Catholic Eldercare On Main

Based on observation, interview and document review, the facility failed to ensure dental needs were coordinated with a dental provider for further care to reduce the risk of complication (i.e., cavities, oral pain) for 1 of 1 residents (R14) reviewed for dental care and services.Findings include:R14's significant change Minimum Data Set (MDS) assessment, 10/9/25, indicated R14's cognition was severely impaired without hallucinations or delusions present with no behaviors, rejection of care, or wandering present. Further, the MDS identified a section titled Section L-Oral/Dental Status indicated unable to examine. Section K: Swallowing/Nutritional Status indicated R14 had complaints of difficulty or pain with swallowing.R14's face sheet, printed 12/17/25, identified relevant diagnoses included: vascular dementia with anxiety, osteoarthritis, anxiety disorder and chronic knee pain.During an interview and observation on 12/15/25 on 2:48 p.m., R14 was observed propelling herself in the hallway in her wheelchair. R14 was observed to be missing numerous teeth. R14 answered questions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adaptive equipment for 1 of 1 resident (R78) reviewed for adaptive equipment and observed having difficulty eating during meal observation.Findings include:R78's quarterly Minimum Data Set (MDS) dated [DATE] indicated R78 was cognitively intact, had no behaviors or rejected personal cares, needed touching assistance with eating, and was dependent with toileting hygiene, dressing, bed mobility and transfers. MDS indicated R78 was at risk for skin breakdown, and limited range of motion (ROM) was not assessed.R78's face sheet dated 12/18/25 indicated diagnoses of benign neoplasm of meninges (non-cancerous tumor growing in the protective membranes covering the brain and spinal cord), chronic obstructive pulmonary disease, hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or inability to move one side of the body) following cerebral infraction affecting right dominant side.R78's Resident Profile dated 12/16/25…

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

Based on observation, interview, and document review the facility failed to ensure residents clothing was covered during storage and delivery to the residents. The uncovered linen had the potential to affect all residents. Findings include: During observation and interview on 10/14/24 at 1:13 p.m. laundry aide (H)-C was observed pushing a large metal uncovered laundry cart down a resident hallway on the first floor containing various cleaned resident clothing items. H-C stated she had worked at the facility as a laundry aide for a long time and they had never covered the personal laundry carts. During observation and interview on 10/15/24 at 1:28 p.m. H-A verified she was delivering cleaned personal linen on the second floor in an uncovered cart. H-A stated the carts used to deliver personal clothing were never covered. During interview on 10/15/24 at 1:34 p.m. the director of environmental services-housekeeping and laundry, (H)-B, stated he had been in his position since 2016, and they had never covered the carts used to deliver personal clothing. H-B added, we only cover the 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.

Based on observation and interview, the facility failed to promote a dignified home-like environment during dining services in 4 of 6 dining rooms reviewed. Finding include: R48's significant change Minimum Data Set (MDS) assessment, dated 8/24/24, indicated R48 had intact cognition with no hallucinations or delusions with an admission date of 4/21/23. During observation on 10/14/24 at 5:08 p.m., on 2nd floor main dining room residents were seated and had been served their meals. It was observed each resident had a hard plastic tray in front of them which contained a plate of food that was sitting on a plate warmer. The drinks (which ranged from juice to coffee to milk) were also placed on the hard plastic tray along with the silverware. In the middle of the table were hard plastic dome shaped lids (which would have been used to cover the food plates). At 5:12 p.m., a staff member walked up to a resident who was sitting with her head down and prompted her to eat. During observation on 10/14/24 at 5:14 p.m., on 2nd floors smaller dining room, it was observed all residents had been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 wheelchair foot supports were provided or, if needed, therapy consulted to promote adequate wheelchair positioning to avoid complication (i.e., pain, edema) for 1 of 1 resident (R51); failed to ensure proactive skin interventions were consistently implemented to reduce the risk of skin tears or bruising for 1 of 1 resident (R110); and failed to assess and revise an insulin administration schedule to promote acceptable diabetes management and improve blood glucose levels for 1 of 1 resident (R161) reviewed for dialysis and who missed multiple doses of insulin related to scheduled dialysis treatments. Findings include: WHEELCHAIR POSITIONING: R51's quarterly Minimum Data Set (MDS), dated [DATE], identified R51 had severe cognitive impairment and demonstrated no rejection of care behaviors during the review period. Further, the MDS outlined R51 had no range of motion limitations in her upper or lower extremities, used 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 