The Villas At Brookview

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report potential neglect (the failure of the facility, it's employees of service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional stress) to the State Agency (SA), no later than 24 hours for 1 of 3 (R1) residents reviewed for reporting. R1 was given insulin at the incorrect time without a provider's order. R1 was sent to the hospital later that day for hypoglycemia (low blood glucose which includes dizziness, fatigue, sweating, and confusion).Findings include: R1's hospital discharge order dated 2/24/26 indicated R1 was prescribed insulin Aspart pen (a rapid acting insulin) 100 units/ml (milliliter) 1-15 units subcutaneous (below the skin) three times a day with meals. If blood glucose is 150-199 mg/dl (milligrams per deciliter) give 3 units, 200-249 mg/dl give 6 units, 250-299 mg/dl give 9 units, 300-349 mg/dl give 12 units, 350 - 400 mg/dl give 15 units. Normal blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 initiate an investigation for potential neglect (the failure of the facility, it's employees of service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional stress) for 1 of 3 residents (R1) reviewed for investigation, prevention and correction of alleged allegation. R1 was given insulin at the incorrect time without a provider's order. R1 was sent to the hospital later that day for hypoglycemia (low blood glucose which includes dizziness, fatigue, sweating, and confusion).Findings include: R1's hospital discharge order dated 2/24/26 indicated R1 was prescribed insulin Aspart pen (a rapid acting insulin) 100 units/ml (milliliter) 1-15 units subcutaneous (below the skin) three times a day with meals. If blood glucose is 150-199 mg/dl (milligrams per deciliter) give 3 units, 200-249 mg/dl give 6 units, 250-299 mg/dl give 9 units, 300-349 mg/dl give 12 units, 350 - 400 mg/dl…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prevent a significant medication error for 1 of 3 residents reviewed for medication errors. R1's Aspart (a short acting insulin) was given at the incorrect time. The Aspart insulin was ordered as an insulin sliding scale (an order in which the insulin dose is based on a resident's blood glucose level) to be taken with meals and was given at 2:15 p.m. without a meal. In addition, during the survey process R1's 8:00 a.m. medications were administered nearly three hours late. Findings include: Upon observation on 4/1/26 at 10:40 a.m. registered nurse (RN)-C was setting up R1's medications for administration. Upon observation on 4/1/26 at 10:51 a.m. (RN)-C entered R1's room to give R1 her morning mediations. R1 was asleep. (RN)-C aroused R1 and assisted her to a sitting position on the side of her bed. R1 stated that her medications were late again and that she had to be woken up to take them. RN-A acknowledged the medications were late to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to maintain accurate medical records for 1 of 3 residents (R1) reviewed for resident records. R1's medication administration was inaccurately documented when R1's medication Aspart (fast acting insulin) was only administered on 3/13/26 at 2:15 p.m. R1's electronic medical record (eMAR) indicated R1's Aspart insulin was administered on 3/13/26 at 12:00 p.m. and 5:00 p.m. Findings include: R1's hospital discharge order dated 2/24/26 indicated R1 was prescribed insulin Aspart pen (a rapid acting insulin) 100 units/ml (milliliter) 1-15 units subcutaneous (below the skin) three times a day with meals. If blood glucose is 150-199 mg/dl (milligrams/deciliter) give 3 units, 200-249 mg/dl give 6 units, 250-299 mg/dl give 9 units, 300-349 mg/dl give 12 units, 350 - 400 mg/dl give 15 units. R1's electronic Medication Administration Record (eMAR) dated 3/13/26 at 12:00 p.m. indicated R1's blood glucose was 355 mg/dl, the eMAR had a check mark indicating the Aspart…

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

Based on observations, interviews, and document review, the facility failed to ensure medications were stored securely in areas where residents, staff and guests could not access medications in 1 of 1 medication carts observed, potentially affecting one unit, Unit 400, of the facility. Findings include: During observation and interviews on 3/13/26 at 12:27 p.m., Employee (E)-I walked away from the medication cart, leaving it unlocked in the hallway of the 400 unit, stationed between resident rooms. At 12:31 p.m., the Director of Social Services (DSS)-A walked by the cart and pulled on the locked narcotics drawer. The DSS-A stated she was making sure the drawer was locked and then walked away. The cart remained unlocked and unattended until 12:37 p.m., when E-I returned to the cart. From 12:27 p.m. to 12:37 p.m. one resident wheeled by the cart, and two nursing assistants (NA) walked by the unlocked cart. E-I acknowledged the medication cart was unlocked when she left but should have been locked when she stepped away. Further, E-I