Rochester Restorative Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide oxygen therapy as ordered for 1 of 1 resident (R44) reviewed for respiratory care.Findings include: R44's admission Minimum Data Set (MDS) assessment, dated 2/20/26, indicated intact cognition, R44 required partial to moderate assistance with toileting hygiene.R44's diagnoses included chronic respiratory failure with hypoxia, dependence on supplemental oxygen, chronic pulmonary edema, moderate persistent asthma, and dependence of renal dialysis.R44's was admitted on [DATE] with including, oxygen 2 liters via nasal cannula continuously.During an observation on 3/09/26 at 7:24 p.m., R44 was on the oxygen concentrator with a flow rate of 3 liters.During observation on 3/10/26 11:11 a.m., R44 came down the unit hallway on her motorized scooter with no oxygen in use. R44 stated, the portable oxygen tank was empty and was in search of staff to have the tank filled. R44 searched for staff for 4 minutes. The director of nursing (DON)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ongoing assessment of the resident's condition and monitoring complications before and after dialysis treatments received at a certified dialysis facility for 1 of 1 resident (R44) reviewed for dialysis. Findings include: R44's admission Minimum Data Set (MDS) assessment, dated 2/20/26, indicated intact cognition, R44 required partial/moderate assistance with toileting hygiene. R44's diagnoses included acute kidney failure, dependence of renal dialysis hypertensive heart and chronic kidney disease with heart failure, type2 diabetes mellitus, Pulmonary edema, moderate persistent asthma, dependence on supplemental oxygen, Chronic respiratory failure with hypoxia. R44's was admitted 0n 02/5/26 and orders dated 2/19/25 included: dialysis pre and post assessment every Tuesday, Thursday and Saturday. Print and send assessment with resident to dialysis, place returned paperwork in manager box.Review of R44's MAR/TAR (medications administration/ treatments administration record) dated 2/5/26 to 2/28/26 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 interview and record review, the facility failed to monitor effectiveness of a medication prescribed for sleep by not completing sleep monitoring for 1 of 1 resident (R33) reviewed for unnecessary medications.Findings include:R33's Minimum Data Set (MDS) assessment, dated 12/3/25, indicated intact cognition, R33 was independent with transfers, w/c mobility and required limited assist with bed mobility. R33 diagnoses included chronic systolic and diastolic (congestive) heart failure (a serious condition of the heart's ability to pump blood efficiently), Chronic obstructive pulmonary diseases (an ongoing lung condition caused by damage to the lungs), generalized osteoarthritis.R33's medication orders included: Melatonin 5 milligrams (mg), oral at bedtime: start date:12/01/25 for insomnia.R33's Medication Administration Record (MAR) record review from 02/1/26 to 3/11/26 reviewed lacked sleep tracking or monitoring.R33' s progress note reviewed from 02/1/25 to 3/11/26 had no reference to R33 sleep monitoring.During an interview on 3/11/2026 at 4:05 p.m., registered 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 ensure proper personal protective equipment (PPE) usage for 3 of 3 residents (R6, R4, R14) reviewed for enhanced barrier precautions (EBP) who receive tube feeding (R6, R14) and dialysis care (R4). Findings include: R6: R6's Minimum Data Set (MDS) quarterly assessment dated [DATE], identified severely impaired cognition and required maximal assistance for mobility. R6's diagnoses included Parkinson's, dementia, major depressive disorder and lack of coordination. R6's physician orders dated 4/24/25, Enhanced Barrier Precautions (EBP) for tube feeding. R6 had a percutaneous endoscopic gastrostomy (PEG) tube for enteral nutrition and medication. Cleanse surrounding skin with warm water using soft cloth, then pat dry. Apply barrier cream to skin under PEG tube disk to prevent moisture related skin redness. R6's care plan (CP) created on 1/27/25, identified R6 was at risk for infection related to indwelling medical device (PEG) tube. EBP when…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 bathroom call light was functioning for the shower room on the 3rd floor having the potential to affect all residents that use the toilet in the shower room, 7 of 7 (R6, R36, R2, R8, R51, R60, R62) residents were brought to and used an EZ stand for toileting.Findings include:R6's Minimum Data Set (MDS) quarterly assessment dated [DATE], identified severely impaired cognition and required maximal assistance for mobility. R6's diagnoses included Parkinson's, dementia, major depressive disorder and lack of coordination.R6's care plan (CP) created on [DATE], identified mobility was an area of concern, indicated was not