The Terrace At Crystal LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure a written transfer notice (including information such as the ombudsman information and the resident's appeal rights) and a written bed hold notice (including information such as the duration of the state bed-hold policy, the reserve bed payment policy, and the nursing facility's policies regarding bed-hold periods) was given as soon as practicable for 2 of 2 residents (R17, R63) reviewed for hospitalization.Findings include:R17's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R17 had moderate cognitive impairment with no hallucinations, delusions, or behaviors.R17's census listing dated 5/28/26, indicated R17 had a status of hospital unpaid leave starting on 5/26/26 and a status of active on 5/28/26.R17's progress note dated 5/26/26 at 2:02 p.m., indicated R17 was transferred to the hospital, and the power of attorney (POA) was contacted.An email correspondence dated 5/26/26 at 6:21 p.m., indicated the facility had asked…

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

Based on interviews and document review, the facility failed to provide the opportunity to attend and participate in a care conference for 1 of 1 residents (R10) reviewed for care conferences.Findings include: R10's quarterly Minimum Data Set (MDS) assessment, dated 5/25/26, identified R10 had intact cognition with no hallucinations, delusions, rejection of care, or behaviors present. During an interview on 6/1/26 at 1:55 p.m., R10 was observed lying in bed with the television on. R10 stated she has not had a care conference recently, and indicated the last one was more than 3 months ago. R10's Social Service Conference form, dated 1/16/26, indicated a care conference was held with R10, R10's family member, nurse manager and social services. R10's progress notes dated 1/30/26 to 6/3/26 were reviewed and lacked indication of any care conference held or scheduled. During an interview on 6/3/26 at 1:29 p.m., registered nurse manager (RN)-D stated care conferences were arranged by social services and should be held quarterly, with any significant changes, and as needed. RN-D stated care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to implement interventions for 1 of 1 residents (R60) who required alternate means of communication due to hearing loss and being non-English speaking. Findings include:R60's admission Minimum Data Set (MDS) dated [DATE], indicated R2 had intact cognition with behavioral symptoms not direct at others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds), had no rejection of care behaviors, and had wandered one to three days during the lookback period (LBP). R2 required set-up help with eating, moderate assistance for hygiene needs, and required supervision for walking. The MDS indicated R2 had highly impaired hearing with no hearing aid or other hearing appliance.R60's care plan dated 4/28/26, indicated R60 had the potential for hearing impairment, so staff were 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, interview, and document review, the facility failed to ensure routine personal hygiene (i.e., shaving) were completed for 1 of 1 resident (R51) reviewed for activities of daily living (ADLs) and who were dependent on staff for their care.Findings include: R51's quarterly Minimum Data Set (MDS) assessment, dated 5/11/26, indicated R51 had intact cognition with no hallucinations, delusions, no behaviors, or rejection of care. MDS indicated R51 was dependent on staff for personal hygiene (i.e., shaving, combing hair, washing/drying hands), toileting, showering, dressing and mobility needs. R51's care plan, printed 6/4/26, indicated R5 had an ADL self-care performance deficit related to fatigue and morbid obesity which included the following interventions: - prefers no facial hair, provide grooming on shower days and as needed which was initiated on 6/26/25- BATHING/SHOWERING: The resident is totally dependent on 2-3 staff to provide bath/shower weekly on Tues and Fri PM and as needed. Resident prefers bed bath- PERSONAL HYGIENE/ORAL CARE: The resident is totally…

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 interview, observation, and record review, the facility failed to provide an ongoing program of activities designed to meet the interests and well-being of a resident(s) and failed to ensure residents were informed of available activities for 2 of 2 resident (R3 and R37) reviewed who identified group activities and participation in favorite activities as important (R3, R37). Findings include: R3's quarterly Minimum Data Set (MDS), dated [DATE], indicated R3 was admitted to the facility on [DATE] and was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. R3's Activity Interview for Daily and Activity Preferences, dated 3/28/25, indicated the facility completed a resident preference assessment designed to identify the importance of various daily routines, social interactions, and leisure activities. The assessment instructed residents to identify each preference as very important, somewhat important, not very important, not important at all, or important, but can't do or 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 interview and document review, the facility failed to ensure physician-ordered vision services were arranged and provided by failing to schedule and follow through with a routine referral to a retinal specialist for 1 of 1 resident (R31) reviewed for vision services. This failure had the potential for more than minimal harm by delaying evaluation and treatment of reported vision symptoms and potential diabetes-related eye conditions. Findings include: R31's annual Minimum Data Set (MDS) assessment, dated 4/1/26, indicated R31 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. Diagnoses included diabetes mellitus, protein-calorie malnutrition, depression, and post-traumatic stress disorder (PTSD). R31's physician orders revealed a routine referral to a retinal specialist dated 1/19/26.R31's electronic medical record (EMR) lacked evidence the retinal specialist appointment had been scheduled or completed. The EMR also lacked documentation of follow-up regarding the referral or any consultation report from a retinal specialist.During 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to ensure a catheter drainage bag (CDB) remained below the level of the bladder for 1 of 2 residents (R6) reviewed for catheter care.Findings include:R6's quarterly Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition, rejection of care one to 3 days, and was dependent on staff assistance with dressing, bed mobility and toileting. R6 was always incontinent of bowel and bladder and had intermittent catheterization. Diagnoses included infective bursitis of the left elbow. R6's care plan dated 4/27/26, identified R6 had a catheter for neurogenic bladder. An intervention dated 5/12/26, identified to position catheter bag and tubing below the level of the bladder. During an observation and interview on 6/3/26 at 10:44 a.m., activities assistant (A)-A brought R6 in his wheelchair to the commons area by hallways and elevator. R6's CDB was hooked on his wheelchair arm rest above the level of the bladder. The catheter tubing…

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 interview and document review, the facility failed to ensure a resident's physician completed the initial comprehensive 30-day visit for 1 of 3 (R50) newly admitted residents reviewed. Findings include:R50's admission Minimum Data Set (MDS) dated [DATE], indicated R50 was diagnosed with cancer, kidney disease, malnutrition, and a seizure disorder.R50's census report dated 4/23/26, indicated R50 remained an active resident at the facility, had a primary payer source of Medicare A, and admitted to the facility on [DATE].R50's medical record was reviewed, and a progress note indicating a visit had been completed by a physician was not found.During an interview on 6/5/26 at 8:52 a.m., the director of nursing (DON) stated that the physician should see the resident within the first 30 days of their stay. The DON stated she would look for a note indicating that a physician had seen R50 during her stay and would provide the records. Records indicating R50 had been seen by a physician were not received.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, interview and document review, the facility failed to follow up on two pharmacy recommendations for 1 of 5 residents (R6) reviewed for unnecessary medications.Findings include:R6's quarterly Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition, rejection of care one to 3 days, and was dependent on staff assistance with dressing, bed mobility and toileting. R6 took an antipsychotic medication.R6's care plan dated 2/7/26, identified antipsychotic medication was used for Parkinson's. R6 was to be monitored for potential adverse effects and nursing staff were directed to document and record any findings. Potential adverse effects included: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, and unusual behavior symptoms.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure patient care equipment was maintained in safe operating condition for 1 of 1 resident (R15) who used a Hoyer lift for transfers. Findings include: R15's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of chronic respiratory failure with hypoxia, morbid (severe) obesity, and muscle weakness. If further indicated R15 had bilateral impairment of his lower extremities and was dependent on staff for transfers.R15's care guide dated 3/27/26, indicated R15 required the assistance of 2-3 staff (using a Hoyer lift) with transfers. R15's care plan dated 3/3/26, indicated R15 required a mechanical lift (Hoyer) and the assistance of 3 staff members when transferring to his power mobility device (PMD) and the assistance of 2 staff when transferring back to bed. During interview on 6/1/26 at 11:58 a.m., R15 stated almost every time he was transferred using the Hoyer lift, the battery would run out in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure residents had a fitted sheet on their bed for 2 of 2 residents (R15, R53) with bariatric beds.Findings include: R15 R15's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of chronic respiratory failure with hypoxia, morbid obesity, and chronic pain. It further included R15 had bilateral impairment of his lower extremities, was dependent on staff for toileting and transfers. During observation and interview on 6/1/26 at 11:58 a.m., R15 was in bed (bariatric) on top of a blanket that had been laid across the bed where large areas of the bare mattress were exposed. R15 stated the facility never put a fitted sheet on his bed because they didn't have any sheets that fit. During observation on 6/2/26 at 10:17 a.m., nursing assistants (NA)-G and NA-H went into R15's room to transfer him from his bed to personal mobility device (PMD). R15 was in bed on top of a blanket that had been laid across 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 interview and document review the facility failed to obtain an order for restraint and perform an assessment following the restraint of 1 of 1 resident (R1) reviewed for physical restraint. Findings include:R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition, no behaviors, independence in activities of daily living and ambulation. R1's diagnoses included schizophrenia. R1's care plan included: 10/9/24 substance abuse/dependence of alcohol and cocaine with interventions to monitor for signs and symptoms of intoxication and update provider as needed7/23/25 resident did not wish to self-administer medications 8/20/25 resident wished to discharge to the community with interventions to arrange required community supports11/6/25 potential to be physically aggressive to others and poor impulse control. Diagnoses included schizotypal disorder (a mental health condition marked by a consistent pattern of intense discomfort with relationships and social interactions), alcohol dependence,…

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 interview and document review the facility failed to perform an appropriate discharge for 1 of 1 resident (R1) when R1 was discharged without a reassessment of the facility's ability to meet R1's needs when R1 returned from jail, and failed to identify the specific needs the facility could not meet nor the facility's efforts to meet those needs.Findings include:R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition, no behaviors, and independence in activities of daily living (ADLs). R1's diagnoses included schizophrenia. R1's care plan included the following: 10/9/24 substance abuse/dependence of alcohol and cocaine with interventions to monitor for signs and symptoms of intoxication and update provider as needed7/23/25 resident did not wish to self-administer medications 8/20/25 resident wished to discharge to the community with interventions to arrange required community supports11/6/25 indicated R1 had the potential to be physically aggressive to others and had poor impulse…

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 interview and record review the facility failed to ensure appropriate discharge documentation was in the medical record for 1 of 1 resident (R1). reviewed for discharge. Findings include:R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition, no behaviors, and R1 was independent with activities of daily living (ADLs). R1's diagnoses included schizophrenia. R1's Discharge summary dated [DATE] at 4:52 p.m., indicated R1 discharged due to non-compliance with facility policy and the facility's inability to meet R1's needs. R1's discharge summary failed to indicate which facility policy R1 was non-compliant with, which of R1's needs the facility was unable to meet, the limitations R1 had in caring for himself at time of discharge, an indication of where R1 was discharging to, and if R1 had post-discharge appointments set-up, medical or non-medical.R1's medical record reviewed 4/11/26 through 4/15/26. R1 medical record failed to include a recapitulation of stay as well as…

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 interview and record review the facility failed to administer long-acting insulin at consistent times according to the manufacturer's instructions for 2 of 3 residents (R2, R3) who were prescribed long-acting insulin.:Findings include:R2R2's face sheet dated 3/19/26, identified diagnoses of type 2 diabetes with diabetic polyneuropathy (breakdown of nerves), and long-term use of insulin.R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 had no cognitive issues. R2 had a therapeutic diet. R2 received insulin injections seven days a week.R2's care plan dated 9/23/25, identified R2 had diabetes mellitus with interventions which included but not limited to- administer diabetes medication as ordered by doctor.R2's physician order dated 9/23/25, identified Basaglar (long-acting) 62 units twice daily.R2's diabetic administration record dated March 2026, did not identify Basaglar order rather identified the physician order that was clinically equivalent. The administration record identified 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident with known cognitive impairment was comprehensively evaluated and had individualized interventions implemented to ensure safety when leaving the facility independently for 1 of 3 residents (R3) reviewed for safety.Findings include:R3's diagnoses list dated 3/5/26 included stroke, hypertension (high blood pressure), repeated falls, and cognitive communication deficit.R3's hospital discharge transfer orders dated 12/3/25 indicated R3 needed ongoing supervision due to continued need for help with moving, thinking, safety, and eating.R3's elopement risk assessments dated 12/3/25 indicated R3 was low risk for elopement.R3's admission Minimum Data Set (MDS) dated [DATE] indicated moderately impaired cognition R3 required maximum assist from staff for transfers, was dependent of staff for wheelchair mobility, and ambulation was not attempted due to medical condition or safety concerns.R3's care plan dated 12/3/25 included 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 interview and document review, the facility failed to maintain a complete and accurately documented medical record in accordance with accepted professional standards and practices for 1 of 1 resident (R3) reviewed for accidentsFindings includeR3's diagnoses list dated 3/5/26 included stroke, hypertension (high blood pressure), repeated falls, and cognitive communication deficit.R3's provider order dated 1/15/26 instructed clonidine (a medication that lowers blood pressure) oral tablet 0.3 milligrams (MG). Give one tablet by mouth three times a day for hypertensive urgency. Hold if heart rate is less than 60 beats per minute or if systolic blood pressure is less than 100 millimeters of mercury (mmHg).R3's nursing notes dated 3/1/26 identified on 2/28/26 around 7:30 pm, R3 had told the receptionist she was leaving the facility. R3 did not indicate where she was going or when she would be back. Around 5am on 3/1/26 R3 still had not returned to the facility so staff attempted to locate her at the facility then called her cell phone. When she could not be located, the police…

