Highland Chateau Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure individualized activities were provided for 1 of 2 resident (R46) reviewed for activities. Findings include:R46's face sheet printed 3/3/26, indicated diagnoses of cerebral infarction due to occlusion of small artery (stroke), hemiplegia (loss of use of left side of body), blindness, unspecified mood disorder, and communication deficit.R46's Resident Preferences Evaluation completed by activity director dated 12/18/26, indicated listening to music was very important to R46. Preferred music genre: reggae and rock.R46's care plan dated 12/16/25, indicated total assistance for dressing, personalized care: staff will accommodate/support resident's activities in care routine as able, but did not address any individualized activities preferences. R46's part A PPS discharge Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, dependent for eating, toileting hygiene, and transfers, and use of wheelchair. R46's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to implement or maintain an appropriate communication and collaboration system with an outside dialysis clinic to promote continuity of care and reduce the risk of complications for 1 of 1 resident (R4) reviewed for dialysis care. In addition, the facility failed to ensure adequate weight monitoring was implemented for 1 of 1 resident (R4) reviewed for dialysis.Findings include: R4's quarterly minimum data set (MDS) dated [DATE], indicated R4 had intact cognition and was diagnosed with heart failure, hypertension, kidney failure, and diabetes. The MDS indicated R4 was receiving dialysis (use of a machine that filters waste, salts, and fluid from the blood when the kidneys are no longer healthy enough to do so) treatments. R4's care plan dated 12/18/25, indicated R4 received hemodialysis due to kidney failure on Tuesdays, Thursdays, and Saturdays. The dialysis care plan included information such as monitoring (excluding resident weight) related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure provider orders for weekly weights were implemented and maintained for 1 of 5 residents (R33) reviewed for unnecessary medication. In addition, the facility failed to ensure non-pharmacological interventions were attempted and recorded before administration of as-needed (PRN) pain medication to reduce the risk of potential complications for 2 of 3 residents (R2, R27) reviewed for pain management.Findings include: R33's admission Minimum Data Set (MDS) dated [DATE], indicated R33 was admitted [DATE], no cognitive impairment, no rejection of care, dependent on toileting hygiene, shower/bathe, chair to bed transfer; required substantial/maximal assistance with personal hygiene and roll left and right; diagnoses included obesity, and medications included diuretic increase the excretion of water from the body). R33's care plan dated 1/5/26, indicated risk for malnutrition and interventions included: evaluate exact height obtain weight…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 antihypertensive (blood pressure) medication were administered or held per physician orders for 1 of 1 resident (R1) reviewed.Findings include:R1's admission Minimum Data Set (MDS, dated [DATE], indicated R1 had intact cognition with no hallucinations, delusions, no behaviors, wandering or rejection of care. MDS indicated R1 was independent with all activities of daily living (ADLs) except for transfers ambulation, and picking items off the floor which required supervisionR1's medical diagnosis report, dated 3/5/26, included the following diagnoses: type 2 diabetes with diabetic nephropathy, legal blindness, acute kidney failure, and chronic kidney disease.R1's care plan, printed on 3/2/26 lacked identification R1 was on blood pressure medication. Furthermore, lacked any intervention to monitor for low blood pressures or signs/symptoms of low blood pressures.R1's Order Summary Report, as of 3/2/26, included the following…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provider's orders for urinalysis were completed for 1 of 2 residents (R57) reviewed for discharge. Findings include: R57's face sheet printed 3/3/26, indicated admission date of 12/24/25, diagnoses of malignant neoplasm of parts of nervous system (cancer), repeated falls, muscle weakness, and schizoaffective disorder.R57's care plan revised 1/13/26, indicated risk for falls, limited to extensive assistance for dressing, independent for eating, extensive assistance for personal hygiene and toilet use.R57's discharge return not anticipated Minimum Data Set (MDS) dated [DATE], indicated intact cognition, no rejection of care, independent with eating, dependent for toileting hygiene, partial/moderate assistance for upper body dressing, lower body dressing, footwear, set up or clean up assistance for personal hygiene, partial/moderate assistance for going from sitting to lying, lying to sitting, sit to stand, and transfer to and from wheelchair,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 identified dental concerns (i.e., broken missing teeth, need for appointment) were acted upon and, if needed, referred to the appropriate resource in a timely manner for 1 of 1 resident (R2) reviewed who voiced dental complaints during the survey.Findings include:R2's significant change Minimum Data Set (MDS) dated [DATE], indicated R2 had intact cognition with no hallucinations, delusions, behaviors, or rejection of care. Furthermore, MDS indicated in Section L: Oral/Dental Status: R2 had obvious or likely cavities or broken natural teeth.R2's care plan, printed 3/2/26, lacked identification of R2's needs with oral hygiene. Furthermore, R2's care plan lacked evidence of R2's dental needs. R2's Social Service Care Conference Note, dated 10/1/25, indicated R2 attended the care conference along with staff. In the Social Services section, a note indicated dentist and ostomy referral.During an interview on 3/2/26 at 12:44 p.m., R2 stated she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure identified preferences for menu selection were honored for 1 of 3 residents (R27) reviewed for nutrition. Findings include:R27's significant change Minimum Data Set (MDS) dated [DATE], indicated R27 had intact cognition with no behaviors exhibited. The MDS indicated R27 was diagnosed with heart failure, kidney failure, diabetes, and arthritis. The MDS indicated R27 was independent with the ability to use utensils to bring food or liquids to her mouth once the meal was placed in front of her. R27's registered dietician note dated 1/6/26 at 5:11 p.m., indicated R27 had a diagnosis of diabetes, and her blood sugars were mostly less than 200 milligrams/deciliter (mg/dl), indicating adequate control. and R27's only concern at that time was that her blood sugars were higher and she would prefer to have a diabetic diet instead of a regular diet. The note indicated the dietician recommends providing a diabetic diet and notified nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess and implement individualized interventions to ensure safe independent community access for 1 of 3 residents (R1) who had expressive aphasia and cognitive impairment and went on community outings independently placing R1 at risk for inability to effectively communicate needs or obtain assistance while unsupervised in the community.Findings include:A vulnerable adult maltreatment report dated 2/14/26 indicated R1 had been out in the community independently without staff or family escort. R1 was unable to articulate clear responses to questions or needs, and information could not be obtained easily.R1's diagnoses list dated 2/20/26 included stroke, bipolar disorder, aphasia (a communication disorder resulting from brain damage), diabetes type II, anxiety disorder, other symptoms and signs involving cognitive functions and awareness, and encephalopathy. R1's admission Minimum Data Set, dated [DATE] indicated R1 had moderate cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure the contents of a 30-day discharge notice included the correct information for 2 of 2 residents (R2, R7) reviewed for admission/discharge.Findings include:Findings include:R2's face sheet dated 1/15/26, identified diagnosis of alcoholic cirrhosis (a final irreversible stage of alcohol associated liver disease), chronic viral hepatitis C (a bloodborne virus that causes liver inflammation), chronic obstructive pulmonary disease (a lung disease that causes severe airflow blockage) , absence of left leg above the knee, anxiety disorder (a mental health condition involving persistent, excessive fear of worry) and depression (a common serious mood disorder characterized by persistent sadness).R2's minimum data set (MDS) dated [DATE], identified R2 was independent with transfers and was cognitively intact.R2's smoking focus care plan dated 9/15/25, identified R2 was a smoker. Goal to not suffer injury from unsafe smoking practices.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 designate a registered nurse to serve as the director of nursing (DON) on a full-time basis following the exit of the former DON. This practice had the potential to affect all 54 residents who resided at the facility. Findings include: Upon entrance interview on 12/29/25 at 9:39 a.m. licensed practical nurse, (LPN)-B stated she was the only administration staff on duty and had been acting as the DON for the last two weeks. The former DON's human resource file indicated she was let go of her duties on 12/17/25. Upon interview on 12/30/25 at 9:17 a.m. the Director of Human Resources stated he was not certain who was acting as the DON currently. He stated that he was not involved in the hiring process of a new DON as the corporate office had been taking care of new DON applications and interviews. Upon interview on 12/30/25 at 3:46 p.m. the Administrator stated the facility did not have a DON. The facility was using a team effort with the ADON, nursing staff and the [NAME] President of Clinical Services to cover the open role.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 revise R1's care plan after a change occurred for 1 of 3 residents reviewed for care plan development and implementation. R1's care plan was not revised to include increased needs in cares for home exercise program dated 9/11/25 by physical therapy (PT), for R1's comprehensive assessment dated [DATE] for maximum assistance in some of her ADL's, and to restart therapy on 11/18/25.Findings include: R1's care plan dated 4/28/25 indicated R1's functional status required: Dressing supervision and set-up only. Eating - independent, no set-up or physical help. Personal hygiene - independent, no set-up or physical help. Toilet use - independent, no set-up or physical help. Transfers - independent, no set-up or physical help. R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 had a Brief Inventory of Mental Status (BIMS) score of 15 indicating R1 was cognitively intact. R1 had no limited ROM in her upper extremities or lower extremities. She was…

