/24/25 at 9:00 AM and 10:20 AM observation was made of the bathroom in the [NAME] unit nurse's station. The base molding was pulled away from…

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 during the initial tour of the facility and staff interviews, it was determined that the facility staff failed to ensure a resident had the call bell control by their side. This was evident for 2 (Resident #9 and #43) out of the 64 residents in the survey sample. The findings include: 1)During the initial tour of the facility on 07/15/2025 8:33 AM this surveyor entered Resident #43's room and observed that the call bell cord and plunger were on the floor to the right of the bed near the headboard and out of reach of the resident. The resident was unaware of the call bell's location. 2)On 07/15/2025 at 9:35 AM during the surveyor’s initial tour of the facility, an observation of Resident #9’s call bell (an item used to press and alert staff that a resident needed assistance) was on the floor and out of reach of the resident. On 07/15/2025 at 09:40 AM during an interview with staff #20 a Geriatric Nursing Assistant/Certified Medication Tech (GNA/CMA) stated the call light should be within reach and verified that Resident #9’s call light was not within reach. 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 review of Resident Council meeting minutes and interview with facility staff, it was determined that the facility failed to have an effective system in place to demonstrate their response and rationale for concerns identified by the Resident Council. This was found to be evident based on review of 4 months of Resident Council meeting minutes.The findings include:The Resident Council is a group of residents that meets regularly on the behalf of all residents in the facility to discuss concerns about facility policies and procedures affecting residents' care, treatment, and quality of life. Facility staff are required to consider resident and family group views and act upon grievances and recommendations. This may include developing or changing policies affecting resident care and life. Facility staff should discuss their decisions with the resident and/or family group and document in writing its response and rationale. The facility must be able to demonstrate their response and rationale. On 7/21/2025 at 8:29 AM a review of the most recent 4 months' Resident Council meeting…

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 medical record review and interview, it was determined the facility staff failed to notify a resident's representative (Resident #13 and #110) and a resident's physician (Resident #13) for a change in condition. This was evident for 2 of 64 residents reviewed during a recertification/complaint survey. The findings include:1.The facility staff failed to notify Resident #13's representative and physician on 6/10/25 when the Resident's BiPAP machine stopped working. BiPAP, or bilevel positive airway pressure, is a type of non-invasive ventilation used to assist breathing, particularly for individuals with sleep apnea or other respiratory conditions. A review of a complaint was conducted on 7/17/25 regarding the Resident's representative (RP) was not notified when the Resident's BiPAP stopped working on 6/10/25. Review of Resident #13's medical record on 7/17/25 revealed the Resident was admitted to the facility with diagnosis to include chronic respiratory failure and obstructive sleep apnea. Obstructive sleep apnea (OSA) is a common sleep disorder where breathing repeatedly…

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 medical record review, review of facility documentation and interview, it was determined the facility staff failed to protect a resident from verbal abuse from facility staff (Resident #104). This was evident for 1 of 64 residents reviewed during a recertification/complaint survey.The findings include: On 7/16/25 a review of facility reported incident 326163 was conducted. The facility reported on 10/3/24 at approximately 6:46 PM, Staff #55 and #56 were providing care to Resident #104. Resident #104 was screaming in pain and stated I am dying, I have cancer. Staff #55 reportedly told Resident #104 well go ahead and die then so you can stop all this screaming. Review of Resident #104's medical record on 7/16/25 revealed the Resident was admitted to the facility in February 2024 with a diagnosis to include malignant neoplasm of the bone (bone cancer). Review of the facility's investigation revealed a statement from the Resident's family member to the Administrator stating at the time of the incident he/she was on the phone with the Resident and heard Staff #55 say 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 review of a facility reported incident, medical records, controlled drug sheets, and interviews it was determined that the facility failed to ensure residents were free from misappropriation of narcotics. This was evident for 1 (#81) of 22 residents reviewed for facility reported incidents during the recertification/complaint survey. The findings include: On 7/18/25 at 6:49 AM a review of facility reported incident 326170 was conducted and it was alleged that narcotic medication was missing from Resident #81 on 5/13/25 at the end of the 3:00 PM to 11:00 PM shift. A review of Resident #81's medical record revealed the resident was admitted to the facility in January 2025 with diagnoses that included, but were not limited to, unilateral primary osteoarthritis of the left knee, pain in the left ankle and joints of the left ankle, low back pain, other polyneuropathies, chronic pain syndrome, and spinal stenosis of the cervical and lumbar region. The resident had an order for the (Opioid) Oxycodone 5 mg 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 medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 3 (#127, #111, #108) of 64 residents reviewed during the recertification/complaint survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) On 7/16/25 at 9:33 AM a review of Resident #127's medical record was conducted. Resident #127 was admitted to the facility in September 2024 with diagnoses that included polyneuropathy, chronic pain, generalized osteoarthritis and gout.Review of Resident #127's September 2024 Medication Administration Record (MAR) documented that the resident received…