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 interview and document review, the facility failed to comprehensively assess pain and failed to offer or attempt non-pharmacological pain interventions prior to the administration of as-needed (PRN) pain medications for 2 of 3 residents (R1, R3) reviewed for pain Findings include:R1's admission minimum data set (MDS) dated [DATE] indicated severely impaired cognition. The MDS further indicated R1 utilized scheduled and prn pain medications for frequent pain that interfered with day-to-day activities.R1's diagnoses list dated 1/29/26 included cellulitis (skin infection) of right leg, type 2 diabetes, and chronic pain syndrome.R1's care plan dated 1/20/26 included a focus of acute/chronic pain with interventions including non-pharmacological pain interventions of ice, heated blankets, massage, repositioning, music, essential oils, food/drink, and relaxation breathing.R1's provider order dated 1/15/26 instructed acetaminophen (a pain-relieving medication) 500 milligram (mg) tablet give 1 tablet every 6…

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 interview and document review, the facility failed to accurately document a weekly bath and a current head to toe skin assessment for 2 of 3 residents (R1 and R3) reviewed when R1 had several bruises and scratches upon discharge from the facility. The facility only documented one weekly skin assessment form during his three-week stay, along with R3 who had two skin assessments completed from 11/1/25 through 1/21/26. Findings include: R1's treatment administration record (TAR) dated 12/1/25 through 12/31/25, indicated R1 was admitted on [DATE]. The weekly skin assessment was started on 12/25/25, nine days after admission. The nurse to complete a skin assessment and document their findings on the weekly skin assessment form under the assessment tab. R1's care plan dated 12/16/25, indicated he had a risk for skin breakdown. Interventions included, keeping his fingernails short to prevent scratching, provide pressure relieving devices on his bed and wheelchair. In addition, staff would prevent him 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a dignified dining experience for all 68 of 68 residents who were served meals using plastic silverware, Styrofoam cups and Styrofoam to-go containers. The facility further failed to ensure cares were provided in a dignified and respectful manner. Findings include: During observation of meal service on third floor on 12/2/25 at 12:12 p.m., dietary aide (D)-A filled four room trays (R8, R17, R34, R48) and set the trays in a rolling meal cart. All meal trays had plastic eating utensils and Styrofoam cups. A nursing assistant wheeled the meal cart down the hall to dispense the trays. At 12:31 p.m., R65 wheeled self-up to serving station with a plastic spoon and knife in his hand and requested a fork. Staff informed him that no forks up here. During interview with dietary manager (DM) on 12/2/25 at 12:31 p.m., DM stated, Silverware is totally missing every single day. I ordered them and I am trying to get them. Everything is gone. Every day it is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure resident mail was delivered on Saturdays for 2 of 2 residents (R8, R17) who voiced concerns with mail delivery. This deficient practice had the potential to affect all 68 residents residing in the facility. Findings include:R8's quarterly Minimum Data Set (MDS) dated [DATE], indicated R8 had no cognitive impairment. R17's comprehensive MDS dated [DATE], indicated R17 had no cognitive impairment. During an observation and interview on 12/1/25 at 3:21 p.m., activities assistant (AA)-A was observed to enter R8's room with a large stack of mail (greater than 50 items) and gave five to ten letters to R8. R8 stated she was lucky if she got her mail every month. R8 stated that sometimes the mail she received was time sensitive, so she would like to get the mail the day it arrived at the facility. R8 confirmed she did not get her mail on the weekends.During an interview on 12/3/25 at 11:56 a.m., R17 stated he received his mail most…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to provide sufficient staffing and or oversight of non-licensed nursing staff to ensure the residents received care and assistance as needed and in a timely manner. This deficient practice had the potential to affect all 68 residents who reside in the facility. Findings include:Refer to F677: The facility failed to ensure routine personal hygiene (i.e., showers) were completed for 6 of 8 residents (R12, R30, R31, R37, R52, and R54) reviewed for activities of daily living (ADLs) and who were dependent on staff for their care.Refer to F919: The facility failed to ensure the resident call light system was functioning throughout the building. The Terrace at [NAME] Facility assessment dated [DATE], indicated their average daily census was 58. Residents' interviews R15's admission Minimum Data Set (MDS) dated [DATE] indicated R15 had moderate cognitive impairment, needed substantial assistance with toileting, dressing, footwear, personal…

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 interview and document review, the facility failed to complete annual performance evaluations for 3 of 3 nursing assistants (NA-M, NA-N, NA-O) who had been employed by the facility for over one year.Findings include:NA-M personnel record identified a hire date of 7/31/24, with no job performance review.NA-N personnel record identified a hire date of 10/31/22, with no job performance evaluation reviews.NA-O- personnel record identified a hire date of 3/4/19, with no job performance evaluation reviews.A voice mail was left for NA-N and NA-O, no call back was received.During interview on 12/4/25 at 4:04 p.m., the administrator stated he was not aware if annual performance reviews were done. The administrator stated currently the facility didn't have a human resources employee, but he would provide the requested information.During interview on 12/8/25 at 11:12 a.m., the administrator stated the annual reviews had not been conducted and it was something the facility would need to correct.Facility's policy titled Performance Evaluations dated 9/2020 indicated the job performance…

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 interview and document review, the facility failed to have evidence of a goal, an action plan, and analysis of data to identify Performance Improvement Projects (PIP). This had the potential to affect all 68 residents of the facility.Findings include:Facility assessment dated [DATE], identified, QAPI Program activities. (3). The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources.Review of the facility's QAPI committee meeting minutes from September to December 2025 lacked information on a Performance Improvement Project (PIP).Review of facility's QAPI Plan, revised 1/20/25, identified the Design and Scope to Develop corrective action or performance improvement activities. In addition, The development of a PIP charter should begin once a specific area for improvement has been identified through data analysis, stakeholder feedback, or because of identified deficiencies needing attention. Also,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure residents' call light system was functioning throughout the building. This had the potential to affect all 70 residents in the facility.Findings include: R78's census list dated 11/26/25, indicated R78 was admitted to the facility on [DATE]. R78's screening tool dated 11/26/25, indicated R78 was oriented to self, place, and time. The tool indicated R78 was able to make his needs known and had the ability to understand others. The tool indicated R78 required maximum assistance from staff for bed mobility and dressing. During an observation and interview on 12/1/25 at 1:13 p.m., R78 was observed lying in bed on his right side with his back facing the wall and looking at the television on the far wall. A soft touch call light was noted hanging over the head of the bed, about three feet from the top of the mattress, out of the reach of the resident. The call light was not plugged into the wall. A manual (non-electronic) call bell was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure staff completed mandatory communication training for 3 of 10 staff (the director of nursing (DON), registered nurse (RN)-B, nursing assistant (NA)-I) reviewed for training requirements. This had the potential to affect all 68 residents residing in the facility. Findings include: The facility assessment dated [DATE], indicated the facility cared for a multi-cultural diverse population. The assessment indicated that clinical staff were to receive training on effective communication annually.Review of personnel records indicated the DON, RN-B, and NA-I had not completed education that included effective communication in the last year. During an interview on 12/8/25 at 10:28 a.m., the administrator was informed that education on effective communication was not found in the personnel records he had provided for the DON, RN-B, and NA-I. The administrator stated he was not previously aware of this and would continue to look for further education 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure staff completed mandatory resident rights training for 2 of 10 staff members (the director of nursing (DON), nursing assistant (NA)-J) reviewed for training requirements. This had the potential to affect all 68 residents residing in the facility. Findings include: The facility assessment dated [DATE], indicated that clinical staff were to receive training on resident rights annually.Review of personnel records indicated the DON and NA-J had not completed education that included resident rights in the last year. During an interview on 12/8/25 at 10:28 a.m., the administrator was informed that education on resident rights was not found in the personnel records he had provided for the DON and NA-J. The administrator stated he was not previously aware of this and would continue to look for further education for these staff members. The administrator stated the facility's human resources staff member, who oversaw staff training completion, had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure staff completed mandatory quality assurance and performance improvement training for 1 of 10 staff members (the director of nursing (DON)), reviewed for training requirements. This had the potential to affect all 68 residents residing in the facility. Findings include: The facility assessment dated [DATE], indicated that clinical staff were to receive training on quality assurance and performance improvement (QAPI) annually.Review of personnel records indicated the DON had not completed education that included QAPI in the last year. During an interview on 12/8/25 at 10:28 a.m., the administrator was informed that education on QAPI was not found in the personnel records he had provided for the DON. The administrator stated he was not previously aware of this and would continue to look for further education for this staff member. The administrator stated the facility's human resources staff member, who oversaw staff training completion, had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure staff completed mandatory compliance and ethics training for 1 of 10 staff members (the director of nursing (DON), reviewed for training requirements. This had the potential to affect all 68 residents residing in the facility. Findings include: The facility assessment dated [DATE], indicated that clinical staff were to receive training on compliance and ethics annually.Review of personnel records indicated the DON had not completed education that included compliance and ethics in the last year. During an interview on 12/8/25 at 10:28 a.m., the administrator was informed that education on compliance and ethics was not found in the personnel records he had provided for the DON. The administrator stated he was not previously aware of this and would continue to look for further education. The administrator stated the facility's human resources staff member, who oversaw staff training completion, had recently left, and if the required annual…

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 interview and document review, the facility failed to ensure staff completed mandatory behavioral health training for 5 of 10 staff members (the director of nursing (DON), registered nurse (RN)-B, nursing assistant (NA)-I, NA-J, NA-K) reviewed for training requirements. This had the potential to affect all 68 residents residing in the facility. Findings include: The facility assessment dated [DATE], indicated that clinical staff were to receive training on caring for residents with mental and psychosocial disorders annually. The assessment indicated the facility cared for residents with various psychiatric/mood disorders, including depression, bipolar disorder, and schizophrenia. Review of personnel records indicated that the DON, RN-B, NA-I, NA-J, and NA-K had not completed education that included behavioral health training in the last year. During an interview on 12/8/25 at 10:28 a.m., the administrator was informed that education on behavioral health training was not found in the personnel records he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure routine personal hygiene (i.e., showers and toileting) were completed for 6 of 8 residents (R12, R30, R31, R37, R52, and R54) reviewed for activities of daily living (ADLs) and who were dependent on staff for their care.Findings include: R12 R12's admission Minimum Data Set (MDS) dated [DATE], identified R12 with intact cognition, and was dependent on staff for toileting, showers and baths, upper body dressing, putting on and taking off footwear and personal hygiene. In addition, R12 had diagnoses of anemia, heart failure, kidney disease, diabetes, and respiratory failure and was dependent on Oxygen. R12's care plan dated 10/27/25 identified R12 required assist of two staff with bathing/showering weekly and as necessary. The facility 2nd floor nursing assistant care guide identified R12 with Bath: Tue PM and Bathing: Dependent 1-2 PA. In addition, R12's 2nd Floor Nurse care sheet identified R12's bath schedule as Tue PM. Also, 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.

During observation and interview, the facility failed to ensure food was served at a preferable temperature to residents. This had the potential to affect all 68 residents of the facility who received meals from the facility. Findings include: R1 R1's quarterly Minimum Data Set (MDS) assessment, dated 11/20/25, identified R1 had intact cognition. During interview on 12/1/25 at 4:03 p.m., R1 stated the food was terrible due to the taste and temperature. R1 stated the hot food was served cold and the taste was just not good. R1 stated due to the taste and temperature of the food, she only eats a bowl of cereal for breakfast and supper and a cold sandwich for lunch. During an observation and interview on 12/2/25 at 8:45 a.m., R1 was observed eating a bowl of cold cereal with a glass of reddish colored liquid with ice in a cup to drink for breakfast. R1 stated this was her preference due to the food being terrible. During interview with R21 on 12/1/25 at 1:42 p.m., R21 stated, food is meh. Everything is icky. Food that should be hot or warm is never warm. During interview with dietary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to provide a safe, sanitary, comfortable environment for residents. This had the potential to affect all 70 residents, staff, and visitors. Findings include: Leaking sink in bathroom During observation on 12/1/25 at 1:29 p.m., R45's bathroom had leaking water from sink into plastic container under the sink with 4 inches of water in the container. Also, no toilet paper was observed anywhere in the bathroom or resident room. R45 was not present during observation. Closet door During observation and interview with R3 on 12/5/25 at 9:56 a.m., R3 bedroom closet door was missing. R3 pointed to wall behind bathroom door, on the floor where the closet door was placed out of the way. Closet contents were visible from room and from hallway of facility. Also, R3 pointed to her bathroom and the mirror was not attached to the wall. It was resting unattached on top of the sink behind the faucet and the wall. R3 stated facility's director of maintenance…