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

Based on observation, interview and document review, the facility failed to ensure metal pans were clean and dry before storing. In addition, the facility failed to monitor dish machine temperatures to ensure dishes were properly cleaned and sanitized. Further, the facility failed to ensure food temperatures were documented at the time of meal service. In addition, the facility failed to follow manufacturer's instructions for cleaning and sanitizing 2 of 2 ice machines used for resident consumption. This had the potential to affect all 42 residents who resided in the facility. Findings include:WET PANSDuring the initial kitchen tour on 9/15/25 at 11:55 a.m., with dietary aide (DA)-B, metal pans of various sizes were observed stacked upside down on top of one another on a tall wire cart. The inside surfaces of three large rectangle pans were dripping wet with water when DA-B lifted them off one another. One of the pans had clearly not been cleaned as the entire bottom of the pan resembled what it would look like if cake were scraped out of the pan. DA-B stated it was from chicken 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 document review, the facility failed to ensure the Quality Assurance Assessment and Performance Improvement Plan (QAPI) committee effectively sustained ongoing compliance related to repeat citations from past surveys in regards to quality of care, accuracy of assessments, activities of daily living (ADL) care provided, accidents, nutrition, tube feeding, sufficient nursing staff, food procurement, infection prevention and control and pest control, and were also identified during this survey. Additionally, the facility failed to have evidence of a Performance Improvement Project (PIP) which focused on high risk or problem-prone areas, identified thorough and appropriate data collection, analysis and evaluation of the identified concern(s) during QAPI. This had the potential to affect all 42 residents residing in the facility.Findings include: Review of the Provider History report printed 9/15/25, identified the facility had repeat deficiencies related to F641 accuracy of assessments, F684 quality of care, F689 free of accident and hazards, F692…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 glucometer was cleaned per manufactures guideline for 1 of 1 resident (R9) observed for blood glucose testing, ensure enhanced barrier precautions (EBP) were followed for 2 of 2 residents (R26 and R41) observed for enhanced barrier precautions, ensure 1 of 1 resident (R26) had a clean water cup in place. In addition, the facility failed to ensure resident lift equipment was cleaned per manufactures guidelines, and a comprehensive Legionella prevention plan was in place. This had the potential to affect all residents who reside in the facility. Findings include: Glucometer R9's face sheet dated 5/17/25, indicated R9 had diagnoses of diabetes and left below the knee amputation. A document titled Evencare G3 Healthcare Professional Operators Manual dated 2017, directed the Evencare G3 meter should be disinfected between each resident. A list of approved products for cleaning were listed. Alcohols wipes were not included in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to implement an effective pest control program to eliminate mice in the building. In addition, concerns related to pest control in the facility were voiced by 4 of 4 residents (R3, R36, R10, R14). This failure had the potential to affect all 42 residents who resided in the facility.Findings include:R3's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated moderately impaired cognition. R36's quarterly MDS assessment dated [DATE], indicated intact cognition. R10's quarterly MDS assessment dated [DATE], indicated intact cognition.R14 significant change MDS assessment dated [DATE], indicated intact cognition.During an interview on 9/15/25 at 6:16 p.m., R3 stated about three weeks ago he had seen mice running in the hallway, entering his bathroom, and going under his closet door. Observations occurred while lying in bed. During an interview on 9/15/25 at 6:24 p.m., R36 stated he had seen a mouse run under his bed recently - could…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to ensure residents were assessed for safe self-medication administration for 4 of 4 residents (R14, R37, R13, R1) who had medications at the bedside. Findings include: R14's face sheet received on 9/19/25, included diagnoses of chronic respiratory failure (lungs unable to adequately exchange oxygen and carbon dioxide over an extended period), high blood pressure, kidney failure and atrial fibrillation (irregular heart rate causing poor blood flow). R14's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, was understood and could understand. R14 required substantial assistance for activities of daily living (ADLs). R14's medical record did not include an assessment for self-administration of medications. R14's care plan reviewed on 9/16/25, did not include self-administration of medications. R14's provider orders reviewed on 9/16/25, lacked indication R13 was able to self-administer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 have sufficient staff available to provide nursing and related services to meet the residents' needs in a manner that promotes each resident's right to physical, mental, and psychosocial well-being for 10 of 10 residents reviewed for sufficient staffing (R4, R53, R11, R18, R5, R3, R29, R37, R43, R23). Findings include: RESIDENT STAFFING CONCERNS R4's part A discharge Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, setup assistance with eating, dependent for toilet use and bathing, partial assistance with upper body dressing, dependent for lower body dressing, and use of wheelchair. R53's admission MDS assessment dated [DATE], indicated intact cognition, independent with eating, extensive assistance for transfers, personal hygiene, and bed mobility, and use of wheelchair. R11's significant change MDS assessment dated [DATE], indicated intact cognition, no rejection of care, dependent with toileting hygiene 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 1 of 4 residents (R23) reviewed for dignified care, was provided toileting assistance in a timely manner.Findings include: R23's face sheet provided on 9/19/25, included diagnoses of congestive heart failure, obesity, diabetes, depression and anxiety. R23's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood. R23's PHQ9 score (depression screening tool) indicated mild depression. Assessment indicated R23 was independent with activities of daily living.R23's physician orders dated 9/1/25, included monitoring R23 for signs and symptoms of depression, including hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing negative statements, repetitive anxious or health-related complaints, and tearfulness, daily for 6 weeks. R23's care plan dated 5/7/25, indicated R23 had impaired coping skills. Care plan with revised date of 9/15/25, indicated R23…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 homelike environment for 1 of 1 resident (R2) who had feeding tube formula hooked up to the feeding tube pump in R2's room after the feeding tube was removed. Findings include:R2's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, did not reject care, was very important to take care of personal items or things, had a diagnosis of malnutrition, and had a feeding tube. R2's Orders form indicated the following orders:6/11/25, regular diet, regular texture, and thin liquids.8/5/25, enteral feed order two times a day for tube feeding to be run 12 hours daily. Administer Nutren or Isosource (types of feeding tube formulas) 1.5 at 100 milliliters (ML) per hour via feeding tube. 9/5/25, consult with GI/colorectal for PEG (feeding tube) removal and colostomy reversal evaluation.R2's medication administration record (MAR) dated September 2025, indicated R2 received enteral feeding up until…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure the Minimum Data Set (MDS) assessment was coded accurately for 2 of 2 residents (R14, R37) reviewed for MDS accuracy.Findings include:R14's face sheet received on 9/19/25, included diagnoses of chronic respiratory failure (lungs unable to adequately exchange oxygen and carbon dioxide over an extended period), high blood pressure, kidney failure and atrial fibrillation (irregular heart rate causing poor blood flow). R14's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, adequate hearing, clear speech, was understood and could understand. R14 required substantial assistance for activities of daily living (ADLs). R14's Section B of the MDS dated [DATE], indicated: ability to hear was adequate, which according to the MDS meant no difficulty in normal conversation, social interaction, listening to TV.R14's care plan dated 12/8/24, indicated risk for impaired communication. Revision on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure the care plan included management and monitoring of an antipsychotic medication for 1 of 2 residents (R2) reviewed for antipsychotic use. Findings include:R2's Medical Diagnosis form indicated the following diagnoses: adjustment disorder with mixed anxiety and depressed mood, schizoaffective disorder, bipolar type, and post-traumatic stress disorder (PTSD). R2's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R2 had intact cognition, did not hallucinate or have delusions, did not have physical, verbal or other behavioral symptoms, did not reject care, and R2's behavior was the same since the previous assessment. Additionally, R2 had