Skies Healthcare & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to develop and implement an accurate, comprehensive care plan for 3 (R #21, R #63 and R #71) of 4 (R #12, R #21, R #63, and R #71) residents reviewed for care plans when staff failed to: 1. Develop a care plan to include interventions for R #21's diagnosis of Multidrug-Resistant Organism (MDRO; a germ that is resistant to many antibiotics),2. Develop a care plan to include interventions for R #21's need for Modified Protective Environment Precautions, (a facility policy with special instructions to protect residents in their environment).3. Develop a care plan for R #63's use of bed rails.4. Develop a care plan for R #71's use of Continuous Positive Airway Pressure Machine (CPAP; a medical device that delivers pressurized air through a mask to keep your airway open during sleep). This deficient practice could likely result in proper care not being provided to residents.The findings are: R #21 A. Record review of R #21's admission record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide respiratory care in accordance with professional standards for 5 (R #20, R #35, R #41, R #71, and R #109) of 6 (R #20, R #35, R #41, R #63, R #71, and R #109) residents reviewed for respiratory care when the facility failed to:1. Ensure medical orders include the amount of oxygen (a specific flow rate; measurement of the volume of liquid or gas moving per unit of time) for R #20 and R #35.2. Ensure a medical order was in place for R #41's supplemental oxygen (extra oxygen required to support the body's vital functions) use. 3. Ensure medical orders, care plan and MDS (Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) were in place and accurate for R #71's use of a continuous positive airway pressure (CPAP; a breathing therapy device used to deliver a steady stream of oxygen through a mask) machine.4. Ensure medical orders indicated when to administer R #109 oxygen and the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to obtain appropriate physician orders and complete assessments prior to installation of bed rails for 1 (R #118) of 2 (R #63 and R #118) residents reviewed for bed rails. This deficient practice could result in the physician and the resident not knowing the needs, risks and benefit of bed rails. The findings are: A. Record review of R #118's admission record revealed R #118 was admitted into the facility on [DATE]. B. Record review of R #118's physician orders revealed there is no order for use of bed rails.C. Record review of R #118's bed rail assessment dated [DATE] revealed R #118 does not need use of bed rails. D. Record review of R #118's baseline care plan dated 01/03/26 revealed there were no interventions for use of bed rails or mobility enablers. E. On 01/04/26 at 1:11 pm during a random observation of R #118's room revealed quarter size bed rails on the upper right and left sides of bed. F. On 01/04/26 at 1:12 pm 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 observations, record reviews and interviews, the facility failed to ensure a medication error rate of less than 5% as ordered to 3 (R #s 5, 20, and 100) of 6 (R #s 1, 5, 20, 33, 86, and 100) residents reviewed. During the survey period, the survey team observed 27 opportunities for error and identified 3 errors, resulting in a medication error rate of 11.11%. Failure to administer medications as ordered could result in residents not receiving the full benefit of the medication regime. The findings are:R #5A. Record review of R #5's physician's order dated 10/15/25 revealed an order of wound care to the sacrum (area of the body at the base of the spine), cleanse with wound cleanser, pat dry, apply zinc (topical medication used to treat and prevent skin irritation), an apply optifoam (a specialty dressing for wound healing).B. On 01/08/26 at 9:16 am, observation of a scheduled wound care to R #5, LPN (licensed practical nurse) #1 used normal saline instead of wound cleanser.C. On 01/08/26 at 9:35 am, during an interview with LPN #1, he stated that he could not find any 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident received dental services for 2 (R #34 and R #56) of 3 (R #3, R #34, and R #56) residents reviewed for dental care. This deficient practice could likely result in residents experiencing tooth decay, tooth pain, and difficulty chewing. The findings are: R #34A. Record review of R #34's admission Record revealed R #34 was admitted to the facility on [DATE] with the following diagnoses:1. Personal history of transient ischemic attack (TIA; when blood flow to part of the brain stops for a brief period),2. Congestive heart failure (CHF; impaired heart function),3. Diabetes mellitus (a condition that results from insufficient production of insulin, causing high blood sugar),4. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),5. Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).B. On 01/04/26 at 2:16 pm, 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, and interviews, the facility failed to protect residents' personal health information (PHI) by leaving a document containing multiple residents' information (such as names, diagnoses, treatment plans, or room numbers) in a hallway. This deficient practice has the potential to affect residents residing on the 300 and 200 hall and can lead to unauthorized access to sensitive information, putting residents' privacy at risk.The findings are:A. On 01/05/26 at 2:11 pm, during an observation of the medication cart outside room [ROOM NUMBER], a white piece of paper with residents full name, room number and code status was left unattended and exposed to public view.B. On 01/05/26 at 2:15 pm, during an interview with Licensed Practical Nurse (LPN) #3, she confirmed that the white paper contained resident's identifier and should be kept hidden from public view and it did not happen.C. On 01/07/26 at 8:46 am, during an observation of the medication cart outside room [ROOM NUMBER], the computer…