stated the cart was supposed to be locked to ensure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop and implement a baseline care plan to properly care for 1 of 3 residents (R2) reviewed for baseline care plan. Additionally, the facility failed to provide a summary of the baseline care plan to 1 of 3 residents (R2). Findings include: R2's admission Data Collection (nursing assessment) dated 2/16/26 at 12:50 p.m., indicated R2 had pain frequently over the past five days that made it hard to sleep at night and limited day-to-day activities. Pain was rated as moderate pain as a five (5) on a scale of 0-10. Nursing assessment indicated R2 had a wound on the coccyx described as, right butt has opening. R2's progress notes indicated on 2/16/26 at 3:18 p.m., R2 was admitted with a chronic stage IV (4) (full-thickness tissue loss with exposure of muscle, tendon, ligament, or bone) sacral ulcer. R2's Physical Therapy (PT) Evaluation and Plan of Treatment dated 2/17/26 (no time), indicated R2 had pain which interfered with functional…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observation, and document review the facility failed to comprehensively develop and implement care plan interventions for 1 of 3 residents (R4) when R4 had poor nutritional intake with a diagnosis of malnutrition. Findings include:R4's admission Minimum Data Sheet (MDS) dated [DATE], indicated R4 admitted to the facility on [DATE], with intact cognition, required set-up assistance for meals, and diagnoses included pneumonia and malnutrition. R4's care plan dated 2/2/26, indicated a potential nutritional problem related to moderate malnutrition with interventions to assist with meal set-up, record nutritional intakes, take orders at meals and offer alternatives. The care plan failed to include interventions for when R4 did not eat meals as well as direction when to offer nutritional supplement that was ordered. During an observation and interview on 3/13/26 at 12:56 p.m., R4 independently drank fluids from her glass, drank her fruit cup instead of using utensils, and ate a few bites of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure pressure ulcer prevention interventions were utilized as ordered for residents at risk of developing pressure ulcers for 2 of 3 residents (R1, R4) reviewed who were at risk for pressure ulcers.Findings include: R1 R1's significant change Minimum Data Set (MDS) dated [DATE], indicated R1 was severely cognitively impaired, at risk for pressure ulcers and used pressure reducing devices for her chair and bed. R1's diagnoses included a brain tumor, difficulty speaking, diabetes, and paralysis on the right, dominant side. R1's care plan dated 11/6/25, directed to float heels with pillow and turn and reposition every two-to-three hours and as needed (PRN). R1's care plan lacked an update or mention of precautions to prevent friction and sheer, although the progress notes indicated that risk. R1's provider orders dated 11/10/25 indicated weekly skin inspection by licensed nurse. R1's progress notes indicated the following:11/20/25 at 2:47…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe transfers for 1 of 3 residents (R5) when one staff transferred R5 with an EZ Stand (mechanical lift used to move a person who can bear weight from one surface to another) but required assistance of two staff with an EZ Stand for safe transfers. Findings include: R5's annual Minimum Data Set (MDS) dated [DATE] indicated intact cognition, dependence on staff for all transfers, and diagnoses that included heart failure and morbid obesity. R5's care plan dated 6/3/24, indicated R5 required assistance of two staff transfers with the EZ Stand and was at risk for falls related to impaired mobility. The care plan dated 9/3/24, indicated care in pairs. R5's orders dated 2/10/26 indicated care in pairs. R5's provider notes dated 3/11/26, with no time, indicated R5 weighed 543 pounds. During an observation on 3/13/26 at 11:47 a.m., R5 's door was closed, and then opened by nursing assistant (NA)-A who was in the room alone with R5. R5 thanked NA-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 sufficiently manage pain or offer non-medication pain management interventions for 1 of 3 residents (R2) reviewed for pain management. R2's admission Data Collection (nursing assessment) dated 2/16/26 at 12:50 p.m., indicated R2 had pain frequently over the past five days that made it hard to sleep at night, limited day-to-day activities, and affected sleep, rated as moderate pain at five (5) on a scale of 0-10. R2 received scheduled and as needed (PRN) pain medication and non-medicine interventions to relieve pain. R2's Physical Therapy (PT) Evaluation and Plan of Treatment dated 2/17/26, (no time) indicated R2 had pain that interfered with functional activity and sleep, and nursing would address the pain. R2's provider progress notes dated 2/17/26, (no time) indicated R2 rated pain at 5/10 (five out of ten) on 2/16/26 at 1:31 p.m. R2's provider orders indicated the