Princeton Health & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure resident was assessed for risk of entrapment (state of being stuck or caught on bed rail) from bed rails for 2 (R #123 and R #296) of 3 (R #101, R #123 and R #296) resident reviewed for accidents. This deficient practice has the potential to cause serious injury by becoming trapped between the mattress and bed rail. The findings are: R #123 A. On 07/22/25 at 8:29 am during an observation of R #123's room, there was a quarter size rail (rails that take up a quarter part of the bed) on each upper side of R #123's bed. B. Record review of R #123's admission Record revealed he was originally admitted to the facility on [DATE] with the following diagnoses: 1. Fracture of Neck of Left Femur (a break in the bone of the upper thigh, specifically within the region just below the hip joint ball), 2. Repeated Falls, 2. Muscle Wasting and Atrophy (decrease in muscle mass and strength), 3. Lack of Coordination, 4. Dementia (a general term for 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 record review and interview, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs by ensuring adequate indication of use based off of the residents' conditions for 3 (R #2, R #123, and R #282) of 4 (R #2, R #44, R #123, and R #282) residents reviewed for unnecessary medications. This deficient practice could likely lead to adverse drug effects and poor patient outcomes. The Findings are: R #2 A. Record review of R #2's physician's orders revealed the following: 1. Topiramate Oral Tablet (an anticonvulsant medication that is used to treat seizures and prevent migraine headaches.) 50 milligrams (MG). Give 1 tablet by mouth one time a day for Seizures (a sudden, abnormal surge of electrical activity in the brain that can cause a variety of symptoms, including changes in behavior, movement, sensation, and awareness). Start Date: 04/12/25 2. Trazodone HCl Oral Tablet (an antidepressant medication primarily used to treat depression, anxiety, and insomnia) 100 MG…

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 residents received routine dental services (an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings (new and repairs), minor partial or full denture adjustments, smoothing of broken teeth, and limited prosthodontic procedures, e.g., taking impressions for dentures and fitting dentures) were provided dental visits annually for 2 (R #1 and R #14) of 2 (R# 1 and R #14) residents reviewed for routine dental services. This deficient practice is likely to negatively impact residents through pain, mood, and state of well-being if dental conditions have not been addressed in a timely manner. R #1 A. Record review of R #1's Electronic Health Record (EHR), R #1 was admitted on [DATE] with the following diagnoses: 1. Muscle wasting and atrophy (the decrease in size or wasting away of a cell, tissue, organ, or muscle), 2. Muscle Weakness, 3. Adult Failure to Thrive…

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, record review, and interview, the facility failed to maintain proper infection prevention measures by: 1. Not disinfecting direct patient care equipment after use. 2. Not adhering to Enhanced Barrier Precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities), 3. Not adhering to contact precautions (used for individuals with infections that can spread through direct or indirect contact with the patient or their environment). These deficient practices have the potential to affect all 291 residents residing in the facility according to the census provided by the Administrator (ADM) on 07/21/25 by experiencing an increase of infections leading to further health concerns. The findings are: Equipment A On 07/24/25 at 9:58 AM during an observation of the medication pass for R #75, Registered Nurse (RN) #32 took R #75 blood pressure with portable blood pressure cuff. Upon completion of blood pressure measurement RN placed cuff…

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 an effective pest control program for 3 (R #2, R #52, and R #172) of 3 (R #2, R #52, and R #172) residents reviewed by allowing insects and their waste in their living space. If the facility does not maintain an effective pest control program, then residents are at a greater risk of contracting certain diseases and may feel disgusted or embarrassed about their living space. The findings are: R #2 A. On 07/22/25 at 12:42 pm, an interview and observation with R #2 revealed the following: 1. R #2 stated the facility has a big bug problem and feels like they could do more to control it. R #2 stated his sister has to purchase bug traps (traps and kills insects) to keep in his room. 2. Two bug traps were located on the floor of the restroom in R #2's room. 3. Duct tape running along the border of the wall that R #2 stated he put there because bugs would come out of the wall there. 4. R #2 stated he has talked with the facility's staff several times regarding the pest infestation but nothing happens. R #52 and R #172 B. 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.