consistently assess a resident's pain level prior administration of an as-need narcotic pain medication, in addition, the facility failed to assess for and implement if requested non-pharmacological pain interventions for 1 of 2 residents (R106) reviewed for pain management. Findings include: R106's quarterly Minimum Data Set (MDS), dated [DATE], indicated R106 had intact cognition with no hallucinations or delusions. R106's diagnoses included polyneuropathy (damage or disease affecting nerves in roughly the same areas on both sides of the body), muscle weakness, radiculopathy (the pinching of the nerves at the root), other symptoms and signs involving the musculoskeletal system-wheelchair dependent and alcohol dependence with withdrawal. and required, at least, substantial/maximal assistance with dressing, sitting up or transferring. Further, under Section J - Health Conditions, the MDS identified R106 consumed no scheduled pain medication but…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident specific target behaviors related to antipsychotic medications use for 1 of 5 residents (R105) reviewed for unnecessary medications. Findings include: R105's quarterly Minimum Data Set (MDS), dated [DATE], indicated R105 had moderately impaired cognition with no hallucinations or delusions and no behavioral symptoms including physical or verbal behavioral symptoms directed at others or behavioral symptoms not directed toward others. Further, it indicated R105 had received an antipsychotic medication during the seven-day look back period. R105's Physician Order Report, dated 10/16/24, included the following orders: -quetiapine (antipsychotic medication used to treat mental/mood disorders) tablet 25 milligrams (mg) take 12.5 mg one time a day at 8:00 a.m. for delusional disorder with a start date of 2/28/24 -quetiapine tablet 25 mg take one tablet by mouth once in the evening at 8:00 p.m. for delusional disorder with 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 dental needs were coordinated with a dental provider for further care to reduce the risk of complication (i.e., cavities, oral pain) for 1 of 1 residents (R88) reviewed for dental care and services. Findings include: R88's quarterly Minimum Data Set (MDS), dated [DATE], indicated R88 had intact cognition with no hallucinations or delusions with an admission date of 4/11/23. Further, R88's face sheet, printed 10/17/24, identified R88's primary payer as, Medicaid. R88's care plan, printed 11/5/23, identified R88 has natural teeth and may require assistance with oral care r/t [related to] Parkinson disease [a disease that affects the central nervous system that affects both motor and non-motor systems of the body], impaired mobility with a goal of adequate oral hygiene will be maintained. The care plan listed several interventions to help R88 meet this goal which included, assess condition of oral cavity, teeth, tongue, lips 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 interview and record review the facility failed to identify, keep resident appraised of ongoing efforts or resolve an ongoing grievance for 1 of 3 residents (R2) reviewed. R2 had a roommate who would cry and scream out at night. In addition, the roommate would wander into R2's side of the room and R2 would have to call the nurses station almost daily to have the roommate removed. Finding Include: R2's nursing progress note dated 1/6/24 at 5:37 a.m. indicated R2 was awake most of the night and concerned about the new roommate. R2 indicated the roommate was disturbing her with noise. She requested the roommate should be moved. R2's nursing progress note dated 1/6/24 at 3:06 p.m. indicated R2 complained of not being to sleep at night due to disturbances by roommate. Family member (FM)-A spoke with staff about the possibility of relocating the roommate due to the resident not being able to sleep. Staff informed FM-A and R2 that frequent checks would be conducted to prevent disturbances and handle 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 report allegations of abuse to the State agency (SA) for 1 of 3 residents (R2) reviewed who reported allegations of abuse in the facility. R2 and R2's family repeatedly reported allegations of rough treatment and verbal abuse to multiple facility staff over a six-month period. Findings include: R2's nursing progress note dated 8/29/23 indicated R2 reported pain to the left ribcage area below the breast and to her pelvic area. She stated it started after she was put to bed with the mechanical lift. She reported that she had the pain before when she is put to bed but then it goes away soon, but this time it had been constant and not going away. R2's annual Minimum Data Set (MDS) dated [DATE], indicated R2 had a Brief Inventory of Mental Status (BIMs) score of 15 indicating no cognitive impairment. R2 required extensive assistance for activities of daily living. R2's pertinent diagnoses included Multiple Sclerosis, acute respiratory failure, displaced…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement identified interventions to prevent alterations in mood and behavior for 1 of 1 resident (R1) reviewed. A video recording identified R1 needing assisting and staff entered the room as R1 was crying. The nursing assistant (NA)-A did not speak with R1, adjusted a blanket, turned off her light and left resident crying. Findings