trouble falling or staying asleep or sleeping too much for 2 to 6 days and took an antipsychotic.R2's care area assessment (CAA) dated 6/26/25, triggered for psychotropic drug use because R2 took an antipsychotic and an antidepressant. The CAA indicated a potential problem and adverse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care plans were revised and updated with current health status for 3 of 4 residents (R4, R27, R13) reviewed for care planning. Findings include: R4's face sheet printed 9/17/25, indicated diagnoses of congestive heart failure, diabetes type two, chronic kidney disease, and dependence on renal dialysis (treatment that replaces the function of the kidneys when they are no longer able to adequately filter waste products and excess fluid from the blood). R4's part A discharge Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, setup assistance with eating, dependent for toilet use and bathing, partial assistance with upper body dressing, dependent for lower body dressing, and use of wheelchair. R4's physician's orders printed 9/16/25, lacked any orders related to dialysis, including monitoring the dialysis site and communicating with dialysis company. R4's care plan revised 8/31/22 lacked information related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure activities of daily living (ADL) assistance was provided for 1 of 1 resident (R27) reviewed for ADLs who required supervision and cueing during meals. Findings include:R27's Optional State Assessment (OSA) dated 8/29/25, indicated moderate cognitive impairment and required limited assistance with bed mobility, transfers, toileting, and supervision for eating. R27's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R27 did not reject care, had impairment on one side to her upper extremity and used a wheelchair. Further, R27's diagnoses included hemiplegia (paralysis of one side of the body) following a cerebral infarction (stroke) affecting her right dominant side, apraxia (the inability to plan and execute purposeful, skilled movements), other speech language deficits following cerebral infarction, dysphagia (difficulty swallowing foods or liquids) following cerebral infarction. Additionally, R27 did not have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ADL (activities of daily living) care to 1 of 1 resident (R14) reviewed for ADLs and who was dependent upon staff for bathing. Findings include:R14's face sheet received on 9/19/25, included diagnoses of chronic respiratory failure (lungs unable to adequately exchange oxygen and carbon dioxide over an extended period), high blood pressure, kidney failure and atrial fibrillation (irregular heart rate causing poor blood flow). R14's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, adequate hearing, clear speech, was understood and could understand. R14 was continent of bowel and bladder; required substantial/maximal assistance for activities of daily living (ADLs) including bathing. R14's care plan dated 1/11/25, indicated R14 had a self-care deficit with bathing and preferences would be considered when providing care. Care plan dated 12/23/24, indicated choosing bath type was very…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 wound care orders were implemented for 2 of 2 residents (R13, R26) who had venous ulcers (skin openings caused by weak blood circulation), failed to ensure provider-ordered leg measurements were completed and documented for 1 of 1 resident (R29) reviewed for edema management, and failed to obtain a weight upon admission and follow orders for 1 of 3 residents (R46) reviewed for hospitalization. Findings include: IMPLEMEATION OF WOUND CARE ORDERS- NON-PRESSURE WOUNDS R13's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R13 had moderate cognitive impairment and diagnoses of venous insufficiency (poor blood flow to lower extremities), cellulitis (skin infection) of the left lower extremity, and heart failure. Furthermore, R13 had 3 venous ulcers and was at risk for skin breakdown R13's skin care area assessment (CAA) dated 7/25/25, indicated R13 was at risk for skin breakdown related to cognitive loss 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 a palm brace was used for 1 of 1 resident (R27) reviewed for range of motion.Findings include:R27's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R27 did not reject care, had impairment on one side to her upper extremity and used a wheelchair. Further, R27's diagnoses included hemiplegia (paralysis of one side of the body) following a cerebral infarction (stroke) affecting her right dominant side, apraxia (the inability to plan and execute purposeful, skilled movements), other speech language deficits following cerebral infarction. Additionally, R27 did not have physical therapy (PT) or occupational therapy (OT) and was not on a restorative nursing program for range of motion or splint or brace assistance. R27's care plan revised 7/7/25, indicated R27 had a functional maintenance plan for the potential for contracture and R27 refused to use the splint that was provided. R27's goal was to maintain her level of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure a nutritional supplement was ordered and implemented per the dietician recommendation for 1 of 1 resident (R3) reviewed for food. Findings include: R3's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated moderately impaired cognition, no rejection of care, setup assistance for eating, and diagnosis included severe protein-calorie malnutrition.R3's care plan revised dated 7/29/25, indicated R3 impaired nutrition. severe protein-calorie malnutrition and interventions encourage resident / representative participation in meal planning provide, serve diet/supplement as ordered, monitor intake and record every meal.R3's dietary note dated 7/29/25 at 2:55 p.m., registered dietician (RD)-N no significant weight changes noted, weight fluctuations are expected related to ETOH (alcohol) abuse and severe protein-calorie malnutrition. RD recommends offering Glucerna (meal replacement product) or similar HNS (house nutritional…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to follow physician orders to provide appropriate gastrostomy/jejunostomy (GJ Tube) tube feeding (TF) solution and to use appropriate tube to administer medication for 1 of 1 resident (R41) reviewed for tube feeding administration. Findings include:G-J tube is a tube placed through the skin into the stomach and fed into the small intestine. There are 3 ports on the tubing outside of the skin that serve different purposes. The gastric port tube sits in the stomach and is used to give medications, vent air and drain fluids. The Jejunal port sits in the small intestines and is used for feeding. (John Hopkins Medicine, undated). R41's face sheet received on 9/19/25, identified current diagnoses including acute hemiplegia (one-sided paralysis) following cerebral infarction (stroke) affecting the right dominant side, protein-calorie malnutrition, metabolic encephalopathy (change in brain function due to an underlying health issue), dysphagia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 continuous positive airway pressure (CPAP) therapy was used in accordance with physician orders to meet the individual needs for 1 of 3 residents (R6) reviewed for respiratory care and services. Findings include:R6's face sheet received on 9/8/25, included diagnoses of morbid (severe) obesity, heart failure, acute respiratory failure, chronic pain, and obstructive sleep apnea (breathing repeatedly stops and starts during sleep due to obstruction in upper airway). R6's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, no behaviors including refusal of care. Activities of daily living (ADL's) included R6 does not walk, and was independent with all transfers, eating and personal hygiene. Special treatments included CPAP and oxygen use. R6's plan of care dated 8/13/25, included administer oxygen as prescribed or per standing order at 4 liters per nasal cannula, CPAP per order, evaluate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, and staff interview, the facility failed to ensure provider-ordered pain medications were administered for 1 of 3 residents (R29) reviewed for pain management.Findings include:R29's significant change in status Minimum Data Set (MDS) assessment dated [DATE], indicated R29 was admitted [DATE], cognitively intact, utilized a manual wheelchair, independent with upper body dressing, personal hygiene, transfers, diagnoses included diabetes, chronic pain, polyneuropathy (malfunction of many peripheral nerves throughout the body causes painful tingling or burning sensations), and morbid obesity.R29's care plan dated 6/12/25, indicated acute pain/chronic pain, apply hot or cold packs for comfort, establish a pain management treatment plan, evaluate for non-verbal indicators of pain.R29's medication administration record (MAR) dated 9/1/25-9/30/25, indicated start date 8/12/25, buprenorphine (manage moderate to severe pain) sublingual (applied under the tongue) tablet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure ongoing assessment of resident's condition and monitoring for complications before and after dialysis treatments and failed to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for 1 of 1 resident (R4) reviewed for dialysis services.Findings include:R4's face sheet printed 9/17/25, indicated diagnoses of congestive heart failure, diabetes type two, chronic kidney disease, and dependence on renal dialysis. R4's part A discharge Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, setup assistance with eating, dependent for toilet use and bathing, partial assistance with upper body dressing, dependent for lower body dressing, and use of wheelchair.R4's physician's orders printed 9/16/25, lacked any orders related to dialysis, including monitoring the dialysis site and communicating with dialysis company.R4's care plan revised 8/31/22, lacked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication error rate of less than 5 percent (%). 