Based on record review and interview, the facility failed to ensure Certified Nurse Aides (CNAs) received the required in-service training of 12 hours per year for 3 (CNA #3, CNA #4, and CNA #5) of 5 (CNA #1, CNA #2, CNA #3, CNA #4, and CNA #5) CNAs reviewed for required in-service training. This deficient practice is likely to result in the CNAs not receiving the necessary training to meet the care needs of the residents. The findings are: CNA #3 A. Record review of CNA #3's personnel file revealed CNA #3 was hired on 05/06/24. B. Record review of CNA #3's in-service training Transcript Report revealed CNA #3 did not complete any of the required trainings. CNA #4 C. Record review of CNA #4's personnel file revealed CNA #4 was hired on 11/29/23. D. Record review of CNA #4's in-service training Transcript Report revealed CNA #4 did not complete the 12 hours of training as required per year. CNA #5 E. Record review of CNA #5's personnel file revealed CNA #5 was hired on 07/26/23. F. Record review of CNA #5's in-service training Transcript Report revealed CNA #5 d did not complete 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 record review and interview, the facility failed to ensure residents and/or their representatives were informed in advance of what medications they received and understood the reasons, risks, and benefits of the medications for 1 (R #282) of 3 (R #2, R #123, and R #282) residents reviewed for unnecessary medications. If the residents or their representatives are not informed of the risks and benefits of the medication or treatment alternatives, they are not able to make informed decisions regarding residents' care. The findings are: A. Record review of R #282's physician's orders revealed the following: - An order for Gabapentin capsule (anticonvulsant; medication used to treat seizure activity), 100 milligrams (mg). Give one capsule by mouth three times a day for intrusive agitation (unwanted thoughts that enter one's mind despite efforts to avoid them, and agitation, a state of being unable to remain still or calm, characterized by motor hyperactivity, restlessness, emotional tension, and sometimes verbal aggression. Start date: 03/14/25. - An order for Trazadone oral…

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 interview, the facility failed to update/revise the advance directive for 1 (R #6) of 1 (R #6) resident reviewed for advanced directives. This deficient practice could likely result in residents' declination of treatment such as refusals of artificial nutrition (a medical treatment for a person to receive nutrition when they are no longer able to) or intravenous (IV; into the vein) hydration as well as life saving measures such as attempting cardiopulmonary resuscitation (CPR; full code, an emergency procedure that combines chest compression with artificial ventilation) against resident's wishes. The findings are: A. Record review of R #6's admission Record revealed he was originally admitted to the facility on [DATE] with the following diagnoses: - End stage renal disease (ESRD; chronic irreversible kidney failure). - Dependence on renal dialysis (a medical procedure that removes excess water, solutes, and toxins from the blood when the kidneys are no longer able to do so), - Type 2…

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 and interviews, the facility failed to provide a comfortable and homelike environment by ensuring safe temperature levels (between 71 degrees to 81 degrees) for residents ensuring and a clean, comfortable, and safe environment. These deficient practices could affect all 291 residents as identified by the Daily Census provided by the Administrator (ADM) on 07/21/25. If the facility does not ensure safe temperature levels, clean and safe environment then the residents could be at risk causing additional or increased adverse health conditions and uncomfortable living conditions for the residents. The findings are: A. On 07/22/25 at 8:00 am observation revealed the following: - Blue painter's tape was hanging off two windows at the front face of the facility. - There were more than 10 cigarette butts on the ground at the front entrance to the facility. - The Physical Therapy room was missing a ceiling tile at the pillar in the room, and above the women's restroom sink. - The atrium had a spot…

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 interview the facility failed to complete the quarterly review Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment within 92 days for 1 (R #179) of 2 (R #179 and R #294) residents reviewed for resident MDS assessments. This deficient practice could likely result in residents not receiving the care and assistance needed. The findings are:A. Record review of R #179's face sheet revealed she was originally admitted to the facility on [DATE]. B. Record review of R #179's most recent quarterly MDS was completed on 02/19/25. C. On 07/25/25 at 9:36 am during an interview with MDS Coordinator, she confirmed R #179 should have had a quarterly MDS completed in May2025. She confirmed the quarterly MDS was not completed and should have been.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS; a federally mandated comprehensive assessment of a resident's functional, medical, psychosocial and cognitive assessment completed by facility staff) was accurate for 1 (R #282) of 3 (R #2, R #101, and R #282) residents reviewed for MDS assessments. This deficient practice could result in a failure to provide adequate care and treatment of the resident's needs. The findings are: A. Record review of R #282's face sheet revealed he was admitted on [DATE]. B. Record review of R #282's physician's orders revealed the following: - An order for Gabapentin capsule (anticonvulsant; medication used to treat seizure activity), 100 milligrams (mg). Give one capsule by mouth three times a day for intrusive agitation. Start date: 03/14/25. - An order for Valproic Acid oral solution (anticonvulsant; medication used to treat seizure activity), 250 milligrams (MG)/5 milliliters (ML). Give 5ML by mouth three times a day for seizure…