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 call lights in the residents' rooms were within reach of the residents while in the room for 2 (R #22 and R #56) of 4 (R #2, R #8, R #22, and R #56) residents reviewed for call lights. This deficient practice could likely result in residents being unable to notify staff when they are in need of assistance. The findings are:R #22 A. On 01/05/25 at 10:34 am during an observation of R #22's room revealed R #22 was asleep in her recliner. The call light lay on top of the bed where she could not reach it.B. On 01/05/25 at 10:36 am during an interview with Hospice Nurse (HN) #1, she confirmed the call light was not within R #22's reach and the call light should have been. R #56C. On 01/05/25 at 8:58 am during an observation of R #56's room, revealed R #56 was asleep in his recliner. The call light lay on top of the bed where he could not reach it.D. On 01/05/25 at 9:05 am during an interview with Certified Nurse Assistant (CNA) #2, she confirmed the call light was not within R #56's reach and the call light should have been.

Based on observation and interview, the facility failed to promote care with dignity and respect for 1(R #22) of 9(R #1, R #6, R #11, R #22, R #28, R #35, R #41, R #64 and R #71) residents reviewed for dignity and respect by not knocking on R#22's door before entering room. This deficient practice is likely to impact residents' dignity and respect for their personal space.The findings are: A. On 01/04/26 at 8:40 am, during a random observation of the 400-hall, Registered Nurse (RN) #5 walked straight into R #22's room without knocking or announcing himself to R #22. B. On 01/04/26 at 8:42 am, during an interview with RN #5, he confirmed that he should have knocked and announced himself prior to entering R #22's room.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the PASARR (Preadmission Screening and Resident Review) Level I Identification Screen accurately reflected the resident's diagnosis for 1 (R #12) of 2 (R #11 and R #12) residents reviewed for accuracy of PASARR screening. If the facility does not ensure PASARR screenings are completed accurately, then residents with serious mental illness may not receive required evaluations or specialized services, placing them at risk for unmet mental health needs and a decline in psychosocial well-being.The findings are:A. Record review of R #12's admission record revealed R #12 was admitted into the facility on [DATE] with the following diagnoses:1. Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life),2. Prolonged grief disorder (a mental health condition characterized by intense and persistent grief that significantly impairs daily…

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, observation 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 1 (R #21) of 2 (R #12 and R #21) 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: A. Record review of R #21's admission record revealed R #21 was admitted into the facility on [DATE] with the following diagnoses:1. Pancytopenia (serious blood condition where there's a lower-than-normal count of all three blood cell types: red blood cells, white blood cells, and platelets, leading to fatigue, infection 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.

Based on observation, record review, and interview, the facility failed to provide quality care that meets professional standards for 1 (R #100) of 1 (R #100) resident reviewed when the staff failed to follow physician orders. This deficient practice is likely to result in residents not maintaining their optimal health as planned by their medical provider. The findings are: A. Record review of R #100's physician's order dated 11/04/25 revealed an order of Rybelsus (prescription medication used to treat type 2 diabetes [DM2; a disease in which the body cannot make or properly use insulin]) tablet 7 Milligrams (mg), Give 7 mg by mouth one time a day, take 30 mins before food/drink.B. On 01/06/26 at 8:41 am, during an observation of medication administration, Licensed Practical Nurse (LPN) #2 administered the medication while R #100 is finishing his breakfast.C. On 01/06/26 at 8:43 am, during an interview with LPN #2, she stated that she did know it should be given 30 mins before any food or drink.

Based on record review and interview, the facility failed to ensure 1 (R #5) of 1 (R #5) resident is receiving restorative services (services necessary to ensure the resident's abilities are not diminished). If the facility is not ensuring residents receive restorative services at the commencement of therapy services when indicated, residents are likely to experience a decrease in their activities of daily living. The findings are: A. On 01/05/26 at 6:10 pm during an interview with R #5, she stated she would like to get some kind of therapy even if it's just restorative therapy. B. On 01/07/26 at 1:00 pm during an interview with Physical Therapist (PT), he confirmed R #5 was discharged from therapy but could not remember the date and should be receiving restorative therapy. C. Record review of R #5's physician orders dated 12/23/25 revealed R #5 was referred to restorative nursing program (RNP) to receive the service three times a week for improved quality of life.D. Record review of R #5's restorative therapy notes did not indicate that R #5 was receiving restorative services. E.…

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 provide restorative physical therapy service devices as recommended by the therapy department for 1 (R #5) of 1 (R #5) residents. This deficient practice is likely to result in residents having pain and a decrease in mobility, causing psychosocial harm and despair. The findings are: A. Record review of R #5's face sheet revealed R #5 was admitted into the facility on [DATE] with the following diagnoses: Non-active primary progressive multiple sclerosis (MS: where symptoms worsen without relapses or new MRI (new or enlarging lesions seen on MRI scans, or lesions that enhance with contrast, showing ongoing inflammation in the central nervous system), Delusional disorders (a delusional disorder is when someone has a fixed false belief that doesn't change with evidence), Tremors unspecified (unspecified means involuntary shaking where the exact type or cause isn't identified), Uninhibited neurogenic bladder (the bladder contracts too often…