following:Lidocaine external patch 4%, apply to painful site topically one time a day…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nurses were timely and competently trained on medication administration for 1 of 3 residents (R1) reviewed with specific orders for administration of oral medication. Findings include: R1's diagnoses list dated 11/4/25, indicated diagnoses that included cancer of the frontal lobe of the brain. R1's significant change Minimum Data Set (MDS) dated [DATE], indicated R1 was significantly cognitively impaired, was dependent upon staff for activities of daily living, had complaints of difficulty or pain with swallowing, and received scheduled and as needed (PRN) pain medications. R1's hospice progress notes indicated the following:12/5/25 at 3:05 a.m., indicated a facility nurse contacted the hospice provider to request all medications be discontinued because R1 was having difficulty swallowing, and indicated R1 had Synthroid and morphine. The hospice provider provided education about lorazepam (medication used to manage anxiety and agitation) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed revise the fall care plan to include individualized intervention (fall mat) for 1 of 3 residents (R4), who was reviewed for quality of care/treatment.Findings include:R4's face sheet identified diagnoses of downs syndrome (genetic disorder), dislocation of right shoulder, Alzheimer's and dementia, intellectual disabilities, and epilepsy (seizure disorder).R4's admission Minimum Data Set (MDS) dated [DATE], identified R4 had limited ability to make self understood or respond to others, had poor cognition, had no behaviors. R4 was dependent on staff for activities of daily living. R4 had a fall prior to admission.R4's care plan dated 9/15/25, identified R4 was a fall risk due to dislocation of right shoulder, epilepsy, Alzheimer's, and Down Syndrome. Interventions included follow therapy instructions for mobility function. Monitor and document on safety. Review information on past falls and attempt to determine cause of falls. Record possible…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents were comprehensively assessed for self-administration of medications for 1 of 1 resident (R27) reviewed for self-administration of medication.Findings include:R27's diagnosis report printed 7/2/25, include Type 2 diabetes mellitus, dermatitis (characterized by inflammation and irritation of skin), other prurigo (skin disorder characterized by intensely itchy spots on the skin) and bipolar disorder.R27's annual Minimum Data Set (MDS) dated [DATE], indicated R27's cognition was intact. R27's behaviors did not include rejection of care and there was not a noted change in R27's behaviors since last MDS dated . R27 required staff assistance with ADLs.R27's care plan, last reviewed 6/29/25, included direction to administer medications per orders. R27's care plan lacked direction for R27 to self-administer medication or indication of R27 being assessed for self-administration of medication.R27's provider progress note dated 6/16/25, did 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 record review the facility failed to ensure nursing rehabilitation services were provided for 1 of 1 residents (R7) who was care planned for passive range of motion (ROM).Findings include:R7's quarterly Minimum Data Set (MDS) dated [DATE], indicated R7 diagnoses of end stage renal disease, altered mental status, muscle weakness, right below the knee amputation and Parkinsonism. R7's MDS further indicated resident was moderately cognitively impaired, and required assist of 1-2 staff for all activities of daily living (ADLs). R7's care plan (print date [DATE]), indicated R7 had Alteration in mobility related to [end stage renal disease]. R7's care plan further documented the provision of NURSING REHAB: Passive ROM to upper and lower extremities - 10 [repetitions] to each joint or as tolerated.During multiple observations, from [DATE] - [DATE] (when not attending dialysis), was observed laying in his bed (sleeping or watching TV). Meals were brought to R7's room, where after set…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nail care was completed for 1 of 2 residents (R27) who were reviewed for being dependent on staff for activities of daily living (ADLs).Findings include:R27's diagnosis report printed 7/2/25, include Type 2 diabetes mellitus, dermatitis (characterized by inflammation and irritation of skin), other prurigo (skin disorder characterized by intensely itchy spots on the skin) and bipolar disorder.R27's annual Minimum Data Set (MDS) dated [DATE], indicated R27's cognition was intact. R27's behaviors did not include rejection of care and there was not a noted change in R27's behaviors since last MDS dated . R27 required staff assistance with ADLs.R27's care plan included diagnosis methicillin-resistant staphylococcus aureus (MRSA) (bacteria that is resistive to many antibiotics, making infections difficult to treat) to R27's