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 review of medical records and interview with facility staff, it was determined that the facility failed to ensure 1) a baseline care plan was completed and 2) a summary, including a current list of medications, was provided to the resident. This was evident for 1 (Resident #101) out of 3 closed records reviewed during the facility's recertification survey.The findings include:A baseline care plan (BLCP) must be completed within 48 hours of a resident's admission to the facility and include the initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. A summary of the BLCP and current medication list must be given to each resident and/or his/her representative. Completion and implementation of the BLCP is intended to promote continuity of care and communication among staff, increase resident safety, and safeguard against adverse events (undesirable outcomes) that can occur right after admission. On 7/23/25 at 11:41 AM review of Resident #101'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview it was determined that the facility staff failed to ensure a care plan was developed to address a resident's catheter use. This was evident for 1 (Resident #80) out 64 residents that were part of the survey sample. The findings include: A Minimum Data Set (MDS) is a federally mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. The information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. A review of Resident #80's clinical record on 7/22/25 at 9:00 AM revealed that the resident's primary physician ordered on 3/11/25 that the resident have an indwelling urinary catheter. The Resident's Admissions MDS was completed on 3/16/25. It had a Care Area Assessment (CAA) that noted the Interdisciplinary team (IDT) agreed to complete a care plan to address the ordered catheter. The Quarterly MDS completed on 5/3/25…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of resident medical records and interviews with facility staff, the facility failed to 1) address a significant weight loss, and 2) follow the recommendations of the Dietitian for a resident. This deficiency was evident in 2 (Resident #9 and #116) of 2 residents reviewed for nutrition during this recertification/complaint survey. Findings included: 1)During a review of Resident #9's medical record on 07/16/25 at 11:52 AM, it was revealed that the resident was readmitted to the facility from the hospital on [DATE]. The resident's body weight was documented as: 06/02/25: 170.2 lbs (via Hoyer lift) 07/09/25: 158 lbs (via Hoyer lift, a loss of 12.2 lbs, 7.17%) 07/15/25: 163 lbs (via Hoyer lift) Further review of Resident #9's medical records showed that their nutrition evaluation was documented on 06/03/25. However, there was no additional evaluation regarding this significant weight loss. In an interview with Licensed Practical Nurse (LPN) #8 on 07/16/25 at 12:55 PM, she stated that the Geriatric…

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, interviews, and medical record review, it was determined that facility staff failed to provide respiratory care to meet the needs of residents. This was evidenced by: absence of physician orders indicating the use of oxygen for residents, failure to maintain nasal cannulas in a sanitary manner, and failure to administer oxygen according to the prescribed settings. This was evident for three residents (#1, #3, and #13) reviewed for respiratory care during the recertification/complaint survey. The findings include:1) Review of Resident #13’s medical record on 7/17/25 revealed the Resident was admitted to the facility with diagnosis to include chronic respiratory failure and obstructive sleep apnea. Obstructive sleep apnea (OSA) is a common sleep disorder where breathing repeatedly stops and starts during sleep due to a blockage of the airway. BiPAP, or bilevel positive airway pressure, is a type of non-invasive ventilation used to assist breathing, particularly for individuals with sleep…