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 interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 2 (R #44 and R #123) of 5 (R #2, R #44, R #55, R #123 and R #321) residents reviewed for baseline care plans. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission. The findings are: R #44 A. Record review of R #44's admission Record revealed he was admitted to the facility on [DATE] with the following diagnoses: 1. Chronic obstructive pulmonary disease (COPD; lung disease), 2. Epilepsy (a seizure disorder), 3. Heart failure (a condition where the heart muscle cannot pump enough blood), B.…

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 interview, the facility failed to develop a comprehensive care plan for 4 (R #2, R #44, R #56, and R #123) of 5 (R #2, R #44, R #55, R #56 and R #123) residents reviewed when staff failed to: 1. Develop a care plan for R #2's anticonvulsant medication and seizure disorder. 2. Develop a care plan for R #44's diagnosis of dementia. 3. Develop a care plan for R #56's use of a trapeze bar (a device suspended above a bed to assist with transferring or repositioning). 4. Develop a care plan for R #123's diagnosis of schizophrenia. This deficient practice is likely to result in staff not being aware of the residents' care needs and preferences, and residents not receiving the needed care. The findings are: R #2 A. Record review of R #2's admission Record revealed he was originally admitted to the facility on [DATE] with the following diagnoses: 1. Acute kidney failure (kidneys no longer function well), 2. Schizophrenia (a disorder that affects an individual's ability to think, feel, 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, record review, and interview, the facility failed to ensure staff revised the care plan for 3 (R #101, R #123 and R #200) of 3 (R #101, R #123 and R #200) residents reviewed when staff failed to -update R #101's, and R #123'scare plan to include use of bed rails. -update R #200's care plan to include interventions for pain management These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are: R #101 A. On 07/24/25 at 10:43 am, an observation of R #101's room revealed a half-sized bed rail (a bed rail that is designed to be installed on the side of the bed) on the left side of her bed. B. Record review of R #101's admission Record revealed she was originally admitted to the facility on [DATE] with the following diagnoses: 1. Fracture of Left Patella (a bone located at the front of the knee joint), 2. Muscle Wasting and Atrophy (decrease in muscle mass and strength), 3. Lack of Coordination, 4. Major…

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 follow Physician Orders for 1 (R #10) of 1 (R #10) residents reviewed for comprehensive care plans (plan with measurable goals and timeframes to meet a resident's medical, nursing, mental health and psychosocial needs). This deficient practice could likely lead to harm of the resident. The findings are:A. Record review of R #10's Face Sheet revealed an admission date of 04/19/24.B. On 07/21/25 at 12:52 PM, during an observation of R #10's room revealed one bed rail attached to the resident's bed. C. Record review of R #10's Physician Orders, dated 02/27/25, revealed an order for bilateral side rails to assist with bed mobility.D. Record review of R #10's most recent Bed Rail Assessment, dated 02/27/25, revealed the following: -Resident does not have difficulty with balance or poor trunk control.-Recommendations for bilateral side rails.E. Record review of R #10's care plan, dated 03/03/25, revealed the resident requires bilateral siderails when in bed to enhance mobility and positioning. F. On 07/25/25 at…

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, record review and interview, the facility failed to utilize infection control practices for handling respiratory equipment for 1 (R #10) of 1(R #10) residents reviewed for respiratory services. This deficient practice is likely to place the resident at risk with cross contamination and the development of respiratory infections. The findings are: A. On 07/21/25 at 12:56 PM, during an observation of R #10's room, the resident's nasal cannula (a small, flexible tube that delivers oxygen to the nose through soft prongs) connected to an oxygen concentrator (device that concentrates the oxygen from a gas supply) sat directly on R #10's fabric covered bedding. B. On 07/24/2025 at 12:56 PM, during an observation of R #10's room revealed the resident's nasal cannula, connected to a running concentrator lay directly on resident's fabric bedding and draped over bed rail. C. On 07/25/25 at 2:04 PM, during an observation of R #10's room revealed resident's nasal cannula connected to concentrator, lay directly on the resident's bed with the nasal prongs touching the floor 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 record review and interview, the facility failed to a resident received appropriate treatment and services for dementia for 1 (R #44) of 1 (R #44) resident reviewed. This deficient practice could likely lead to residents not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being. The findings are: A. Record review of R #44's admission Record revealed he was admitted to the facility on [DATE] with the following diagnoses: 1. Chronic obstructive pulmonary disease (COPD; lung disease), 2. Epilepsy (a seizure disorder), 3. Heart Failure (a condition where the heart cannot pump enough blood to meet the body's needs), 4. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), with agitation, 5. Post-traumatic stress disorder (PTSD; a mental health condition triggered by a terrifying event, causing flashbacks, nightmares, and severe anxiety). B. Record review of R #44's quarterly Minimum Data Set…