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 interview and document review the facility failed to provide a written notice of bed hold for one of 1 resident (R70) reviewed for hospitalization.Findings include:R70's Medicare-5-day Minimum Data Set (MDS) dated [DATE] indicated R70 was cognitively intact.R70's diagnosis form dated 12/8/25 indicated diagnoses of thoracic region discitis (infection of the intervertebral disc space), encephalopathy, heart failure, hypertension, renal insufficiency, depression and diabetes. This form indicated R70 was admitted to the facility on [DATE].R70's discharge MDS dated [DATE], included R70 had an unplanned discharge with return anticipated and was discharged to a short-term acute hospital. R70 returned to the facility on 9/6/25.R70's discharge MDS dated [DATE], included R70 had an unplanned discharge with return anticipated and was discharged to a short-term acute hospital.R70's progress note dated 8/28/25 at 6:48 p.m., indicated R70 was transferred to a local hospital due to confusion and lethargy. However,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the faciality failed to ensure a resident's comprehensive care plan was appropriately implemented for 1 of 2 resident (R30) who had interventions for specialized boots and cares is pairs that were not implemented. Findings include: R30's quarterly minimum data set (MDS), dated [DATE] indicated R30 was admitted to the care facility on 7/12/24 and was cognitively intact. The MDS further indicated R30 was dependent on staff for most ADLs, including toileting. R30's care plan, dated 7/17/24, indicated R31 had a behavior of making sexual comments towards staff with an intervention of cares in pairs initiated on 7/23/24. R30's care plan also indicated R30 had potential impairment to skin integrity with interventions initiated 8/24/25 for controlled ankle motion (CAM) boot while out of bed and offloading boots to right foot when in bed.During an interview on 12/1/25 at 6:15 p.m., R30 stated he did not wear any boots while in, or out of, bed and was not observed 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 interview, and document review, the facility failed to provide the opportunity for 2 of 2 residents (R1, R31) reviewed to participate in care planning and care conferences.Findings include: R1 R1's quarterly Minimum Data Set (MDS) assessment, dated 11/20/25, identified R1 had intact cognition, and demonstrated no delusional thinking. Further, the MDS identified R50 as having a primary medical condition of, Medically Complex Conditions, along with diagnoses of heart failure, high blood pressure, renal failure or insufficiency, and respiratory failure. Previous MDS assessments were dated 7/31/25 and 9/30/25. R1's progress notes, dated 9/1/25 to 12/5/25, were reviewed. Progress notes lacked evidence of R1 having a care conference during that time. A note on 10/3/25 indicated a care conference was scheduled for 10/10/25 but no follow up or indication the care conference was completed. R5's assessment tab in the electronic medical record (EMR) reviewed for care conferences. The last completed care conference…

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

Based on observation, interview and document review, the facility failed to ensure effective collaboration between the facility and a contracted hospice organization that affected 1 of 1 residents (R1) reviewed for hospice services. Findings include: R1's quarterly Minimum Data Set (MDS) assessment, dated 11/20/25, identified R1 had intact cognition, and demonstrated no delusional thinking. Further, the MDS identified R50 as having a primary medical condition of, Medically Complex Conditions, along with diagnoses of heart failure, high blood pressure, renal failure or insufficiency, and respiratory failure and indicated R1 was on hospice.R1's hospice chart included a blank calendar; however, it lacked identification of planned hospice visits. The chart included a section for hospice staff to use for collaboration of care between the hospice staff and facility staff. This section lacked any coordination from the hospice social worker. R1's Provider Orders for Life-Sustaining Treatment (POLST), signed and dated by R1 on 9/22/25, indicated R1's wishes DNR (Do Not Resuscitate) 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 observation, interview, and document review, the facility failed to ensure nursing staff were appropriately trained and competent in the use of a cough assist machine for 1 of 1 resident (R78) reviewed for the use of a cough assist machine. Findings include: R78's diagnosis list dated 11/26/25, indicated R78 was admitted to the facility on [DATE] and was diagnosed with chronic obstructive pulmonary disease (COPD), diabetes, quadriplegia (paralysis affecting all limbs), and a history of pneumonia. R78's screening tool dated 11/26/25, indicated R78 was oriented to self, place, and time. The tool indicated R78 was able to make his needs known and had the ability to understand others. The tool indicated R78 required maximum assistance from staff for bed mobility and dressing. R78's hospital paperwork dated 11/26/25, indicated R78 was admitted to the hospital for pneumonia and was discharged now that he was breathing comfortably. The hospital paperwork did not address the use of a cough-assist machine. R78'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 observation, interview and document review the facility failed to ensure 1 of 1 resident (R30) who had chronic pain received adequate pain control to include non-pharmacological pain interventions and appropriate communication and coordination with an outside pain provider.Findings include:R30's quarterly minimum data set (MDS), dated [DATE] indicated R30 was admitted to the care facility on 7/12/24 and was cognitively intact. The MDS further indicated R30 received scheduled and PRN pain medication and frequently had pain rated an eight out of ten. R30's diagnoses, dated 7/12/24, indicated R30 had a primary diagnosis of rheumatoid arthritis and a secondary diagnosis of chronic pain syndrome.R30's care plan, dated 7/19/25 indicated R30 had a behavior of calling police and requesting hospital transfer for pain medication without informing nursing and dated 8/26/25 indicating R30 had multiple hospitalizations for intractable headaches and chronic pain r/t rheumatoid arthritis.R30's signed physician orders,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure nursing staff were appropriately trained and competent in the use of a cough assist machine for 1 of 1 resident (R78) reviewed for the use of a cough assist machine. Findings include: R78's diagnosis list dated 11/26/25, indicated R78 was admitted to the facility on [DATE] and was diagnosed with chronic obstructive pulmonary disease (COPD), diabetes, quadriplegia (paralysis affecting all limbs), and a history of pneumonia. R78's screening tool dated 11/26/25, indicated R78 was oriented to self, place, and time. The tool indicated R78 was able to make his needs known and had the ability to understand others. The tool indicated R78 required maximum assistance from staff for bed mobility and dressing.R78's hospital paperwork dated 11/26/25, indicated R78 was admitted to the hospital for pneumonia and was discharged now that he was breathing comfortably. The hospital paperwork did not address the use of a cough-assist machine. R78'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 observation, interview and record review the facility failed to ensure 1 of 1 resident (R31) reviewed received appropriate behavior health management to address continued rejection of care and behaviors of urinating and defecating in inappropriate places.Findings include:R31's quarterly minimum data set (MDS), dated [DATE], indicated R31 was admitted to the care facility on 1/14/25 and was cognitively intact. The MDS further indicated R31 did not have any rejection of care within the lookback period but needed partial to moderate assistance with most activities of daily living (ADLs) and bathing did not occur.R31's diagnosis list, dated 1/15/25, indicated R31 had several medical diagnoses including schizophrenia and patient's noncompliance with other medical treatment and regiment due to unspecified reason.R31's Orders, dated 2/6/25, directed facility staff to write a progress note every shift regarding R31's behaviors including throwing her meal tray, dishes, trash, or linen on the floor, urinating on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to monitor for potential side effects for 1 of 3 residents (R3) reviewed who received an anticoagulant (blood thinner) medication. Findings include:R3's admission minimum data set (MDS) dated [DATE], indicated R3 had intact cognition and was receiving anticoagulant medication. R3's order summary dated 9/19/25, indicated R3 had an order for five milligrams (mg) of apixaban (an anticoagulant) two times a day. R3's diagnosis summary dated 10/15/25, indicated R3 had a history of blood clots and a stroke.R3's progress note dated 11/24/25 at 9:39 a.m., indicated R3 was on apixaban related to a history of blood clots.R3's medical record (including the care plan) was reviewed and did not include instructions for staff to monitor R3 for side effects of apixaban use. During an observation and interview on 12/1/25 at 1:52 p.m., R3 was observed sitting up in bed. R3 did not have any observable signs of bleeding or bruising. R3 confirmed that she had…

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

Based on observation, interview, and document review, the facility failed to ensure opened dairy products (i.e., milk) for resident' consumption was either consumed or discarded in a timely manner to reduce the risk of foodborne illness; and failed to ensure 1 of 2 unit refrigerators were adequately monitored for temperature and food quality to reduce the risk of complication or illness. In addition, the facility failed to ensure staff covered their hair during food preparation and service; failed to ensure dry baking and frozen foods were stored in a manner to reduce the risk of cross-contamination; failed to ensure food items were properly stored, labeled, dated, and discarded properly; failed to ensure metal pans were completely dry before stacking to prevent bacterial growth; failed to These findings had potential to affect all 51 residents within the care center.Findings include: UNDATED MILK: A USDA (United States Department of Agriculture) article labeled, How long can you keep dairy products like yogurt, milk, and cheese in the refrigerator[?], dated 5/2024, identified milk…

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.

During observation, interview and record review the facility failed to ensure facility was kept sanitary and maintained in good repair which had the potential to affect all 51 residents, staff, and visitors of the facility. In addition, the facility failed to ensure the dish machine in the main kitchen was kept in a clean and sanitary manner and free of debris.Findings include: Walls: During observation of R15 on 6/29/25 at 10:24 a.m., R15 in resident room on second floor sitting in hospital gown with brown substance streaked on the floor. During observation and interview with R31 on 6/29/25 at 10:35 a.m., R31 stated she was disappointed in her facility stay in part due to the environment is dirty pointing to ceiling in her room with yellowing stain on it and a gash in the wall with brown drip stains down the wall. During observation and interview with R12 on 6/29/25 at 10:52 a.m., R12 lying in bed which was horizontally against the wall. Wall had numerous black marks along it with a yellow-colored stained area that extended on the wall for approximately half the length of his bed.…

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

Based on observation, interview and record review the facility failed to ensure adequate pest control measures were in place to eliminate small black flies from the building. This had the potential to affect all 51 residents of the facility.Findings include:During observation and interview with R8 on 6/29/25 at 10:27 a.m., in second floor resident room, several small black flies were observed flying around the room during interview. R8 stated the facility is full of small black flies and they are all over the f*ing building. R8 stated the flies been issue for a while.last few months I guess. R8 stated he was disappointed with facility's lack of action to address the flies. R8 stated he was not sure what's being done about it.During observation and interview with R31 on 6/29/25 at 10:35 a.m., in third floor resident room R31 stated she occasionally sees fruit flies both in her room and out in hallway and dining room.During observation and interview with R36 on 6/29/25 at 10:43 a.m., in third floor resident room, R36 stated facility gets bugs in here and was not pleased 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 observation, interview, and document review, the facility failed to provide a dignified dining experience for 1 of 1 resident (R25) who was referred to as a feeder.Findings include:R25's quarterly Minimum Data Set (MDS) dated [DATE], indicated R25 had severely impaired cognitive skills for daily decision making. R25 was dependent on staff for eating.R203's entry tracking record indicated R203 admitted to the facility on [DATE].R203's care plan printed 6/29/25, indicated R203 required setup assistance by one staff member to eat.During meal service on 6/29/25 at 12:14 p.m., dietary aide (DA)-A plated and served food to residents in the dining area. There were approximately eight residents in the dining area, both from the memory care area and non-memory care area. DA-A went to serve R25 when nursing assistant (NA)-E stated she was a feeder out loud, and DA-A placed the plate on top of the steam table instead of serving to the resident. During interview on 6/29/25 at 1:31 p.m., DA-A stated a person who was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure meals were served in a warm, palatable manner to promote quality of life and nutritional intake for 3 of 3 residents (R12, R8, R153) who complained about cold food at meals. This had potential to affect a total of 25 residents identified to reside on the unit where the meals were served and sample tray tested.Findings include:R12's quarterly Minimum Data Set (MDS), dated [DATE], identified R12 demonstrated no delusional thinking. However, the section to record R12's cognition was dashed with, Not Assessed [See F638]. On 6/29/25 at 10:53 a.m., R12 was interviewed about his quality of life at the care center. R12 complained about the food and described it as garbage, and nasty. R12 stated the meals were often served cold and he wanted warm food to eat. R8's quarterly MDS, dated [DATE], identified R8 demonstrated no delusional thinking. On 6/29/25 at 10:23 a.m., R8 was interviewed and expressed aloud, The food sucks. R8 explained…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to provide the ordered diet texture for 1 of 2 residents (R35) reviewed for dietary texture.Findings include:R35's annual Minimum Data Set (MDS) dated [DATE], indicated R35 had moderate cognitive impairment and diagnoses of gastro-esophageal reflux disease, hyperlipidemia, Alzheimer's disease, dementia, dysphagia, anxiety disorder, depression, and psychotic disorder. The MDS indicated R35 required setup or clean-up assistance to eat. R35's care plan printed 6/29/25, directed staff to serve diet as ordered. R35 had a regular diet with pureed textures and thin liquids and was independent with eating after setup.R35's physician order dated 3/13/24, indicated R35 had a regular diet with pureed texture and thin liquid consistency.R35's Terrace at [NAME] Rehabilitation Screen/Update dated 9/11/24, indicated R35 was evaluated by a speech language pathologist (SLP) to assess possibility of upgrading diet texture. SLP reported R35 was unsafe to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to obtain and document an informed consent, including with explanation of risk and benefits, before giving psychotropic medications for 2 of 5 residents (R24, R25) reviewed for unnecessary medication use. Findings include: R24 R24's admission Minimum Data Set (MDS), dated [DATE], identified R24 admitted to the care center in April 2025 from the acute care hospital, and she had multiple medical conditions including heart failure, dementia, and a history or stroke. The MDS recorded R24 as having severe cognitive impairment and consuming both antipsychotic and antidepressant medications. R24's Order Summary Report, signed 5/15/25, identified R24's current physician-ordered medications and treatments along with their respective start date(s). These included orders for duloxetine (antidepressant medication) 20 milligrams (mg) once daily, haloperidol (an antipsychotic medication) with multiple doses ordered daily, and mirtazapine (antidepressant medication)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure there was reasonable access to private phone use for 1 of 1 residents (R153) reviewed who utilized the facility phone.Findings include:R153's entry tracking record dated 6/20/25, indicated R153 was admitted to the facility on [DATE].R153's profile dated 6/23/25, indicated R153 resided on the third floor. During an observation on 7/1/25 at 1:03 p.m., R153 was observed sitting in a wheelchair in front of a long desk with multiple staff members surrounding it, including trained medication aide (TMA)-B and licensed practical nurse (LPN)-A. The long desk at the nursing station was observed at the middle of two parallel hallways on the third floor with resident's rooms and in front of an elevator. R153 was observed talking on a corded phone and asking someone to get me out of here.During an interview at 7/1/25 at 1:12 p.m., R153 stated that he did not have his own phone so had asked the facility staff if there was one he could use.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to promptly notify the provider consistently of high blood sugars for 1 of 1 residents (R36) of reviewed for notification of change. Findings include: R36's quarterly Minimum Data Set (MDS) assessment, dated 4/24/25, indicated R36 had intact cognition with no hallucinations, delusions, behaviors or rejection of care present. R36 was independent for all activities of daily living (ADLs). Section N-Medications indicated R36 received insulin 7 of 7 days during look back period of MDS assessment. Pertinent medical diagnoses included type 1 diabetes with other specified complication (a chronic condition that affects the insulin producing cells of the pancreas). During an interview on 6/29/25 at 10:45 a.m., R36 stated she had diabetes and had been told she was a pretty fragile diabetic. R36 stated her blood sugars went up and down and sometimes she required insulin and sometimes she did not. R36's care plan, printed 7/2/25, included R36 had diabetes mellitus…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to appropriately follow up on continued and repeated voiced grievances of provided food for a diabetic diet for 1 of 2 residents (R31) reviewed for grievances who gained 35% of their weight since being admitted to the care facility. Findings include:R31's annual Minimal Data Set (MDS), dated [DATE], R31 was admitted to the care facility on 4/29/25 and was cognitively intact. The MDS further indicated R31 had the following diagnoses; hypertension (high blood pressure), peripheral vascular disease, hyperlipidemia (high cholesterol), asthma and diabetes. R31's weights, listed in the electronic medical record (EMR), indicated R31 weighed 165 pounds at admission to the care center and their most recent weight was listed as 231 pounds, a 35.8% increase. R31's EMR indicated an order, dated 4/29/24 for a diabetic, regular textured diet.R31's EMR lacked any progress notes from dietary or nutritional services and lacked any mention of R31's food…

