Skyline Heights Nursing And Rehabilitation

Based on interview and record review, the facility failed to update a resident's comprehensive care plan with new interventions for incontinence care for 2 (#s 4 and 7) of 8 sampled residents. Findings include:During an interview on 12/30/25 at 9:11 a.m., resident #4 stated, The staff told me I cannot wear a liner and a brief anymore (for incontinent episodes). They make us use reusable liners, and they are very small. They don't last as long, and I have more accidents. I have talked to the staff about how much I don't like them. I want to go back to the disposable big liners I had before. Resident #4 stated, I used to participate in care planning, but I don't anymore.During an interview on 12/30/25 at 12:27 p.m., staff member A said the care plans should reflect all the incontinence products tried for the resident or any changes related to incontinence care. During an interview on 12/30/25 at 1:56 p.m., resident #7 stated, I am having too many accidents (with incontinence), and the little reusable pads just aren't working for me.Review of resident #4's comprehensive care plan, with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide physician-ordered medications at the prescribed dose and frequency, for 3 (#s 73, 81, and 109); and failed to ensure the availability of prescribed medications resulting in re-hospitalization for one 1 (#81) resident, resulted in 1 (#73) resident discharging against medical advice, and 1 (#109) resident experienced opioid withdrawal, of 4 sampled residents for medication concerns. Findings include: a. Review of resident #73's nursing progress notes, dated 3/5/25, showed resident #73 was admitted to the facility following a hospitalization. The nurse's notes showed the physician orders were being entered into the resident's electronic health record. Review of #73's pharmacist note, written at 8:32 p.m. on 3/5/25, showed there were no irregularities with the medications. The pharmacy note failed to show there were no medication orders in the resident electronic medical record. Review of #73's social services note, written on 3/6/25 showed no…

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

Based on observation, interview, and record review, the facility failed to provide palatable food; cooks were not following the facility menu; and the dietary department failed to provide foods specified on the resident's meal tickets, for 5 (#s 1, 37, 46, 69 and 92) of 24 sampled residents. These deficient practices had the potential to affect the quality of life and nutritional status of the residents. Findings include: During a lunch observation and interview on 3/25/25 at 1:00 p.m. residents #37 received a serving of mashed potatoes with brown gravy, macaroni salad, and chicken salad. Resident #37's friend was assisting him with his meal. When asked if the food tasted good, he shook his head no, and grabbed his friend's hand. Resident #37 did not receive a vegetable on his plate. During a lunch observation and interview on 3/25/25 at 1:02 p.m., resident #69 was observed to have mashed potatoes with brown gravy, macaroni salad, and a meat salad. Resident #69 states she doesn't like tuna salad. Staff sitting nearby had to tell resident #69 what the meat salad was. Resident #69 did…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nursing staff failed to ensure treatment was provided, according to acceptable standards of practice, for PICC lines, for 1 (#109) one sampled resident. Findings include: Review of resident #109's admission medication administration record, for March 2025, failed to show IV antibiotics were being administered by a picc line. The medication administration record showed the medication was supposed to be administered via IV. During an interview on 3/25/25 at 8:00 a.m., NF2 said medications were not entered timely on resident #109's medication administration record, and due to this, she missed doses of antibiotics. Resident #109 pulled her picc line out sometime after admission. NF1 said resident #109 ended up back in the emergency room for pain management and to have her picc line replaced. During an interview on 3/25/25 at 11:09 a.m., staff member B said resident #109 was getting dilaudid and strong pain medications when she was in the hospital. She only had an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure call lights were answered in a timely manner for 11 (#s 7, 10, 11, 15, 27, 31, 41, 56, 58, 66, and 69), and failed to provide regular bathing and personal cares for 3 (#s 346, 347, and 348) of 40 sampled residents. This left some residents feeling afraid they would not receive care, felt unsafe due to the provision of improper care, felt dirty due to lack of hygiene/bathing assistance, were angry for lack of care and services, and had a feeling of being forgotten when services were not provided as necessary. Findings include: 1. a. During an interview on 1/27/25 at 3:36 p.m., resident #7 stated lunch was served late in her room sometimes (at 1:30 p.m.), and she would not have enough time to eat without missing bingo. Resident #7 stated she felt low staffing was a contributing factor to why her food was served late. b. During an interview on 1/27/25 at 3:55 p.m., resident #56 stated she waited 15 minutes most of the time for her…

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

Based on observation and interview, the facility failed to ensure medications were properly labeled and failed to properly dispose of expired medications and medical supplies, allowing them to remain available for use. These failures could negatively affect a resident receiving expired medications and or medical supplies. Findings include: During an observation and interview on 1/27/25 at 2:00 p.m., Staff member E stated the night nurse had been responsible for monitoring medical supplies and discarding any expired products. Staff member E stated the facility had experienced a high turnover of nurse management over the last year and was not sure if the night nurse was currently responsible. One medication refrigerator was identified, and it was located on Copper Crest unit, in the medication storage room. Three vials of Tubersol intradermal injection solution 5/0.1 ml, were observed to be previously opened. The opened, multi-dose vials, were not dated with the date the vials were originally opened. Staff member E stated Tubersol intradermal solution should be dated when it is…