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 a resident with a foley catheter (a flexible, tube-like medical device inserted into the bladder to drain urine) had an order that demonstrated that a catheter was necessary, what type of catheter was needed, and how to care for the catheter for 1 (R #63) of 1 (R #63) resident reviewed for catheter use. This deficient practice could likely result in an increased and unnecessary risk of infections for residents. The findings are: A. Record review of R #63 admission record revealed R #63 was admitted on [DATE] with the following diagnoses:1. Lymphedema (chronic swelling),2. Chronic pain,3. Bi-polar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs),4. Adjustment disorder (a strong emotional or behavioral reaction to a specific, identifiable stressor),5. Hypothyroidism (the thyroid is not making enough thyroid hormone).B. Record review of R #63 physician orders revealed there were…

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 post nurse staffing data on a daily basis at the beginning of the shift that included the following: 1. Facility name. 2. The current date. 3. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: 1. Registered nurses. 2. Licensed practical nurses. 3. Certified nurse aides. 4. Resident census. This deficient practice has the potential to affect all 109 residents as identified by the census provided by the Administrator on 01/04/2026 and could likely result in residents and visitors not having the staffing information readily available. The findings are:A. On 01/04/2026 at 11:30 AM, during observation of the main entrance, the nurse staffing data was dated 01/02/2026 and was not posted for the current day. B. On 01/04/2026 at 11:35 am, during an interview with the Interim Director of Nursing (IDON) she confirmed the nursing staff data should be posted daily and was not.

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 medications have an adequate indication of use and ensuring indication of use is based off the residents' current diagnosis for 1 (R #63) of 2 (R #21 and #63) residents reviewed for unnecessary medications. This deficient practice could likely lead to adverse drug effects and poor patient outcomes. The findings are: A. Record review of R #63's admission record revealed R #63 was admitted on [DATE] with the following diagnoses:1. Lymphedema (chronic swelling),2. Chronic pain,3. Bi-polar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs),4. Adjustment disorder (a strong emotional or behavioral reaction to a specific, identifiable stressor),5. Hypothyroidism (the thyroid is not making enough thyroid hormone).B. Record review of R #63's physician record revealed an order for Carbidopa-Levodopa (a medication used primarily…

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 interviews, and record reviews, the facility failed to ensure transportation was provided for a scheduled oncology (the study and treatment of tumors) appointment for 1 (R #94) of 1 (R #94) resident reviewed. This failure resulted in the resident missing a prescribed chemotherapy treatment, potentially impacting the resident's health outcomes.The findings are:A. Record review of R #94's face sheet revealed he was admitted to the facility on [DATE] with the following diagnoses (including but not limited to):1. Malignant neoplasm of colon, unspecified (also known as colon cancer, cancer that forms in the tissues of the colon).2. Secondary malignant to neoplasm of liver and intrahepatic bile duct (cancers that arise in the liver or the bile ducts within the liver).3. Encounter for antineoplastic chemotherapy (resident is receiving chemotherapy treatment).B. Record review of the oncology visit dated 12/09/25 revealed R #94 has upcoming oncology treatment schedules dated 12/16/25, 12/30/25, 01/06/26, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident received rehab therapy (intended to restore the body to their highest degree of performance) services within a reasonable timeframe after the doctor ordered it for 1 (R #5) of 1 (R #5) resident reviewed for rehab services. This deficient practice is likely to result in a decrease in residents' functional mobility. The findings are:A. On 01/05/26 at 6:30 pm during an interview with R #5, she stated, I have not been in therapy and no one has seen me about it. I would like to go to therapy. B. Record review of R#5 face sheet revealed R #5 was admitted on [DATE] with the following diagnosis:1. Non-active primary progressive multiple sclerosis (a gradual worsening of neurological symptoms without the occurrence of relapses or remissions),2. Contracture of muscles (a permanent shortening or tightening of the muscle) in the right lower leg, left leg, and right upper arm,3. Secondary progressive multiple sclerosis unspecified (a stage 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 record review and interview, the facility failed to ensure Certified Nurse Aides (CNAs) and Nurse Aides in Trainings (NAIT) received the required in-service training of 12 hours per year for 2 (CNA #4 and NAIT #1) of 5 (CNA #2, CNA #4, NAIT #1, NAIT #2, NAIT #3) CNA's reviewed for 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 #4A. Record review of CNA #4's personnel file revealed CNA #4 was hired on 04/17/24.B. Record review of CNA #4's in-service training transcript report revealed CNA #4 completed nine and a half hours of in-service training from 01/27/25 to 09/23/25.C. On 01/08/26 at 12:00 pm during an interview with the Director of Nursing (DON), she stated that she expects all CNAs to complete the required amount of training each year and confirmed that CNA #4 has not. NAIT #1D. Record review of the facility's staff list provided by the administrator on 01/08/25, listed NAIT #1's as a certified nurse aide.E. Record review of NAIT #1's personnel file…