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 record review, observation and interview, the facility failed to ensure trash receptacles were covered to minimize odors and prevent pest or mice. If staff fail to keep trash cans closed both inside and outside the facility, then the environment may become unsanitary and increase the risk of pest infestation and disease transmission to residents.Finding are: A. Record review of the facility's Sanitation Policy, dated October 2024, revealed kitchen waste shall be kept in clean, leakproof, nonabsorbent, tightly closed containers.B. On 07/25/25 at 2:18 PM, observation revealed a dumpster located outside was uncovered. Further observation revealed the trash can lid in the kitchen was up, and trash was in the trash can and dumpster.C. On 07/25/25 at 2:18 PM, during an interview, the Kitchen Manager stated the outside trash cans must always remain closed to prevent flies and pests. The Kitchen Manager stated the kitchen trash can lid should be down. She stated it was her expectation for kitchen staff to follow the facility's Sanitation Policy.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to document a pain medication was given to 1 (R #1) of 1 (R #1) resident reviewed for pain. This deficient practice could likely cause confusion with staff on whether a pain medication was administered and could cause harm to the resident if the pain medication was administered again. The findings are: A. Record review of R #1's face sheet revealed R #1 was admitted to the facility on [DATE]. R #1 was on hospice with the following diagnoses: - Anoxic brain damage (oxygen is completing cut off from the brain), - Chronic respiratory failure with hypoxia (when your respiratory system is unable to remove enough carbon dioxide from your blood, causing it to build up in your body). - Chronic obstructive pulmonary (damage results in swelling and irritation, also called inflammation, inside the airways that limit airflow into and out of the lungs), - Alzheimer's (a type of dementia that affects memory, thinking and behavior) and dementia (symptoms affecting…

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 interview, the facility failed to complete and document a thorough investigation, implement measures to prevent further incidents, and implement corrective actions regarding allegations of neglect (failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness), abuse (knowingly causing physical or mental harm or failing to provide goods and services necessary to avoid physical or mental harm), and injury of unknown origin for 3 (R #4, #5, and #6) of 3 (R #4, #5, and #6) residents reviewed for abuse and neglect allegations when staff failed to complete and submit thorough follow-up reports for R #4, #5, and #6. If facilities do not submit follow up reports then the SA cannot assure the residents are safe and free of abuse. R #4 A. Record review of R #4's face sheet, undated, revealed R #4 was admitted into the facility 10/03/24. B. Record review of the Facility Reported Incident report, dated 10/14/24, revealed the following: - Staff found R…

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, record review, and interview, the facility failed to ensure staff did not leave medications on the bedside table for 1 (R #13) of 1 (R #13) resident. This deficient practice could likely result in residents misplacing or not taking medications which could cause the resident to be pain. The findings are: A. On 11/20/24 at 1:54 pm, observation of R #13's room revealed a small cup with two pills sat on the bedside table. B. On 11/20/24 at 1:54 pm, during an interview with R #13, she stated the medications were not there that long. She stated she did not take them when the nurse brought them to her, because she was waiting for staff to change her brief. C. On 11/20/24 at 2:07 pm, during an interview with Register Nurse (RN) #1, she stated she left the pills in R #13's room on her bedside table. She stated R #13 was ready for her medications, but she was waiting to be changed. The RN stated R #13 did not want to sit up in bed. She stated she knew better then to leave the medications on the resident's bedside table. She said she should have brought the 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.

Based on observation and interview, the facility failed to ensure medication carts were locked when unattended. This deficient practice is likely to negatively impact the health of residents on the 600 unit if they were to ingest (swallow) medications not intended for them. The findings are: A. On 11/21/24 at 7:47 am, during an observation of the 600-unit medication cart, the medication cart was unattended and unlocked. B. On 11/21/24 at 7:47 am, during an interview with Registered Nurse (RN) #1, she confirmed that medication carts should be locked and secured at all times when left unattended.