3 medication errors occurred out of 35 opportunities resulting in an error rate of 8.57% for 2 of 5 residents (R41, R19) observed during medication administration. Findings include: G-J tube is a tube placed through the skin into the stomach and fed into the small intestine. There are 3 ports on the tubing outside of the skin that serve different purposes. The gastric port tube sits in the stomach and is used to give medications, vent air and drain fluids. The Jejunal port sits in the small intestines and is used for feeding. (John Hopkins) R41's face sheet provided on 9/19/25, identified that R41's current diagnoses included acute hemiplegia (one-sided paralysis) following cerebral infarction (stroke) affecting the right dominant side, protein-calorie malnutrition, metabolic encephalopathy (change in brain function due to an underlying health issue), dysphagia (difficulty…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 antibiotics were administered as prescribed for 1 of 1 resident (R13) reviewed for infection, thus leading to a significant medication error. Findings include: R13's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R13 had moderate cognitive impairment and diagnoses of chronic respiratory failure, cellulitis (common bacterial infection of the skin and underlying tissues which causes inflammation, redness, swelling, and pain) of the left lower extremity, and heart failure. R13's provider order dated 9/11/25, indicated R13 required doxycycline hyclate capluse100 milligrams (mg) twice daily for 7 days for cellulitis. R13's medication administration record (MAR) dated 9/2025, indicated R13 received doxycycline hyclate on the evening of 9/11/25. The MAR indicted the dose was not available for the morning of 9/12/25 and then was discontinued. R13's Automatic Therapeutic Interchange Communication form dated 9/12/25,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and document review, the facility failed to timely refer 1 of 2 residents (R27) to dental services reviewed for dental services. Finding include:R27's Optional State Assessment (OSA) dated 8/29/25, indicated moderate cognitive impairment, and required supervision for eating. R27's quarterly Minimum Data Set (MDS) dated [DATE], indicated R27 had moderate cognitive impairment, did not reject care, had impairment on one side to her upper extremity and used a wheelchair. Further, R27's diagnoses included hemiplegia (paralysis of one side of the body) following a cerebral infarction (stroke) affecting her right dominant side, apraxia (the inability to plan and execute purposeful, skilled movements), other speech language deficits following cerebral infarction, dysphagia (difficulty swallowing foods or liquids) following cerebral infarction. Additionally, R27 did not have signs and symptoms of a possible swallowing disorder, was on a therapeutic diet, and did not have broken or loosely…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to provide a diet as ordered for 1 of 1 resident (R27) reviewed for correct diet textures.Findings include:R27's Optional State Assessment (OSA) dated 8/29/25, indicated moderate cognitive impairment and required limited assistance with bed mobility, transfers, toileting, and supervision for eating. R27's quarterly Minimum Data Set (MDS) dated [DATE], indicated R27 did not reject care, had impairment on one side to her upper extremity and used a wheelchair. Further, R27's diagnoses included hemiplegia (paralysis of one side of the body) following a cerebral infarction (stroke) affecting her right dominant side, apraxia (the inability to plan and execute purposeful, skilled movements), other speech language deficits following cerebral infarction, dysphagia (difficulty swallowing foods or liquids) following cerebral infarction. Additionally, R27 did not have signs and symptoms of a possible swallowing disorder, was on a therapeutic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 their antibiotic stewardship program was implemented for 1 of 1 resident (R13) who was taking an antibiotic. Findings include:R13's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R13 had moderate cognitive impairment and diagnoses of chronic respiratory failure, cellulitis (common bacterial infection of the skin and underlying tissues which causes inflammation, redness, swelling, and pain) of the left lower extremity, and heart failure. R13's provider order dated 9/14/25, indicated R13 required doxycycline monohydrate capsule100mg twice a day for 7 days for cellulitis on the lower legs.R13's medical record lacked indication R13 had monitoring in place for the cellulitis infection. R13's care plan revised 7/21/25, indicated R13 was at risk for infection due to vascular ulcers on bilateral lower extremities. Interventions included to monitor for signs and symptoms of infection. When interviewed on 9/17/25 at 10:03…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2 of 5 residents (R6 and R35) were offered, educated on risks and benefits and administered or refused the pneumococcal vaccine in accordance with the Center for Disease Control (CDC) recommendations. Findings include:R6's face sheet received 9/18/25, included diagnoses of morbid (severe) obesity, heart failure, acute respiratory failure, chronic pain, and obstructive sleep apnea (breathing repeatedly stops and starts during sleep due to obstruction in upper airway). R6's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R6 had intact cognition, no behaviors including refusal of care. Activities of daily living (ADL's) included R6 did not walk, and was independent with all transfers, eating and personal hygiene. Special treatments included CPAP and oxygen use. R6's Immunization Report undated, did not include offer, refusal or education on risks and benefits of the pneumoccal vaccine. R6 was [AGE] years of age, 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 document review, the facility failed to ensure oxycodone hydrochloride (HCL, a narcotic pain medication used to treat moderate to severe pain) was administered per physician orders for 1 of 3 residents (R1) reviewed for pain management. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact, admitted to the facility on [DATE], and had diagnoses that included multiple fractures and trauma. R'1 s care plan dated 5/19/25 and reviewed 6/5/25 and lacked information related to pain management. R1's Provider Orders indicated the following for pain management: acetaminophen oral tablet 500 mg, dated 5/17/25, give 1000 mg by mouth three times a day for pain, max 4000 mg in 24 hours gabapentin oral capsule (medication used to treat nerve pain) 600 mg, dated 5/11/25 to start 5/18/25, give 1200 mg by mouth one time a day for pain gabapentin oral capsule 300 mg, dated 5/11/25 to start 5/17/25 at 8:00 p.m., give 900 mg orally one time a day for nerve…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Facility Resident Call System policy dated 3/5/25, indicated calls for assistance were answered as soon as possible, but no later than 5 minutes. Urgent requests for assistance are addressed immediately. Call light response times were reviewed as part of the QAPI program. Based on observation, interview, and document review, the facility failed to provide sufficient staffing and/or oversight of non-licensed nursing staff to ensure 7 of 7 residents (R16, R37, R12, R38, R8, R4, R21) received care and assistance as needed and in a timely manner. These deficient practices had the potential to affect all 47 residents who resided in the facility. Findings include: Refer to F677: The facility failed to ensure routine personal hygiene care (i.e., nail care) was provided for 1 of 1 resident (R22) reviewed for activities of daily living (ADLs) who was dependent on staff for his care. Refer to F690: The facility failed to have comprehensive incontinence care plan and provide timely assistance with toileting for 1 of 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure employed and agency nursing assistants (NA's) received appropriate orientation, training and supervision. In addition, the facility failed to ensure 2 of 5 nursing assistants (NA-A and NA-C) received and demonstrated required competency skills for resident cares. Further, NA-C had not completed all in-service trainings upon hire. This had potential to affect all 47 residents who resided in the facility. Findings include: R33's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R33 was cognitively intact. R47's quarterly MDS assessment dated [DATE], indicated R47 was cognitively intact. During an interview on 4/21/25 at 4:53 p.m., R33 stated agency staff had no get up and go. R33 stated there were no standards; no one holding them accountable to make sure they were doing their job. Reviewed binder provided by the administrator which was used for new employee and agency orientation. Review of the binder indicated one or two…

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

Based on interview and document review the facility failed to employ either a full-time registered dietician (RD) or a qualified dietary manager (DM) to carry out the functions of the food and nutrition service, which had the potential to affect 44 of 44 residents who received food from the kitchen. Findings include: During interview on 4/21/25 at 2:39 p.m., the dietary manager (DM) stated she had a food safety certification and an MDH certification, but did not have her qualifications on hand. During interview on 4/22/25 at 12:16 p.m., DM stated, the administrator told DM to bring her certifications in on Thursday, 4/24/25. DM stated the registered dietician (RD)-I worked every day. During interview on 4/23/25 at 7:53 a.m., RD-I stated he was the dietician for the facility, was contracted, and had been with the facility for 5 or 6 years and worked on Mondays. When asked about RD-I's FTE status, RD-I stated he had to look at his hours report and stated he worked 10 to 12 hours per week and again stated he usually only came in on Mondays. During interview on 4/23/25 at 2:38 p.m., DM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 During an interview on 4/24/25 at 1:44 p.m., the director of nursing (DON) was informed of the dead mouse finding and stated the facility had not had a mouse sighting in over 90 days or longer but would put a plan in place. Facility Pest Control policy dated 9/6/23, indicated on-going measures are taken to prevent, contain and eradicate common household pests such as roaches, ants, mosquitoes, flies, mice and rats. General measures to decrease pests include elimination of cracks and crevices, proper