ambulatory and needed transfer assistance of 2 and mechanical lift (EZ stand). Furthermore, the CP identified an area of concern, indicated was at risk for falls due to dementia, impaired coordination and mobility, medications, impulsiveness and safety awareness.R36's MDS comprehensive assessment 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 observation, interview, and document review, the facility failed to complete a comprehensive assessment for self-administration of medications for 1 of 1 resident (R1) reviewed for respiratory and oxygen. Findings include: R1's face sheet dated 9/10/25, identified diagnoses of chronic obstructive pulmonary disease (a group of lung disease that block airflow and make it difficult to breathe) and asthma (a condition in which a person's airway becomes inflamed, narrows, swells, and produces mucus). R1's admission Minimum Data Set (MDS) dated [DATE] identified R1was oxygen dependent and had moderate impaired cognition. R1's care plan focus dated 8/12/25, identified R1 was at risk for respiratory impairment with a goal to not develop acute respiratory distress. Interventions were as followed: administer medications as ordered; administer oxygen as ordered; encourage deep breathing exercises; and elevate head of bed. R1's physician orders included the following:-Ventolin (inhaler used to treat or prevent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a complete, accurate, and readily accessible medical record for 2 of 4 residents (R1, R4) reviewed for medical record accuracy. Findings include:R1's face sheet dated 9/10/25, identified diagnoses of chronic obstructive pulmonary disease (a group of lung disease that block airflow and make it difficult to breathe), asthma (a condition in which a person's airway becomes inflamed, narrow, and swell, and produce mucus).R1's admission Minimum Data Set (MDS) dated [DATE], identified R1was oxygen dependent. R1's care plan focus dated 8/12/25, identified R1 was at risk for respiratory impairment with a goal to not develop acute respiratory distress. Interventions were as followed: administer medications as ordered; administer oxygen as ordered; encourage deep breathing exercises; and elevate head of bed.R1's physician orders included the following:-Oxygen continuous at 3 liters/minute (L/min) via nasal cannula (NC) (start date 8/12/25 with an end…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review and update the facility assessment to identify the facility's staffing plan for number of staff needed to ensure sufficient qualified staff were available to meet residents' needs. This deficient practice had the potential to affect all 51 residents residing in the facility. Findings include:The facility assessment dated [DATE], identified Staffing Levels Process: As potential residents are referred for intake into our community, they are evaluated by the nursing department, DON, Unit Manager, in conjunction with other members of the IDT Team to assure that we are capable of meeting their individual needs. We may also review the potential resident with our regional directors for guidance and support. If necessary, a call can be made to our Medical Director. At times a face-to-face assessment may be attained. The staffing ratios are fluid and vary day to day and shift to shift. The staffing is based on resident need. Needs such as two person…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review, the facility failed to ensure the Quality Assessment and Assurance committee effectively identified quality deficiencies, developed and implemented appropriate actions; and provided its written Quality Assurance and Performance Improvement plan when requested at the time of survey. This deficient practice had the potential to affect all 51 residents in the facility at the time of the survey.Findings include:During an interview on 7/29/25 at 10:56 a.m., documentation and evidence of the facilities ongoing QAPI program was requested. [NAME] president of success (VPS)-A stated she would have to check with the corporate office due to QAPI minutes being protected by their legal team. The director of nursing (DON) stated the QAA team meets monthly, the committee members include myself, the executive director, pharmacist, medical director, social worker, managers from nursing, dietary, housekeeping, medical records personnel, scheduler, human resources, maintenance, and the business office manager. DON was unable to articulate the date of the last…

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