Based on observation and interview, the facility failed to ensure residents had a safe and functional environment when the facility failed to ensure flooring was flat, smooth, and level for 1 (R #1) of 1 (R #1) residents reviewed. This deficient practice could likely result in residents living in an unsafe environment and could increase their risk for injuries and decrease their quality of life. The findings are: A. On 11/20/24 at 8:37 am, during observation of the R #1's room, the floor was uneven, and multiple tiles were missing near the window. An unoccupied bed sat over the missing tiles near the window. Further observation revealed a floor tile was missing near the toilet in the resident's bathroom. B. On 11/20/24 at 8:40 am, during an interview with R #1, he stated the floors in the bathroom and the bedroom were gross, and he told the facility four times to fix it. He stated he reported this to the nurses and the maintenance man. C. On 11/21/24 at 10:20 am during an interview with the Maintenance Director (MD), he stated that the air conditioning unit was causing some…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a safe, clean, and comfortable environment for and R #13 and all residents who utilized the courtyard and the 600 unit hallway. This deficient practice is likely to cause all residents in this facility to be exposed to environmental hazards and not to feel comfortable, which could affect their psychosocial well-being. The findings are: A. On 07/29/24 at 1:02 pm, an observation revealed the following: -The patio of the resident courtyard smoking area and grass edge were littered with cigarette butts. -The floors down the 600-unit hallway were visibly stained and unkempt. B. On 07/27/24 at 1:15 pm, an observation of resident occupied rooms revealed the following: - room [ROOM NUMBER]: The closet door was falling off the hinges. - room [ROOM NUMBER]: The closet door was falling off the hinges. - room [ROOM NUMBER]: The closet door was falling off the hinges. C. On 07/30/24 at 10:34 am, during an interview and observation, R #11 stated the floors…

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 record review and interview, the facility failed to notify the Power of Attorney (POA; a health care power of attorney grants, in writing, a particular agent the power to make healthcare decisions on another's behalf) when R#2 wandered into another resident's room and sustained an injury from an unknown resident, for 1 (R #2) of 1 (R #2) resident reviewed. If the facility is not notifying the resident's POA when the resident has a change of condition, then the POA is unable to make decisions related to treatment and advocate for the resident's care. The findings are: A. Record review of R #2's face sheet dated 07/24/24 revealed the following: - admission date of 05/22/24. - Dementia, with other behavioral disturbance (a chronic disease that causes a progressive decline in memory, judgment, including poor decision making). - Muscle wasting and atrophy (loss of muscle tone and lack of movement). - Emergency contact #1 and POA - relationship daughter B. Record review of R #2's progress notes revealed the following: - Dated 07/05/24, Certified Nursing Aide (CNA) #1 found R #2…

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 interview, the facility failed to prevent an accident for 1 (R#2) of 2 (R#2 and R #3) when the facility failed to implement interventions to prevent R #2 from walking into other residents' rooms without permission and potentially putting himself at risk for harm. This deficient practice could likely result in physical harm to residents, physical harm and/or psychosocial distress (unpleasant emotions associated with a highly stressful situation), or worsening of current mental health conditions for the residents who were subject to this behavior. The findings are: R #2 A. Record review of R #2's medical record revealed he was admitted on [DATE] with the following diagnoses: 1. Benign intracranial hypertension (high pressure around the brain causes symptoms like vision changes and headaches). 2. Dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) in other diseases classified elsewhere, unspecified severity,…