lighting and ventilation, use of screen on windows and doors, and the use of self-closing doors. All food stored in the dietary area is kept in a designated area in securely covered containers, is off the floor and away from walls. All food items kept in resident rooms are stored in covered containers, with the exception of uncut fruits such as bananas and oranges, a contract with a pest control company will be elected to assure regular inspection and application of chemical pesticides. Staff will report all…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 kitchen food items were labeled and dated, scoops were not stored in the dry bins, opened foods were properly wrapped or stored, outside food containers were cleaned. In addition the facility failed to ensure resident meals brought from outside were labeled and dated in the 1 of 1 kitchenettes. This had the potential to affect all residents who consumed food from the kitchen. Findings include: See also F925 related to pest control. During the tour of the kitchen on 4/21/25 from 2:01 p.m., to 2:15 p.m., with the dietary manager (DM), observed the following: The kitchen refrigerator: • A sponge cake that was opened, unlabeled and undated and the DM asked to have it labeled. • A container of dried milk dated 1/11, DM verified was dated 1/11 and stated dried milk was good for a week and it wasn't kept because it could grow yeast inside the bag. The kitchen freezer: • 1 box containing gluten free pasta shells was stored on the floor and packages of vegetables were located on top of the box and DM stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to provide a dignified experience for 2 of 2 residents (R30 and R1) who did not have clothing to wear and were spoken to in an undignified manner by staff. Findings include: R30's face sheet printed 4/24/25, indicated diagnoses of weakness, adult failure to thrive, morbid obesity, and bipolar disorder with psychotic features. R30's significant change minimum data set (MDS) assessment dated [DATE], indicated intact cognition, no rejection of care, use of a wheelchair, substantial assistance with upper body dressing, and dependence on staff for lower body dressing. R30's care plan printed 4/24/25, indicated R30 required extensive assistance of one staff for dressing, and limited assistance of one staff for bed mobility and eating. During interview on 4/21/25 at 3:27 p.m., R30 stated one of the nursing assistants had a terrible attitude and scolded her for accidentally getting vomit on her shirt. R30 stated she did not think it was abuse, 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 interview and document review, the facility failed to provide timely notification to a family member for change of condition and hospitalization for 1 of 1 resident (R22) reviewed for change in condition. Findings include, R22's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R22 was severely cognitively impaired, had no behaviors and did not refuse personal cares. R22's MDS indicated diagnoses of cerebral infarction, quadriplegia, essential hypertension, and seizure disorders. A review of R22's progress notes contained the following information: - Progress noted dated 2/4/25, indicated R22 was coughing more than usual, and blood was coming out of his mouth. R22 had bitten his lower lip. Progress note indicated the nurse practitioner was updated and gave an order for cough medication as needed. - Progress note dated 2/5/25, indicated change in health condition. Progress note indicated the nurse practitioner was updated and ordered to send R22 to the hospital for further 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 observation, interview, and document review the facility failed to investigate a report of missing clothing for 1 of 1 resident (R30) who reported missing clothing items to nursing staff. Findings include: R30's face sheet printed 4/24/25, indicated diagnoses of weakness, adult failure to thrive, morbid obesity, and bipolar disorder with psychotic features. R30's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, no rejection of care, use of a wheelchair, substantial assistance with upper body dressing, and dependence on staff for lower body dressing. R30's care plan printed 4/24/25, indicated R30 required extensive assistance of one staff for dressing, and limited assistance of one staff for bed mobility and eating. During interview on 4/21/25 at 3:32 p.m., R30 stated she was missing clothing and had told a nurse about it but could not recall the nurse's name. R30 stated the nurse responded that she would look into the missing clothing, but R30 had not heard…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Minimum Data Set (MDS) was accurately coded for 1 of 2 residents (R16) reviewed for MDS accuracy. Findings include: R16's annual MDS assessment dated [DATE], indicated R16 had limited range of motion of upper extremities and was cognitively intact with diagnoses including renal insufficiency, amputation, diabetes, heart failure and atrial fibrillation. Section N0415 indicated R16 was taking an antidepressant, an antibiotic but didn't indicate taking an anticoagulant. A section of the RAI labeled, Section N-Medications, outlined directions for coding the subsequent sections including N0415: High-risk Drug Classes. High-risk drug classes included antipsychotics, antianxiety, antidepressant, hypnotic, anticoagulant, antibiotic, diuretic, opioid, antiplatelet, hypoglycemic or none of the above. During interview on 4/24/25 at 2:59 p.m., director of nursing (DON) stated the MDSs were completed by a person at the corporate office. DON stated she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to offer/provide a summary of the baseline care plan to the resident and/or resident's representative for 1 of 1 resident (R36) reviewed for baseline care plan. Findings include: R36's Clinical Profile dated 4/23/25, identified an admission date of 3/12/25, with diagnoses of infection and inflammatory reaction due to unspecified internal joint prosthesis. R36''s admission Minimum Data Set (MDS) assessment dated [DATE], indicated R36 was admitted to the facility on [DATE], was cognitively intact, and had no behaviors or delusions. MDS indicated resident was on a pain management program, received medications for pain as needed, had a surgical wound, had oxygen, and received occupational and physical therapy services. R36's Electronic Medical Record (EMR) lacked evidence of a baseline care plan had been provided to R36. R36's EMR included a progress note authored by social services (SS)-A dated 4/4/25, indicating R36 wished to discharge to a sober house…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care plan was developed and maintained for 2 of 2 residents reviewed, (R7) who was assessed for facility acquired pressure ulcers and (R4) for respiratory cares. Findings include: R7's face sheet printed 4/24/25, indicated R7 had diagnoses including fracture of shaft of right tibia (main long bone of lower leg), type 2 diabetes mellitus, morbid obesity and pulmonary embolism (blood clot that blocks blood flow in the lung). R7's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R7 was cognitively intact, had no behaviors, had a Foley catheter present and was always incontinent of stool. Activities of daily living assessment indicated not assessed. Risk of pressure ulcers (PU) was answered no and R7 had no unhealed pressure ulcers. A Braden Scale (risk assessment tool for patient's risk of developing pressure injuries) completed for R7 on 2/14/25, indicated a score of 13 which indicates moderate risk…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 R31's face sheet received on 4/24/25, included diagnoses of left below the knee amputation, diabetes, protein calorie malnutrition, and depression. R31's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R31 was cognitively intact, had clear speech, could understand and be understood. R31 was able to transfer from bed to wheelchair independently and self-propel wheelchair throughout the facility. R31's care plan with revised date of 1/7/25, indicated R31's preferences would be considered when providing care. During an interview on 4/22/25 at 9:42 a.m., R31 stated she did not recall having had a care conference. A care conference was explained to her, and she still did not recall having had one. During an interview on 4/23/25 at 12:19 p.m., social services (SS)-A stated care conferences were conducted quarterly, as needed, or at family or resident request. SS-A provided two care conference notes for R31 titled Social Services Care Conference - one dated 6/5/24, and one dated 4/18/25. Both notes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure routine personal hygiene care (i.e., nail care) was provided for 1 of 1 resident (R22) reviewed for activities of daily living (ADLs) who was dependent on staff for his care. Findings include: R22's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R22 was severely cognitively impaired, had no behaviors and did not refuse personal cares. R22's MDS indicated diagnoses of cerebral infarction (stroke), quadriplegia (paralysis of arms and legs), essential hypertension, and seizure disorders. R22's care plan printed 4/24/25, indicated R22 had a self-care deficit with bathing, dressing and feeding. This care plan directed staff to assist R22 with activities of daily living (ADL). A care plan titled Current Functional Performance identified R22 needed total assist with personal hygiene. During observation on 4/21/25 at 4:10 p.m., resident was sleeping in bed. R22's fingernails were about half an inch long and had black…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 properly transcribe and implement physician orders for a resident requiring edema and surgical incision monitoring for 1 of 1 resident (R36) reviewed for edema and skin conditions. Findings include, R36's Clinical Profile dated 4/23/25, identified an admission date of 3/12/25. R36's Clinical Diagnoses report printed 4/23/25, indicated diagnoses of infection and inflammatory reaction due to unspecified internal joint prosthesis, presence of right artificial knee joint, acute on chronic diastolic heart failure, cellulitis of right lower extremity, and acute and chronic respiratory failure. R36's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R36 