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 interview and document review, the facility failed to ensure appropriate side effect monitoring for potential orthostatic hypotension (sudden drop in blood pressure what occurs when a person stands up after sitting or lying down) was completed for 1 of 5 residents (R7) reviewed for unnecessary medication use and who consumed antipsychotic medication. Findings include:A National Library of Medicine (NIH) Management of Commons Adverse Effects of Antipsychotic Medication article, dated 9/2018, identified the elderly were at risk of adverse effects (i.e., falls) of antipsychotic medication. The article outlined, All antipsychotics carry some risk of orthostatic hypotension . [which can] lead to dizziness, syncope, falls . orthostatic hypotension should be evaluated by both history and measurement . Risk factors include systemic diseases causing autonomic instability (e.g., diabetes, alcohol dependence, Parkinson's disease), dehydration, drug-drug interactions, and age.R7's quarterly Minimum Data Set (MDS),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure the comprehensive Minimum Data Set (MDS) was completed in a thorough manner to ensure all areas of resident performance and activities preference were evaluated for 1 of 4 residents (R24) reviewed for MDS accuracy and completion. Findings include: The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2023, identified a purpose of providing guidance with how to complete the Resident Assessment Instrument (RAI), and it outlined an admission MDS was considered a comprehensive assessment. The manual listed a section labeled, SECTION F: Preferences For Customary Routine and Activities, along with directions to complete the section. The directions outlined, The intent of items in this section is to obtain information regarding the resident's preferences for their daily routine and activities. The manual directed to interact with the resident or, if needed, complete the staff…

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 interview and document review, the facility failed to ensure the quarterly Minimum Data Set (MDS) was completed in a thorough manner to ensure areas of cognition and potential depressive symptoms were fully evaluated for 2 of 4 residents (R22, R23) reviewed for MDS accuracy and completion. Findings include: The Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, dated 10/2023, identified the RAI consists of three basic components including the MDS, the Care Area Assessment (CAA) and the utilization guidelines and this process (i.e., use of the entire RAI) was mandated by CMS. The manual outlined a quarterly assessment was a non-comprehensive assessment which was to be completed every 92 days and was used to track a resident' status between comprehensive assessments . to ensure critical indicators of gradual change in a resident's status are monitored. The manual included a section labeled, SECTION C: COGNITIVE PATTERNS, which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect discharge status for 1 of 1 residents (R50) reviewed for hospitalization.Findings include: R50's Discharge-return not anticipated Minimum Data Set (MDS) dated [DATE] identified discharge from facility was planned and R50 discharged to Short-Term General Hospital (acute hospital, IPPS).During record review, R50's nursing progress noted dated 4/13/25 identified Resident discharged from the facility to home with all her medication and instruction with her family members at 3:30 p.m.During interview with licensed practical nurse (LPN)-A on 6/30/25 at 5:01 p.m., LPN-A stated she recalled R50 and stated, She went home it was planned. During interview with R50 on 6/30/25 at 6:00 p.m., R50 stated, Yes I was there and discharged home.During interview with registered nurse and MDS facility liaison (RN)-MDS on 7/1/25 at 10:36 a.m., RN-MDS reviewed R50's electronic medical record (EMR) and stated R50…

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 interview and document review, the facility failed to ensure a comprehensive care plan was developed for 1 of 2 residents (R37) reviewed for diet preferences/allergies. Findings include: R37's quarterly Minimum Data Set (MDS) assessment, dated 5/17/25, indicated R37 had intact cognition with no hallucinations or delusions with no behaviors or rejection of care. Pertinent diagnoses include type 2 diabetes (long term condition in which body has trouble controlling blood sugars), morbid obesity and depression. During an interview on 6/29/25 at 1:05 p.m., R37 stated he had an allergy to fish and seafood, and the facility continued to serve him fish and seafood despite the meal tickets indicating an allergy to fish and seafood. R37 stated the facility was aware of his food allergy. R37 stated he did not eat it, but it happened again just a few days ago and he had followed up with staff. R37's Care Guide, printed 6/30/25, indicated R37's diet was a regular diet with thin liquids and was independent with eating. The document lacked indication of food allergies or food preferences.…

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 interview and document review, the facility failed to provide routine care conferences to allow for resident participation and interdisciplinary review, and update, if necessary, of the care plan for 1 of 2 residents (R41) reviewed for care conferences. Findings include:R41's quarterly minimum data set (MDS), dated [DATE], indicated R41 was admitted to the care facility on 7/3/24 and was cognitively intact. R41's electronic medical record (EMR) indicated R41 had one care conference since being admitted to the care facility. A progress note, dated 10/24/24, indicated R41 had her care conference today at 1:00pm. Pt [patient], SW [social worker], and Nurse Manager were in attendance.During an interview on 6/29/25 at 3:07 p.m., R41 stated she had been to maybe one care conference since being admitted to the facility and had concerns about her care. During an interview on 7/1/25 at 8:17 a.m., licensed social worker (LSW)-A stated the resident care conferences and care plan review should be held roughly every…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to provide assistance to complete personal hygiene cares for 1 of 1 resident (R23) reviewed who needed assistance with fingernail care.Findings include:R23's quarterly Minimum Data Set, dated [DATE], indicated R23 had no behaviors or rejection of cares, unclear speech, and responded adequately to simple, direct communication. R23 had functional limitation in range of motion to one upper extremity and one lower extremity. R23 required substantial/maximal to dependent assistance with most activities of daily living (ADLs). The MDS indicated R23 needed substantial/maximal assistance with person hygiene which included combing hair, shaving, washing/drying face and hands, etc R23's diagnoses included stroke, hypertension, and hemiplegia (severe or complete loss of strength to one side of the body) and hemiparesis (weakness on one side of the body).R23's care plan printed 6/30/25, directed staff to check nail length and trim and clean on bath…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to comprehensively assess and, if needed or able, develop or implement activities programming to promote quality of life for 1 of 2 residents (R24) reviewed for activities.Findings include: R24's admission Minimum Data Set (MDS), dated [DATE], identified R24 admitted to the care center in April 2025 from the acute care hospital, and she had multiple medical conditions including heart failure, dementia, and a history or stroke. However, the section to record R24's activity preferences and routines was left blank or marked, Not Assessed [See F636].On 6/29/25 at 10:46 a.m., R24 was observed lying in bed while in her room on the locked unit. R24's television was turned on and positioned along the opposite wall of her bed. R24 was interviewed and expressed aloud, I don't know, when asked how long they'd lived at the center. R24 was dressed in a hospital-type gown and her hair appeared with a light, greasy-looking shine. R24 was asked about…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure proper wheelchair positioning for eating was maintained to promote comfort for 1 of 1 resident (R22); and failed to ensure medical devices for edema management were consistently applied to reduce peripheral swelling for 1 of 2 residents (R258) reviewed for edema care. Findings include: R22 R22's quarterly Minimum Data Set (MDS), dated [DATE], identified R22 had dementia but demonstrated no delusional thinking, however, the section to record R22's cognition was dashed as, Not Assessed [see F638]. On 6/29/25 at 8:48 a.m., R22 was observed seated in the Broda-style wheelchair while in the dining room on the locked unit. R22 was positioned next to the table with his meal served on the table. R22's wheelchair back was in a reclined position at approximately 50 degrees and R22 was observed leaning forward approximately 12 to 14 inches from the wheelchair back to eat his meal. The seat of the wheelchair was approximately 12 to 14 inches…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to provide services to maintain and/or prevent loss of range of motion and contracture care for 1 of 1 resident (R23) reviewed for limited range of motion (ROM).Findings include:R23's quarterly Minimum Data Set, dated [DATE], indicated R23 had no behaviors or rejection of cares, unclear speech, and responded adequately to simple, direct communication. R23 had functional limitation in range of motion to one upper extremity and one lower extremity. R23 required substantial/maximal to dependent assistance with most activities of daily living (ADLs). R23's diagnoses included stroke, hypertension, and hemiplegia (severe or complete loss of strength to one side of the body) and hemiparesis (weakness on one side of the body). The MDS indicated R23 was not on a restorative nursing program during the look-back period (LBP). R23's care plan printed 6/30/25, indicated R23 required extensive assistance of two staff to turn and reposition in bed,…

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 interview and document review, the facility failed to comprehensively assess and develop interventions as needed to reduce the risk of accidents or injury for 2 of 2 residents (R41, R38) reviewed with a history of substance abuse and suspected current use. In addition, the facility failed to implement interventions for 1 of 1 resident (R35) reviewed for falls.Findings include:R41's quarterly minimum data set (MDS), dated [DATE], indicated R41 was admitted to the care facility on 7/3/24 and was cognitively intact.R41's diagnoses list, dated 7/13/24, indicated R41 had several medical diagnoses including psychoactive substance dependence. R41's Associated Clinic of Psychology (ACP), dated 5/20/25, indicated facility staff informed the ACP practitioner of concerns of suspected substance use, which was also listed as a barrier to care on the ACP visit note. R41's electronic medical record (EMR) lacked any documented interventions, assessments, or monitoring protocols related to suspected substance use.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to recognize and respond to a resident's weight gain in the facility to ensure they maintained acceptable parameters of nutritional status, such as desirable body weight, for 1 of 2 residents (R31) reviewed for nutritional status who gained 35% of their weight since admittance to the care facility. Findings include:R31's annual Minimal Data Set (MDS), dated [DATE], R31 was admitted to the care facility on 4/29/25 and was cognitively intact. The MDS further indicated R31 had the following diagnoses; hypertension (high blood pressure), peripheral vascular disease, hyperlipidemia (high cholesterol), asthma and diabetes. R31's weights, listed in the electronic medical record (EMR), indicated R31 weight 165 pounds at admission to the care center and most recent weight was listed as 231 pounds, 66 pounds and a 35.8% increase. R31's EMR indicated an order, dated 4/29/24 for a diabetic, regular textured diet.R31's most recent Nutrition Data, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to ensure a resident's pain was adequately controlled and failed to implement non-pharmacological pain interventions (i.e. heat, ice, massage, aromatherapy) if needed for adequate pain control for 1 of 2 residents (R41) reviewed for pain.Findings include: R41's quarterly Minimum Data Set (MDS), dated [DATE], indicated R41 was admitted to the care facility on 7/3/24 and was cognitively intact. The MDS lacked a pain assessment. R41's diagnoses, dated 7/3/24 indicated in R41 had several medical diagnoses including person injured in unspecified motor-vehicle accident, traffic, subsequent encounter; intervertebral disc degeneration lumbosacral region with discogenic back pain and lower extremity pain; and dorsalgia (back pain). R41's electronic medical record (EMR) contained several orders for medication and monitoring that included; oxycodone oral capsule 5 milligrams (mg) - Give 5 mg by mouth every four hours as needed for breakthrough knee…