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 medical record review, resident and staff interview, it was determined that the facility failed to 1) properly assess for pain, 2) have parameters for pain medications used for pain management, 3) provide nonpharmacological intervention for a resident's reported pain, 4) received PRN (as needed) pain medication according to the Physician order set parameters (a specific instruction given for administration of medication), and 5) failed to administer a scheduled pain medication according to a Physician order. This was evident for 2 (Resident #1 and # 2) out of 2 residents reviewed for pain during this recertification/complaint survey.The findings include: Oxycodone is a strong short acting prescription pain medication classified as an opioid, used to manage moderate to severe pain. Oxycontin is a long-acting pain medication classified as an opioid that is specifically formulated as a controlled-release tablet designed to deliver oxycodone over a 12-hour period, providing sustained pain relief for chronic or constant pain that requires around-the-clock pain management. 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.

Based on clinical record review and staff interview it was determined that the nursing staff failed to monitor behavior of a resident. This was evident for 3 (Resident #3, #6, and #45) out of 64 residents assessed for behavior monitoring during this recertification/complaint survey.The findings include:1)The surveyor conducted an initial interview with Resident #3 on 7/15/25 at 10:35 AM. During the interview the resident became tearful, expressing sadness stating a family member had passed away a few weeks ago. On 07/21/2025 at 10:40 AM in review of Resident #3’s medical record revealed the following physician orders dated 05/05/2025: Bupropion HCI ER oral tablet Extended Release 24-hour 300 MG (Bupropion HCI) give one tablet by mouth one time a day for depression. Sertraline HCI Oral tablet 100 MG give 1 tablet by mouth one time a day for Depression. Trazadone HCI Oral Tablet 50 MG give 25 MG by mouth at bedtime for Depression. Continued review of Resident # 3's medical record revealed that there was a care plan dated 05/06/2025 for use of antidepressant medication related 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 clinical record review and staff interview, it was determined that the facility staff failed to ensure medications were held according to the physician orders. This was evident for 1 (Resident #43) out of 64 residents in the survey sample. The findings include: A review of Resident #43's clinical record revealed that the resident had an order for Midodrine 5mg three times a day for orthostatic hypotension and to hold if systolic (top number) blood pressure is above 130. A review of the July Medication Administration Record revealed that on 7/2/25 at 6:30 AM the blood pressure was 132/74, but the medication was still given. A review of the June Medication Administration Record revealed that on 6/2/25 at 6:30 AM the resident had a blood pressure of 132/75, but the medication was still given. On 6/8/25 at 11:30 AM the resident had a blood pressure of 136/72, but the medication was still given. On 6/15/25 at 6:30 AM the resident had a blood pressure of 136/70, but the medication was still given. On 6/16/25 at 11:30 AM the resident had a blood pressure of 134/68, but 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, documentation review, and interview with resident and staff, it was determined that the facility staff failed to 1) properly store medication by leaving a narcotic medication on the bedside table in the resident's room, and 2) keep treatment carts locked when unattended and discard medications/biologicals when expired. This was evident for 1 (Resident # 40) of 29 residents bedroom areas observed, and 1 of 3 nursing units observed during random observations made during the recertification/complaint survey. The findings include: 1) On [DATE] at 09:40, Resident #40 informed the surveyor that his/her medication was left on his/her bedside table. The surveyor observed a small bottle of medication labeled Methadone 115mg on the resident’s bedside table. An interview was conducted on [DATE] at 09:43 with Staff # 12 who stated that s/he was administering medication and resident was getting care and she left the medication on his/her bedside table. Staff #12 stated that it was not the right thing 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, interviews, and medical record review, it was determined that the facility failed to arrange for dental services within a reasonable time frame following the dental consultant recommendation. This was evident for 1 of 2 residents (#45) selected for dental complaints during this recertification/complaint survey process.The findings include:On 07/15/2025 at 12:20 PM Resident #45's Son stated that the resident often complained of tooth pain. The son stated that the resident had a dental consultation, but there had been no follow up. An interview was conducted with the resident on 07/16/2025 at 10:06 AM and when asked if the resident had dental pain, the resident showed surveyor his/her teeth and stated, I have no teeth on top, or bottom and it hurts when I eat. The surveyor observed resident missing teeth to top and bottom of mouth with 2 side teeth on the top of the mouth.A review of the resident's care plan on 7/16/25 at 12:02 PM revealed that the resident had oral/dental health problems as evidenced by broken teeth/likely cavity. Date Initiated: 07/22/2022…