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 administer medication as prescribed for 3 (R #1, R #2 and R #3) of 3 (R #1, R #2 and R #3) reviewed for medication administration when staff failed to: 1. Ensure medications were administered to R #1 and R #2 as ordered and documented.2. Ensure R #1 and R #2 were given the correct medications. 3. Ensure R #3 's Fentanyl patch (medication used to treat pain) was properly paced on resident.If the facility does not administer medications as prescribed, the resident is likely to not get the therapeutic results of medication needed and may result in unmanaged symptoms or adverse outcomes.The findings are:R #1A. Record review of R #1's face sheet dated 05/18/2025 revealed the following diagnoses:Congestive Heart Failure, (CHF: a condition when the heart can't pump well, causing fluid buildup and trouble breathing).Type 2 Diabetes with Diabetic Neuropathy (a condition where high blood sugar damages nerves, causing pain or numbness).Atrial Fibrillation…

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 PAST NON-COMPLIANCE Based on record review and interview, the facility failed to ensure a resident was free of accident hazards when staff failed to assist a resident who required two persons assistance and a mechanical lift (a device such as Hoyer Lift that is used to lift and move a person from on location to another) when changing positions for 1 (R #1) of 1 (R #1) resident. This failure could likely result in resident to fall and inquire injuries. The findings are: A. Record review of R #1's face sheet dated 06/16/25 revealed she was admitted to the facility on [DATE] with the following diagnoses: -Demyelinating (break down and destruction of the outer lining of nerves) Disease of Central Nervous System (the core portion of the nervous system). -Quadriplegia (paralysis-partial or complete-of the arms and legs). Anoxic (lack of oxygen) Brain Damage. B. Record review of R #1's care plan created 09/12/23, revealed R #1 was to be transferred by a mechanical lift, assisted by two persons and supervised by a nurse…

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

Based on record review and interview, the facility failed to ensure medications for 2 (R #2 and 3) of 3 (R #2, 3 and 9) residents were: - available in the facility to be administered to R #3, - administered at the right time 6:30 AM for R #2. These deficient practices could likely result in unresolved infections, worsening of infection or uncontrolled pain. The findings are: Medication availability A. On 06/11/25 at 1:10 PM, during an interview with R #3's daughter, she stated that her mother's hospital discharge orders indicated oral antibiotics (medicines that are taken by mouth to kill bacteria) were to be started on 05/05/25, when intravenous (IV) antibiotics (administered directly into a vein) were discontinued. However, they were not initiated until 05/07/25. She further stated that this delay was very concerning due to R #3's diagnoses of pneumonia (infection of the lungs) and sepsis (an extreme immune response to infection that can lead to tissue damage, organ failure, or death if not treated right away). B. Record review of R #3's hospital discharge orders dated 04/30/25,…

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

Based on interviews, the facility failed to ensure the facility had sufficient staff to meet the needs of all 114 residents who resided in the facility when staff failed to: 1. Offer baths or showers to the residents as scheduled and per residents' preference. 2. To answer call lights within a reasonable timeframe (under 10 minutes) for residents that require activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance. These deficient practices are likely to negatively impact resident comfort. The findings are: Baths/Showers: A. Refer to F561 and F677 for related findings. B. On 04/14/25 at 2:10 pm during an interview with Certified Nursing Assistant (CNA) #2, she stated on most days she will be the only CNA on her unit and the residents do not receive showers per the shower schedule due to low staffing. C. On 04/14/25 at 4:04 pm during an interview with CNA #4, she stated this past weekend (04/12/25 through 04/13/25), she was the only CNA on her unit on Saturday and Sunday. CNA #4 confirmed…

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, observation and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for baths and showers by the facility staff for 2 (R #'s 5, and 6) of 2 (R #'s 5, and 6) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents. The findings are: R #5: A. Record review of R #5's face sheet revealed R #5 was admitted to the facility on [DATE]. B. Record review of R #5's care plan 02/11/25 revealed R #5 is at risk for decreased ability to perform ADLs related to: Limited mobility, history of multiple fractures including hip fracture, chronic obstructive pulmonary disease, pain and obesity. C. Record review of the facility's bath and shower schedule revealed R #5 was scheduled to bathe or shower on Tuesday, Thursday, and Saturdays. D. Record review of R #5's documentation survey report (Activities of Daily…

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, and interviews, the facility failed to ensure the PEG (Percutaneous (through the skin) Endoscopic (a medical procedure that uses a scope to look into the digestive system) Gastrostomy (a surgical procedure that creates an opening through the abdominal wall) tube (a device utilized to provide liquid nutrition and medications, via a tube into the stomach or intestine) for 1 (R #1) of 1 (R #1) resident, was managed according to current acceptable standards of practice to ensure safety of the resident. This deficient practice could cause significant health problems such as infection or displacement of the tube The findings are: A. Record review of R #1's face sheet dated 04/18/25 revealed she was admitted to the facility on [DATE] with the following diagnoses: -Cerebral (brain) Infarction (damage of tissue due to blood loss) (stroke). -Gastrostomy (surgical opening through the abdominal wall and into the stomach). B. Record review of R #1's provider orders dated 04/14/25…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents had a written, signed, and dated progress note from their physician after each visit for 1 (R # 2) of 1 (R # 2) resident reviewed for current physician progress notes and documentation. This deficient practice is likely to result in resident's records being incomplete and resident care not being documented and reviewed. The findings are: A. Record review of R #2's face sheet dated 04/16/25 revealed that she was admitted to the facility on [DATE] with the following diagnoses: -Delusional (thoughts that are not real) Disorders -Major Depressive (a feeling of sadness) Disorder -Dementia (a chronic, progressive disorder that reduces memory and recall) The face sheet further revealed that her care provider (PCP) was not a physician that was associated with the facility, but had admitting privileges to the facility. The PCP was associated with a local clinic (LC) within the community. B. Record review of R #2's Electronic Medical 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.