Based on observation, interview, and record review, the facility failed to ensure the Quality Assessment and Performance Improvement (QAPI) plan and program identified, analyzed, implemented corrective actions, and re-evaluated corrective actions to address adverse events and quality deficiencies. This deficient practice had the potential to affect all 51 residents in the facility. Actual harm occurred related to the quality of care to one resident (R1).Findings include:During an interview on 7/29/25 at 10:56 a.m., the director of nursing (DON) stated the QA committee meets monthly. We discuss quality issues and get feedback form our IDT team. DON indicated the facility was cited previously for failure to comprehensively assess falls, root cause analysis, putting appropriate interventions in place and failure to implement the care plan. DON stated after the last fall citation the facility received their plan of correction identified to do fall audits from 2/12/25 to 3/11/25. DON indicated as part of the audit they ensured a fall intervention was put in place and ensured the…

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

Based on interview and record review, the facility failed to ensure that its Quality Assessment and Assurance Committee (QAA) consisted of the required members and to meet at least quarterly, which had the potential to affect all 51 residents residing in the facility.Findings include:During an interview on 7/29/25 at 10:56 a.m., the director of nursing (DON) stated the QAA team meets monthly, the committee members include myself, the executive director, pharmacist, medical director, social worker, managers from nursing, dietary, housekeeping, medical records personnel, scheduler, human resources, maintenance, and the business office manager. DON was unable to articulate the date of the last meeting but stated it was in June 2025 sometime. DON indicated that the executive director was the contact person for the QAA committee, was responsible for documentation of QAPI meeting minutes and was currently on vacation.The facility provided quality meeting documentation, including QAPI Committee attendance signature logs for meetings held between January 2025 and June 2025. However, 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 1 of 1 resident (R1) received a copy of their medical record per request in a timely manner, within 2 working days upon request excluding weekends and holidays. Findings include:R1's admission Minimum Data Set (MDS) dated [DATE], noted R1 had moderately impaired cognition. Section F identified preferences for customary routine and activities. Interview for daily preferences indicated it was very important to have family, or a close friend involved in discussions about your care.R1's Medical Record Request form dated 7/1/25, identified family member (FM)-A requested R1's entire medical record from 5/19/25 until 6/11/25. The facility form was signed by FM-A and director of nursing (DON) on 7/1/25.During a phone interview on 7/23/25 at 1:09 p.m., FM-A stated for the last three- and one-half weeks, she had been trying to get R1's medical records and still had not received them. FM-A indicated she spoke with the DON on 7/1/25, she had her fill out 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 the baseline care plan was revised and updated as needed to meet 1 of 1 resident (R1) toileting needs reviewed for falls.R1's admission Evaluation dated 5/19/25, identified under section J., R1 was incontinent of bladder more than a month, but less than a year. R1 was wet one to two times daily during the day and the nighttime, also exhibited dribbling. Bladder incontinence care plan identified a goal will be maintained in as clean and dry dignified state as possible. Continence in the last 14 days identified R1 was frequently incontinent of bladder daily but some control present.R1's baseline care plan dated 5/19/25, at 7:30 p.m., identified initial goals were to rehab and go home. Section titled, Personal Care, had a list of tasks going down the page vertically, that included: bath/shower, skin care, brushing teeth/dentures, shaving, hair care, dressing/undressing, walking, bathroom needs, eating, exercise and moving in chair/bed and other.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comprehensive care plan was developed to maintain or restore bladder continence for 1 of 3 residents (R2) reviewed for falls. Findings include:R2's admission Evaluation dated 5/2/25, identified under section J., R2 was continent of bladder.R2's Daily Skilled progress notes from 5/3/25 to 7/2/25, identified R2 was both incontinent and continent of bladder. R2's admission Minimum Data Set (MDS) dated [DATE], identified R2 had severe cognitive impairment and was occasionally incontinent of bladder and bowel. R2 had diagnoses of stroke with hemiplegia and urinary retention. R2's Care Area Assessment (CAA) dated 5/9/25, identified actual Urinary incontinence. Type of incontinence identified was functional (can't get to toilet in time due to physical disability, external obstacles, or problems thinking or communicating). Alteration in urinary elimination r/t occasional incontinence with need for assistance to complete task. Noted to have underlying…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comprehensive fall care plan was revised for 2 of 3 residents (R2 and R3) reviewed for falls. Findings include:R2's care plan identified a focus dated 5/2/25, at risk for falls related to right sided hemiplegia and right sided hemiparesis secondary to a cerebral vascular infarction. Interventions dated 5/2/25, included to encourage to transfer and change positions slowly. 