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 medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 3 (Resident #67, #75, and #108) of 64 residents reviewed during an recertification/complaint survey. The findings include. A medical record is the official documentation of a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1) Review of Resident #75’s medical record revealed the Resident was admitted to the facility in July 2024 and after a hospitalization was readmitted to the facility on [DATE]. Review of Resident #75’s hospital discharge summary on 5/23/25 stated Patient was subsequently discharged in stable condition. All non-essential medications from a palliative standpoint were discontinued. Further 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 medical record reviews and staff interviews, it was determined that the facility staff failed to ensure timely updates to the residents' hospice status. This was evident for 1 (Resident #9) of 2 residents reviewed for hospice care during this recertification/complaint survey. Finding includes: During a review of Resident #9's medical record on 07/16/25, at 2:32 PM, it was revealed that a document from a contracted company in their hard copy chart indicated hospice care began on 03/29/25 and was discharged on 05/29/25.However, a review of Resident #9's care plan on 07/17/25, around 9:00 AM, showed an active care plan for hospice care. The Minimum Data Set (MDS) Section O (Special Treatments, Procedures, and Programs), dated 06/20/25, also indicated the resident was in hospice care.Additionally, during an interview with Staff #10 (Rehab Director) on 07/17/25, at 11:36 AM, they stated that the resident was not evaluated for a rehabilitation program due to being under hospice care.In an interview with the Director of Nursing (DON) on 07/16/25 at 2:50 PM, she confirmed that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interviews, it was determined that the facility failed to provide education regarding the risks versus benefits of the pneumonia vaccine. This was evident for 2 out of 5 residents (Resident #1 and #5) whose immunization records were reviewed during this recertification/complaint survey. Finding included: Pneumococcal vaccine help prevents pneumococcal disease, which is any type of illness caused by streptococcus pneumonia bacteria. The Centers for Disease Control and Prevention (CDC) recommends a pneumococcal vaccine for age [AGE] years or older and adults 19 through [AGE] years old with certain medical conditions or risk factors. (Centers for Disease Control and Prevention- vaccines and preventable disease) On July 22, 2025, at 8:46 AM, immunization records for five randomly selected residents were reviewed. The immunization tab in the electronic medical record documented that both Resident #1 and Resident #5 refused the pneumonia vaccine. However, there was no…

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 interviews, it was determined that the facility failed to ensure residents' COVID-19 vaccination status was properly monitored. This was evident for one (Resident #5) of five residents whose COVID-19 vaccination records were reviewed during this recertification/complaint survey. The findings include: A COVID-19 vaccine is designed to provide acquired immunity against severe acute respiratory syndrome coronavirus 2, the virus that causes coronavirus disease. On July 22, 2025, at 8:46 AM, immunization records for five randomly selected residents were reviewed. Resident #5, who was admitted in July 2024, this resident had no evidence of COVID-19 vaccination, neither historical data nor an offer from the facility. During an interview with the Director of Nursing (DON) on 7/22/2025, at 1:26 PM, she stated that the Infection Preventionist typically monitors residents' vaccination status (e.g., Pneumonia, Flu, and COVID-19) upon admission. When informed there was no information for Resident #5's COVID-19 vaccination status, the DON validated the concern.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview it was determined that the facility failed to provide reasonable accommodations for 1.) Resident #40 as evidenced by failing to have a language line communication system. The Language Line allows the Service Provider to access a translator by phone to communicate with people who speak a language other than English and 2). failed to ensure call bells were within reach of the Residents (#25 and #26). This was evident for 3 (Residents #40, #25 and #26) out of 66 residents reviewed during an annual recertification survey. The findings include: Minimum Data Set (MDS) is a standardized, primary screening and assessment tool of health status which forms the foundation of the comprehensive assessment for all residents of long-term care facilities certified to participate in Medicare or Medicaid. The MDS contains items that measure physical, psychological, and psycho-social functioning. The items in the MDS give a multidimensional view of the patient's functional…