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

Based on interview and record review, the facility failed to utilize and maintain a QAPI system to identify performance improvement issues related to staffing concerns, resident showers, and infection control, and failed to show how the QAPI committee was involved in addressing these quality of care issues which could negatively affect many, or all, of the residents residing at the facility. Refer to F725 Sufficient Staffing, F677 ADL care for Dependent Residents, and F880 - Infection Control, for findings related to the concern areas identified. Findings include: A request was made for the facility's QAPI plan, as stated as item number 31 on the entrance conference worksheet, on 1/27/25 at 1:15 p.m. The QAPI Plan was to be provided by the facility within four hours of entrance, but the facility document for the QAPI plan only showed QAA committee members. A request was made for the facility's QAPI plan again, on 1/27/25, at 5:00 p.m. The facility provided two pages, both undated, on 1/29/25. One page showed one PowerPoint slide of a QAPI Plan - Quarterly with page number 45 on the…

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

Based on observation, interview, and record review, the facility and staff failed to follow a resident's care plan by not placing a gel cushion on a resident's recliner for pressure ulcer prevention, and the resident had a pressure ulcer, for 1 (#13); and failed to update the care plan for a resident requiring enhanced barrier precautions for 1 (#14) of 40 sampled residents. Findings include: Review of resident #13's current care plan showed a gel cushion was to be placed on the recliner on 3/29/23. On 1/18/25, the care plan showed bed linens should be wrinkle free, and a specialty air mattress was to be used. During an observation on 1/27/25 at 1:46 p.m., resident #13 was sitting in her recliner chair, and she was asleep. There was no gel cushion in resident #13's recliner. During an interview on 1/27/25 at 3:29 p.m., NF1 said resident #13 had slept in a recliner for fifteen or twenty years. NF1 said resident #13 recently developed a sore on her buttocks. Due to this, the care plan interventions of the bed linens and speciality air mattress would not be applicable as the resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 3 (#s 11, 36, and 66) of 40 residents received dental services, and resident #36 was embarrassed and had discomfort due to her dental needs, and #11 gave up wearing dentures because they did not fit correctly. Findings include: During an interview and observation on 1/27/25 at 3:16 p.m., resident #36 stated she had a missing upper right tooth that she felt was embarrassing. She stated she also had a left lower tooth that needed a crown because it would hurt sometimes. Observation of resident #36's left lower molar showed a deep space in the middle of the tooth with some cracks, and a yellowish color throughout the top surface of the tooth. Resident #36 stated, I would like to get that taken care of because that bugs me. Resident #36 was admitted to the facility on [DATE]. Review of resident #36's MDS, dated [DATE], showed: No for the following categories: Broken or loosely fitting full or partial denture . and Mouth or facial pain,…

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

Based on observation, interview, and record review, the facility failed to ensure meals were served timely and were served at a palatable temperature, for 5 (#s 5, 11, 12, 13 and 22) of 18 sampled residents. This deficient practice caused cold food and late delivery of meals for residents who received room trays. Findings include: During an observation on 5/13/25 at 1:22 p.m., room trays were being delivered on the 300 hallway. During an interview on 5/13/25 at 1:28 p.m., staff member M stated the lunch meal was usually served around noon time. Staff member M stated the lunch meal was served late on this day. During an interview on 5/13/25 at 1:30 p.m., resident #11 stated her meal was served late. During an interview and observation on 5/13/25 at 1:44 p.m., resident #22 stated, This food is so late, I don't know what the problem is. The food is barely warm, I don't know what to do about it, but I eat it anyway, it's just barely warm. During an interview on 5/13/25 at 4:35 p.m., resident #12 stated room trays are not served hot. Resident #12 stated staff will heat the food up for…

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

Based on observation, interview, and record review, the facility failed to ensure physician ordered therapeutic diets were followed, for 7 (#s 7, 10, 11, 15, 36, 39, 66) of 40 sampled residents. Findings include: a. During an interview on 1/28/25 at 8:53 a.m., resident #11 stated the food she was served at the facility did not follow a renal diet. She stated she was not supposed to have tomatoes as they have too much potassium and phosphate. She stated the facility often served her tomatoes. She also stated she was served high sugar foods. b. During an interview on 1/27/25 at 4:13 p.m., resident #15 stated the diet served depended on which cook was scheduled for the day. c. During an interview and observation on 1/29/25 at 8:38 a.m., resident #7 was served oatmeal with brown sugar, eggs, orange juice, coffee, a bagel, and cream cheese. Resident #7 stated this was a large amount of carbohydrates for her and she did not even like bagels. Resident #7 stated she was a diabetic. Review of resident #7's breakfast meal ticket showed a CCHO diet. e. During an observation on 1/29/25 at 12:24…