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 interview and document review, the facility failed to identify triggers or attempt to identify triggers to avoid potential re-traumatization, and failed to develop a care plan to include individualized trauma-informed approaches for 1 of 1 residents (R36) who had a history of trauma. Findings include: R36's quarterly Minimum Data Set (MDS) assessment, dated 4/24/25, indicated R36 had intact cognition with no hallucinations, delusions, behaviors or rejection of care present. R36 was independent for all activities of daily living (ADLs). R36's diagnosis report, printed 7/2/25, included the following pertinent medical diagnoses: post-traumatic stress disorder, alcohol dependence, adjustment disorder with mixed anxiety and depressed mood, major depressive disorder, unspecified affective mood disorder, and chronic pain. During an interview on 6/29/25 at 10:40 a.m., R36 stated she had PTSD and had known triggers. R36 stated no staff at the facility had ever talked to her about her triggers or her trauma. R36 stated her triggers included when the staff started getting loud outside…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure physician-ordered medications were re-ordered timely to prevent delay in administration and reduce the risk of complications for 1 of 5 residents (R10) reviewed for unnecessary medications. Findings include: R10's quarterly Minimum Data Set (MDS) dated [DATE], indicated R10 had intact cognition. R10's quarterly MDS dated [DATE], indicated R10 was on a scheduled pain medication regimen and received opioids (narcotic pain medication) during the look-back period (LBP). The MDS indicated R10 was diagnosed with heart failure, kidney failure, and chronic low back pain. R10's Medication Administration Record (MAR) dated 6/1/25 through 6/30/25, indicated R10 had the following orders:- 2.5 milligrams (mg) of oxycodone (an opioid) three times a day starting on 2/20/25, and discontinued on 6/23/25. The order was documented as given on 6/1/25 through 6/18/25, and the evening dose on 6/19/25. The medication was documented as a 9 (other/see…

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 interview and document review, the facility failed to ensure a resident was free from unnecessary medication by failing to attempt to decrease a resident's nicotine patch (a known psychotropic medication) despite the consulting pharmacist's and Centers for Disease Control and Prevention's recommendations for 1 of 5 residents (R7), and failed to monitor, assess, and clarify an antibiotic without an end date for 1 of 5 residents (R25) reviewed for unnecessary medications.Findings include: R7's quarterly Minimum Data Set (MDS), dated [DATE], indicated R7 was admitted to the care facility 7/18/22, and was cognitively intact. The MDS further indicated R7 had consumed the following medication during the seven-day look back period of the assessment; antipsychotic, antianxiety, antidepressant, and hypnotic medications. R7'S electronic medical record (EMR) contained an order, dated 3/8/24, for a Nicotine Transdermal Patch 24 Hour 21 milligrams (MG) per 24 hours (Nicotine) - Apply one patch transdermal (on 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, interview, and record review, the facility failed to ensure residents were free from significant medication errors when a narcotic pain medication was not administered as ordered for 1 of 5 (R10) residents reviewed for unnecessary medications. Findings include: R10's quarterly Minimum Data Set (MDS) dated [DATE], indicated R10 had intact cognition. R10's quarterly MDS dated [DATE], indicated R10 was on a scheduled pain medication regimen and received opioids (narcotic pain medication) during the look-back period (LBP). The MDS indicated R10 was diagnosed with heart failure, kidney failure, and chronic low back pain. R10's Medication Administration Record (MAR) dated 6/1/25 through 6/30/25, indicated R10 had the following orders:- 2.5 milligrams (mg) of oxycodone (an opioid) three times a day starting on 2/20/25 and discontinued on 6/23/25. The order was documented as given on 6/1/25 through 6/18/25 and the evening dose on 6/19/25. The medication was documented as a 9 (other/see progress…

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

Based on observation, interview, and document review, the facility failed to ensure prescribed inhaled medications were stored in their correct packaging to prevent potential administration error for 1 of 5 residents (R3); and failed to ensure prescribed oral medications were labeled with minimum identifiers to ensure correct administration (i.e., right patient, right medication) for 1 of 5 residents (R3) observed to received medication during the survey. Findings include: INCORRECT STORAGE: R3's Medication Administration Record (MAR), dated 7/2025, identified R3's current physician ordered medications, directions for their use, and staff spaces to record their administration or refusal. The MAR included an order for Mometasone (a steroid medication) 50 micrograms (MCG) with directions to administer 2 sprays in each nostril once daily for a respiratory infection. The MAR listed a start date for this medication as, 06/13/2025, and scheduled administration time of 8:00 a.m. On 7/1/25 at 8:02 a.m., medication administration was observed with licensed practical nurse (LPN)-B preparing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure food allergens and/or preferences were followed for 3 of 4 residents (R258, R35, and R37) reviewed for food allergens/preferences.Findings include:R258 R258's quarterly minimum data set (MDS), dated [DATE], indicated R258 was admitted to the care facility on 7/20/21 and was cognitively intact. R258's face sheet, printed 7/2/25, indicated R258 had several allergies including cornstarch, gluten, and soybean Oil.R258's care plan, dated 6/19/25, indicated resident [R258] has reported food intolerances that cause abdominal pain (corn starch, dairy (butter, American Cheese & Hard Cheeses ok), egg whites (ok if cooked into things), gluten, soy, soybean oil. The care plan contained an intervention, dated 2/10/25, that directed staff to not serve corn starch, dairy (butter, American Cheese & Hard Cheeses are ok per [NAME]), egg white (ok if cooked into something), gluten, soy, or soybean oil unless requested. R258's meal ticket, used by…

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 interview and document review, the facility failed to ensure a therapeutic diet was ordered upon return to facility per orders on hospital discharge for 1 of 1 residents (R36) reviewed for therapeutic diets. Findings include: R36's quarterly Minimum Data Set (MDS) assessment, dated 4/24/25, indicated R36 had intact cognition with no hallucinations, delusions, behaviors or rejection of care present. R36 was independent for all activities of daily living (ADLs). R36 received insulin 7 of 7 days during look back period of MDS assessment. Pertinent medical diagnoses included type 1 diabetes with other specified complication (a chronic condition that affects the insulin producing cells of the pancreas).R36's progress note dated 4/16/25 at 5:21 p.m., indicated resident was readmitted from the hospital and had new and changed orders and to see the facility electronic medical record (EMR). R36's Hospital Discharge summary, dated [DATE], indicated R36 required a consistent carbohydrate diet. During an interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure current infection control standards of practice were followed when performing resident personal care for 1 of 4 residents (R153) observed for personal care.Findings include: R153's entry tracking record dated 6/20/25, indicated R153 was admitted to the facility on [DATE].R153's Medical Diagnosis list dated 6/23/25, indicated R153 was diagnosed with diabetes, a stroke, and heart disease. R153's care plan dated 6/30/25, indicated R153 required the assistance of one to two staff members for bed mobility and dressing, and the assistance of two staff members for toileting and transferring. During an observation on 7/1/25 at 8:27 a.m., R153 was observed lying in bed. Nursing assistant (NA)-I and NA-J were observed assisting R153 with personal care. NA-I, with gloved hands, was observed to assist R153 with perineal care while R153 was lying on his back. NA-J was observed to assist the resident in rolling towards her, while NA-I…

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

Based on observation, interview, and record review the facility failed to complete a comprehensive assessment for self-administration of medication for 1 of 1 resident (R2) reviewed for self-administration of medications. Findings includeR2's face sheet dated 6/26/25, identified diagnoses of chronic respiratory failure with hypoxia (body cannot adequately exchange gases, leading to deficiency of oxygen in the tissues). R2's physician orders dated 6/16/25, identified albuterol hydrofluoroalkane (HFA) 90 micrograms (mcg)/actuation inhaler for acute hypercapnic respiratory failure. Directions included to inhale 2-4 puffs by mouth every two hours as needed for shortness of breath or wheezing. R2's medication administration record (MAR) dated 6/2025 identified, albuterol sulfate HFA 90 mcg/actuation aerosol solution. Give two puffs by mouth every two hours for acute hypercapnic respiratory failure. Inhale 2-4 puffs by mouth beginning 6/16/25. The hours marked on the MAR identified 12:00 a.m., 2:00 a.m., 4:00 a.m., 5:45 a.m., 8:00 a.m., 10:00 a.m., 12:00 p.m., 1:45 p.m., 4:00 p.m., 6:00…

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 interview and record review the facility failed to sufficiently prepare, orientate, and understanding of discharge 1 of 3 residents (R1) reviewed for discharge. R1 was sent home without ordered home care services, which led to worsening of his wounds and an admission to the hospital. Findings include: R1's care plan dated 4/23/25 - 5/19/25 did not indicate any discharge focus, goals, or interventions. R1's admission Minimum Data Set (MDS) dated [DATE] did not include a Brief Inventory of Mental Status (BIMS) score to indicate his cognition level. R1 was dependent upon staff for toileting hygiene, bathing, and rolling in bed. He required maximum assistance with dressing lower body and minimal assistance dressing his upper body. R1's pertinent diagnoses were after care for surgical amputation, immunodeficiency (bodies inability to defend the body from foreign or abnormal cells), diabetes, obesity, absence of right leg above the knee. R1 required application of nonsurgical dressing, applications of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure appropriate discharge documentation was in the medical record for 3 of 3 residents (R1, R2, & R3). R1, R2 and R3's medical records were missing discharge summaries, a recapitulation of their stay, a final summary of their status and reconciliation of all pre-discharge and post-discharge medication (both prescribed and over the counter medications). Findings include: R1's care plan dated 4/23/25 - 5/19/25 did not indicate any discharge focus, goals, or interventions. R1's list of assessment completed dated 4/23/25 - 5/6/25 did not include a discharge summary assessment. R1's admission Minimum Data Set (MDS) dated [DATE] did not include a Brief Inventory of Mental Status (BIMS) score to indicate his cognition level. R1 was dependent upon staff for toileting hygiene, bathing, and rolling in bed. He required maximum assistance with dressing lower body and minimal assistance dressing his upper body. R1's pertinent diagnoses were after care 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish an effective system of reconciliation and disposition to properly dispose of medications that were discontinued for 20 of 29 residents (R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, and R29) reviewed. During observations, there were two trash bags full of approximately 153 medication cards of non-narcotic medications that were discontinued. This deficient practice had the ability to affect all sixty residents. Findings include: During an observation on 3/24/25 at 2:05 p.m. on the third-floor locked medication room, there was a trash bag full of non-narcotic medications that were discontinued but had yet to be disposed of. In this trash bag were medications for R10, R11, R12, R13, R14, R15, R16, and R17. During an observation on 3/24/25 at 2:45 p.m., on the second-floor locked medication room, there was a trash bag and two basin bins full of non-narcotic medications that were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure side rails were comprehensively assessed to determine if they were appropriate and safe, discuss the risks and benefits, and obtain informed consent prior to use of bed rails for 1 of 3 residents (R1) who was observed to have side rails raised on their bed. Findings include: R1's admission minimum data set (MDS) dated [DATE] indicated moderately impaired cognition. R1 required maximum assistance from staff for bed mobility and was dependent on staff for transfers. R1's diagnoses included right humerus (longest bone in the upper arm) fracture. R1's care plan dated 2/26/25 indicated R1 required extensive assistance of two staff members to turn and reposition in bed and assistance of two staff members with a mechanical standing lift for transfers. R1's care plan lacked information about bed rails. R1's electronic medical record (EMR) lacked evidence a side rail assessment had been completed to determine necessity, and whether R1…

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 interview and document review, the facility failed to ensure a registered nurse (RN) was scheduled for a minimum of eight consecutive hours a day. This had the potential to affect all 62 residents who resided at the facility. Findings Include: Review of Payroll Based Journal (PBJ) Staffing Data Report, submitted for the fourth quarter of 2024 (July 1- September 30), identified no RN hours for the following dates: 7/7/24, 7/21/24, 8/18/24, 9/1/24, and 9/15/24. Review of the facility staffing schedules for the following dates 8/18/24, 9/1/24, and 9/15/24 were identified as Sundays and no RN was scheduled. Staffing schedules for 7/7/24 and 7/21/24 were not provided and were also identified as Sundays. During interview on 2/12/25 at 2:36 p.m., staffing coordinator (SC) explained she had started the staffing position a month ago and there was no record of staff schedules prior to 7/20/24. Upon review of staffing schedules for 8/18/24, 9/1/24, and 9/15/24, SC confirmed no RN was scheduled on those dates. SC identified an RN must be scheduled for at least eight hours each day and…