Based on record review and interview, the facility failed to promote resident choices for 1 (R #9) of 1 (R #9) resident reviewed for choices when staff failed to offer R #9 showers per her preference. This deficient practice is likely to result in the residents' personal choices not being honored. The findings are: A. Record review of the facility's bath and shower schedule revealed R #9 was scheduled to bathe or shower on Tuesday, Thursday and Saturdays. B. Record review of R #9's care plan dated 03/16/25 revealed the following: -Focus: R #9 requires assistance for ADL (Activities of Daily Living) care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion and tilting. C. On 04/15/25 at 8:55 am during an interview with R #9, she stated that she cannot shower as often as she would like due to the shortage of Certified Nursing Assistants (CNAs). R #9 stated she would like to shower every day, but she is told by nursing staff that she cannot shower because there are not enough staff available to take her. R #9 stated she feels anger, sadness,…

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 medical records were updated with the post fall neurological evaluations/assessments (a thorough assessment of your nervous system, including your brain, spinal cord, and peripheral nerves) for 1 (R #4) of 1 (R #4) resident reviewed for falls. This deficient practice could likely result in staff not knowing residents' daily care events, changes, and their needs. The findings are. A. Record review of R #4's face sheet revealed R #4 was admitted into the facility on [DATE]. B. Record review of nursing progress notes dated 04/11/25 revealed R #4 experienced an unwitnessed fall and R #4 was found between the beds with the curtain over her head and her left leg over the bedside table leg. C. Record review of R #4's Electronic Health Record (EHR) revealed R #4's post fall neurological evaluations were not present in R #4's EHR. D. On 04/16/25 at 10:32 am during an interview with Registered Nurse (RN) #3, she stated nursing staff are to begin…

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 residents are able to receive mail on Saturdays for all 114 residents residing at the facility. This deficient practice is likely to result in residents not receiving timely communication which could result in feelings of isolation. The findings are: A. On 9/04/24 at 3:20 pm during a resident council meeting with R # 30, # 37, # 51, # 69, #73 and #75, the residnets mentioned the mail is not delivered on Saturdays and they would like to receive their mail when it is delivered to the facility. B. On 09/09/24 2:46 pm during an interview with Activities Assistant (AA), she stated, We don't have anybody working the front desk on weekends; therefore, mail is not delivered on weekends.

Based on interviews, the facility failed to ensure the facility had sufficient staff to meet the needs of all 114 residents who resided in the facility when staff failed to: 1. Offer baths or showers to residents as scheduled. 2. Provide meals and snacks to residents timely. 3. Meet the needs of the residents. These deficient practices are likely to negatively impact resident comfort. The findings are: Resident Baths/Showers: A. Refer to F0677 for findings related to baths/showers. B. On 09/05/24 at 1:29 pm during an interview with Certified Nursing Assistant (CNA) #3, she confirmed resident showers are missed due to low staffing. C. On 09/05/24 at 1:46 pm during an interview with Licensed Practical Nurse (LPN) #3, she stated that there is staffing issues and she is aware of residents missing baths/showers due to staffing issues. D. On 09/05/24 at 1:56 pm during an interview with CNA #5, she confirmed staffing issues and that residents missed baths/showers due to staffing. E. On 09/05/24 at 2:55 pm during an interview with Registered Nurse (RN) #2, she stated that 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 observation and interview, the facility failed to ensure food holding temperatures were at 135° (degrees). Failure to ensure the food is at appropriate temperature is likely to cause residents not to eat meals which could lead to weight loss. The findings are: A. On 09/04/24 at 5:37 pm during an observation of the dinner meal, revealed the turkey's temperature was at 134 degrees, steamed broccoli was at 128 degrees and mashed potatoes were at 132 degrees. Hot food should be at 135° or higher and cold food should be at 41° or lower. B. On 09/04/24 at 5:39 pm during an interview with Dietary Manager (DM), she confirmed the turkey, steamed broccoli and mashed potatoes temperatures were not within safe serving range. Hot foods should be at 135 degrees or above and cold food should be 41 degrees.