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

Based on observation, interview, and record review, the facility failed to ensure consistent enhanced barrier precautions were provided for 4 (#s 5, 6, 63, and 346) of 40 sampled residents; and the facility failed to provide staff education on proper donning and doffing of PPE, and the expectations of enhanced barrier precautions, which had an increased risk of a negative outcome to the facility population due to those staff working with or around other residents not on precautions. Findings include: 1. Review of resident #63's Weekly Head to Toe Skin Check form, dated 1/22/25, showed the resident had a below the knee amputation on the left leg. The assessment identified the incision area had three open areas to the mid incision, and one small open area, to the medial aspect of the incision line. During an interview on 1/27/25 at 4:45 p.m., resident #63 said when the nurses change the dressing on her leg, they only wear gloves. Resident #63 said the facility is not in Covid outbreak, so the nurses don't have to wear gowns. During an observation on 1/28/25 at 9:41 a.m., staff member…

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

Based on observation, interview, and record review, the facility failed to address medications appropriately for a resident who self administered medications, and ensure medications and narcotics were properly supervised during medication administration, for 1 (#15) of 40 sampled residents. Findings include: During an interview and observation on 1/28/25 at 9:35 a.m., resident #15 stated the facility staff would typically leave her medications in her room. Upon observation, there were eight pills in a medication cup at resident #15's bedside. Additionally, there was Advair, Fluticasone Propinate, and Ventolin (inhalers) at resident #15's bedside. Resident #15 stated staff would drop the medications off in her room at 6:30 a.m. or 7:00 a.m., depending on who the nurse was that shift. Review of resident #15's MAR showed the following medications: Bupropion, Buspirone, Cholecalciferol, Concerta (methylphenidate), Duloxetine, Loratadine, and Montelukast, were administered to resident #15 the morning of 1/28/25. During an interview on 1/28/25 at 9:52 a.m., staff member K stated resident…

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

Based on interview and record review, the facility failed to ensure a baseline care plan was developed and implemented to reflect the resident's care needs after admission, for 1 (#339) of 40 sampled residents. Findings include: During an interview on 1/28/25 at 9:17 a.m., resident #339 was sitting on his bed. Resident #339 stated he had recently been in the hospital with pneumonia and was transferred to the long-term care facility on 1/23/25, to regain his strength, so he could continue to live independently at home. Resident #339 stated he started working with physical therapy on 1/24/25 and participates in therapy five days a week. During an interview on 1/30/25 at 11:45 a.m., staff member C stated baseline care plans were developed by the admitting nurse, and would then be updated by the interdisciplinary team, if any changes occurred prior to the comprehensive care plan being developed. Review of resident #339's electronic medical record, showed on 1/22/25, the resident was to transfer to a subacute rehab facility due to his deconditioned status to maximize resident #339's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to provide showers for 2 (#s 346 and 347); residents who felt personal cleanliness was important due to skin concerns and comfort, and repositioning for a dependent resident, for 1 (#346) of 40 sampled residents. Findings include: During an observation and interview on 1/28/25 at 7:46 a.m., resident #346 was lying on his back in bed; his hair looked oily and matted. Resident #346 stated, I have only had one bath since I was admitted on [DATE]th. You would think with my wounds I would get a shower more often. I generally run hot, and I have the window open, or I sweat. I am dependent on staff to assist with most of my cares, including bathing and repositioning. During an observation and interview on 1/28/25 at 1:43 p.m., resident #346 was still lying on his back in bed. NF4 stated, He (resident #346) has only had one shower since he arrived at the facility. He has wounds from surgery and had skin breakdown on his backside. They (the…

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

Based on observation, interview, and record review, the facility nursing staff failed to ensure treatment was provided, utilizing the physician orders, for changing a dressing for a PICC line for 1 (#346) of 40 sampled residents. Findings include: During an observation on 1/28/25 at 7:46 a.m., resident #346 had a PICC line in his right arm. The bandage was rolled down and closer to his elbow. During an observation and interview on 1/28/25 at 1:43 p.m., resident #346's PICC line bandage was rolled up near his elbow on his right arm. The PICC line port moved around when the resident moved his arm. NF4 stated, The bandage on his right arm for the PICC line has not been changed. It looked like it was going to come out the other day, so I used some gauze that he had on his dresser and wrapped it around his arm so it would be more stable. I don't think the staff have changed it since I wrapped it. During an interview on 1/29/25 at 7:19 p.m., staff member E stated, We (staff) don't have enough time to complete everything that is expected of us. The residents don't understand that, and they…