5/9/25 have commonly used articles within easy reach, therapy eval and treat as ordered and use wheelchair for independent locomotion and walker with gait belt and assist of 1 for ambulation. R2's CAA dated 5/9/25, identified Falls an actual problem. No falls noted since admission. Care plan considerations identified R2 had alteration in mobility with risk for falls following hospital stay for pneumonia, underlying hemiplegia, DM, acute kidney injury (AKI), chronic kidney disease (CKD), right foot pain, medications that could affect his overall mobility status.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete a comprehensive assessment and implement individuals interventions to ensure a resident who was continent of bladder upon admission received appropriate treatment and services to maintain/restore or prevent increased incontinence for 1 of 3 residents (R2) reviewed for falls.Findings include:R2's admission Evaluation dated 5/2/25, identified under section J., R2 was continent of bladder.R2's admission Minimum Data Set (MDS) dated [DATE], identified R2 had severe cognitive impairment and was occasionally incontinent of bladder and bowel. R2 had diagnoses of stroke with hemiplegia and urinary retention.R2's Care Area Assessment (CAA) dated 5/9/25, identified actual urinary incontinence. Type of incontinence identified was functional (can't get to toilet in time due to physical disability, external obstacles, or problems thinking or communicating). Alteration in urinary elimination related to (r/t) occasional incontinence with need for assistance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dishwashing sanitization at the correct level and was appropriately monitored during dishwashing. Further, staff failed to ensure expired food was identified and removed from a unit refrigerator that stored resident personal food. Findings include: Dishwashing On 1/27/25 at 3:00 p.m., during the kitchen tour dietary aide (DA)-A placed dishes through the dish machine. DA-A stated the wash dial needed to indicate a temperature of 120 degrees Fahrenheit (F) and rinse dial at 140 degrees F. During the observation DA-A placed dishes through the dish machine and the wash dial indicated a temperature of at 130 degrees F and rinse dial at 140 degrees F. A vial of Ecolab chlorine test paper strips was on top of the dish machine. DA-A stated the dish machine sanitized dishes with hot water. DA-A stated the bottle with the test strips were used to test the chemicals of the water after dishwashing was completed. DA-A confirmed she had not checked the chemicals of the water and had already washed dishes. DA-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 personal protective equipment (PPE) was utilized for 2 of 2 residents (R54, R23) reviewed for medication administration and performed cares on these residents that were on enhanced barrier precautions (EBP). Finding include: R54's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated severe cognitive impairment, dependent on staff for activities of daily living (ADL's), feeding tube, diagnoses included Parkinson's disease, gastrostomy (g-tube, surgical procedure used to insert a tube through the abdomen and into the stomach, and dysphagia (condition that makes it difficult to swallow). R54's care plan revised 1/27/25, indicated at risk for infection r/t (related to) indwelling medical device tube-feeding and interventions included enhanced barrier precautions when performing high-contact care activities. On 1/27/25 at 3:38 p.m., registered nurse (RN)-A entered R54's room and failed to don PPE, R54 was lying 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 observation, interview and document review, the facility failed to ensure 2 of 2 residents (R6, R49) who were observed to have medications in their rooms, had been appropriately assessed and deemed safe to self-administer medications. Findings include: R6's facesheet printed on 1/28/25, included diagnoses of rheumatoid arthritis and dementia. R6's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R6 had moderately impaired cognition, clear speech, could understand and be understood. R6 required assistance of staff for most activities of daily living (ADL). R6 did not ambulate. R6's physician orders dated 10/28/24, included Voltaren (treats joint and muscle pain) external gel 1%. Apply 2 g (grams) to knees topically as needed for pain four