was admitted to the facility on [DATE]. R36 was cognitively intact, had no behaviors or delusions. MDS indicated resident was on pain management, received medications for pain as needed, received intravenous antibiotics, had a surgical wound, used oxygen, and received…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to implement interventions to prevent the development of new pressure ulcers for 1 of 3 residents (R7) who were reviewed for pressure ulcers. Findings include: R7's Face Sheet printed 4/24/25, indicated R7 had diagnoses including fracture of shaft of right tibia (main long bone of lower leg), type 2 diabetes mellitus, morbid obesity and pulmonary embolism (blood clot that blocks blood flow in the lung). R7's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R7 was cognitively intact, had no behaviors, had a Foley catheter present and was always incontinent of stool. Activities of daily living assessment indicated not assessed. Risk of pressure ulcers (PU) was no and R7 had no unhealed pressure ulcers. A Care Area Assessment (CAA) dated 2/14/25 included a risk for wound care plan will be initiated. A PU/injury will not be addressed in the plan of care. Diagnosis and condition putting patient at increase risk includes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 was unaware of and failed to comprehensively assess a resident for safe vaping practices for 1 of 1 resident (R37) reviewed for accidents. Findings include: R37's face sheet received on 4/24/25, included diagnoses of malignant cancer of the bladder, chronic pain due to cancer, anxiety, and insomnia. R37's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R37 had moderately impaired cognition, clear speech, could understand and be understood. R37 was dependent on staff for some activities of daily living and could walk short distances with the aid of a walker. R37 had pain almost constantly which interfered with sleep and day to day activities. R37's physician orders did not indicate use of medical marijuana or vaping THC (tetrahydrocannabinol). R37's care plan did not indicate use of medical marijuana or vaping THC. Smoking assessments dated 8/21/24, 11/25/24, and 2/24/25, indicated R37 was a non-smoker. Vaping was listed as an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to have a comprehensive incontinence care plan and provide timely assistance with toileting for 1 of 1 resident (R21) reviewed for bladder incontinence. Findings include R21's face sheet printed 4/24/25, included diagnoses of orthopedic aftercare (hip replacement), mixed incontinence, pressure ulcer of right buttock and muscle weakness. R21's admission Minimum Data Set (MDS) assessment dated [DATE], identified R21 was cognitively intact and did not have rejection/refusal of care behaviors. The MDS identified R21 required substantial to maximum assistance for lower body dressing and footwear. R21 requires supervision or touching assistance for toilets transfers. The MDS indicated R21 was always incontinent of urine and bowel. MDS identified no toileting program had been or is currently being attempted. A Care Area Assessment (CAA) dated 3/30/25 included R21 is always incontinent of bowel and bladder. R21 requires assist with transfers…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure 1 of 1 resident (R46) reviewed for nutrition and weight loss had received ice cream to increase calorie intake and weight per provider order. Findings include: R46's face sheet printed 4/24/25, included diagnoses of unspecified severe protein-calorie malnutrition, chronic kidney disease, depression, and repeated falls. R46's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, no rejection of care, weight loss of five percent or more in the last month or loss of ten percent or more in the last six months, and setup assistance for eating. R46's care plan revised 2/16/25, indicated resident has a nutritional problem related to diagnosis of adult failure to thrive with goal of maintaining adequate nutritional status as evidenced by maintaining weight within five percent of 124 pounds or gain three to four pounds per month to reach 130 pounds and consume 50 percent of meals. 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 observation, interview, and document review the facility failed to ensure staff provided cares according to standard of practice for gastrostomy tube care for 1 of 1 resident (R22) reviewed for tube feeding. Findings include: R22's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R22 was severely cognitively impaired, had no behaviors and did not refuse personal cares. R22's MDS indicated diagnoses of cerebral infarction (stroke), quadriplegia, essential hypertension, moderate protein-calorie malnutrition, and seizure disorders. R22's Clinical orders printed 4/23/25, indicated Jevity 1.5 feeding at 65 milliliters (ml) per hour for 22 hours daily. R22's care plan dated 10/25/24, indicated R22 required a tube feeding and was NPO (nothing per mouth). Care plan indicated R22 will be free of aspiration through the review date and maintain adequate nutritional and hydration status. R22's care plan indicated R22's head of bed (HOB) needed to be elevated 45 degrees during and thirty minutes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 non-invasive ventilator (uses positive pressure to increase lung volume and decrease work of breathing, and allows for support of breathing without breathing tube) was used in accordance with physician orders to meet the individual needs for 1 of 1 resident (R4) reviewed for respiratory care and services. In addition, the facility failed to have an oxygen administration order for R4 who was on continuous oxygen. Findings include: R4's face sheet printed 4/24/25, indicated R4 had diagnoses including morbid (severe) obesity, chronic pain, reduced mobility, and obstructive sleep apnea (breathing repeatedly stops and starts during sleep due to obstruction in upper airway). R4's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R4 had intact cognition, no behaviors including refusal of care. Special treatments included non-invasive mechanical ventilator. Oxygen was not checked as being used. Activities of daily living…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain safe storage of medications when over the counter stock medications were left unlocked and unattended in an office. Findings include: On observation and interview on 4/21/25 at 3:31 p.m., through an open door, observed bottles/containers of over the counter (OTC) medications spread out on a table in an office located at the end of 1 [NAME] wing, a resident hallway. At the end of the hallway by the office was a vending machine for soda pop and snacks for staff and residents. There was no exit or entry located in this area. Medications included vitamins, acetaminophen, probiotics, lidocaine patches and ibuprofen. Some medications were still in boxes, and some were unpackaged and on the table. Medical Records Director (MRD)-O was present in the room and stated she was also central supply and ordered supplies including OTC medications. MRD-O stated she was in the process of unpacking the medications to refill the medication closet on the nursing unit. MRD-O stated she locked the door when she left her office. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure identified preferences for menu selection were honored for 1 of 1 resident (R16) reviewed for choices. Findings include: R16's 5-day Minimum Data Set (MDS assessment dated [DATE], indicated R16 had intact cognition with no behaviors and diagnoses included end stage renal disease, dependence on renal dialysis, diabetes, paroxysmal atrial fibrillation, and essential hypertension. R16 was independent with eating, required substantial assistance from staff for toileting, lower body dressing and transfers, and required moderate assistance for bed mobility. R16's Order Summary Report printed 4/23/25, indicated an order for renal diet, regular texture and thin liquids. Progress note dated 3/18/25, authored by registered dietician (RD) indicated resident states that he has no questions or concerns regarding nutrition with the exception that he would like larger portion sizes . Dietician provided education regarding weights and encouraged…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 water, consistent with the resident needs and preferences, and sufficient to maintain hydration for 1 of 1 resident (R31) reviewed for hydration. In addition, 2 of 2 resident (R18 and R33) voiced concern of not receiving clean water mugs. Findings include: R31's face sheet received on 4/24/25, included diagnoses of left below the knee amputation, diabetes, and protein calorie malnutrition. R31's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R31 was cognitively intact, had clear speech, could understand and be understood. R31 was independent in her ability to transfer from bed to wheelchair and to self-propel her wheelchair. R31's physician order dated 1/7/25, indicated consistent carbohydrate diet regular texture, thin liquids consistency. R31's care plan dated 4/26/23, indicated the facility would encourage good nutrition and hydration in order to promote healthier skin. R31's care plan with revised date of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure enhanced barrier precautions (EBP) were followed for 1 of 1 resident (R22) reviewed for EBP. In addition, facility failed to ensure proper use of gloves while providing personal cares for 1 of 1 resident (22) observed for personal cares. Findings include: EBP R22's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R22 was severely cognitively impaired, had no behaviors and did not refuse personal cares. R22's MDS indicated diagnoses of cerebral infarction, quadriplegia, essential hypertension, and seizure disorders. R22's Clinical Profile printed 4/23/25, indicated R22 was on enhanced barrier precautions (EBP). R22's Clinical Orders report printed 4/23/25, indicated orders for care of gastrostomy tube and wound care orders for his buttocks and left great toe. R22's care plan printed 4/23/25, indicated R22 had a risk for infection related to gastrostomy tube placement and directed staff to initiate appropriate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure resident call lights were functioning for 1 