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

Based on observation, interview, and record review, the facility failed to follow a physician's order and provide nebulizer treatment supplies for 1 (#347) of 1 sampled resident for respiratory concerns. Findings include: During an observation and interview on 1/28/25 at 9:11 a.m., resident #347 stated, I was doing nebulizer treatments at home, and I wonder if I should have my daughter-in-law bring my machine to me. I feel like my breathing is getting worse, and I have had more breathing attacks lately. No nebulizer machine was observed in resident #347's room. During an observation and interview on 1/29/25 at 9:54 a.m., resident #347 stated, I still haven't received any nebulizer treatments. I was taking them every four hours at home. There was still no nebulizer machine observed in her room. During an interview on 1/29/25 at 7:46 p.m., staff member J stated, . I have never administered a nebulizer treatment to her (resident #347). She does have an order for them in her MAR. Review of resident #347's physician orders, dated 1/22/25, showed, (Nebulizer) Resident has a diagnosis of:…

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

Based on interview, and record review, the facility failed to ensure that a licensed pharmacist adequately addressed and documented the monthly medication regimen review for 1 (#63) of 40 residents who received four psychotropic medications. Findings include: Review of resident #63's medication administration record for January 2025 showed the following: - Olanzapine 20 mg by mouth every day which was ordered on 6/12/24 - Clonazepam 0.5 mg by mouth every day ordered 6/12/24 - Trazodone 150 mg by mouth at bedtime every day ordered 6/12/24 - Paroxetine 20 mg by mouth every day ordered 7/11/24 Review of the facility's Monthly Medication Reviews, for resident #63, dated June 2024 through January 2025, showed: - 7/22/24, a request was made to get an appropriate diagnosis for Olanzapine - 10/24/24, a request was made to get an appropriate diagnosis for Olanzapine, and a note which showed, GDR on 4 medications. The pharmacy review failed to identify or make appropriate recommendations as to what medication dosage should be changed or reduced. Resident #63's medication administration 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 interview and record review, the facility failed to ensure a gradual dose reduction (GDR) was implemented or documented by a provider as clinically contraindicated for residents receiving psychotropic medications, for 3 (#s 5, 18, and 63) of 40 sampled residents. Findings include: 1. A request was made to the facility on 1/29/25 at 5:29 p.m., for documentation of the GDRs for resident #5 and resident #18. During an interview on 1/30/25 at 10:59 a.m., staff member A stated there were no GDRs for resident #5 or resident #18. Staff member A stated the pharmacist provided monthly medication reviews, but no GDRs were documented. Review of resident #5's care plan, dated July 2024, showed an identified focus related to medications causing potential adverse effects. The intervention for antipsychotics showed: .educate about the following areas: increased mortality in elderly patients with dementia-related psychosis . Antipsychotic are to be used for the shortest duration at the lowest dose possible in older…

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

Based on interview and record review, the facility failed to ensure resident immunizations were up to date with the CDC recommendations for 3 (#s 10, 32, and 336) of 40 sampled residents. Findings include: Review of resident #10's EHR showed two pneumococcal vaccines were given: a. Pneumococcal Polysaccharide Vaccine (PPSV23) on 1/2/2017, and Pneumococcal Conjugate Vaccine (PCV13) on 7/10/2016. According to the CDC recommendations for pneumococcal vaccines in adults, an additional vaccine (PCV20 or PCV21) was recommended to be administered for resident #10. b. Review of resident #336's EHR showed no pneumococcal vaccines were administered. Review of a facility document, titled Pneumococcal Vaccination Consent/Declination, dated 1/17/2025, showed a refusal by resident #336 with the comment: up to date explaining the reason for the refusal. c. Review of resident #32's EHR showed no pneumococcal vaccines were administered. Review of a facility document, titled Pneumococcal Vaccination Consent/Declination, dated 11/26/2024, showed a refusal by resident #32 with the comment: up to date…

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

Based on interview and record review, the facility failed to ensure nursing staff transcribed and initiated physician orders of prescribed medications, and failed to ensure the completion of the full course of medication treatment for a resident who returned from a hospital for 1 (#5) of 5 sampled residents. Findings include: During an interview on 11/19/24 at 2:21 p.m., resident #5 stated she had been to the hospital recently for bronchitis. Resident #5 stated medications she had taken after her return from the hospital helped with her coughing and breathing, and she did not have those issues currently. Resident #5 stated the prescribed medications were not started when she returned from the hospital, they were a day or so late. During an interview on 11/19/24 at 3:35 p.m., NF3 stated there was a delay in the antibiotic and steroid medication ordered by the hospital provider for resident #5 to start on her discharge from the hospital. NF3 stated the physician discharge orders were entered a few days after resident #5 was discharged . NF3 stated when she asked the nursing staff…