skin. Staff were instructed to educate R27 regarding the importance of hand washing, to remind R27 to wash hands…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 skin abrasions were adequately assessed and monitored for 1 of 1 resident (R27) reviewed for non-pressure related skin concerns.Findings include:R27's diagnosis report printed 7/2/25, include Type 2 diabetes mellitus, dermatitis (characterized by inflammation and irritation of skin), other prurigo (skin disorder characterized by intensely itchy spots on the skin) and bipolar disorder.R27's annual minimum data set (MDS) dated [DATE] indicated no current skin concerns. R27 had intact cognition. R27 had no behavior concerns and there was no change in behavior since last MDS.R27's care plan included diagnosis methicillin-resistant staphylococcus aureus (MRSA) (bacteria that is resistive to many antibiotics, making infections difficult to treat) to R27's skin. Staff were instructed to educate R27 regarding the importance of hand washing, to remind R27 to wash hands immediately after activities of daily living (ADLs), care tasks and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure recommended dental services were provided for 1 of 2 residents (R13) reviewed for dental services.Findings include:R13's quarterly minimum data set (MDS) dated [DATE], indicated R13 was cognitively intact, and was independent with activities of daily living. R13 had diagnosis of protein-calorie malnutrition.R13's dental care assessment area (CAA) dated 2/18/25, indicated R13 was edentulous (having no teeth) which can put resident at risk for nutritional deficits. When interviewed on 6/29/25, at 2:27 p.m. R13 stated he had no teeth, had waited a long time for them but had not received them and was not aware of what was happened with getting his dentures. A dental visit note dated 10/24/24, indicated R13 had previously declined to start denture fabrication process because he believed he would be discharged within a few weeks. Dental group spoke with social worker who reported he was on the list for a new placement, believed he would…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to notify a resident's physician of the deterioration of a non-pressure related skin wound for 1 of 3 residents (R3) reviewed for non-pressure related skin wounds. Findings include: R3's annual Minimum Data Set (MDS) assessment dated [DATE], indicated he admitted to the facility with 6/7/24 and had diagnoses including non-pressure chronic ulcer of left heel and midfoot, morbid obesity, chronic respiratory failure, difficulty in walking, and diabetes mellitus (type 2 diabetes). R3 had diabetic foot ulcer(s) and treatments included application of dressings to feet. R3's care plan dated 6/7/25, identified he had diabetes. Interventions included check all of body for breaks in skin per protocol and treat promptly as ordered by doctor. The care plan identified an actual impairment in skin integrity related to diabetes with left heel diabetic ulcer. Interventions included follow facility protocols for treatment of injury, wedge pillow to offload…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 professional standards of practice for treatment orders were followed for 2 of 3 residents (R1, R2) reviewed for non-pressure related skin wounds who had wound care orders which were not transcribed. Findings include: R1 R1's admission Minimum Data Set (MDS) assessment dated [DATE], indicated she admitted to the facility on [DATE] with diagnoses including non-pressure chronic ulcer of buttock, encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, and cellulitis of buttock (bacterial infection of skin and underlying tissues). R1 had recent major surgery of repair of a deep ulcer and had a surgical wound with surgical wound care treatment. R1's Skin Evaluation and Skin Risk Factors assessment dated [DATE], identified she had a surgical incision on her coccyx (tail bone) with treatment of a wound vacuum-assisted closure (VAC, a negative pressure wound therapy (NPWT) that applies suction via…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 non-pressure related skin wounds for 2 of 3 residents (R1, R2) reviewed for non-pressure related skin wounds. In addition, the facility failed to administer non-pressure related skin wound treatments in accordance with physician orders for 1 of 3 residents (R1) and failed to identify deterioration of a non-pressure related skin wound for 1 of 3 residents (R3) reviewed for non-pressure related skin wounds. Findings include: R1 R1's Minimum Data Set (MDS) assessment dated [DATE], indicated she admitted to the facility on [DATE] with diagnoses including non-pressure chronic ulcer of buttock, encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, and cellulitis of buttock (bacterial infection of skin and underlying tissues). R3 had recent major surgery of repair of a deep ulcer and had a surgical wound with surgical wound care treatment. R3 was cognitively intact. R1's Skin