Based on observation, record review, and interview, the facility failed to: 1. Deliver meals consistently and timely 2. Deliver snacks consistently and timely These deficient practices affected all 114 residents residing in the facility and are likely to cause anger and frustration with the residents. The findings are: 1. Deliver meals consistently and timely A. Record review of meal times revealed that the lunch meal was to be served at 12:00 pm daily. B. On 08/29/24 at 12:01 pm during the lunch meal observation, meal service in the dining area began at 12:33 pm and trays were sent in food carts to: -Hall 100 at 12:30 pm -Hall 200 at 1:10 pm -Hall 300 at 1:25 pm C. On 09/03/24 at 12:19 pm during the lunch meal observation, meal service in the dining area began at 12:19 p and trays were sent in food carts to: -Hall 100 at 12:17 pm -Hall 200 at 12:58 pm -Hall 400 at 12:28 pm D. On 09/06/24 at 12:10 pm during the lunch meal observation, meal service in the dining area began at 12:15 pm and trays were sent to food carts to: -Hall 100 at 12:20 pm -Hall 200 at 12:39 pm -Hall 300 at 12:55…

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 maintain the kitchen in a sanitary manner when staff failed to : -Store open food in a manner that prevents cross contamination and label and date food. -Utilize hair restraints and beard guards in a manner which restrained all hair while in the kitchen. - Document the correct sanitizing solution as required. -Maintain the kitchen environment in a clean and sanitary manner. These failures have the potential to result in cross contamination, the growth of foodborne pathogens, and foodborne illnesses. This failure had the potential to affect all residents who ate food from the kitchen. The findings are: Unlabeled and Undated Food Items A. On 08/29/24 at 9:42 am during an observation of the walk-in refrigerator revealed the following: -One (12 ct.) of flour tortilla pack open to air and not dated. - One 6( inch) steel pan with salsa not labeled and not dated. - One 6 steel pan with green Chile not labeled and not dated. - One 6 steel pan with what appeared to be puree food not labeled and not dated. - Two 18 qt…

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 1 (R #56) of 1 (R #56) resident was provided privacy in his own room and with visitors. Facility staff invaded R #56's privacy by assigning a staff member to to provide 1:1 sitter (a staff member assigned to monitor and accompany a resident) care. The sitter consistently sat at a table in his room during all hours of the day and night. This deficient practice is likely to cause residents to feel invaded and overwhelmed by staff. The findings are: A. Record review of R #56's face sheet revealed, R #56 was admitted to facility on 08/05/22 with multiple diagnoses including: -Hepatic Failure (liver disease). -Unspecified Dementia (a progressive, chronic disease that reduces mental thought and memory) with behavioral disturbances. -Alcoholic Cirrhosis (damage of the liver caused by excessive, long-term alcohol use) of Liver with Ascites (internal buildup of fluids in and around the liver and stomach). B. Record review of R #56's care plan dated 09/05/24 revealed the following: -focus: Tendency to exhibit…

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 provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for baths and showers by the facility staff for 2 (R #'s 96 and 105) of 2 (R #'s 96 and 105) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents. The findings are: R #96: A. Record review of R #96's face sheet revealed R #96 was admitted into the facility on [DATE]. B. Record review of R #96's care plan dated 08/09/24, revealed R #96 required ADL care assistance with bathing, grooming, personal hygiene, dressing, eating, bed mobility, and transfer due to: memory changes, anxiety, depression, and pain. C. Record review of the facility's shower schedule revealed R #96 was scheduled to be showered/bathed on Mondays, Wednesdays, and Fridays. D. Record review of R #96's documentation survey report (ADL tracking form located in the…

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

Based on record review, interview and observation, the facility failed to provide an ongoing program of activities designed to meet the interests for 1 (R # 72) of 1 (R # 72) residents reviewed for activities by not providing meaningful individualized activities based upon residents' interests as identified on his individual care plan. If resident is not provided or encouraged to attend/participate in activities that meets his interests, then he is likely to experience an increase in boredom, isolation, and depression. The findings are: A. Record review of R #72's care plan dated 01/24/24 revealed the following: -Focus: [Name of R #72] is at risk for limited and/or meaningful engagement related to LTC (Long Term Care). R #72 is a Hospice patient. --Approaches: Provide one to one room visits individualized to R #72 interests and activities. B. Record review of Activity Individual Resident Daily Participation Record dated 08/01/24 through 08/31/24 revealed R #72 participated in the following activities: 1. Watching or Listening to TV or Movies 15 times 2. The record 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 interview and record review, the facility failed to ensure ongoing communication and collaboration with the dialysis (clinical purification of blood as substitute for normal kidney functioning) facility regarding dialysis care and services for 2 (R #'s 29 and 115) of 2 (R #'s 29 and 115) residents reviewed for dialysis. If the facility is unaware of the status, condition or complications that arise during dialysis treatment, then residents are likely to not receive the appropriate monitoring and care they need. The findings are: R #29: A. Record review of R #29's physician orders revealed an order for Dialysis on Mondays, Wednesdays, and Fridays at 3:30 pm. Arrive 30 minutes early to complete paperwork. B. Record review of R #29's Hemodialysis Communication Records revealed, incomplete communication notes (post dialysis form) and the facility's follow-up report related to the dialysis visits on the following days: -08/02/24 -08/09/24 -08/12/24 -08/14/24 -08/19/24 - 09/04/24 C. On 09/04/24 at 11:52 am…