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

Based on observation, interview, and record review, the facility failed to provide the necessary ADL assistance for dependent residents for bathing and showering, at least every seven days, and residents were not assisted with grooming, per observations, and this caused the residents to feel unkempt, for 3 (#s 4, 5, and 7) of 8 sampled residents for bathing and hygiene services. Findings include: 1. During an observation and interview on 10/2/24 at 3:30 p.m., resident #7 was sitting in a wheelchair in his room. The resident's hair appeared greasy and uncombed. Resident #7 said it had been over four weeks since he had a shower, and he was to receive a shower on Mondays and Fridays, each week. Resident #7 stated, The staff were always busy just doing the things they had to do and run out of time to give showers. Review of resident #7's ADL/Bathing record, from 7/4/24 to 10/3/24, showed resident #7 received a shower on 7/17/24, 9/3/24, and 10/3/24. Resident #7 had gone 47 days from 7/18/24 to 9/2/24 without a shower, and 29 days from 9/4/24 to 10/2/24 without a shower. The resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide supervision for a resident who had a dementia diagnosis and was left at a clinic unattended which placed the resident at risk of elopement, for 1 (#8) of 3 sampled residents with a diagnosis of dementia. Findings include: A review of a documentation submitted to the State Survey Agency, on 8/8/24, showed resident #8 was transported to an outside medical appointment and left at the medical office, unattended, by a facility employee. A review of resident #8's Minimum Data Set, with an Assessment Reference Date of 7/7/24, showed the Brief Interview for Mental Status score was five, which showed the resident had severe cognitive impairment. A review of resident #8's care plan showed, [Resident #8] presents with wandering tendencies, is at risk for exit-seeking and wandering tendencies and [Resident #8] has a DX of UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, AND ANXIETY exhibits cognitive impairments as evidenced by period of confusion and forgetfulness, impaired…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 necessary catheter supplies available, and therefore supplies were used which caused an allergic reaction, and failed to notify the medical provider in a timely manner, for 1 resident (#6) of 3 sampled residents with catheters. Findings include: During an observation and interview on 10/2/24 at 4:40 p.m., resident #6 was sitting in a wheelchair in his room. Resident #6 had a covered catheter bag hanging on the underside of the wheelchair. Resident #6 stated he developed a rash after his suprapubic catheter was replaced, at the end of August. Resident #6 stated his catheter was changed two times within a week, at the end of August, because it was pulled, and the nurse was not able to flush it. Resident #6 stated a silver tip catheter is the only one that works because he is allergic to several different (catheter) materials. Review of resident #6's electronic medical record document, titled Clinical Allergy, dated 10/30/21, showed,…

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

Based on observation, interview and record review, the facility failed to ensure food was served in a sanitary manner; and failed to practice hand hygiene while serving meals between residents. This deficient practice had the potential to affect all residents receiving meals provided by the facility. Findings include: During an observation and interview on 5/18/24 at 5:23 p.m., a half-eaten grilled cheese sandwich was observed to be setting on the starting area of the resident tray line while the resident trays were being prepared. Staff member G said the sandwich belonged to him. Staff member G then picked up the sandwich and removed it from the tray service area. Staff member H was observed drinking her personal drink in the tray line area while preparing the resident dinner trays. During an observation and interview on 5/18/24 at 6:18 p.m., staff member K was observed serving trays to the residents who chose to eat in their rooms without providing hand hygiene between resident meal delivery. Staff member K would assist each resident with their meal tray and serve them a drink 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 record review, the facility failed to provide assistance with meals for a resident identified with weight loss for 1 (#8) of 8 sampled residents. Findings include: During an observation on 5/19/24 at 12:15 p.m., a meal tray was delivered to resident #8 and placed on her bedside table by staff member J. The resident was lying in bed on her right side, covered with a blanket, asleep. No attempt was made to rouse resident #8 from sleep by staff member J. During an observation on 5/19/24 at 1:15 p.m., resident #8 was still lying in her bed on her right side, covered with a blanket, asleep. The meal tray remained covered and untouched on the bedside table. During an observation and interview on 5/19/24 at 1:57 p.m., staff member J was collecting meal trays and placing them on the cart. Resident #8 was still lying in her bed, asleep. Her meal tray remained untouched. Staff member F said resident #8 required assistance with meals and set up. Staff member F said resident #8 should be…

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

Based on observation, interview, and record review, the facility failed to serve food that was palatable and at a safe and appetizing temperature for 5 (#s 11, 21, 43, 63, and 134) of 46 sampled residents. This deficient practice had the potential to effect all residents in the facility by exposing them to potentially hazardous foods. Findings include: 1. During an observation and interview on 1/17/24 at 9:30 a.m., resident #11 stated the eggs were always snotty and the meat was tough. Observation of the breakfast showed the whites of the eggs were runny and not cooked thoroughly. Resident #11 stated the food was never warm. During an observation and interview on 1/18/24 at 8:07 a.m., resident #11 was eating breakfast in her room. She stated the eggs were runny and cold, like always. Resident #11 stated meal times varied depending on how many people were working in order for your tray to be delivered. 2. During an interview on 1/16/24 at 3:21 p.m., resident #61 stated, The food is not great, I have worked in the dietary field before, and I know it should be better. It should be…