times a day. Orders did not include authorization for self-administration of medication. R6's care plan dated 12/5/23, indicated R6 had pain in her knees related to arthritis and to administer pain medications per physician orders. The care plan 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 interview and document review, the facility failed to notify resident representatives following falls with subsequent transfer to the hospital for 2 of 2 residents (R20, R164) reviewed for falls. Findings include: R20's facesheet printed on 1/29/25, included diagnoses of chronic kidney disease with heart failure, dependence on renal dialysis, recent femur fracture, morbid obesity and diabetes. R20's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R20 was cognitively intact, had clear speech, could understand and be understood. R20 was independent with some activities of daily living (ADL) including eating, toileting, and self-propelling in her wheelchair. R20 was dependent upon staff for dressing, showering and transferring in and out of bed. R20's care plan dated 3/25/18, indicated a history of falls. Care plan dated 12/28/24, indicated R20 had pain and impaired mobility related to recent femur fracture with surgical repair. During an interview on 1/27/25 at 5:12 p.m., R20…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete a baseline care plan for 1 of 2 residents (R164) reviewed who was newly admitted to the facility. Findings include: R164's facesheet printed on 1/29/25, indicated R164 had been admitted on [DATE]; diagnoses included post-op orthopedic after-care for neck surgery. R164's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R164 had moderate impaired cognition, clear speech, was usually understood and could usually understand. R164 needed assistance with ADLs and did not walk independently. During an interview on 1/27/25 at 4:29 p.m., family member (FM)-B stated neither she nor R164 had received a copy of a care plan after he was admitted on [DATE]. FM-B looked through a folder of all the paperwork she had received from the facility and a baseline care plan was not among them. During review of R164's electronic medical record (EMR), a baseline care plan was not found. During review of R164's paper chart, observed a two-page,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a comprehensive care plan for 1 of 2 residents (R163) reviewed for urinary catheter. Findings include: R163's facesheet printed on 1/29/25, included a diagnoses of urinary retention. R163's discharge assessment/return anticipated Minimum Data Set (MDS) assessment dated [DATE], indicated R163 was dependent upon staff for most activities of daily living (ADL) and had an indwelling urinary catheter. R163's physician orders dated 1/27/25, indicated indwelling Foley catheter (drains urine from bladder). R163's care plan dated 1/27/25, did not include R163's urinary retention, use of an indwelling Foley catheter, leg bag, or urinary drainage bag. During an interview on 1/29/25 at 9:02 a.m., registered nurse (RN)-C who was also the MDS nurse stated she added focus areas to resident care plans, as did the nurse manager and director of nursing (DON). RN-C was informed R163's care plan did not include urinary retention or urinary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide ongoing treatment for edema for 1 of 2 residents (R5) who required leg wraps to prevent and treat edema. Findings include: R5's face sheet printed 1/29/25, included diagnoses of pneumonia, urinary tract infection, Alzheimer's disease, traumatic arthropathy (inflammation of joint) left ankle and foot, and patent foramen ovale (flap-valve opening in the heart from right to left of the top two heart chambers which generally closes at birth, causing abnormal flow of blood). R5's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R5 understands and is understood, has moderately impaired cognition, requires moderate to substantial and maximal assist with transfers and walking and has impaired range of motion in both lower extremities. R5 has had multiple falls without major injury and takes anticoagulant, diuretic and opioid medications. R5's provider orders dated 10/21/24, included…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assess and evaluate causal factors for a fall and failed to ensure interventions were implemented to reduce the risk of falls for 2 of 2 (R5, R164) who were reviewed for accidents. Findings include: R5's facesheet printed 1/29/25, included diagnoses of pneumonia, urinary tract infection, Alzheimer's disease, traumatic arthropathy (inflammation of joint) left ankle and foot, and patent foramen ovale (flap-valve opening in the heart from right to left of the top two heart chambers which generally closes at birth, causing abnormal flow of blood). R5's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R5 understands