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 review of Resident Council meeting minutes and interview with members of the resident council it was determined that the facility staff failed to consistently update the residents with responses to their concerns. This was evident for 6 out of the 18 months reviewed. The findings include: Members of the resident were interviewed on 9/15/22 at 1:30 PM. During the interview the residents said that they make complaints to staff that attend the resident council meetings but they don't have an answer. When I asked if staff provide a response the following month. The residents responded, they never come back with an answer. A review of the resident council meeting notes revealed the following: The minutes for the 2/23/22 Resident Council meeting mention that the residents brought up concerns of restrooms not being cleaned, weekend housekeeping staff just taking out trash, and the courtyard not being cleaned with overflowing trash cans. The minutes for the 3/23/22 Resident Council meeting mention the housekeeping concerns from the February minutes as old business. New business…

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 clinical record review and staff interview it was determined that the facility staff failed to ensure that Advanced Directives were offered and/or available in the clinical record for 5 out of the 66 residents reviewed as part of the survey sample (Residents #16, #32, #41, #42, and #43). The findings include: A review of the facility's policies and procedures for Advanced Directives revealed: On admission, the facility will determine if the resident has executed an advanced directive, and if not, determine whether the resident would like to formulate an advance directive. Upon admission, should the resident have an advanced directive, copies will be made and placed on the chart as well as communicated to the staff. 1. A review of Resident #16's clinical record on 9/6/22 at 11:18 AM revealed that there was no note stating that the resident was informed of the right to formulate an Advanced Directive nor was there a copy of an Advanced Directive. Resident #16 was interviewed on 9/9/22 at 10:06 AM. The resident could not remember if an Advanced Directives were discussed 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 and interviews with facility staff it was determined the facility failed to ensure that residents' rooms were maintained in a homelike environment by failing to conduct routine assessments of the resident room and completing repairs when needed. This was found to be evident while touring the facility during the facility's annual Medicare/Medicaid survey. Findings include: A tour of the facility on 09/07/22 at 8:35 AM revealed multiple areas that needed to be repaired/maintained: 1. room [ROOM NUMBER] had 3 large bags of clothes sitting on the floor, flies in the room, and smashed grapes on the floor. 2. room [ROOM NUMBER]'s dry wall was in various stages of disrepair. Clothes and supplies were piled high on chairs making the chair unusable for residents or visitors. 3. room [ROOM NUMBER] had a pile of clean towels and gowns folded and on the floor. The Ceiling tile above bed was observed with brown and dark black patches, wound vac medical equipment packets were observed on the floor, over…

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 medical record review and interview with staff it was determined the facility staff failed to provide written notice for emergency transfers to the resident's responsible party and/or the Ombudsman. This was found to be evident for 5 out of 66 (Resident #27, #75, #14, #12 and #47) residents reviewed for a facility-initiated transfer during the investigation of the survey. The findings include: 1. On 9/7/22 at 8:30 AM a review of Resident #27's clinical record revealed that in April 2022, the resident was sent to the hospital for treatment and evaluation. The review also revealed that the facility staff failed to provide written notice for emergency transfers to the Ombudsman. 2. On 9/7/22 at 11 AM a review of Resident #14's clinical record revealed that in January 2022, the resident was sent to the hospital for treatment and evaluation. The review also revealed that the facility staff failed to provide written notice for emergency transfers to the Ombudsman. 3. On 9/7/22 at 9:30 AM a review of Resident #75's clinical record revealed that in July 2022, the resident was sent…