Evaluation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain complete, accurate, and up-to-date medical records of administered wound care treatments for 1 of 3 residents (R1) reviewed for non-pressure related skin injuries. Findings include: R1's Minimum Data Set (MDS) assessment dated [DATE], indicated she admitted to the facility on [DATE] with diagnoses including non-pressure chronic ulcer of buttock, encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, and cellulitis of buttock (bacterial infection of skin and underlying tissues). R1 had recent major surgery of repair of a deep ulcer and had a surgical wound with surgical wound care treatment. R1's physician order with start date 5/14/25 and end date 5/15/25, directed to continue large wound VAC and dressing on right buttock wound, change Monday Wednesday and Friday, suction at 125 millimeters of mercury (mm Hg). R1's medication administration records (MAR) progress note dated 5/14/25, indicated the wound VAC…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop and implement discharge plans that addressed all the needs for 1 of 3 (R2) residents reviewed for discharge. R2 was discharged before a waiver evaluation was completed at the facility resulting in discharging to home without a personal care assistant (PCA). In addition, incorrect orders were transcribed as R2 was ordered to have a skilled nurse (SN) from the home care agency, the facility ordered a home health aide instead and R2's medications and dialysis were not ordered correctly. Findings include: Email correspondence on [DATE] at 10:21 a.m. sent by R2's community case manager (CM) to the facility social worker (SW) indicated the CM was asking the SW if she had contacted R2's waiver provider to resume services for his discharge on [DATE]. Email correspondence on [DATE] at 6:57 a.m. sent by R2's CM to the facility SW indicated she was again following up on R2's discharge plans and services. R2's providers Discharge summary dated [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 interview and document review the agency failed to maintain current certification for the Clinical Laboratory Improvement Amendments (CLIA) waiver, which is required for agencies performing blood testing. This had the potential to affect patients who received blood testing by the agency, including those residents who had received routine glucose testing (check of blood sugar). This included R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, and R35. On [DATE], at 10:00 a.m. a review of the facility certifications was completed upon entrance to the facility. At this time, a document dated [DATE], indicated the CLIA waiver became effective [DATE] and expired on [DATE]. On [DATE], at 2:00 p.m. inquired of administrator if there had been a CLIA certificate received following the date of expiration on [DATE]. An email was received in follow up at 2:50 p.m. and indicated there was not an updated CLIA waiver in house, 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 facility failed to ensure physician orders were followed to promote good nutritional intake for 1 of 1 residents, (R1), with the diagnoses of end stage renal disease and diabetes. Findings include: R1's annual Minimum Data Set (MDS) dated [DATE], identified R1 was cognitively intact. R1's medical diagnoses identified R1 was medically complex, and his diagnoses included anemia, peripheral vascular disease, renal disease and diabetes. R1's physician orders dated 6/11/24, indicated R1 was to receive a regular diet, regular texture, and regular (thin) consistency. In addition, the order indicated R1 was to receive double meat/protein for nutrition. R1's care plan, initiated on 12/26/17, identified R1 had diabetes mellitus II (adult onset). The care plan directed staff to monitor for breaks in skin, and, if noted, to treat promptly as ordered by the doctor. The care plan directed staff to check skin when assisting with activities of daily living (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 observation, interview and document review, the facility failed to ensure community use glucometer were properly cleaned and disinfected between resident use for 1 of 2 glucometers on the second floor. Findings include: During an observation on 4/4/24 at 10:36 a.m., licensed practical nurse (LPN)-A gathered the supplies to perform a blood sugar reading for R12. LPN-A went to R12's room. LPN-A inserted the test strip, donned gloves, wiped R12's finger with alcohol wipe and used the lancet to poke the finger. LPN-A applied the drop of blood to the test strip and got a reading of 193. LPN-A removed the gloves and took the community glucometer (more than one resident utilizes the glucometer for testing. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents) and sharp out of the room. LPN-A placed the sharp in the sharps container. LPN-A took an alcohol wipe and wiped the community glucometer. LPN-A put the community glucometer in the medication cart…

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