and is understood, has moderately impaired cognition, requires moderate to substantial and maximal assist with transfers and walking and has impaired range of motion in both lower extremities. R5 had more than 2 falls without major injury and takes anticoagulant, diuretic and opioid medications. A 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 ensure appropriate management of an indwelling catheter was provided for 1 of 1 residents (R163) reviewed for urinary catheter, when his leg bag had not been changed to a urinary drainage bag at night. Findings include: R163's facesheet printed on 1/29/25, included a diagnoses of urinary retention. R163's discharge assessment/return anticipated Minimum Data Set (MDS) assessment dated [DATE], indicated R163 was dependent upon staff for most activities of daily living (ADL) and had an indwelling urinary catheter. R163's physician orders dated 1/27/25, indicated indwelling Foley catheter (drains urine from bladder). R163's care plan dated 1/27/25, did not include R163's urinary retention, use of an indwelling Foley catheter, leg bag, or urinary drainage bag. During an observation on 1/27/25 at 2:21 p.m., R163 was resting in bed; urinary drainage bag visible. During an observation on 1/28/25 at 10:19 a.m., R163 was sitting on top 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure meals were served at a warm and palatable temperature to promote quality of life and nutritional intake for 3 of 3 residents (R6, R9, R35) reviewed for dining. This had the potential to affect all 30 residents who resided on second floor. Findings include: R6's facesheet printed on 1/28/25, included diagnoses of congestive heart failure (when the heart doesn't pump as it should) and diabetes. R6's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R6 had moderate cognitive impairment and ate independently after set up help. R6 was on a consistent carbohydrate, cardiac diet. R6's care plan dated 11/27/23, indicated her food preferences would be honored. R9's facesheet printed on 1/29/25, included diagnoses of stroke and diabetes. R9's admission MDS assessment dated [DATE], indicated moderate cognitive impairment and ate independently after set-up help. R9 was on a consistent carbohydrate, cardiac diet. R9's care plan dated 1/8/25,…

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 and interview, the facility failed to ensure 1 of 1 tub/shower room on second floor was maintained in good repair and in sanitary conditions for the 30 residents on second floor who could potentially use the area. Findings include: During an observation on 1/28/25 at 2:26 p.m., the second floor tub/shower room had a wall partially enclosing the shower area. The wall was covered with yellow tiles, approximately 4 inches x 4 inches in size. On the lower portion of a wall adjacent to the floor, six tiles were missing creating an opening in which wood and plaster were visible. During an interview and observation on 1/28/25 at 3:52 p.m., along with the corporate maintenance director (CMD), looked at the wall in the tub room. CMD was not aware of the missing tiles and stated maintenance relied on staff to inform them of this sort of thing so it could be repaired. CMD acknowledged this was not sanitary nor a homelike environment for residents. During an interview on 1/29/25 at 8:24 a.m., housekeeper (H)-A stated he was aware of the missing tile and stated he had told…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintained at proper temperatures to ensure palatability for 6 of 6 residents (R6, R12, R13, R14, R15, R16) interviewed who complained about cold food. Findings include: R6's face sheet dated 10/8/24, identified R6 admitted 4/24. R6's quarterly Minimum Data Set (MDS) dated [DATE], identified R6 was cognitively intact. R6 was independent with meals. R6's Grievance Form completed 9/2/24, inidicated R6 was concerned lunch had not been served until 2:00 p.m. and he had not recieved what was ordered. Additionally, almost every meal lately had been cold. Grievance was reviewed with dietary manager and interdisciplinary team at morning meeting, along with maintenance notified that hot plate warmer needed to be serviced. Corrective action included utilization of a second warmer to warm plates and stainless-steel inserts while repairs done on warmer. Dietary staff retrained on proper temperature procedures and holding temperature…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 oxygen was delivered according to physician orders for 1 of 3 residents (R8) reviewed for respiratory care. Findings include: R8's face sheet dated 10/8/24, identified R8's diagnoses included chronic respiratory failure (condition in which the lungs have trouble loading blood with oxygen or removing carbon dioxide), interstitial lung disease (progressive scarring of lung tissue), iron deficiency anemia (body does not have