include: R1's care plan dated 1/7/24 indicated R1 had a potential for communication deficits due to ability to understand, ability to be understood, hallucinations or delusions and decision-making ability. R1's goal was to be able to follow instructions. The staff's approach was to break down instructions into simple tasks, avoid lengthy explanations, face R1 when speaking with her. In new situations support and reassure her. Obtain R1's attention before speaking with her. Provide a quiet, non-hurried environment, free of distractions or conversations. Encourage resident to voice feelings and concerns about mood,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reassess, evaluate/analysis the fall hazards and risk and implement interventions consistent with the residents needs to reduce further falls for 1 of 3 residents (R1) reviewed for falls. R1 had one fall where no assessments or interventions were completed. R1 had another fall five days later. Finding include: R1's care plan dated 1/7/24 indicated R1 was at risk for falls related osteoporosis, gait/balance problems, visual impairments, hearing impairment, elimination needs, impaired cognitive status and pain. R1's goals were to remain free from falls and fall related injuries. The staff's approach was a pharmacy consult per protocol. Promote scheduled rested periods. Reinforcement to request assistance. Safety check on shoes and monitor for foot pain. Monitor for glasses and/or hearing aid. Ensure proper lighting/night lights. Provide non-skid material in wheelchair. When falls occur to investigate the root cause through IDT meeting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure all staff knock on individual resident bedroom doors and introduce themselves prior to entry for 8 of 8 residents (R7, R15, R20, R28, R54, R56, R95, R99, R101, R109, R118, R138) reviewed for dignity. Findings include: R7's significant change Minimum Data Set (MDS) dated [DATE] indicated R7 with intact cognition. R7's diagnoses include seizures, multiple falls, osteoarthritis, and chronic pain. In addition, R7 required supervision with toileting and dressing with partial to moderate assistance needed for mobility. R15's quarterly MDS dated [DATE], indicated R15 with intact cognition. R15's diagnoses included coronary artery disease, heart failure, and depression. In addition, R15 required partial to moderate assistance with toileting, showering, and lower body dressing with supervision or touching to partial to moderate assistance for mobility. R20's annual MDS dated [DATE] indicated R20 with moderate impaired cognition. R20 required 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 observation, interview and document review, the facility failed to ensure nebulizer tubing and masks were changed according to physician orders and professional standards for 2 of 2 residents (R37 and R104) reviewed for respiratory therapy. In addition, the facility failed to ensure proper cleaning of a continuous positive airway pressure (CPAP) machine to reduce the risk of complication (i.e., respiratory infection) for 1 of 1 residents (R153) observed for CPAP use. Findings include: R37's quarterly Minimum Data Set (MDS) dated [DATE], indicated R37 had severe cognitive impairment and required total assistance for eating and was dependent with all other activities of daily living (ADLs). R10's diagnosis included Alzheimer's disease, seizure disorder, malnutrition, asthma, and delusional disorder. R37's active orders indicated an order dated 10/1/23 for ipratropium-albuterol solution for nebulization, 0.5 milligrams (mg) - 3mg (2.5 mg base) 3 milliliters (ml); one inhalation once a day. In addition, 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 interview and document review the facility failed to communicate changes in medications for 1 of 1 residents (R56) reviewed for notification of change in medications. Findings include: R56's Physician Order Report printed on 11/15/23, identified an admission date of 4/21/23, with diagnoses including type 2 diabetes, hypertension (high blood pressure), heart failure, chronic pain, major depressive disorder, adjustment disorder with anxiety and Parkinson's disease. R56's admission Minimum Data Set (MDS) dated [DATE], indicated R56 was cognitively intact. R56's most recent quarterly MDS dated [DATE], indicated R56 was cognitively intact, had type 2 diabetes, heart failure, high blood pressure, Parkinson's disease, anxiety, depression, and chronic pain. When interviewed, on 11/13/23, at 4:22 p.m., R56 expressed that she didn't know what medications she received. R56 stated she thinks she is on a blood thinner, doesn't know if her insulin dose changed after she had an incident with a low blood sugar 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 reasonable accommodation of need related to call lights within reach for 1 of 1 residents (R51) with high risk for falls. Findings include: R51's face sheet indicated admission on [DATE], with admission diagnoses of multiple fractures of ribs including other diagnoses of fracture of left pubis, dementia, repeated falls, wedge compression fracture of vertebra, unspecified fall, fracture of skull and facial bone, fracture of arm and chronic pain due to trauma. The admission Minimum Data Set (MDS) dated , 3/28/23, indicated R51 had cognitive impairment, suffered a fracture as a result of a fall prior to