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

Based on observation, interview, and document review, the facility failed to ensure meals were served in a warm, palatable manner to promote quality of life and nutritional intake for 2 of 2 residents (R18, R15) reviewed. This had potential to affect a total 33 of 33 residents identified to reside on the unit where the meals were served and sample tray tested. Findings include: R18's admission Minimum Data Set (MDS) assessment, dated 1/16/25, indicated R18 had intact cognition. R15's admission MDS assessment, dated 1/2/25, indicated R15 had intact cognition. On 2/09/25 at 09:18 a.m., R18 was interviewed. R18 stated meals are always cold. On 2/09/25 at 2:23 p.m., R15 was interviewed. R15 stated the food sucks. Furthermore, R15 stated the food is cold when should be hot, hot when should be cold, they were running out of apple juice, and sometimes it was watered down. R15 stated they don't get the planned menu. On 2/12/25, the following observations were made: -12:20 p.m. steam table was set up on the 3rd floor. Dietary aid (DA)-A was going through the meal tickets with the nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure food was served at the proper temperature to 3 of 3 residents (R1, R7, and R9) reviewed for residents during breakfast and lunch on the third floor of the building. This had the potential to affect all 37 residents who resided on the third floor. Findings Include: R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1 had a Brief Inventory of Mental Status (BIMS) of 15 indicating R1 was cognitively intact. R1 required set-up and clean-up assistance with activities of daily living. R1's pertinent diagnoses were cardiac failure, renal insufficiency, morbid obesity, and borderline personality (a mental disorder characterized by unstable moods. R1 required a therapeutic diet. R7's quarterly MDS dated [DATE] indicated R7's cognitions status was not completed. R7 used a wheelchair for mobility. Diagnosis included hypertension, seizure disorder, metabolic encephalopathy, malnutrition, anxiety, depression, and bipolar. R9'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 interview and record review the facility failed to ensure that 1 of 2 residents (R6) reviewed received services in a dignified manner to promote quality of life when staff failed to respond timely to call light and provide assistance per residents needs resulting in R6 missing time with family. Findings include: R6's admission Minimum Data Set (MDS) dated [DATE], indicted R6 had a Brief Inventory of Mental Status (BIMs) score of 15 indicated R6 was cognitively intact. R6 required maximum assistance with lower body dressing, toileting, transferring and bathing. R6's pertinent diagnoses were severe obesity with alveolar hypoventilation (a breathing disorder in which a person with obesity breathes too slowly, resulting in too much carbon dioxide and not enough oxygen in the blood), diabetes, thyroid disorder, chronic pain, and lymphedema (swelling in the body due to build-up of lymphatic fluid) and chronic pain. R6's care plan dated 11/11/24, indicated R6 required a mechanical lift Hoyer with 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, interview, and record review the facility failed to implement care plans for 3 of 3 residents (R2, R3, and R4) reviewed when the residents did not receive care according to the comprehensive assessment. The residents were not turned and/or repositioned every two to three hours as indicated on the care plan. Findings include: R2's annual MDS dated [DATE] indicated R2 had a BIMS score of 00 indicating R2 had severe cognitive impairment. R2 was totally dependent upon staff for eating, dressing, grooming, bathing, toileting and transferring. R2 was always incontinent of bowel and bladder. R2's pertinent diagnoses were multiple sclerosis (a disease where the immune system eats away at the protective covering of the nerves), muscle wasting, repeated falls, and adult failure to thrive. R2's care plan dated 9/30/24 indicated R2 was to be offered to be laid down following meals. R2's care plan with a revision dated of 10/27/24 indicated R2 was to be turned and repositioned every 2-3 hours due to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide a systematic approach to assess and evaluate residents' fluid status to monitor the effectiveness of interventions for 2 of 2 residents (R1 and R8) reviewed. R1 and R8 were on a daily fluid restriction. The facility partially documented the fluid intake; however, the facility did not have a system in place to evaluate the total daily fluid intake to determine adequacy or if the provider required notification. Findings include: R1's care plan dated 7/22/21, indicated R1 required a fluid restriction of 2000 milliliters (ml) per day related to chronic kidney disease with fluid overload or potential for fluid overload. Staff was to monitor intake and output. R1's care plan dated 8/1/21 indicated the facility was to provide and serve a no added salt diet with a 2000 cubic centimeter (CC) daily fluid restriction as ordered with (double portions). Due to many allergens R1 can be resistive to eating facility meals, so wife brings in food. R1 prefers…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to accommodate foods for resident allergies and/or intolerances for 1 of 3 residents (R1) reviewed. R1 had an allergy to gluten and was given gluten meals so often at the facility that R1 was buying her own food and stocking-up on foods from the facility kitchen to have when she was served a gluten meal. Findings include: R1's clinical allergy sheet dated 7/20/21 indicated R1 had allergies to soybean oil, gluten, ciprofloxacin (an antibiotic), adhesive tape, latex, and cornstarch. R1's care plan dated 8/1/21 indicated the facility was to provide and serve a no added salt diet with a 2000 cubic centimeter (CC) daily fluid restriction as ordered with (double portions). Due to many allergens R1 can be resistive to eating facility meals, so her wife brings in food. R1 prefers high protein/low carbohydrates, large entrée portions. The facility purchases sour dough bread per her request (provided at breakfast with butter pads), chicken breasts…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide the prescribed diet to 2 of 3 residents (R6 and R8) reviewed for therapeutic diets. R6 and R8 were both prescribed a low sodium diet, and the facility was unable to demonstrate how they provided the specialized diet. Findings include: R6's admission Minimum Data Set, dated [DATE] indicted R6 had a Brief Inventory of Mental Status (BIMs) score of 15 indicated R6 was cognitively intact. R6 required maximum assistance with lower body dressing, toileting, transferring and bathing. R6's pertinent diagnoses were severe obesity with alveolar hypoventilation (a breathing disorder in which a person with obesity breathes too slowly, resulting in too much carbon dioxide and not enough oxygen in the blood), diabetes, thyroid disorder, chronic pain, and lymphedema (swelling in the body due to build-up of lymphatic fluid) and chronic pain. R6's weight summary dated 11/11/24 indicated R6 weighed 445.9 pounds (lbs.) R6's care plan dated 11/20/24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure proper handwashing/hand hygiene, personal protective equipment, and enhanced barrier precautions (EBP) were implemented for 2 of 2 residents (R1, R2) observed during wound care, an intravenous (IV) flush, and catheter care. Findings include: R1's Face Sheet indicated R1 had diagnoses of nondisplaced trimalleolar fracture of unspecified lower leg (broken leg), need for assistance with personal care, spondylosis without myelopathy or radiculopathy (spinal cord disorder). R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated he needed the assistance of two staff for bed mobility and eating, one staff for toileting, and he transferred independently. R1's cognitive test dated 8/5/24 indicated he was cognitively intact. R1's Physician Orders for wound care dated 12/11/24, directed New right ankle dressing orders. Cleanse with Vashe (wound cleanser), apply skin prep around the wound, apply Xerofoam (occlusive dressing)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to develop a comprehensive care plan for skin integrity for 1 of 3 (R2) residents reviewed for wound care. Findings include: Stage 2 pressure ulcers are defined as superficial wounds that do not involve adipose tissue or deeper structures like bone or muscle. Unstageable pressure ulcers are defined as ulcers covered with slough (white or yellow dead skin tissue) and eshar (dark, crusty tissue) and cannot be staged. R2's Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE], indicated he demonstrated rejection of care 1-3 days per week. He required substantial assistance with most activities of daily living. R2's cognitive assessment, dated 11/4/24 indicated he was severely cognitively impaired. R2's face sheet dated 12/05/24 indicated he had diagnoses of cellulitis of groin, cellulitis of right lower limb, pressure ulcer of right buttock stage 2, atherosclerosis (plaque buildup) of native arteries of right leg with ulceration of heel and…

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

Based on observation, interview and document review, the facility failed to ensure structural issues and items in disrepair throughout the facility were addressed and fixed in order to help promote a functional, sanitary and safe environment. This had the potential to affect all 53 residents residing within the facility. Findings include: Kitchen During observation on 8/26/24 at 1:24 p.m., the floors throughout all areas of the main kitchen were dirty and had particles of food and small dry black particles stuck to the floor. During observation on 8/27/24 at 7:58 a.m., the main kitchen floor was dirty with food particles, small pieces of paper, and many small dry black particles stuck to the floor. During interview on 8/27/24 at 8:11 a.m., cook (C)-A stated he mopped the floor on 8/26/24 before the end of his shift. C-A verified the kitchen floor still had debris and dry black particles stuck to the floor. C-A stated, he started to work at this facility a week ago and the floor needed a deep clean. During observation and interview on 8/28/24 at 12:56 p.m., regional kitchen manager…

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 interview and document review, the facility failed to ensure new, person-centered fall interventions were implemented to prevent further falls and potential injury for 1 of 1 residents (R28) reviewed for repeat falls. In addition, the facility failed to accurately and comprehensively assess for smoking practices for 1 of 1 residents (28) reviewed for smoking. In addition, the facility failed to ensure an overiszed and unsecured mattress was assessed for correct fit to a resident's bed for (R44) who was reviewed saftey hazards. Findings include: FALLS R28's admission MDS dated [DATE], indicated R28 had severely impaired cognition and had no rejection of care behaviors. The MDS indicated R28 was diagnosed with hypertension, diabetes, and osteomyelitis. The MDS indicated R28 used a walker and a wheelchair as mobility devices and required set-up help with toilet transfers, moderate assistance with walking ten feet, and was independent with wheelchair use. R28's care plan dated 6/24/24, indicated R28 was a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure toileting needs were comprehensively evaluated and appropriate to meet the resident' needs and prevent complication (i.e., skin damage, soiled clothing) for 1 of 2 residents (R27) reviewed who was dependent on staff for care. Findings include: R27's quarterly Minimum Data Set (MDS), dated [DATE], identified R27 had unclear speech, severe cognitive impairment and could typically respond to simple, direct communication only. The MDS outlined R27 demonstrated no rejection of care behavior, had frequent urinary incontinence (seven or more episodes, but at least one continent void), and a toileting program trial had never been attempted. On 8/26/24 at 1:31 p.m., R27 was observed seated in a high-back geri-chair while in her room. R27's eyes were closed and R27 responded with only mumbled, non-sensical speech with surveyor' interaction. R27 had no visible catheter drainage bag attached to the wheelchair, however, immediately underneath…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure vision needs were comprehensively assessed or tracked and, if needed, referred to an appropriate service for 1 of 2 residents (R7) reviewed who complained about worsening vision. Findings include: R7's admission Minimum Data Set (MDS), dated [DATE], identified R7 admitted to the care center on 5/20/24 and had moderate cognitive impairment but no delusional thinking. Further, the MDS outlined R7 had adequate vision (able to see fine detail, regular print) and used corrective lenses. On 8/26/24 at 2:42 p.m., R7 was observed seated in a high-back wheelchair while in her room. Next to her was a bedside table which had various items on it including a single black-framed pair of glasses. R7 was interviewed and stated her eye sight seemed to be worsening and her glasses needed to have the prescription checked adding, They [Rx] need to be changed. R7 stated they had last seen an eye doctor prior to admitting to the care center and nobody…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to deliver pressure ulcer care consistent with professional standards of care to prevent a facility acquired pressure ulcer for one of one resident (R8) reviewed for pressure ulcers. Findings include: R8's admission Minimum Data Set (MDS) assessment, dated 7/25/24, indicated R8 had moderately impaired cognition with no hallucination, delusions or other behavioral symptoms noted and required maximal assistance with all activities of daily living (ADLs) except eating, oral, and personal hygiene. The MDS further indicated R8 did not have any pressure ulcers and identified R8 was at risk for developing pressure ulcers. R8's Braden Scale Assessment (a standardized, evidence-based assessment tool commonly used in health care to assess and document a patient's risk for developing pressure injuries), dated 7/23/24, indicated R8 was at very high risk for skin breakdown. R8's progress note, dated 7/19/24, indicated, [R8] skin looks clean and intact…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure dental needs were assessed, offered and, if needed, referred to appropriate dental services in a timely manner for 2 of 3 residents (R7, R28) reviewed for dental care. Findings include: R7's admission Minimum Data Set (MDS), dated [DATE], identified R7 admitted to the care center from the hospital and had moderate cognitive impairment but no delusional thinking. Further, the MDS outlined Section L - Oral/Dental Status, which identified R7 had no natural teeth but did have mouth or facial pain or difficulty chewing. R7's Clinical Census, printed 8/29/24, identified R7's current payer source as, Minnesota Medicaid. On 8/26/24 at 2:40 p.m., R7 was observed seated in a high-back wheelchair in her room with her family member (FM)-G present. Immediately next to her, a bedside table was present which had various items sitting on it including a cup filled with water and an upper denture plate in it. R7 stated she had no bottom dentures…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure enhanced barrier precautions (EBP) were implemented or followed for 2 of 2 residents (R6 and R8) reviewed for EBP. Findings include: The CDC article titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) dated 4/2/24, indicated MDRO transmission in skilled nursing facilities was common and contributed to substantial resident morbidity. EBP is an infection control intervention to reduce transmission of MDROs by using gowns and gloves during high contact resident care activities. The article indicated high-contact activities include changing linens, bathing, dressing, feeding tube care, etc. The article indicated EBP should be implemented (when contact precautions did not apply) for residents with wounds or indwelling medical devices (central lines, urinary catheter, feeding tube) regardless of MDRO colonization status. R6's quarterly Minimum Data…

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 interview and document review, the facility failed to thoroughly investigate a fall from a mechanical lift that resulted in a broken femur for 1 of 3 residents (R1) reviewed for accidents. A report submitted to State Agency (SA) dated 4/4/24 at 7:45 p.m. indicated R1 had a fall on 4/2/24 during a transfer with a Hoyer (mechanical) lift that resulted in a left femur fracture. R1's diagnoses list included metabolic encephalopathy (a change in brain function that may cause confusion, memory loss, and/or sleepiness) and Alzheimer's Disease. R1's quarterly MDS dated [DATE] indicated R1 rarely/never understands or is understood, and was dependent on staff for all transfers. R1's care plan dated 2/27/24 indicated she required total assist of two staff using the Hoyer lift for all transfers. The care plan lacked indication of what size sling was to be used. On 4/2/24 at 9:30 a.m. a progress note indicated during transfer with a Joerns Hoyer lift (mechanical lift), one of the straps from the Lumex brand sling…