enough red blood cells or iron), history of pulmonary embolism (blood clot that blocks the artery in the lung), and dependence on supplemental oxygen. R8's quarterly Minimum Data Set (MDS) dated [DATE], identified R8 did not reject cares. R8 required moderate assistance with personal hygiene. R8 did not have shortness of breath. R8's physician orders dated 12/26/23, included oxygen 1 liter per minute (LPM) via nasal cannula (NC) continuously. R8's care plan dated 8/19/24, identified R8 was at risk for respiratory…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 food was stored in accordance with professional standards for food service safety by failing to label and date food, to remove expired food from food storage areas. In addition , the facility failed to ensure proper cleaning for 1 of 1 commercial mixer, ensure pans in the kitchen were completely dry before storing, accurately monitor chemical sanitization for 1 of 1 dish machine, and perform hand hygiene while serving food. These practices had the potential to affect all residents, staff and visitors consuming food at the facility. Findings include: During a tour of the kitchen's dry storage on 11/29/23 at 10:42 a.m., dietary manager (DM)-H confirmed the following observations: -an undated, opened package of marshmallows, manufacturer's expiration date of July 2023, which was not tied shut. -canned goods were not removed from their shipping flats and shrink wrap, just cut open and cans taken out from the middle. DM-H identified two dented cans of Campbell's Cream of Chicken soup amongst a flat of of…

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

Based on observation, interview and document review, the facility failed to ensure staff completed proper hand hygiene and glove use during meal preparation and distribution of meals, and failed to properly disinfect a glucometer for 1 of 2 residents (R2) . This had the ability to affect all 55 residents who consumed food in the facility. Finding include: Hand Hygiene During an observation on 11/27/23 at 6:53 p.m., nursing assistant (NA)-H removed a three-ring binder from a table and brought it to the counter. Without performing hand hygiene, NA-H got a resident meal tray from the delivery cart, removed the plate cover, and cut the sloppy joe into pieces with a fork. NA-H then started stacking plate covers from trays onto the counter, grabbed some ketchup packets, brought them to a resident table and opened one squeezing the contents onto the plate. NA-H then proceeded to gather dirty glasses by the rims, dropped them off at the counter and got two clean mugs, filled them with water and dropped them off at a resident table. During an observation on 11/27/23 at 7:03 p.m., trained…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 served meals were provided in a dignified, homelike manner when the residents food was served on trays, second floor dining room was used as a plating and serving area in 1 of 2 dining rooms reviewed. In addition, staff failed to ensure privacy during insulin administration for 1 of 1 resident (R31). Findings include: During observation on 11/27/23 at 5:45 p.m., nine residents were seated in the second floor dining room, no table settings were present, glassware, or décor. The residents were overheard and made comments they wanted to eat, when do we get to eat, I guess we don't get supper tonight, and wonder if we will ever get our food. At 5:47 p.m., dietary manager (DM)-D was observed and brought an insulated cart with plates and cook-(C)-A brought another insulated cart with food and placed the food in the warmers on the steam table located in the second floor dining room. At 5:50 p.m., nursing assistant (NA)-A and NA-B offered residents seated in the dining room beverages and stated to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and document review the facility failed to ensure all residents were consistently offered and provided a nutrient and/or calorie substantive snack after the dinner meal and before bedtime for 7 of 7 residents (R3, R8, R24, R25, R30, R35, R49) who voiced a concern. Findings include: R3's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition. R8's quarterly MDS assessment dated [DATE], indicated intact cognition. R24's quarterly MDS assessment dated [DATE], indicated intact cognition. R25's quarterly MDS assessment dated [DATE], indicated intact cognition. R30's quarterly MDS assessment dated [DATE], indicated intact cognition. R35's quarterly MDS assessment dated [DATE], indicated intact cognition. R49's quarterly MDS assessment dated [DATE], indicated intact cognition During an interview on 11/28/23 at 2:57 p.m., at a resident council meeting, residents were asked if they received snacks after dinner and before bedtime. All seven residents 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 ensure 2 of 2 residents (R51 and