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 record review, observation, and interviews the facility failed to: 1. Ensure eye drops were disposed of within 30 days of opening. 2. Ensure all expired supplies were not kept with unexpired supplies. 3. Ensure medications are kept in original package. 4. Ensure all expired medications were not kept with unexpired supplies. These deficient practices are likely to result in all 261 residents', identified on the census list provided by the Executive Director (ED) on 04/21/24, medications that were pre-poured (put into unmarked cups, without patient identifiers), to receive expired medications or supplies that have lost either their potency or effectiveness, or to receive medication or vaccines that have lost either their potency or effectiveness. The findings are: Ensure eye drops are disposed of within 30 days of opening. A. Record review of a National Institute of Health, peer reviewed article titled, Shelf Life and Efficacy Eye Drops, dated October 2018, revealed it was recommended to discard ophthalmic drugs 30 days after opening. B. On 04/21/24 at 11:46 am, 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 observation, record review, and interview the facility failed to maintain proper infection prevention measures when staff failed to: 1. Ensure safe transport of soiled laundry from resident room to laundry chute. 2. Ensure staff members wore appropriate personal protective equipment (PPE; gloves, face mask, eye protection, and a gown) while sorting contaminated laundry in the laundry room. Failure to adhere to an infection control program could likely cause the spread of infections and illness to all 261 residents listed on the census provided by the Administrator on 04/21/24. The findings are: Ensure staff members wore appropriate personal protective equipment while sorting contaminated laundry in the laundry room. D. On 04/24/24 at 2:31 pm, during an observation and interview, Housekeeper (HK) #1 wore gloves and sorted dirty laundry from the laundry chute. HK #31 stated she used gloves but should also use a yellow gown, face mask, and eye wear while going through the soiled clothes. HK #1 knew where the PPE items were kept. HK #1 stated she did not have it on all 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 and interview the facility failed to provide a homelike environment for 2 (R #190 and R #37) out of 3 (R #190, R #37, and R #23) residents (residents were identified by the resident matrix provided by the Administrator on 04/21/24), when they failed to: 1) Repair damaged or missing drawer face from one resident's room. 2) Prevent or remove cockroaches inside a resident's continuous positive air pressure (CPAP; helps keep your airway open when asleep) humidifier tank. 3) Repair water leaks and damaged ceiling in the therapy room. If residents do not have a homelike environment, they may become depressed and anxious about things in disrepair. The findings are: Resident #190 A. On 04/22/2024 at 9:23 am, during observation of R #190's room, her closet drawer was missing the face and handle, which made it inoperable. B. On 04/22/2024 at 12:32 pm, during an interview with R #190, she stated her closet drawer face has been missing/broken for weeks. R #190 stated she cannot use the drawer because she cannot open it. She stated this made her feel like the facility 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.

Based on observation, record review, and interview, the facility failed to meet professional standards of quality for 2 (R #26 and R # 87) of 2 (R #26 and R #87) residents reviewed by when staff failed to administer medications per recommend guidelines. If the facility is not administering medications in accordance with physician orders and accepted professional practices, then residents are likely to not get the therapeutic results needed. The findings are: Findings for R #26 A. On 04/21/24 at 12:36 pm, during an observation of the 500 south medication cart, Licensed Practical Nurse (LPN) #5 opened the top drawer of the medication cart to reveal two small medication cups that held medications. One of the cups belonged to R #26 and had the resident's room number written on the outside of the cup. B. Record review of R #26's care plan, dated 02/25/24, revealed the care plan did not contain instructions for staff to hide medications in R #26's food without knowledge of the resident. C. Record review of R #26's electronic medical records revealed the records did not contain…

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 maintain records of controlled substances (drugs subject to strict government control because they may cause addiction) on the 400 north, 500 south, and 600 front medication carts. This deficient practice could likely cause controlled substances to be diverted (the transfer of any legal prescribed controlled substance from the individual for whom it was prescribed to another person for any illegal use). The findings are: A. Record review of the facility's policy titled Controlled Substances, revised date December 2012, revealed nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse [NAME] off duty must make the count together. They must document and report any discrepancies to the Director of Nursing. B. On 04/21/24 at 12:16 pm, an observation of the 500 south medication cart revealed staff failed to sign the narcotic book [a book used to manually track inventories of prescribed…

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, observation, and record review, the facility failed to ensure the comprehensive care plan was accurate for 1 (R #202) of 1 (R #202) residents reviewed for care plan accuracy. This deficient practice could likely result in staff not understanding and implementing the most appropriate interventions and treatments for the resident. The findings are: A. On 04/22/24 at 9:57 AM during an observation, R #202 wore a catheter bag for an indwelling (left in place) urinary catheter. B. Record review of R #202's current physician order summary revealed an order to change the resident's catheter monthly and as needed for blockage or leaking. C. Record review of R #202's care plan revised on 02/14/24 revealed the resident had an intermittent catheter (catheter inserted several times a day to drain the bladder then removed) related to a neurogenic bladder (lack of bladder control due to brain, spinal cord, or nerve impairment.) D. On 04/25/24 at 9:36 AM during an interview with Nurse Unit Manger (UM) #1 and the Director of Nursing (DON), UM #1 stated R #202's care plan…

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 interview, the facility failed to document weekly wound assessments for 1 (R #7) of 1 (R #7) residents reviewed for wound care. This deficient practice could likely result in a resident's wound progression not being evaluated on a weekly basis. A. Record review of R #7's face sheet revealed R #7 was admitted to the facility on [DATE] with the pertinent diagnoses of: metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), cerebral infarction (an ischemic stroke- caused by disrupted blood flow to the brain due to problems with the blood vessels that supply it), and type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). B. Record review of physician orders revealed the following: 1. Physician order, dated 02/01/24, Clean open area [stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed)] to left buttock with wound…