of 1 resident (R31) reviewed for call lights. Findings include: R31's facesheet received on 4/24/25, included diagnosis of left below the knee amputation. R31's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R31 was cognitively intact, had clear speech, could understand and be understood. R31 was frequently incontinent of bowel and bladder, used briefs for toileting and was dependent upon staff for toileting hygiene. R31's care plan with revised date of 3/27/25, indicated R31 was incontinent of bladder and bowel related to immobility and would remain free from skin breakdown due to incontinence and brief use. Care plan dated 10/29/24, indicated R31 was a total assist/one-person physical assist. During an interview on 4/21/25 at 4:53 p.m., R33 who resided in the same hallway as R31, stated that on 4/20/25, at about 7:00 p.m., R31 was hollering for help because she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to include residents bathing preferences and bathing in the care plan for 2 of the 3 residents (R1, R3). Findings include: R1 R1's face sheet dated 3/6/25, identified R1 had diagnoses of morbid obesity (extremely overweight) and weakness. R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had no cognitive impairment. R1 required substantial/maximum assistance for bathing activities, dependent on staff for lower body dressing, and substantial/maximum assistance for upper body dressing. R1's care plan dated 1/14/25, identified a focus of current functional performance. Interventions included total one person assist for dressing, extensive assist for bed mobility, transfers total assist of two people. R1's care plan did not identify R1's bathing preferences or level of assistance R1 required for bathing. R3 R3's face sheet dated 3/6/25, identified R3 had diagnoses that included quadriplegia (paralysis that affects all four limbs…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete at a minimum, weekly baths/showers for residents for 2 of 3 residents (R1, R2) which resulted in the residents not being bathed for an extended time period. Findings include: R1 R1's face sheet dated 3/6/25, identified R1 had diagnoses of morbid obesity (extremely overweight) and weakness. R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had No cognitive impairment. Required substantial/maximum assistance for bathing activities. Dependent on staff for lower body dressing and substantial/maximum assistance for upper body dressing. R1's care plan dated 1/14/25, identified a focus of current functional performance. Interventions included total one person assist for dressing, extensive assist for bed mobility, transfers total assist of two people. R1's care plan did not identify R1's bathing preferences or how much assistance R1 required with bathing. R1's point of care charting dated 3/6/25, identified bathing was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to update their facility assessment when they no longer provided restorative nursing (continuous specialized approach in nursing care to maintain and improve physical and emotional wellbeing of individuals who have experienced a decline in function abilities) at the facility. Two of two residents (R1 and R2) had the potential to benefit from restorative nursing. This failure had the potential to affect all 56 residents who resided at the facility. Findings include: The facility assessment dated [DATE], indicated under the category of activities of daily living, the specific care of practices of residents needs indicated restorative nurse was offered at the facility. R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had a Brief Inventory of Mental status (BIMs) score of 15 indicating R1 was cognitively intact. R1 was dependent upon staff for toileting hygiene. He required moderate assistance with dressing the upper body and personal hygiene.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure the Medical Director (MD) assisted in the implementation and guidance of resident care policies, coordination, and admission of three bariatric residents (body weight greater than 100 poiunds (lbs.) of ideal body weight) residents (R1, R2 and R3). The facility was unable to safely manage these residents due to lack of guidance upon admission and provided cares received at the facility. This had the potential to affect all 56 residets who resided at the facility. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had a Brief Inventory of Mental status (BIMs) score of 15 indicating R1 was cognitively intact. R1 was dependent upon staff for toileting hygiene. He required moderate assistance with dressing the upper body and personal hygiene. Lower body dressing, sitting to lying position change, lying to sitting position change, and sit to stand were not attempted due to medical condition or safety…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 attempt to try alternative devices before using bedrails on resident's beds for 5 of 5 residents (R1, R2, R3, R6, & R7) when the facility failed to accurately assess the resident for risk of entrapment by assessing residents' medical diagnoses, height and weight, cognition, communication, mobility, and risk of falling. In addition, the facility failed to provide ongoing assessments to assure the bedrail was used to meet the resident's needs. Findings include: Centers for Medicare and Medicaid Services, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 dated October 2023 indicated a physical restraint is defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily and that restricts freedom of movement or normal access to one's body. The important consideration is the effect of the device on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan. The care plans for 3 of 3 residents (R1, R2, and R3) failed to indicate specifically which mechanical lift and sling was to be used during transfers. In addition R3 had conflicting information on his care plan of how he was to transfer out of his bed. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 had a Brief Inventory of Mental status (BIMs) score of 15 indicating R1 was cognitively intact. R1 was dependent upon staff for toileting hygiene. He required moderate assistance with dressing the upper body and personal hygiene. Lower body dressing, sitting to lying position change, lying to sitting position change, and sit to stand were not attempted due to medical condition or safety concerns. R1 was occasionally incontinent of urine and frequently incontinent of bowel. R1's pertinent diagnoses were chronic ulcer of the left foot with necrosis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 carry out activities for 1 of 3 (R3) dependent residents reviewed for assistance with activities of daily living (ADLs). Findings include: R3's provider order dated 2/25/25, indicated R3 was to be assisted with bathing every other day. R3's eMAR dated 2/1/25 - 2/28/25, indicated R3 was to be assisted with bathing every other day. No document was obtained to indicate R3 received assistance with bathing. Upon observation and interview on 2/28/25 at 2:18 p.m., R3 was in bed, in a hospital gown. R3 had shoulder length, thick greasy hair and a full beard. R3 stated he complained to the Physician Assistant (PA) he hadn't had his hair washed since he was in the hospital in 12/2024. He stated he hadn't been in the actual shower ever at the facility and maybe got a bed bath weekly without his hair being washed. Upon interview on 2/28/25 at 3:09 p.m., PA stated R3 complained to him about not getting cleaned-up at the facility and not having his hair washed since had been in the hospital in 12/2024. The PA wrote an order on 2/25/28,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 support the facility-sponsored and individual activities for residents preference to support their physical, mental and psychosocial well-being for 3 of 3 residents (R1, R2, & R3) who were dependent on staff for activities. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had a Brief Inventory of Mental status (BIMs) score of 15 indicating R1 was cognitively intact. R1 was dependent upon staff for toileting hygiene. He required moderate assistance with dressing the upper body and personal hygiene. Lower body dressing, sitting to lying position change, lying to sitting position change, and sit to stand were not attempted due to medical condition or safety concerns. R1 was occasionally incontinent of urine and frequently incontinent of bowel. R1's pertinent diagnoses were chronic ulcer of the left foot with necrosis (death) of the muscle, diabetes, and morbid obesity. R1's weight was 547 pounds (lbs.). R1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to weigh residents per their standing order guidelines for 2 of 3 residents (R1 and R2) reviewed for weekly weights. Findings include: R1's standing orders dated 12/10/24, indicated R1 was to have weekly weights taken. R1's care plan dated 12/16/24, indicated R1 was to be weighed per facility protocol. R1's electronic medication administration record (eMAR) dated 12/1/24 - 12/31/24, indicated R1 was to be weighed every seven days on 12/11/24, 12/18/24, and 12/25/24. The record indicated on 12/11/24, a chart code of drug refused was entered and no weight was documented. On 12/18/24, a weight of 548 lbs. was documented. On 12/25/24, a chart code indicated to other / progress notes. No weight documented. R1's electronic medication administration record (eMAR) dated 1/1/25 - 1/31/25, indicated R1 was to be weighed weekly on 1/8/25, 1/15/25, 1/22/25 and 1/29/25. On 1/15/25 the record indicated R1 weighed 548 lbs. On 1/8/25, 1/22/25 and 1/29/25 the record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 perform an assessment for self-administration of medications (SAM), and failed to perform Interdisciplinary Team (IDT) review for SAM for 1 of 3 residents (R5) reviewed for accurate medication administration, who kept an antiseizure medication locked in her bedside table and self-administered the medication twice daily without staff oversight. Findings include: R5's admission Minimum Data Set (MDS) dated [DATE], indicated R5 was cognitively intact. R5's Orders dated 1/23/25, indicated levetiracetam (generic Keppra) 500 milligrams (mg), Give 1500 mg by mouth two times a day for seizures. Take three tablets. Make sure that a nurse witnesses