R1) who were observed to have medications in their rooms, had been appropriately assessed and deemed safe to self-administer medications. Findings include: R51's facesheet printed on 11/29/23, included a diagnosis of orthopedic after care following surgery for leg amputation. R51's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R51 was cognitively intact, had adequate vision and hearing, could understand and be understood. R51 required assistance or was dependent upon staff for most activities of daily living. R51's care plan initiated on 10/13/23, did not address self-administration of medications. R51's medical record did not include an assessment for self-administration of medications. R51's physician orders did not include an order for self-administration of medications. During an observation and interview on 11/27/23 2:10 p.m., observed a bottle of Prevagen (memory enhancer)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the root cause of falls and incorporate new fall interventions to prevent falls and injury for 1 of 1 resident (R45) who had frequent falls. Findings include: R45's facesheet printed on 11/29/23, included diagnoses of acute and chronic respiratory failure, COPD (chronic obstructive pulmonary disease), arthritis of both knees, muscle weakness, unsteadiness on feet, and lack of coordination. R45's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R45 was cognitively intact, had adequate vision and hearing, could understand and be understood. R45 was independent in most activities of daily living (ADL's) and did not walk due to medical condition. R45's care plan dated 8/31/22, indicated R45 was at risk for falls due to impaired mobility. Interventions included gripper socks, commonly used articles within easy reach, reinforced need to call for assistance and to wait for assistance with transfers. 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 develop and implement activity programming for 1 out of 3 residents (R15) with dementia residing in a secure dementia care unit. Findings include: R15's admission Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and diagnoses of Alzheimer's dementia, dementia with mood disturbance, major depressive disorder, and insomnia. R15's MDS identified observation of wandering behavior on up to three of seven days, and very important for her to listen to music she liked, to do things with groups of people, to get fresh air, and to attend religious activities. R15 required extensive assistance with her activities of daily living. R15's care plan identified a focus for activities, initiated on 8/18/23, which included interests of music, pets, group activities, outdoors and religious practices. Facility staff were to provide transport for R15 to and from activities of choice, to attend activity therapy exercise programming,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an insulin pen stored in the medication cart was labeled for one resident (R31) and the facility failed to ensure eye drops were discarded per manufactures instructions for one resident (R26). Findings include:. R26's medication administration record (MAR) dated [DATE]-[DATE], indicated netarsudil dimesylate (Rhopressa eye drop used to lower eye pressure) ophthalmic solution 0.02 % instill one drop in both eyes at bedtime and Latanoprost (eye drop used to treat certain kinds of glaucoma) instill one drop in both eyes at bedtime. R31's MAR dated [DATE]-[DATE], indicated an order for Novolin N Flexpen subcutaneous suspension pen-injector 100 unit/ml inject 29 unit subcutaneous in the evening. During an observation and interview on [DATE] at 6:46 p.m., registered nurse (RN)-A removed an insulin pen from R31's labeled designated space from the medication cart, the insulin pen was labeled with a manufacturers sticker with Novolin N…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 timely notification of a fall with injury according to the facility policy for 1 of 1 residents (R1) who had a bleeding disorder and a fall with a head injury. Findings include: R1's hospital Discharge summary dated [DATE], identified R1 had been admitted to the hospital on [DATE], with chief complaint of generalized weakness and acute blood loss anemia. R1 had a history of acquired platelet dysfunction with multiple bleeding events leading to frequent hospitalization. R1 was discharged from the hospital to the facility in stable condition on 10/26/23. R1's Face Sheet identified R1 had diagnoses of myelodysplastic syndrome (a group of cancers in which immature blood cells in the bone marrow do not mature or become healthy blood cells,) thrombocytopenia (a condition that occurs when the platelet count in your blood is too low,) and muscle weakness. R1's care plan dated 10/27/23, did not identify R1 had a bleeding disorder. R1's occupational…

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