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 administered medications with an error rate greater that 5%. Medications were observed being administered to 2 (R #33 and 54) residents past the ordered medication administration time. Of 25 opportunities, 12 medication were administered late, an error of administration. This likely resulted in a medication error rate of 48%. If medications are not administered at the scheduled ordered times, the treatment will be less effective and residents will receive less than optimal care. The findings are: Medication Administration R #33 A. On 09/05/24 at 10:44 am during observation of medication administration, Licensed Vocational Nurse (LVN) #1 poured the following medications: -Acetaminophen (a medication to relieve pain and swelling) 2 tablets -Aspirin (a medication to relieve and reduce risk of blood clots) 81 mg (milligrams) -GlycoLax Powder (a medication to promote bowel movement) 17 grams mixed with water -Senna (a medication to prevent and treat constipation) 2 tablets -Vitamin B Complex (a medication to supplement…

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: 1. Ensure all medications were stored properly and in the original, labeled packaging. 2. Ensure medical supplies in the medication storage room were not expired. These deficient practices are likely to negatively impact the health of all residents, if staff administered or used potentially compromised or contaminated medications and medical supplies due to inappropriate storage. The findings are: Medication Storage and Labels A. On [DATE] at 10:52 am during an observation of medication storage on the 400 unit, one gallon whiskey was not labeled in medication room refrigerator. B. On [DATE] at 10:52 am during an observation of medication storage on the the 400 unit, revealed one expired Intravenous (IV-within a vein) dressing change kit (a single use kit with sterile contents to start and maintain an IV site) with the expiration date of [DATE]. C. On [DATE] at 10:52 am during an observation of Medication Storage revealed four boxes of [name brand 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, record review and interview, the facility failed to promote care with dignity and respect for 1 (R #418) of 1 (R #418) resident reviewed for residents rights by administering an insulin injection in the dining room while having lunch. This deficient practice is likely to result in residents feeling as if they were unimportant and not having privacy. The findings are: A. On 09/03/24 at 12:30 pm during observation of the dining area during the lunch hour, R #418 entered the dining area, took a seat at a dining table and received his lunch. While R #148 ate his meal, an unidentified nurse entered the dining area and went to R #148 side and injected him in the left upper arm with an unknown substance. B. On 09/03/24 at 12:40 pm during interview with R #418, he stated that the nurse from his unit had came to him in the dining area and the nurse administered 6 units of insulin (a medication used to control and reduce blood sugars). C. On 09/04/24 at 10:00 am during interview with R #418 in his room, he confirmed that the unit nurse had came to him in the dining hall…

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 a Comprehensive MDS (Minimum Data Set) Assessment was accurate for 1 (R # 72) of 1 (R #72) residents reviewed for accurate MDS Assessments. If resident assessments are not accurate, the facility could misidentify clinical complications resulting in failure to provide adequate care to treat the resident's medical condition. The findings are: A. On 8/30/24 at 2:41 pm, during an observation and interview with R #72, R #72 was only able to hear if spoken to loudly and close to his ear. He also did not have vision out of his right eye. R #72 stated that he had problems seeing and was blind on his right eye and his hearing was bad. B. Record review of R #72's quarterly MDS assessment dated [DATE] indicated that he had adequate vision and hearing. C. On 09/09/24 12:39 PM, during an interview with the MDS Coordinator, she stated she did complete MDS incorrectly and should have coded hearing and vision as not adequate.

Based on observation, record review and interview the facility failed to develop and implement a comprehensive person-centered care plan for 1 (R #56) of 3 (R #56, 58, and 104) residents. Failure to develop and implement a resident centered care plan may result in staff's failure to understand and implement the needs and treatments of residents possibly resulting in decline in abilities and a failure to thrive. The findings are: A. On 08/29/24 at 10:00 am during an observation of the 200 unit, a staff member sat at a desk just inside the door to room and R #56 laid in bed and watched TV. B. On 09/05/24 at 12:02 am during an observation of the 200 unit, a staff member sat at a desk just inside of the door to R #56's room. The staff member exited the room and told Licensed Practical Nurse (LPN) #2, she was going on break. LPN #2 acknowledged this and then walked to the end of the hall into another resident room. A staff member was not was designated to provide 1:1 monitoring of R #56. C. On 09/06/24 at 11:56 am during an observation of the 200 unit, a staff member sat at a desk just…

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 revise the care plan for 2 (R #25 and #56) of 2 (R #25 and #56) residents reviewed. If the facility is not updating the care plan to reflect the coordination of care with outside entities then the facility may not be providing the appropriate care and treatment to meet the residents' needs. The findings are: A. On 09/03/24 at 10:24 am during an interview with R #25's responsible party, he stated, he had been informed by the facility that an unidentified gentleman wearing hospital scrubs had been observed in the facility providing personal hygiene care to R #25, but was unsure of the date. B. On 09/04/24 12:14 PM during an interview with Weekend Nurse Supervisor (WNS), she stated. I am not sure of the date, I walked into [name of R #25's] room looking for the nurse on duty and I noticed a gentleman in scrubs standing over [name of R #25] who was laying in bed with a towel covering his abdomen, the gentleman stated he was ready to give personal care to [name of R #25]. I assumed it was a hospice worker, so I went to look 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure residents obtained routine dental care for 1 (R #68) of 1 (R #68) resident reviewed for dental services. This failure is likely to result in the resident experiencing pain, embarrassment over condition of teeth, and potential weight loss. The findings are: A. Record review of R #68's face sheet revealed R #68 was admitted into the facility on [DATE]. B. Record review of R #68's care plan dated 07/30/24 revealed R #68 exhibits or is at risk for oral health or dental care problems as evidenced by altered mucous membranes/gums (blistering in the mouth and gums). C. On 08/30/24 at 1:22 PM during an observation and interview with R #68, R #68 had visual evidence of tooth decay and discoloration of his teeth. R #68 stated, he had not been to the dentist while a resident of the facility and had not been offered an appointment. R #68 stated he had not been to the dentist in a long time and has occasional pain. D. On 09/04/24 at 2:03 PM…