her taking the Keppra. R5's Diagnoses List printed 1/24/25, lacked indication R5 had a diagnosis of seizures. R5's care plan printed 1/24/25, lacked indication R5 could self-administer Keppra (antiseizure medication). R5's Medication Administration Record (MAR) indicated R5 had not missed doses of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure adequate staffing to answer call lights timely for 3 of 3 residents (R2, R3, R4) reviewed for call lights. In addition, the facility failed to provide adequate staffing to ensure scheduled baths were provided to residents who required assistance from staff for activities of daily living (ADLs). Findings include: R2 R2's Medicare 5-day Minimum Data Set (MDS) dated [DATE], indicated R2 was cognitively intact. The MDS further indicated R2 was dependent upon staff for toileting, was always incontinent of bowels, and required maximum assist of staff for bathing and rolling left and right in bed. R2's diagnoses list printed 1/23/25, included acute and chronic respiratory failure, weakness, failure to thrive, chronic pain, and obesity. R2's care plan dated 1/14/25, indicated R5 required extensive assistance of one staff for bed mobility, personal hygiene, and toileting. R2 required total assistance of two staff for transfers. R2's call…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assess and determine safety for 1 of 1 resident (R3) reviewed for self-administration of medication. Findings include: R3's care plan initiated 6/8/24, included the resident had a swallowing problem. Interventions included the resident would have small bites alternated with sips of fluid and use a teaspoon for eating. The resident was to eat only with supervision and was to be instructed to eat in an upright position. R3's electronic medical record (EMR) included a nursing note dated 6/9/24 which included the resident was on a dysphagia diet with thick nectar liquids. Medication was to be given whole in a spoonful of puree or applesauce. R3's Self Administration of medications assessment dated [DATE], indicated the resident did not want to self-administer medications. R3's EMR was failed to include an order for self-administration of medications. R3's medication administration record (MAR) for June included an order for Metoprolol Tartrate (a medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to develop a baseline care plan for 2 of 3 residents (R1, R3) reviewed for wounds, pain, and respiratory concerns. Findings include: R1's Nurse Admission/readmission assessment dated [DATE], included under the respiratory status section, R1 was short of breath while lying, with exertion, and he received oxygen with a concentrator or liquid oxygen via a nasal cannula. Under the pain section, R1's pain was listed at 8/10, described as chronic pain. Ice, pain medication and rest were marked for alleviating factors to reduce R1's pain. The admission summary included Resident had knee [pain] prior to total knee replacement. Continues to have pain, post op. R1's MDS Pain Assessment V5 dated 6/10/24, R1 rated his pain frequency in the past 5 days as almost constantly. R1 answered pain effects his sleep frequently, interference with therapy activities occasionally. R1 rated his pain as a 10 on a 1-10 pain scale, with 10 being the worst pain you can imagine.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 monitor 2 of 3 residents (R1, R3) reviewed for monitoring. Findings include: R1's Nurse Admission/readmission assessment dated [DATE], included under the respiratory status section, R1 was short of breath while lying and with exertion, and received oxygen with a concentrator or liquid oxygen via a nasal cannula. The skin integrity section listed the resident's skin was intact and the resident had right total knee. The admission summary included Resident had knee [pain] prior to total knee replacement. Continues to have pain, post op. The assessment failed to document any skin impairments or surgical incisions. R1's New Patient provider visit note dated 6/10/24, included under the skin section; R1 had a right knee incision covered with dressing. R1's electronic medical record (EMR) indicated admission date of 6/9/24. However, the record lacked a comprehensive skin assessment or formal wound observation/assessment or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 properly assess and obtain orders for 1 of 1 residents (R1) receiving oxygen therapy. Findings include: R1's admission record dated 6/27/24, include diagnosis of chronic congestive heart failure (a serious condition where the heart cannot effectively pump blood to meet the body's needs) and emphysema (a condition where there is damage to the air sacs in the lungs making it difficult to breathe). R1's hospital discharge orders dated 6/9/24, failed to include orders for oxygen. R1's hospital records prior to admission to facility reviewed. A nursing shift care plan summary note from 6/8/24 at 6:33 p.m. included R1 wears 2 liters of oxygen via nasal cannula. A Nursing Shift Care Plan Summary Note from 6/9/24 at 6:30 a.m., included R1 was on 2 liters of oxygen via nasal cannula, which was his baseline. R1's electronic medical record (EMR) included a nursing note dated 6/9/24 at 12:15 p.m., included resident arrived with oxygen on via nasal cannula at 2.5…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurately obtain blood pressure reading prior to administering blood pressure medication per provider orders for 1 of 1 resident (R3) reviewed for medication administration in accordance with physician instructions. Findings include: R3's medication administration record (MAR) for June 2024, included an order for Metoprolol Tartrate (a medication to lower blood pressure) Oral Tablet 25 mg, give ½ a tab twice a day by mouth. Parameters were included indicating to hold the medication if R3's blood pressure had a systolic (the top number on a blood pressure) reading below 100 or a diastolic (the bottom number on a blood pressure) reading below 60. The blood pressure reading for the 6/27/24 was marked NA or not applicable. The metoprolol tartrate was marked as being given. During interview on 6/27/24 at 11:45 a.m., R3 stated he assumed his blood pressure pill was mixed in with his morning medications. R3 did not remember staff taking his blood pressure prior to giving his morning medications. R3 stated he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure monitoring of hypertension for one of one resident (R1) reviewed for quality of care. R1 had a history of hypertension and an order for Hydralazine as needed for a systolic blood pressure 140 or greater but the facility failed to monitor R1's blood pressure. Findings include: R1 was admitted to the facility on [DATE] with a primary diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Additional diagnoses included chronic obstructive pulmonary disease, anxiety disorder, low back pain, type 1 diabetes mellitus with other circulatory complications, type 1 diabetes mellitus with hyperglycemia, attention-deficit hyperactivity disorder, essential (primary) hypertension (high blood pressure), cerebral infarction due to unspecified occlusion or stenosis of left cerebellar artery, acquired absence of right leg below the knee, and acquired absence of left leg below the knee. R1's physician progress note…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adequate pest control when surveyor observed three mice in the building during survey. This had the ability to affect all sixty-seven residents in the building. Findings include: During an observation on 2/12/24 at 1:18 p.m., surveyor observed a mouse run across the floor in the main dining room on the second floor. During an observation on 2/12/24 at 4:15 p.m., surveyor observed a mouse run across the floor in the main dining room on the first floor. During an observation on 2/13/24 at 9:09 a.m., surveyor observed a mouse run across the floor in the first hallway on the first floor. R2's admission record printed on 2/12/24 indicated R2 was admitted to the facility on [DATE] with an admission diagnosis of an acute kidney injury. R2 does not have a history of delusions or hallucinations. R2's Quarterly Resident Review assessment dated [DATE] indicated R2 is visually impaired but glasses were present during the assessment and are used…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to develop a comprehensive care plan with appropriate services, treatments, and prevention interventions and reevaluation of intervention effectiveness for substance use disorders for 1 of 1 resident (R5) reviewed for behavioral health needs. R5's care plan lacked person-centered planning identifying mental health stressors, an interdisciplinary approach to care, and meaningful activities to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing. In addition, R5 had falls related to alcohol use while in the facility. Findings include: During observation and interview on 1/31/24 at 12:18 p.m. R5 speech appeared slurred, cheeks appeared red, and R5's behavior in conversation appeared to be variable from agitated to making jokes in a quick time frame. R5 noted to have an open and consumed 1.75-liter bottle of Windsor next to his bed as well as a coffee cup R5 was drinking from. Multiple other 1.75-liter bottles of Windsor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff were trained to appropriately to respond to a residents need of an active substance use disorder and to address a history of trauma for 1 of 1 resident (R5) reviewed for behavioral health needs. The facility assessment identified the ability to serve residents with mental health disorders and staff did not have appropriate competencies and skills sets to ensure residents attain or maintain the highest practicable physical, mental, and psychosocial wellbeing. Findings include: The Facility Assessment Tool reviewed 1/2024 identified the resident population to have individuals with behavioral health need, active or current substance use disorders, and psychiatric and mood disorders. Staff training education and competencies identified it is necessary to provide the level and types of support and care needed for the resident population. Including staff certification requirements as applicable. Potential data sources include…

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