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

Based on observation, interview, and record review, the facility failed to label and date food items, and clean and maintain sanitary conditions in the food service areas of the kitchen. These deficient practices had the potential to affect any resident consuming or receiving food from, or prepared by, the kitchen, and 83 residents resided at the facility. Findings include: During an observation of the kitchen, refridgerator(s)/coolers/storage areas on 1/16/24 at 1:22 p.m.: - the drink refrigerator had a sticky white substance splattered on the front of it, - there were two big drink containers in the walk-in refrigerator that were not labeled or dated, - macaroni salad in a metal pan, sliced lunch meat, and a pan of thick brown liquid all were wrapped with plastic wrap and did not have a label or date on them, - the dishes that were stored below the steam table had chunks of yellow and white debris on them, - the oven had dark brown build up around the doors. - the open fryer had black chunks built up around the edges and the grease was black, - the shelf below the fryer, and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect residents from actual or potential physical and psychosocial harm for 3 (#s 7, 25, 29, and 49); and failed to adequately address residents who displayed verbal and physical abuse behaviors for 2 (#s 64 and 68) of 12 sampled residents investigated for abuse. Findings include: 1. During an observation and interview on 1/16/24 at 3:40 p.m., resident #7 was observed sitting quietly looking out her window. Resident #7 stated she could not get out of bed without, a lot of help. When asked how she got along with other residents, resident #7 looked over toward her roommate's side of the room and whispered, She scares me. The resident's roommate (resident #64) came into the room at that time, and resident #7 refused to continue the conversation. During an interview on 1/17/24 at 2:09 p.m., staff member S stated resident #64 had a history of mental health concerns, requiring one-to-one observation by staff members, and had at one time been…

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

Based on observation, interview, and record review, the facility failed to provide physician-ordered medications at the prescribed dose and frequency for 3 (#s 11, 51 and 79); and failed to ensure the availability of prescribed medications resulting in the misappropriation of a resident's medication for 1 (#27) for residents sampled for medication reviews. Findings include: 1. During an interview on 1/17/24 at 3:05 p.m., staff member D stated she was a travel nurse and her first shift was on 1/16/24. Staff member D stated she was told if she needed any medications out of the Nexsys (automated dispensing unit), she had to ask one of the regular staff nurses to get the medication for her. Staff member D stated she gave resident #51 the last Eliquis (apixaban) 5 mg tablet on the morning of 1/16/24. Staff member D stated when she attempted to give the resident her morning dose of Eliquis on 1/17/24, there were none available. Staff member D stated she checked the overflow drawer in the medication cart and the stock medication supply kept in the Nexsys (automated dispensing unit). Staff…

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

Based on interview and record review, the facility failed to maintain evidence of the resolution of a resident's grievance for 1 (#134) of 46 sampled residents and failed to ensure the facility's policy met regulatory guidelines with regard to the identity and contact information for the grievance official. Findings include: During an interview on 1/17/24 at 8:56 a.m., NF7 stated resident #134 was admitted to the facility in November of 2023 after having a new colostomy placed via a surgical procedure. NF7 stated resident #134 was unhappy with the food and some aspects of her care. NF7 stated she talked to staff member H regarding resident #134's complaints. During an interview on 1/17/24 at 11:03 a.m., resident #134 stated she received a cold breakfast every day while at the facility. Resident #134 stated she complained to the staff about the dietary service, including cold food, a breakfast tray with no food on it, and getting black bananas, not getting out of bed earlier in the day, and not getting routine catheter care. Resident #134 talked to the chef regarding her food…

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

Based on observation, interview, and record review, the facility failed to report the findings of an allegation of resident-to-resident verbal abuse to the State Survey Agency for 1 (#61) of 46 sampled residents. Findings include: Review of a Facility-Reported Incident, dated 12/3/23 and submitted to the State Survey Agency reporting system on 12/4/23, showed there was a verbal altercation between resident #61 and another resident over cigarettes. Resident #61 was accused by the other resident of stealing his cigarettes and he stated he was going to put resident #61 in the hospital. During an interview on 1/16/24 at 3:21 p.m., resident #61 stated, The facility talked to me about another resident accusing me of stealing his cigarettes, and I told them it really didn't bother me. I have felt safe in the facility the whole time. The guy said he was going to put me in the hospital for stealing his cigarettes, he's old though. It's not even possible to steal cigarettes; they are locked in the cabinet at the nurse's station. The guy came and apologized. Everything is fine now. During an…