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 interview and document review, the facility failed to ensure a potential allegation of neglect was recognized and reported to the State agency (SA) in a timely manner for 1 of 1 resident (R1) reviewed who reported a burn to staff during therapy treatment. Findings include: R1's significant change Minimum Data Set (MDS) dated [DATE], indicated R1 was moderately cognitively intact, had bilateral amputation of lower extremities, coronary artery disease, heart failure, peripheral vascular disease (PVD) and diabetes mellitus. R1's Integrated Wound Care (IWC) note dated 9/26/23, indicated R1 was seen for ongoing assessment and management wounds left legend pressure ulcer to right stump, and bilateral wounds to middle finger. The report further indicated the right middle finger burn was 1.1 centimeter (cm) x 1.8 cm x 0.2 cm. with small serosanguineous (a combination of serous fluid and blood. It's usually a light pink to red color. This is a sign that your body is healing the wound and isn't a concern in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to comprehensively reassess and develop interventions to provide safety for 1 of 4 residents (R1) who sustained a burn from a heat pad machine in the therapy department and 1 of 2 residents (R2) who was documented to have a cigarette burn. Findings include: R1's significant change minimum data set (MDS) dated [DATE], indicated R1 was moderately cognitively intact, had bilateral amputation of lower extremities, coronary artery disease, heart failure, peripheral vascular disease (PVD) and diabetes mellitus. R1's Care Plan (CP) reviewed 3/05/24, indicated R1 had coronary artery disease, hypertension, peripheral vascular disease and diabetes mellitus. The Care plan further indicated educate the patient on importance of good nutrition and hydration and give medications for improved blood flow or anticoagulants as needed. In addition, to report any signs or symptoms of skin problems related to PVD: redness, edema, blistering, itching, burning,…

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 interview and document review, the facility failed to ensure 2 of 5 nursing assistants (NA-O, NA-R) received and demonstrated required competency skills for resident cares. This had the potential to affect all 61 residents who resided in the facility. Findings Include: Review of NA-O and NA-R's employee files indicated no skills competencies were completed within the last year. During interview on 3/27/24 at 10:01 a.m., human resource director (HRD)-J indicated NA-O, and NA-R had not completed the annual NA competencies, but the new administration was planning on completing a facility wide review of all employee files for competency completion. During interview on 3/27/24 at 2:18 p.m., the administrator stated the employee files lacked documentation for annual competencies however, with the new administration there was a plan underway for a facility wide skills fair. The facility Competency of Nursing Staff policy updated 5/2019, indicated facility and resident-specific competency evaluations was to be conducted upon hire, annually and as deemed necessary based on 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 R109's quarterly Minimum Data Set, dated [DATE], indicated R109 had mild cognitive impairment, required substantial/maximal assistance with most activities of daily living (ADLs), and had diagnoses of traumatic brain injury (TBI), seizure disorder, and aphasia (loss of ability or difficulty expressing speech). R109's care plan (CP) revised 3/1/24, indicated R109 had a communication problem and was at risk for falls. The CP instructed staff to ensure call light was in reach. R109's care plan revised 3/1/24, included R109 had a communication problem, was at risk for falls and directed staff to ensure call light near him in case he should want to use it. During observation and interview on 3/24/24 at 4:43 p.m. R109 was in bed with bed perpendicular to the wall and away from the wall. The call light button attached to the wall and absent of a call light cord was behind the head of R109's bed and out of R109's reach. R109 indicated he would not be able to yell if he needed something. During observation and interview…

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

Based on observation, interview, and document review, the facility failed to ensure they were free of a medication error rate of five percent or greater. The facility had a medication error rate of 63.64% with 21 errors out of 33 opportunities involving 8 of 8 residents (R10, R15, R20, R22, R25, R33, R46, R53) who were observed during medication administration. Findings include: R46's face sheet printed on 3/26/24, included diagnoses of type two diabetes, mood disorder, chronic obstructive pulmonary disease, heart disease, constipation, acute gastric ulcer. R46's medication administration summary (MAR) for March 2024, identified the following orders included: -start date 7/26/23, Protonix (Pantoprazole Sodium) Give 40 milligrams (mg) by mouth two times a day for Gas reflex at 7:30 a.m., and 4:00 p.m. -start date 1/6/24, Gabapentin 300mg capsule give one capsule by mouth two times a day for nerve pain at 7:30 a.m., and 4:00 p.m. -start date 7/26/23, Carvedilol 25mg tablet give 25mg by mouth two times a day for hypertension (high blood pressure) at 8:00 a.m., and 8:00 p.m. -start 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 interview and record review, the facility failed to provide meals at a palatable temperature for any resident who choose to eat in their rooms. This had the potential to affect 61 residents in the facility who could eat meals in their rooms. On 3/26/23 at 12:13 p.m., Dietary Aide (DA)-B started assembling room tray. Lunch was tacos, beans, rice, and a slice of watermelon. Food Service Director (FSD) assisted with the tray preparations for 11 residents on the 3rd floor. The watermelon and drinks were not covered. On 3/26/23 at 12:28 p.m., the first room tray was delivered. At 12:36 p.m., the last room tray was delivered, a test tray was reviewed. The rice and beans were 102 degrees Fahrenheit (F), and the meat on the taco did not reach 100 degrees F. The FSD indicated the food should be 130 degrees and the temperature were not acceptable. The FSD also indicated all food and drinks should be covered when leaving the dining room, and the temperature of the food should be taken when leaving 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, interview and document review, the facility failed to ensure residents' call lights were functioning for 2 of 2 residents (R15, R36) reviewed for call lights. Findings include: R36's quarterly Minimum Data Set (MDS) dated [DATE], indicated R36 had impaired cognition and required substantial to maximal staff assistance for mobility and was dependent on staff assistance for transfers. R36's diagnoses included left-side weakness and immobility, chronic pain, personality disorder, depression, post-traumatic stress disorder, traumatic brain injury (TBI), akathisia (movement disorder that makes it difficult to sit still due to inner restlessness), and psychotic disorder with hallucinations. R36's Care Area Assessments (CAA) for activities of daily living (ADL) functional, communication, and cognitive loss / dementia dated 9/15/23, were triggered but lacked supportive documentation. The CAAs indicated these areas would be addressed in R36's care plan. R36's care plan, dated 6/18/21, indicated 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, interview and document review, the facility failed to maintain a dignified dining experience for 1 of 6 resident (R109) reviewed for dignity. Findings include: R109's quarterly Minimum Data Set, dated [DATE], indicated R109 had mild cognitive impairment, required supervision with eating with a mechanically altered diet (change in texture). The MDS indicated R109 did not exhibit rejection of care behaviors and had diagnoses of traumatic brain injury (TBI), seizure disorder, and aphasia (loss of ability or difficulty expressing speech). R109's care plan (CP) dated 3/1/24, indicated R109 was on a mechanical soft diet r/t (related to) recent choking episode and erratic eating patterns. The CP instructed staff to encourage R109 to eat in the dining room and assist with meal intake as needed. R109's physician orders dated 3/21/24, indicated, Regular diet, dysphagia texture .Mechanically altered texture solids. No straws or utensils. Use 2-handled cup with spout or anti-splash lid. Eat in dining…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure appropriate therapeutic diets were consistently provided for 1 of 5 residents (R109) reviewed for nutrition. Findings include: R109's quarterly Minimum Data Set, dated [DATE], indicated R109 had mild cognitive impairment, required supervision with eating with a mechanically altered diet (change in texture). The MDS indicated R109 did not exhibit rejection of care behaviors and had diagnoses of traumatic brain injury (TBI), seizure disorder, and aphasia (loss of ability or difficulty expressing speech). R109's care plan (CP) dated 3/1/24, indicated R109 was on a mechanical soft diet r/t (related to) recent choking episode and erratic eating patterns. The CP instructed staff to encourage R109 to eat in the dining room and assist with meal intake as needed. R109's undated nurse aide care sheet indicated, Eating: Limited assist-set up assist and cueing. Resident to eat in the dining room for all meals!!! Report refusals to NURSE.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide necessary respiratory care consistent with professional standards of practice for 1 of 2 residents (R46) reviewed for oxygen use. Furthermore, the facility failed to ensure 1 of 1 resident (R46), who used intermittent oxygen via nasal cannula, had current physician orders. Findings include: R46's quarterly Minimum Data Set (MDS) dated [DATE], indicated he had intact cognition and diagnoses of asthma, chronic obstructive pulmonary disease (an inflammatory lung disease that causes obstructed airflow from the lungs), shortness of breath, tobacco use, alcohol abuse, and depression. R46's smoking assessment dated [DATE], indicated he did not use supplemental oxygen. R46's orders were reviewed on 3/25/24, and lacked provider's orders and indication for oxygen use, ongoing assessment of respiratory status, response to oxygen therapy. R46's care plan was reviewed and lacked interventions for oxygen therapy. A nursing progress note dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure menu items were prepared and served as written to the resident population for (R1, R210, R109) and failed to ensure foods were provided according to preferences for 1 of 1 resident (R210) Findings include: A menu located by both elevators on the second floor indicated Week At A Glance menu for week 1. The menu indicated for dinner on Sunday, rotisserie chicken, whole kernel corn, cheesy mashed potatoes, cornbread, cranberry crunch bar, milk, coffee or hot tea. A menu located in the second floor dining room indicated Week At A Glance menu for week 2. The menu indicated for dinner on Sunday, chicken tenders, honey mustard, roasted green beans, macaroni and cheese, cornbread, margarine, oatmeal [NAME] cookie. A provided weekly menu in the facility survey binder indicated a Week At A Glance menu for week 4. The menu indicated for dinner on Sunday, grilled ham and cheese sandwiches, creamy coleslaw, tater tots, ketchup, and a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure an allegation of sexual abuse was reported to the State Agency (SA) immediately, within 2 hours as required, for 1 of 3 residents (R1) reviewed who alleged sexual abuse by a staff member. Findings include: R1's quarterly Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses which included depression, anxiety, and no cognitive impairments. Further, MDS indicated R1 did not exhibit any behaviors. Review of facility report submitted to the SA dated 11/30/23 at 6:04 p.m., indicated on R1 reported a nursing assistant (NA) had come into her room while she was sleeping and squeezed her buttocks, she woke up, started to hit the NA, and he walked away laughing, which occurred on 4/7/23. R1 reported the same NA opened the door while she was showering and had complemented her breasts. R1 reported these incidents made her feel uncomfortable. On 12/7/23 at 2:37 p.m., the assistant director of nursing (ADON) stated she was completing an assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to thoroughly investigate an allegation of sexual abuse for 1 of 3 residents (R1) reviewed. Findings include: R1's quarterly Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses which included depression, anxiety, and no cognitive impairments. Further, MDS indicated R1 did not exhibit any behaviors. Review of facility report submitted to the SA dated 11/30/23 at 6:04 p.m., indicated R1 reported a nursing assistant (NA) had come into her room while she was sleeping, squeezed her buttocks, she woke up, started to hit the NA and he walked away laughing which occurred on 4/7/23. R1 reported the same NA opened the door while she was showering and had complemented her breasts. R1 reported these incidents made her feel uncomfortable. On 12/7/23 at 2:07 p.m., the director of nursing (DON) stated she completed the investigation for R1's allegation of sexual abuse and DON stated the investigation included interviewing R1 and other residents on 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 interview, observation, and document review, the facility failed to ensure the care plan was updated to ensure smoking interventions were re-evaluated and implemented for 1 of 1 resident (R1) reviewed for smoking. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact. R1's Diagnosis List printed 11/28/23 indicated R1 had diagnoses of tobacco use, and history of traumatic brain injury. R1's Smoking assessment dated [DATE], indicated R1 had a history of burned clothing, smoking in bed, and smoking in a non-smoking area. The assessment further indicated staff did not review the policy related to smoking times and storage of smoking materials with the resident, and indicated the care plan was not updated. R1's care plan indicated the following: 2/23/23, R1 had a history of smoking in his room and refused to allow staff to secure smoking materials. 6/25/23, R1 was identified as a smoker with an intervention to instruct about the facility smoking policy.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure oral cares and shaving were offered or provided for 1 of 3 residents (R2) who was dependent upon staff for assistance with activities of daily living (ADLs). Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 was cognitively intact,and indicated R2 required the assistance of two staff for personal hygiene. R2's Diagnosis List printed 11/28/23, indicated R2 had hemiplegia (paralysis on one side of the body)/hemiparesis (partial paralysis on one side of the body) and weakness. R2's care plan dated 7/16/23, lacked direction for shaving or tooth brushing. On 11/28/23 at 2:01 p.m., R2 was observed with chin hair approximately 1/2 inch long. R2 stated she wanted the chin hair removed prior to going to visit family for Thanksgiving, but staff told her they did not have time to shave her. R2 stated she had an electric razor but did not know where it was. R2 further stated, I feel embarrassed I am 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to develop and implement smoking policies to include smoking marijuana to ensure 1 or 1 residents (R1) reviewed for smoking was assessed for the safe use of a marijuana pipe, and failed to address the risks of smoking marijuana in resident rooms. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1 was cognitively intact. R1's care plan dated 6/25/23, identified R1 as a smoker. The care plan failed to address the use of marijuana/ smoking marijuana in the facility. R1's Smoking assessment dated [DATE], lacked mention or assessment of R1 smoking marijuana in the facility. On 11/28/23 at 1:44 p.m., R1 was observed sitting up in bed with a bag of marijuana, a marijuana pipe, and lighter on the bed next to R1. R1 stated he was, more apt to hit my weed pipe in here than my cigarette, but I do both. Here is my pipe, here is my weed. R1 declined to say when he last smoked marijuana in his room. On 11/28/23 at 4:41…