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 clinical record review and staff interview it was determined that the facility staff failed to ensure a copy of the facility bed hold policy was provided to the resident's responsible party. This was evident for 2 (#12 and #47) out of the 66 residents in the survey sample. The findings include: 1. Review of Resident #12's medical record on 9/8/22 revealed the Resident was transferred from the facility to the hospital in August 2022. Further review of the resident's medical record failed to reveal any documentation that a written notice regarding the bed hold policy had been provided to the resident's responsible party. Interview with Director of Nursing and Administrator on 9/13/22 at 8:00 AM confirmed the facility had no evidence Resident #12's responsible party had been given written notification of the facility's bed hold policy upon transfer. 2. Review of Resident #47's medical record on 9/8/22 revealed the Resident was transferred from the facility to the hospital in July 2022. Further review of the resident's medical record failed to reveal any documentation that 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 clinical record review and staff interview it was determined that the facility staff failed to ensure care plan meetings were held, failed to update care plans for residents and failed to ensure the full interdisciplinary team including residents and/or their responsible parties were invited to the quarterly care plan meetings. This was evident for 5 (Resident #2, #16, #41, #7, and #27) out of 66 residents in the survey sample. The findings are: A comprehensive care plan is an outline of nursing care showing all the resident's needs and the ways of meeting those needs. It is a dynamic document initiated at admission and subject to continuous reassessment and change by the nursing staff caring for the resident. The care plan includes nursing and medical diagnoses, nursing interventions, and outcomes to ensure consistency of care. 1. Resident #2 was interviewed on 9/7/22 at 8:28 AM. The resident was uncertain if a care plan meeting has been held. A review of Resident #2's clinical record revealed that the last care meeting was held on 4/15/21. A progress note dated 12/28/2021…

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.

Based on observation and interviews with facility staff, it was determined that the facility failed to ensure that food was stored in accordance with professional standards for food service safety. This had the potential to affect all residents in the facility. The Findings: On 09/06/22 at 9:19 AM during the initial facility tour and observation of the facility kitchen with the Dietary Manager, it was found that: 1. The pipes behind the stove had a build-up of grease and grease-laden dust hanging from the pipes. 2. The wall above the double sink had 2 large holes. 3. The kitchen walls had chipping paint. 4. The kitchen walls were missing random baseboard tiles and had holes in the baseboard where the tiles used to be. 5. Standing water on the floor near the dishwasher. 6. The drain traps had paper, food particles, and flies. 7. A rusted cast iron pan was noted on the shelf. 8. The knife holder had a build-up of grease and dust on the top with the knives in place in the holder. 9. A scoop was on lying inside the oat cereal container. 10. The cereal was marked with an expiration date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and resident interview it was determined that the facility staff failed to ensure a cord used to turn on/off a call light was in working condition to allow the residents a means of directly contacting staff. This was evident for 5 rooms (room [ROOM NUMBER], 17, 41, 56, and Resident #27's room) toured as part of the annual survey. The findings include: 1. On 09/07/22 at 8:15 AM, an interview with Resident #27 revealed that she/he had no way of contacting the nurse and that her call bell was broken for a week. The Resident made staff aware of the broken call light and the Resident stated that she/he needs staff assistance for turning in bed. Observation of the called light cord revealed it was attached to an outlet on the wall, but the end of the cord was frayed, and the push button was missing from the cord. On 9/7/22 at 10:18 AM the Administrator and DON were made aware. 2. The call bell cord for room [ROOM NUMBER] was observed on 9/8/22 at 8:44 AM to have one end plugged into the wall plate…