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 help maintain acceptable parameters of nutritional status, such as usual body weight, for 1 (R #409) of 3 (R # 26, R # 87, and R # 40) residents sampled for nutrition, when they failed to put a plan into place for R #409 who had weight loss. This deficient practice could likely result in the residents losing weight, causing physical and mental health issues. The findings are: A. Record review of R 409's face sheet revealed an admission date of 12/20/23 with the following diagnoses: -Parkinson's disease (a progressive disorder that affects the nervous system and causes tremors, stiffness and slow movement) with dyskinesia with out mention of fluctuations (uncontrolled, involuntary movements of the face, arms or legs). -Major depressive disorder (a mental disorder with at least two weeks of low mood, low self esteem, and loss of interest or pleasure of normal things). -Chronic kidney disease, stage 3 (mild to moderate damage to the kidneys and can be treated with diet, medications, and lifestyle changes). B. Record review of…

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

Based on observation, interview, and record review, the facility failed to provide an orderly, homelike environment for 1 (R [Resident] #1) of 3 (R #1, R #2, & R#3) residents reviewed for resident rights by leaving unused medical equipment in the resident's room for 24 days after last use. This deficient practice could lead to residents feeling disrespected, uncomfortable, and depressed. The findings are: A. On 10/16/2023 at 12:55 pm during an observation of R #1's room, a rolling IV (intravenous [medication administered into a vein]) pole, with attached pump and a mostly empty bag of clear fluid hanging from the pole, stood in the corner of the room near the head of the resident's bed. The bag was labeled .09% Sodium Chloride (an intravenous solution of salt and water commonly used as a source of hydration), 1000 ML (milliliters). The pump was unplugged with the power cord wrapped around the pole. B. On 10/17/2023 at 11:22 am during an interview with R #1, he stated the IV pole had been in his room for weeks. He added that he wished it would be removed, and it makes the room feel…

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 interview the facility failed to ensure that services were provided to meet professional standards for 3 ( R #123, R #132, and R #135 ) of 3 (R #123, R #132 and R #135) residents reviewed by: 1. Not administering and discharging medications as indicated on pharmacist's recommendations and physician's agreement and orders. 2. Not accurately documenting and reporting skin assessments conducted with refusals and per resident's self-report, and 3. Not implementing and documenting care measure interventions to prevent contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). 4. Not getting R#135 out of bed and into the wheelchair (a chair fitted with wheels for use as a means of transport by a person who is unable to walk as a result of illness, injury, or disability) regularly (with a constant or definite pattern) per the physician order and care plan. If the facility is not ensuring that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure residents were free from accident and safety hazards and supervised for 4 (R #14, R #123, R #157, R #77) residents of 4 (R #14, R #123, R # 157, R #77) ) residents reviewed for accident hazards by: 1. Having a loose grab bar (a graspable bar attached to the wall as an assistance to maintain balance) in resident bathroom. 2. Having insufficient length of call light cord in resident bathroom. 3. Not removing fall mats from the floor when residents are not in bed 4. Not supervising residents on 300 locked care unit when they failed to have staff present to supervise residents seated in dining room prior to a meal. This deficient practice could likely affect the safety and health of the residents. The findings are: Findings for R#14 A. On 01/05/23 at 8:53 AM, during an observation of R #14's bathroom, towel bar (bar used to hold a towel) was missing from wall of bathroom, the grab bar (a graspable bar attached to the wall as an assistance to maintain…

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 that 3 (R #14, R #70 and R #106) residents of 3 (R#14, R #70, and R #106,) residents reviewed were free from any significant medication errors by: 1. Having been administered (given) the incorrect dosage of a medication for 5 consecutive (in order) days for R #14. 2 Not receiving (getting) medication as prescribed (written by medical doctor) prior to receiving a shower for R #106. 3. Not following the physician's orders by crushing medication that did not have an order to be crushed for R #70. These deficient practice are likely to negatively (in a bad way) impact (result in) a residents' status (how one feels) by increasing anxiety (feeling of worry) and fear (unpleasantness), and can cause dangerous side effects (death; life-threatening; hospitalization; disability or permanent damage). Findings for Resident #14 A. Record review of R #14's physician orders, dated 11/17/22, indicated an open order (no script required for refills) for Morphine (a Schedule II (high risk for addiction) medication used 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.