admission, did not display any inappropriate behavior symptoms, required substantial/extensive assistance with activities of daily living including toileting assistance and mobility, always incontinent of bladder and continent of bowels. R51's fall assessment dated [DATE], identified R51 as a high fall risk. R51's quarterly Minimum…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete a person-centered care plan for 1 of 2 residents (R63), reviewed for trauma informed care. Findings include: R63's face sheet, dated 11/14/23 identified admission to the facility on 8/4/2020, with a diagnosis of post-traumatic stress disorder (PTSD). R63's annual Minimum Data Set (MDS) dated [DATE], indicated post-traumatic stress disorder, depression, dementia, aphasia (language disorder that affects a person's ability to communicate), and attention-deficit hyperactivity disorder (condition including attention difficulty, hyperactivity, and impulsiveness). The assessment indicated cognitive impairment and inattentiveness wyhich fluctuates in severity. R63's care plan last revised on 10/31/2023, lacked documentation of an interrelation between trauma and symptoms of trauma. The document acknowledged history of PTSD however lacked identification on how to mitigate or eliminate triggers that may cause re-traumatization of R63 as no triggers are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 feeding tube supplies were changed according to professional standards to avoid the possibility of feeding tube complications and/or infections for 1 of 1 resident (R37) reviewed for tube feedings. Findings include: R37's quarterly Minimum Data Set (MDS) dated [DATE], indicated R37 had severe cognitive impairment and required total assistance for eating, and was dependent with all other activities of daily living (ADLs). R10's diagnosis included Alzheimer's disease, seizure disorder, malnutrition, asthma, and delusional disorder. R37's care plan titled Feeding Tube dated 6/21/21, indicated, use of enteral nutrition via a gastric tube related to dehydration, history of refusal to eat, drink or take her medication. R37's care plan interventions included check for tube feeding (TF) placement and patency, assess for dehydration, cleanse site, monitor for signs of malnutrition and hypoglycemia. The care plan lacked interventions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 attempt and document non-pharmacological interventions before as needed antipsychotic medications were administered to 1 of 5 residents (R104) reviewed for unnecessary medications. Findings include: R104's significant change Minimum Data Set (MDS), dated [DATE], indicated R104 was severely cognitively impaired and required extensive assistance with all ADLs. R104's Medical Diagnoses list, printed 11/16/23, indicated R104 had several medical diagnoses including dementia, delusional disorder (a type of mental health condition in which a person can't tell what's real from what's imagined) and major depressive disorder. R104's Physician Orders indicated an order for quetiapine (an antipsychotic medication that can treat schizophrenia, bipolar disorder, and depression) 25 milligrams (mg) once a day at 4:00 p.m., dated 10/11/23 and twice a day as needed, dated 11/3/23 to be used for delusional disorder. R104's Medication Administration Record (MAR) for 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 ensure assessed oral and dental abnormalities were acted upon and, if needed or desired, referred to a dental provider to reduce the risk of complication (i.e., further breakdown, oral pain) for 1 of 1 residents (R34) reviewed for dental hygiene and services. Findings include: R34's quarterly Minimum Data Set (MDS) dated [DATE], noted R34 with a facility admission date of 9/14/22 and indicated R34 had moderate cognitive impairment and required assistance with personal hygiene. R34's Oral Health Plan and Consent Form dated 9/13/22, indicated R34 chose to use an outside dental provider for all routine dental cares. This form lacked a resident signature. R34's care plan (CP) with dates prior to 11/14/23, lacked mention of offering to assist with dental hygiene and services. During observation and interview on 11/14/23 at 1:07 p.m., R34 was observed with no upper teeth and missing most of the bottom teeth. R34 stated she had upper dentures and lower…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accommodate dietary preferences for 1 of 1 residents (R153) reviewed for dietary preferences. Findings include: R153's significant change Minimum Data Set (MDS) dated [DATE], indicated R153 had intact cognition and was diagnosed with pancreatic cancer, kidney disease, diabetes, and malnutrition. The MDS indicated R153 required help setting up for oral care and meals and required substantial assistance with transferring and toileting hygiene. R153's Physician Note dated 8/21/23, indicated R135 had been diagnosed with type 1 diabetes (an autoimmune disorder where the body stops producing insulin, a hormone the body needs to process the sugar in food) at age twenty-four. The note indicated R153's blood sugars had recently become increasingly elevated with results in the range of 200 to 300 milligrams/deciliter (mg/dL). The note indicated that R153's blood sugars were often more elevated after the completion of her meals. The note indicated…

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