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 medical record review and interview, it was determined the facility staff failed to notify the physician of a resident's abnormal radiology results in a timely manner (Resident #47). This was evident for 1 of 66 residents reviewed during an annual survey. The findings include: Review of Resident #47's medical record on 9/12/22 revealed the Resident had a fall at the facility on 7/4/22. On 7/4/22 the facility obtained a left hip X-ray that showed no fracture. On 7/6/22 the Resident was seen and assessed by Physician #1 who documented, Unwitnessed fall with left hip pain: First X-ray negative but having persistent pain and exam significant for high possibility of left hip fracture. Repeat X-ray pending. Further review of Resident #47's medical record revealed on 7/6/22 at 1:39 PM the X-ray was completed and reported at 5:00 PM. The Radiology Results Report stated, There is an acute intertrochanteric fracture. Further review of the Resident's record revealed the facility staff did not notify Physician Assistant #1 of the Resident's abnormal X-ray results until 7/7/22 at 10:00…

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 a review of the facility's investigation of a facility reported incident and staff interview it was determined that the facility failed to protect a resident from abuse. (Resident #41). This was evident for 1 out of 17 residents selected for review for abuse during the annual survey process. The findings include: A review of the facility's investigation revealed that on 6/5/22 Resident #41 reported Nurse #5 gave him/her the middle finger and it was witnessed by Nurse #2. During interview with Resident #41 on 9/15/22 at 8:30 AM, he/she stated he/she was going to visit Resident #45 when Nurse #5 told him/her that he/she was not allowed in the room and he/she was a creep. Resident #41 stated he/she went to tell Nurse #2 and Nurse #5 told him/her why don't you tell your mother and the [NAME]. Resident #41 stated he/she said to Nurse #5 why do you have to be such a bitch and Nurse #5 stated your mom is a bitch and gave Resident #41 the middle finger. During the interview, Resident #41 stated he/she was not…

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

Based on medical record review, staff interview and review of facility statements, it was determined the facility staff failed to report an incident of alleged abuse to the Office of Health Care Quality (OHCQ) and local law enforcement as required (Resident #186). This was evident for 1 out of 17 residents reviewed for abuse during an annual survey. The findings include: During investigation of an anonymous complaint, it was reported the facility staff failed to report an allegation of alleged abuse regarding an unknown geriatric nursing assistant (GNA) and Resident #186. Review of the facility investigation revealed that on 3/25/22 Resident #191 reported to Social Worker #2 that last Saturday or the Saturday before he/she heard Resident #186 yelling and moaning. Resident #191 stated could not see anything but heard an unknown GNA changing and yelling at Resident #186. Resident #191 then stated he/she heard a sound that sounded like a slap, the sound a glove makes against the skin. Further review of the facility investigation revealed although the facility investigated 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 medical record review, observation and staff interview it was determined that the facility staff failed to accurately code the resident's status on the Minimum Data Set (MDS) assessment (Resident #7 and #23). This was evident for 2 out of 66 residents selected for review during an annual survey. The findings include: The MDS is a federally-mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. 1. Observation of Resident #7 on 9/7/22 at 11:30 AM revealed the Resident had a Foley catheter. Review of Resident #7's medical record on 9/8/22 revealed the Resident was readmitted to the facility from the hospital on 3/28/22. Review of the resident's physician's orders revealed an order for Foley catheter care on 3/28/22. A Foley catheter is a thin, flexible tube placed in your bladder to drain your…

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 medical record review and staff interview, it was determined the facility failed to provide the resident or resident representative with a summary of their baseline care plan upon admission. This was evident for 1 of 6 (Resident #27) residents reviewed during the complaint investigations. The findings include: A baseline care plan must be prepared for all residents within 48 hours of a resident's admission. Its purpose is to provide the minimum healthcare information necessary to properly care for a resident until a comprehensive care plan can be completed for the resident. The baseline care plan, along with a copy of their medications, is given to the resident and details a variety of components of the care that the facility intends to provide to that resident. This allows residents and their representatives to be more informed about the care that they receive. On 9/9/22 at 9 AM, a review of Resident #27's medical record revealed documentation that Resident #27 was admitted to the facility on [DATE],…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined the facility staff failed to develop comprehensive care plans for residents (Resident #38 and #32). This was evident for 2 out of 66 residents reviewed during an annual survey. The findings include: A care plan is an outline of nursing care showing all the resident's needs and the ways of meeting the needs. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the individual's specific needs. It is a dynamic document initiated at admission and subject to continuous reassessment and change by the nursing staff caring for the resident. The care plan typically includes nursing and medical diagnoses, nursing interventions, and outcomes to ensure consistency of care. 1. The facility staff failed to develop a care plan addressing Resident #38's need for oxygen therapy. Observation of Resident #38 on 9/6/22 at 1:49 PM revealed the resident was wearing…