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 interview and document review, the facility failed to identify specific care or practices necessary to meet identified care needs regarding substance abuse disorders. This had the potential to affect all residents currently residing in the facility with a diagnosis or history of substance use disorders. Findings include: The facility assessment dated [DATE], indicated administrator and interim director of nursing (DON) were involved in completing the facility assessment. The facility assessment lacked evidence of including residents with diagnosed substance abuse disorders. The facility assessment revealed there were no special treatments and conditions for mental health such as behavioral health needs or active or current substance use disorders, which were both marked with a 0. Further, the facility assessment lacked evidence of substance abuse and specific cares or practices related to alcohol and/ or substance abuse. On 10/31/23 at 8:59 a.m., interim DON stated the administrator completed 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 interview and document review, the facility failed to have a discharge planning process to ensure discharge goals were achieved for 2 of 3 residents (R1, R2) who were reviewed. Findings include: R1's quarterly minimal data set (MDS) dated [DATE], identified R1 had diagnoses which included opioid dependence, post-traumatic stress disorder, anxiety and had moderate cognitive impairment. R1 was independent with activities of daily living (ADLs) such as dressing, transferring, toileting or mobility. Further, MDS revealed R1's discharge planning had not been assessed. R1's Social Service Care Conference dated 11/15/22, revealed discharge planning was needed as well as enrolling for relocation services. R1's care plan dated 11/14/22, indicated R1's goal was discharge to the community and social services will coordinate services for necessary discharge. R1's care plan lacked evidence of detailed discharge plan or services needed upon discharge and had not been revised since 11/15/22. R2's quarterly MDS dated…

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 interview and document review the facility failed to develop a comprehensive care plan with appropriate services, treatments, and prevention interventions for substance use disorders for 2 of 3 residents (R1, R2) reviewed. In addition, the facility failed to follow physician orders for referral to behavioral health services 1 of 3 residents (R1) and failed to follow behavioral health specialist's recommendations regarding managing continued substance abuse for 1 of 3 residents (R2) reviewed for behavioral health services. Findings include: R1's quarterly minimal data set (MDS) dated [DATE], identified R1 had diagnoses which included opioid dependence, post-traumatic stress disorder, anxiety and had moderate cognitive impairment. R1 was independent with activities of daily living (ADLs) such as dressing, transferring, toileting or mobility. R1's physician orders dated 10/24/23, revealed R1 had orders for antidepressant and antipsychotic medications. R1's care plan lacked evidence of substance abuse…

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 interview and document review, the facility failed to address a diagnosis of post-traumatic stress disorder (PTSD) by obtaining a history of trauma, and develop a person-centered care plan to avoid triggers related to past trauma for 1 of 3 residents (R1) reviewed for mental disorders. Findings include: R1's quarterly minimal data set (MDS) dated [DATE], identified R1 had diagnoses which included opioid dependence, post-traumatic stress disorder, anxiety and had moderate cognitive impairment. R1 was independent with activities of daily living (ADLs) such as dressing, transferring, toileting or mobility. R1's physician orders dated 10/24/23, revealed R1 had orders for antidepressant and antipsychotic medications. R1's Primary Care PTSD Screen dated 11/15/22, directed PTSD should be considered positive if a resident answered yes to any three items to which R1 had responded yes to having had any experience that was so frightening, horrible or upsetting that she had night [NAME] about it or thought about it…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure the call light system was set-up in a functional manner to allow residents to call for staff assistance through a communication system which relays the calls directly to the staff member or a centralized work area. This had the potential to affect all 72 residents who resided within the facility. Findings include: During an observation on 9/19/23, at 8:41 a.m. on the third floor there were electronic call light display boxes (black rectangular shaped box with red colored electronic display) at the end of each hallway and one in front of the south nurses' station for a total of five boxes. There was not a box in front of the north nurse's station desk, if someone were sitting at this nurse's station they would have to get up and walk to their left or right to see the call light display boxes at the ends of the northeast and northwest hall. The display boxes displayed the room number pressed and the display identified which bed in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to provide sufficient staffing to ensure resident care needs were provided for 4 of 4 residents (R1, R3, R4, R5 and R6) who expressed concerns of not being toileted timely and concerns with dependent residents not assisted with activities of daily living (ADL's) timely. Findings include: R3 - See F686. Resident Listing printed 9/19/23, indicated 33 of 72 resident resided on the third floor. And the facility listing of residents who require two staff assist for activities of daily living included 18 of 33 residents that reside on the third floor. R1's quarterly minimum data set (MDS) dated [DATE], indicated R1's cognition was intact and diagnoses of diabetes, anxiety disorder and depression. R1 required extensive assist of two staff with bed mobility, toileting, dressing and hygiene and transfers, walking and locomotion did not occur. R1 was frequently incontinent of bowel and bladder. R1's care plan, dated 5/27/22 indicated a focus of ADL…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure the call light system was set-up in a functional manner to allow residents to call for staff assistance through a communication system which relays the calls directly to the staff member or a centralized work area. This had the potential to affect all 72 residents who resided within the facility. Findings include: Upon observation on 9/6/23 at 10:12 a.m. electronic call light display boxes hung at the end of two hallways on the first floor for a total of four boxes. The display box cannot be visualized from the centralized work area of the nursing office on the first floor without the nurses having to get up and walk out of the office to look at the display box. On the second and third floors there were call light display boxes at the end of each hallway and one in front of the nurses' station for a total of five boxes. The display boxes displayed the room number pressed and the display identified which bed in the room needs…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to notify the ombudsmen for long term care regarding facility discharges tor 4 of 4 residents (R1, R5, R6, R7) reviewed for discharge. Findings include: R1's admission assessment dated [DATE] indicated R1 was admitted to the facility on [DATE] with diagnoses of shortness of breath, generalized weakness, physical deconditioning, and cellulitis. R1's Progress note dated 8/9/23, indicated R1 was discharged to home. The notes did not indicate if the discharge was a facility-initiated discharge of a resident-initiated discharge. R5's admission assessment dated [DATE] indicated R5 was admitted to the facility on [DATE] with diagnoses of bilateral lower extremity wounds, diabetes, dialysis, and a pressure ulcer of the coccyx. R5's Progress note dated 6/26/23 indicated R5 was discharged to his home. The note did not indicate if the discharge was a facility-initiated discharge of a resident-initiated discharge. R6's admission assessment dated [DATE] indicated R6…

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 interview and document review the facility failed to document required health information for 4 of 4 residents (R1, R5, R6, R7) reviewed for discharge summary. Findings include: R1's admission assessment dated [DATE] indicated R1 was admitted to the facility on [DATE] with diagnoses of shortness of breath, generalized weakness, physical deconditioning, and cellulitis. R1's Progress note dated 8/9/23, indicated R1 was discharged to home. A seven-day supply of medication was sent with R1 with two insulin pens. Information faxed to R1's physician per discharge orders, no concerns noted. The note did not indicate if the discharge was a facility-initiated discharge of a resident-initiated discharge. R1's medical record did not include a discharge summary that included a recapitulation of R1's stay that included a diagnoses, course of illness/treatment/therapy and pertinent lab, radiology, and consultations, a final summary of R1's status, reconciliation of all predischarge medications and post-discharge…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure sufficient staffing was available to provide timely assistance with personal cares according to the residents' assessed need and as directed by the care plan for 4 of 4 residents (R2, R4, R8, and R9) reviewed for staffing needs. Findings include: R2's care plan dated 4/18/23 indicated R2 required extensive assistance of one staff member to dress him. He required extensive assistance of one staff member to assist with personal hygiene. R2 required total assistance of one staff for toilet use. The care plan indicated an update on 7/4/23 to always have two staff members with resident when performing cares. R2's significant change Minimum Data Set (MDS) dated [DATE] indicated R2 had a Brief Inventory of Mental Status (BIMs) score of six indicating severe cognitive impairment. R2 required extensive assistance of two staff members for bed mobility, transferring, dressing and personal hygiene. R2's diagnoses were a wedge compression…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure the facility offered a comfortable homelike environment for 2 of 2 residents (R2 and R8) when R2 and R8's room was not kept free of odors, and R2 was laying on soiled linens and R8 was found without proper linens on his bed. Findings include: R2's significant change Minimum Data Set (MDS) dated [DATE] indicated R2 had a Brief Inventory of Mental Status (BIMs) score of six indicating severe cognitive impairment. R2 required extensive assistance of two staff members for bed mobility, transferring, dressing and personal hygiene. R2's diagnoses included a wedge compression fracture of the first lumbar vertebrae, adult failure to thrive, chronic obstruction pulmonary disease, and liver disease. R8's quarterly MDS dated [DATE] indicated R8 had a BIMS score of nine indicating moderate cognitive impairment. R8 required extensive assistance of two staff members for bed mobility, transferring, dressing and personal hygiene. R8's diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to consistently monitor vital signs for 1 of 3 residents (R1) reviewed for vital sign monitoring. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact and had diagnoses of high blood pressure and heart failure. R1's care plan dated 5/27/22, included give cardiac medications as ordered, and to monitor, document, and report any signs or symptoms of congestive heart failure including increased heart rate and respirations. The care plan lacked instruction to monitor R1's blood pressure. R1's Order Summary Report dated 8/24/23, included an order for Losartan Potassium tablet, 25 milligrams (mg) one time per day for high blood pressure starting 3/22/23, and Furosemide 20 mg one time per day for heart failure starting 5/26/22. The report lacked an order for monitoring of R1's vital signs including heart rate, respirations, or blood pressure. R1's Weights and Vitals Summary dated 8/24/23,…

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, interview, and document review, the facility failed to ensure licensed nursing staff were competent to count carbohydrates for 1 of 1 resident (R1) reviewed for insulin administration. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact, had diagnosis of diabetes mellitus, and daily insulin injections during the seven-day look back period. During document review, a progress note was entered on 8/22/23 at 1:12 p.m., which indicated a nurse and R1 disagreed on the amount of insulin that should be given. The note indicated R1 requested 18 units of insulin, but nurse told R1 18 units was too much for R1's blood sugar of 112 and reviewed the food R1 ate. The resident was difficult to redirect, did not accept education on insulin, and was encouraged to allow nurses to make insulin decisions. During observation on 8/23/23 at 9:45 a.m., R1 reported to registered nurse (RN)-D [R1] needed 14 units of insulin. R1's breakfast tray was already…

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 interview and document review, the facility failed to identify a system to obtain and track a carbohydrate count to ensure the correct dose of insulin was administered for 1 of 1 resident (R1) and the facility failed to monitor blood glucose levels and administer diabetes medications for 1 of 3 residents (R2) reviewed for diabetic management. Findings include: R1's quarterly Minimum Data Set (MDS), dated [DATE], indicated intact cognition, behavior of rejection of care for one to three days during look-back period, assist of two for bed mobility, dressing, toileting, and personal hygiene, and indicated diagnosis of diabetes mellitus and insulin injections received all seven days of look-back period R1's physician orders sheet for August 2023, included Insulin Lispro Kwik pen 2 units per 15 g [grams] of carbs [carbohydrates] with meals for diabetes. R1's medical record lacked assessment for R1's ability to count carbohydrates in her diet to accurately report to nursing staff how much insulin R1 required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to notify a resident representative timely of an incident that occurred for 1 of 2 (R2) residents reviewed for abuse. Findings include: R2's Diagnoses List undated indicated R2 had dementia. R2's Face Sheet listed two family members as her emergency contacts. R2's quarterly Minimum Data Set (MDS) dated [DATE] indicated R2 had moderately impaired cognition, and no history of verbal or physical aggression exhibited toward others. The MDS further indicated R2 required assistance of one staff with cares, and was independent with mobility with the use of her walker. R2's care plan dated 9/28/22, indicated R2 had a potential for abuse due to cognitive impairment, dementia, or poor decision making. The care plan also indicated R2 wandered with a purpose, but was at low risk for elopement. On 8/10/23, at 12:54 p.m. nursing assistant (NA)-A stated R2 had been physically abused by another resident in the dining room a couple of weeks ago. NA-A stated she informed…

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 interview and documentation review, the facility failed to ensure incidents of potential abuse were reported to the State Agency (SA) immediately (within two hours) for 1 of 2 residents (R2) reviewed for allegations of abuse. Findings include: Findings include: R2's Diagnoses List undated indicated R2 had dementia. R2's Face Sheet listed two family members as her emergency contacts. R2's quarterly Minimum Data Set (MDS) dated [DATE] indicated R2 had moderately impaired cognition, and no history of verbal or physical aggression exhibited toward others. The MDS further indicated R2 required assistance of one staff with cares, and was independent with mobility with the use of her walker. R2's care plan dated 9/28/22, indicated R2 had a potential for abuse due to cognitive impairment, dementia, or poor decision making. The care plan also indicated R2 wandered with a purpose, but was at low risk for elopement. On 8/10/23, at 12:54 p.m. nursing assistant (NA)-A stated R2 had been physically abused by another…

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.