Central Continuing Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, the facility failed to provide Centers for Medicare and Medicaid Services (CMS)-10055 Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) prior to discharge from Medicare Part A skilled services for 1 of 3 residents reviewed for beneficiary protection notification review (Resident #71).The findings include:Resident #71 was admitted to the facility on [DATE].A review of the medical record revealed a NOMNC was issued to Resident #71 which explained Medicare Part A coverage for skilled services would end on 7/25/2025. The form was reviewed by Resident #71's Responsible Party (RP) on 7/23/2025. Resident #71 remained in the facility after 7/25/25. A review of the medical record revealed a SNF-ABN was not provided to Resident #71 or their Responsible Party. Resident #71 had 15 Medicare part A days remaining.On 9/10/2025 at 8:47 AM an interview was completed with the Social Service Director confirmed the NOMNC was issued when Resident #71's Medicare Part A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff and resident interviews, the facility failed to protect a resident's right to be free from verbal and physical abuse when Family Member #1 pulled Resident #50 by her hair back into her room, which resulted in no physical harm to Resident #50. In addition, Family Member #1 raised her hand and stated to Resident #50 I will slap you out of the chair, this resulted in restricted visitation for the Family Member of Resident #50. This affected 1 of 3 residents reviewed for abuse (Resident #50). Findings included:Resident #50 was admitted to the facility on [DATE] with the diagnoses of chronic obstructive pulmonary disease (a lung disease that makes it hard to breathe), and Parkinson's disease (a movement disorder that affects the nervous system and worsens over time).The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 was cognitively intact and had no behaviors or rejection of care.Review of the initial allegation report submitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, resident and staff interviews, the facility failed to implement a pressure-relieving chair cushion for 1 of 4 resident reviewed for pressure ulcers (Resident #30). This resulted in Resident #30 experiencing discomfort while up in her wheelchair and prevented her from remaining in her wheelchair for social activities. The findings included:Resident #30 was admitted on [DATE] with diagnoses including pressure ulcers, diabetes, heart failure, and debility.Review of the physician orders dated 7/9/2025 indicated a gel cushion to wheelchair for pressure reduction and to check placement daily. The Minimum Data Set (MDS) comprehensive assessment dated [DATE], revealed Resident #30 was cognitively intact. The initial assessment indicated one Stage II pressure ulcer, one Stage III pressure ulcer, and one unstageable, deep tissue injury. Resident #30 was at risk for developing pressure ulcers and a pressure reducing device was provided in the chair. Record review of the initial care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews the facility failed to post cautionary safety signs that indicated the use of oxygen for 5 of 7 residents reviewed for oxygen use (Resident #47, #30, #48, #19, and #70). The findings included: a. Resident #47 was admitted to the facility on [DATE] with a diagnosis of respiratory failure. A physician's order dated 7/30/2024 revealed Resident #47 was ordered to wear 2 liters per minute of oxygen continuously. An observation was conducted on 8/4/2024 at 9:56 am. Resident #47 was observed with his eyes closed in bed and oxygen being administered at a rate of 2 liters per minute via nasal cannula. There was no oxygen signage outside of Resident #47's room or on the doorframe. An interview was conducted on 8/5/2024 at 3:34 pm with Medication Aide (MA) #1. MA #1 stated when a resident was ordered oxygen, there was an order on the Medication Administration Record (MAR). MA #1 stated the nurses let the Nurse Assistants (NAs) know if a resident was ordered oxygen.…

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 record review and staff interviews, the facility failed to develop a baseline care plan that addressed a resident's weight-bearing status and the use of a sling to the right upper extremity for 1 of 1 resident (Resident #47) reviewed for baseline care plan. The findings included: Resident #47 was admitted to the facility on [DATE] with a diagnosis of a right distal clavicle (collarbone) fracture (break). A review of a baseline care plan dated 7/30/2024 revealed Resident #47 had a fracture and staff were to follow rehabilitation orders and/or recommendations. A review of a physician's order dated 7/30/2024 revealed Resident #47 was to always wear sling on his right upper extremity and was non-weightbearing to his right upper extremity. An interview was conducted on 8/6/2024 at 10:05 am with the Care Plan Nurse. The Care Plan Nurse stated a baseline care plan was completed when a resident was admitted to the facility. The Care Plan Nurse stated it was the responsibility of the hall nurse who admitted 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 observations, record review, and staff interviews the facility failed to provide fingernail care for a dependent resident for 1 of 4 residents reviewed for activities of daily living (ADL) (Resident #35). The findings included: Resident #35 was admitted to the facility on [DATE] with diagnosis' which included hemiplegia (inability to move one side of the body). A review of a care plan dated 5/13/2024 revealed Resident #35 had impaired mobility related to left-sided hemiplegia with interventions which included for staff to encourage Resident #35 to participate in activities of daily living (ADL) care as able and to assist him as needed. A review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #35 was cognitively intact and was not coded for rejection of care. Resident #35 was coded for impairment on one side of his upper extremities and required moderate assistance with personal hygiene. A review of the Electronic Health Record shower documentation dated 8/3/2024 revealed 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 observations, record review and interviews the facility failed to secure an indwelling urinary catheter tubing to prevent tension or trauma for 1 of 3 residents reviewed for urinary catheter (Resident #86). The finding included: Resident #86 was admitted to on 08/02/24 to the facility with diagnoses that included urinary retention. The baseline care plan dated 08/02/24 revealed Resident #86 was alert and oriented to person and to check catheter strap every shift. The admission Minimum Data Set assessment was not yet completed as of 08/07/24. A review of Resident #86's physician orders dated 08/02/24 revealed an order for a urinary catheter to straight drainage due to the diagnosis of urinary retention. There was also an order to check placement of a catheter strap every shift. On 08/04/24 at 9:49 AM an observation was made of Resident #86 lying in bed with an indwelling urinary catheter attached to the left side of the bed frame. When asked the Resident uncovered her left thigh to show there was no stabilizing device present on the catheter tubing to prevent tension 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 observations, record review, resident, staff, Psychiatric Nurse Practitioner, and Medical Director interviews the facility failed to protect a resident's right to be free from abuse when Resident #1 hit Resident #2 with a tissue box causing a very small cut to his left eyebrow with a bruise because Resident #2 was banging a tissue box on his bedside table. This affected 1 of 2 residents (Resident #1) reviewed for resident-to-resident abuse. The findings included: Resident #1 was readmitted to the facility on [DATE] with diagnoses that included: restlessness, agitation, anxiety, and cognitive communication deficit. A review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #1 was moderately cognitively impaired and had no signs of delirium and no behaviors, rejection of care, or wandering were noted. Review of 24-hour initial report dated 11/10/23 read in part, at 4:05 PM Resident #1 threw a tissue box at Resident #2 causing a laceration and discoloration 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 record review and staff interviews, the facility failed to develop and implement their abuse policy in the area of reporting for 2 of 2 residents reviewed for abuse (Resident # 1 and Resident #2) The findings included: A review of the facility's policy titled, Abuse Prevention Program: Policies and Procedures dated revised 10/24/22 indicated all alleged violations involving abuse, neglect, and misappropriation of patient property were to be reported immediately to the Administrator and the Director of Nursing (DON). The policy also indicated that any time there was an allegation of staff to resident abuse Adult Protective Services (APS) was to be contacted. Additionally, the policy stated the administrator or his/her designee will report allegations to the Health Care Personnel Registry within the specified timeframes: (a) immediately, but no later than 2 hours if the alleged violation involves abuse or results in serious bodily injury or (b) not later than 24 hours if the alleged violation involved…

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.