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 medical record review and staff interviews, it was determined that the facility failed to document or assess the care for a peripherally inserted central catheter (PICC) line in accordance with generally accepted standards of nursing practice for Resident #235. This was evident in 1 of 66 residents selected for review during the annual survey process. The findings included: A peripherally inserted central catheter (PICC) is a long, thin tube that is advanced into the body in the veins until the internal tip of the catheter is in the superior vena cava. The PICC insertion procedure is to provide medicinal therapy and fluids through an intravenous catheter. On 9/20/22 at 11 AM an investigation of complaint MD00175761 revealed that Resident #235 was admitted to the facility on [DATE] for IV antibiotic treatment through his/her PICC line. A further record review revealed that the facility staff failed to document or assess the sight for infection and verify that the PICC line was functional by using flushes…

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 medical record review and staff interview, it was determined the facility staff failed to follow physician's orders in the care of a resident (Resident #187). This was evident for 1 out of 66 residents reviewed during an annual survey. The findings include: Review of Resident #187's medical record on 9/15/22 revealed the Resident was admitted to the facility on [DATE] from the hospital with diagnosis to include right hip open wound. Further review of the resident's medical record revealed on 7/2/22 at 9:15 AM, the facility staff documented a Change of Condition Note that stated, resident received methadone 120 mg in error. Methadone is a narcotic medication that is used to treat moderate to severe pain. It can also treat narcotic drug addiction. Review of the resident's physician orders revealed the resident was not ordered Methadone. Further review of the Change of Condition Note on 7/2/22 at 9:15 AM revealed the facility staff documented, resident received methadone 120 mg in error, receive every 2…

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 medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers for a resident (Resident #7). This is evident for 1 of 4 residents reviewed for pressure ulcers during an annual survey. The findings include: A pressure ulcer also known as pressure sore, or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed). Review of Resident #7's medical record on 9/8/22 revealed the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interviews, the facility staff failed to ensure that a resident's environment was reasonably free of hazards (Resident #20 and # 133). This was evident for 2 of 66 residents reviewed during an annual survey. The findings include: 1. An observation was made of the Resident #20's room on 9/06/22 at 10:49 AM, 9/07/22 at 9:50 AM, and 9/8/22 at 8:50 AM and revealed the television that was present in the room with the legs attached was resting on top of a box on the nightstand. The TV was bigger than the nightstand's top surface therefore a box was sitting on the nightstand and the TV was on top of the unsecured box surface. The administration was made aware of the concerns on 9/8/22 at 9:30 AM. 2. A review of Resident #133's clinical record on 9/20/22 revealed that the resident was admitted to the facility on [DATE] during the evening shift. The resident had orders to be fed by tube feeding alone and nothing by mouth. Further record review revealed that on 4/16/21 at 10:50 AM 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 medical record review and interview it was determined the facility staff failed to thoroughly assess the need for pain medication and medicate Resident #63. This was evident for 1 of 66 residents selected for review of pain assessment during the annual survey. The findings include: Pain is often regarded as the fifth vital sign in healthcare because it is accepted now in healthcare that pain, like other vital signs, is an objective sensation rather than a subjective one. As a result, nurses are trained and expected to assess pain. A component of pain assessment-focusing on words to describe pain, intensity, location, duration, and aggravating or alleviating factors. It is the expectation the facility staff assesses pain prior to and after the administration of pain medication to determine the need for the medication and its effectiveness of the medication. The pain scale is a numerical scale from 0 to 10. Number 0 means no pain; one to three means mild pain; four to six is considered moderate pain; seven and above is severe pain. A medical record review for Resident #63…

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.