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

Based on interview and record review, facility staff failed to provide pertinent medical information to the receiving facility at the time of transfer for 1 (#44) of 46 sampled residents. Findings include: Review of resident #44's nursing progress notes, dated 10/20/23, showed the resident was transferred to a hospital with an elevated heart rate, decreased oxygen saturation, and tremors. The medical record showed the hospital contacted the facility after resident #44's admission to the hospital and requested resident #44's medical information. Review of resident #44's electronic medical record failed to show facility staff had sent medical information with the resident. On 1/17/24, a request was made for a copy of resident #44's medical information provided to the receiving facility for the resident's hospital transfer on 10/20/23. No documentation had been received by the end of the survey. During an interview on 1/18/24 at 11:00 a.m., staff member B said when a resident was transferred to the hospital the nurse was to fill out an e-interact transfer document in the resident'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.

Based on interview and record review, the facility staff failed to complete the resident assessment portion for the Annual MDS assessment for 1 (#36) of 46 sampled residents. Findings include: Review of resident #36's Annual MDS, with an ARD of 11/4/23, showed In Progress and was 60 days overdue. The MDS should have been completed by 11/18/23 (ARD + 14 days). During an interview on 1/17/24 at 12:12 p.m., staff member J stated he was aware MDS assessments were late, and had been in his position since June of 2023 and . at that time it (MDS assessments) was already two months behind ., and he had been working to get the MDS assessments caught up.

Based on interview and record review, facility staff failed to complete the resident assessment portion for the Quarterly MDS assessments for 2 (#s 2 and 34) of 46 sampled residents. Findings include: Review of resident #34's Quarterly MDS, with an ARD of 11/10/23, showed In Progress which was 54 days overdue. The Quarterly assessment should have been completed by 11/24/23. Review of resident #2's Quarterly MDS, with an ARD of 11/15/23, showed In Progress which was 49 days overdue. The Quarterly assessment should have been completed by 11/29/23. During an interview on 1/17/24 at 12:12 p.m., staff member J stated he was aware MDS assessments were late. Staff member J stated he had been in his position since June of 2023 and, .at that time it (MDS assessments) was already two months behind ., and he had been working to get the MDS assessments caught up.

Based on interview and record review, the facility failed to ensure an updated PASARR was submitted for a resident diagnosed as having a serious mental health diagnosis with escalating and dangerous behaviors, including homicidal threats, violent attacks on staff, and hypersexual behaviors for 1 (#64) of 16 residents sampled for PASARR screenings. Findings include: Review of resident #64's medical record showed the following current mental health diagnoses: chronic bipolar II disorder most recent episode major depressive, paranoid schizophrenia, and violent behavior. Review of resident #64's PASARR I, dated 8/2/23, showed, 1. Does the individual have a diagnosis of serious mental illness (MI)? * Yes Describe mental illness diagnosis Depression and Schizophrenia, Patient is stable on current medications. 2. Does the individual have any indications of a mental illness? If yes, describe. * No. No revised PASARR evaluation was located in the medical record for resident #64's high-risk mental status change. Review of resident #64's hospital note, dated 9/12/23, showed, Patient requires…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission for 1 (#134) of 46 sampled residents. Findings include: During an interview on 1/17/24 at 11:03 a.m., resident #134 stated she was admitted on [DATE] for care related to a recent surgical procedure. Resident #134 stated she had a urinary catheter and a new colostomy when she was admitted . The resident stated the facility staff only provided routine catheter care three times during her stay between 11/22/23 and 12/16/23. Resident #134 stated she was diagnosed with a urinary tract infection on 11/27/23. Review of resident #134's admission summary, dated [DATE], showed the resident had an indwelling urinary catheter and a colostomy on admission to the facility. Review of resident #134's baseline care plan, dated 11/23/23 and 11/24/23, showed the following focus areas: - 11/23/23, physical functioning deficit due to paraplegia, - 11/24/23, pain management monitoring, - 11/24/23, 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 Based on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for 2 (#s 64 and #134) of 46 sampled residents. Findings include: 1. Review of resident #64's comprehensive care plan showed the following incomplete focus areas: - Cardiac with Qualifying Etiology - Impaired Cardiovascular status related to: Date Initiated: 9/29/2023 by NF9, and updated by staff member B on 10/1/23. - Resident has physical functioning deficit related to: Date Initiated: 7/31/2023 by NF9, and updated by staff member B on 10/1/23. Resident #64's care plan failed to identify person-centered focus concerns and interventions. The failure had the potential to result in inadequate care for the resident. During an interview on 1/18/24 at 8:23 a.m., staff member F stated she was unaware of any physical functioning deficits for resident #64. Staff member F stated, I know she uses a wheelchair sometimes, but I have also seen her walking around too, she is pretty active. During an…

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

Based on interview and record review, the facility failed to update resident care plans as resident care needs changed for 1 (#11) of 46 sampled residents. Findings include: During an interview on 1/17/24 at 9:30 a.m., resident #11 stated she was having increasing problems with her vision in both eyes. She stated this made it difficult for her to see the bingo cards at activities, and she inquired about services or aides for those with vision difficulties. During an interview on 1/18/24 at 9:12 a.m., staff member I stated she knew resident #11's vision was poor. Staff member I showed the bingo cards with large numbers and stated there could also be a helper to assist if the resident was unable to see the numbers. Review of resident #11's care plan, with a most recent revision date of 11/21/23, showed a lack of a focus area or interventions related to the resident's poor eyesight.