Based on observation and interview, the facility failed to ensure that medications and supplies stored in the medication storage rooms on both the 300 and 500 units and inside of the medication storage refrigerators on the 500 units were not expired. This deficient practice has the potential to negatively impact the health of all the residents on both the 300 and 500 units. Receiving expired medications could likely result in residents receiving medications that have lost their potency and effectiveness leaving them vulnerable to acquiring infections. The findings are: Findings for 300 Unit A. On 01/04/23 at 1:20 pm during observation of unit 300's medication storage room the following was observed: 1. One 5 mL (milliliter) multidose vial of Influenza Vaccine Flucelvax Quadrivalent (used to protect against infection from flu virus) dated on box as being opened on 10/12/22 which indicated that it was expired. 2. One clear bag containing twenty four 3M (brand of product) Curos Disinfecting Port Protectors (alcohol-containing caps which twist onto I. V.( an apparatus used to 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 interview and record review the facility failed to keep accurate, up to date resident records for 6 (R #6, R #90, R #129, R #132, R #157 and R #167) of 8 (R #6, R #35, R #90, R #126, R #129, R #132, R #157 and R #167) residents reviewed by not having the following: 1. A Pre-admission Screening and Resident Review (The PASRR Level II is a comprehensive evaluation required as a result of a positive Level I Screening. A Level II is necessary to confirm the indicated diagnosis noted in the Level I Screening and to determine whether placement or continued stay in a Nursing Facility is appropriate) for resident #6 looked at for PASRR level II screening. 2. Inaccurate care plan and nursing documentation around a Foley catheter (Rubber tube that is inserted into the bladder to drain the urine) for resident #167. 3. Inaccurate diagnosis of Schizophrenia for resident #157. 4. Medical records and notes related to resident #132 actively undergoing chemotherapy (using chemotherapy drugs to kill cancer cells by…

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 record review and interview, the facility failed to ensure that Certified Nursing Assistants (CNA's) had their required 12 hours of yearly in-service training completed for 3 (CNA # 10, 11, and 12) of 5 (CNA #10, 11, 12, 13 and 14) CNA's looked at for staffing competencies. This deficient practice could potentially cause CNA's to not be up to date with the knowledge that they need to care for the residents they work with; which could cause the residents harm. The findings are: A. Record review of staff training log sheets for the past year 2022 indicated the following: CNA #10 completed two training's in 2022 on the electronic training system. CNA #11 completed one training in 2022 on the electronic training system. CNA #12 completed one training in 2022 on the electronic training system. The above staff members did work for the facility this past year. B. On 01/13/23 at 12:00 pm, during an interview with Assistant Director of Nursing (ADON) she stated that they do some trainings through their electronic system and HR (Human Resources) keeps track of those trainings 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 record review and interview, the facility failed to follow physician orders for 1 ( R #107) of 1 (R #107) residents reviewed for therapeutic medication levels of an antipsychotic medication. This deficient practice could likely result in a resident not receiving the accurate dosage of a medication that would ensure clinical effectiveness while avoiding side effects. The findings are: A. Record review of the facility policy Test Results, last revised April 2022, revealed the facility process to be The resident's Attending Physician will be notified of the results of diagnostic tests. 1. Results of laboratory, radiological, and diagnostic tests shall be reported in writing to the resident's Attending Physician or to the facility. 2. Should the test results be provided to the facility, the Attending Physician shall be promptly notified of the results. 3. The Director of Nursing Services, or Charge Nurse receiving the test results, shall be responsible for notifying the physician of such test results. 4.…

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 interview the facility failed to ensure a resident with an order for a Foley catheter (A soft tubing that drains urine from the bladder to a collection bag) that was removed, had the Foley catheter re-inserted due to urinary retention (inability to fully empty the bladder) for one resident (R #77) of one (R #77) reviewed for catheter care. This deficient practice could likely result in resident having an infection and urinary retention. The findings are: A. Record review R #77's face sheet revealed the following diagnoses: Diabetes Type II with hyperglycemia (have insufficient insulin and insulin resistance, leading to hyperglycemia, or high blood sugar), Acute Kidney Failure (when your kidneys suddenly become unable to filter waste products from your blood), Neuromuscular dysfunction of bladder (refers to urinary bladder problems due to disease or injury of the central nervous system or peripheral nerves involved in the control of urination), cognitive function and awareness (issues…

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.