Based on observation, interview, and record review, the facility failed to monitor and consistently document a resident's wound status and any dressing changes performed for the resident's wound, for 1 (#27) of 46 sampled residents. Findings include: During an observation and interview on 1/17/24 at 8:23 a.m., resident #27 was in his motorized wheelchair. When asked about skin issues, the resident pointed to a wound dressing on his left shin. Resident #27 stated it was a wound which came and went. The resident could not remember when the wound dressing was applied. The dressing did not have a date or any identifying information on it. Review of resident #27's MAR, dated December of 2023, showed the resident had orders for a dressing change on his left shin until 12/27/23. Review of resident #27's provider progress note, dated 1/2/24, showed the resident had a wound on the front of his shin, . suspected to be caused by edema and venous stasis . The note showed the wound was healed on 1/2/24. Review of resident #27's EHR, dated from 12/27/23 through 1/15/24, failed to show any…

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

Based on observation and interview, the facility failed to ensure all medication carts were securely locked when not being attended by an authorized staff member. The deficient practice had the potential to affect all residents whose medications were stored in the medication cart. Findings include: During an observation on 1/18/24 at 9:20 a.m., the medication cart used for the rehabilitation unit and located in front of the nurse's station at the entrance to the rehabilitation unit was found to be unlocked and unattended. During an observation and interview on 1/18/24 at 9:40 a.m., staff members F and G were shown the unlocked medication cart initially observed at 9:20 a.m. Neither staff member F or staff member G could explain why the medication cart was left open. Staff member F stated it was the facility's expectation the medication carts would be locked securely when not attended by an authorized staff member.

Based on observation, interview, and record review, the facility failed to ensure staff utilized therapeutic communication and adequate personal hygiene care to meet residents care needs, while providing assistance to dependent residents, which resulted in feelings of intimidation, reluctance to ask for assistance, and tearfulness for 2 (#s 8 and 10); and failed to provide timely services necessary to meet dependent residents' individual care needs for 2 (#s 9 and 11) of 8 sampled residents. Findings include: 1. Review of a Facility Reported Incident, reported to the State Survey Agency on 3/24/23, showed resident #10 reported staff member H was rude to him and did not clean him adequately during the changing of his briefs, peri care, and baths. Review of the facility's investigative file for the incident, provided by the facility on 10/10/23, showed the facility substantiated resident #10's allegation of staff member H's care performance, based on resident's and staff statements. Resident #10 reported he would not allow staff member H to give him a bath anymore because he could get…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow the prescribed treatment for the management of pressure ulcers for 1 (#7) of 1 sampled resident. Findings include: Review of the Facility Reported Incident, reported to the State Survey Agency on 4/6/23, showed the wound nurse noted the last dressing/treatment on resident #7's wounds were on 3/31/23, when she had changed and initialed the dressings. The dressings on the wounds to the left gluteal fold and left medial thigh were saturated. It was reported the wound nurse immediately treated and changed the dressings on the wounds. An investigation was initiated into why the dressing changes were not done. Review of the facility's investigative file for the incident, provided by the facility on 10/10/23, showed the facility substantiated the allegation of not following provider's orders regarding wound dressing changes for resident #7, based on the wound care nurse's observations. Review of the electronic health records showed the wound dressing changes were marked on the TAR as completed on the day they were due but had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the dietary department failed to provide a gluten free diet, per providers orders for 1 (#5) of 3 sampled residents. Findings include: During a telephone interview on 10/10/23 at 1:43 p.m., resident #5 stated she was admitted to the facility on [DATE] for rehabilitation after a recent back surgery. She stated the facility was aware of her diagnosis of celiac disease before she was admitted and assured her and her family, they would be able to provide the appropriate gluten-free diet. Resident #5 described in detail the food she was served containing gluten, which included but was not limited to a breakfast sandwich with regular bread, a hamburger with regular bun, regular dinner roll, creamed corn (thickened with flour), and dessert with a graham cracker crust. Resident #5 stated all these foods had the potential to make her sick with diarrhea and it made her fearful due to her surgery and the long incision down her backside. Resident #5 stated she did not meet with the…

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