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 the nutritional needs and preferences were met for 1 (R #51) of 1 (R #51) residents reviewed for food preferences. If the facility is not incorporating resident preferences into resident diets the residents are likely to experience weight loss, frustration and depression. The findings are: A. On 08/29/24 at 12:39 PM during the lunch meal observation, R #51 sat at a table with his lunch meal, R #51was served carrots B. On 09/03/24 at 11:18 AM, during an interview with R #51, he stated he does not like some foods and has asked that they not be served to him. R #51 stated They still do. I won't eat, what I don't like and sometimes I just leave the dining room cause I get tired of telling them not to serve me the food I don't like. R #51 stated he does not like rice, carrots and fish, he is served those foods and has requested tahr they not be served to him. C. Record review of R #51's dislikes report, revealed R #51 does not like fish group, shellfish group, turkey group, carrots, green/red peppers, milk…

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 maintain a process to ensure residents were bathing on a regular basis, for 3 ( R #10, R #9, and, R #8) of 6 ( R #10, R #9, R #12, R #13 , R #8, and R #11 ) residents reviewed for showers. This deficient practice could likely result in residents feeling frustrated and uncomfortable. Findings for R #10: A. Record review of R# 10's face sheet revealed that R #10 was admitted to the facility on [DATE]. B. Record review of R #10's shower sheets and bathing documentation for February 1st through February 21st 2024, revealed she had four showers. C. On 02/21/24 at 9:21 am, during an interview with R #10, she stated during her care plan conference, she preferred to shower three times a week. She said many times the nursing aides told her they were short handed on the hall; and since she was a two person lift, they could not shower her that day. Findings for R #9 D. Record review of R #9's face sheet revealed that R #9 was admitted into the facility on [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, observation, and record review, the facility failed to serve food according to the presented menu and meal ticket for 1 (R #8) of 2 (R #8, R #1) reviewed for food. The findings are: Resident #8 A. Record review of R #8's breakfast meal ticket, dated 02/20/24, stated R #8 was to receive pancakes for breakfast. B. On 02/20/24 at 9:45 am, during observation of R #8's meal tray, staff did not serve the resident pancakes. C. Record review of R #8 breakfast meal ticket, dated 02/21/24, stated R #8 was to receive two bowls of cereal for breakfast. D. On 02/21/24 at 10:00 am, during observation of R #8's meal tray, she received one bowl of cereal for breakfast instead of two. E. On 02/21/24 at 10:15 am during an interview, R #8 stated many times her meal tray does not match what was on the meal. F. On 02/21/24 at 10:58 am, during an interview with the Dietary Manager (DM), he stated he was aware of the residents' complaints about meals not matching what was on their meal tickets. The DM stated it is expected residents receive exactly what is on their meal tickets.

Based on observation, interview, and record review, the facility failed to ensure food was stored in a manner that prevented foods in dry storage from becoming contaminated from rodent activity. This deficient practice could lead to foodborne illnesses that could affect all 115 residents identified on the alphabetical census list provided by the Administrator on 10/23/23 who eat food prepared in the kitchen. The findings are: A. On 10/20/23 at 3:09 pm during an interview, the Complainant stated, he was concerned about mice at the facility. He stated that due to the mice problem, food had to be thrown away because the mice would eat the food in dry storage. The mice continued to be drawn to the dry storage room, so the bread rack was moved out of dry storage. The complainant expressed concerns that the residents could become sick if the food was served to the residents. B. On 10/23/23 at 5:23 am, during a tour of the facility's kitchen, an observation was made of the dry food storage room. Rodent activity and droppings were in the following areas: -A shallow, clear plastic pan…

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 maintain an effective pest control program by not ensuring the facility was free of rodents. This deficient practice is likely to affect all 115 residents listed on the resident census list provided by the Administrator on 10/23/23 and could likely lead to contamination of food prepared in the kitchen causing illness in the residents. The findings are: A. On 10/20/23 at 3:09 pm during an interview, the Complainant stated, he was aware of a mouse problem at the facility. He stated that he did not believe that the pest management system was effective and that large quantities of food had to be thrown out on a regular basis due to the mice eating the food in storage. The complainant also stated that the mice droppings had to be cleaned daily due to the presence of the mice. The complainant had concerns that there were many places the mice could be hiding in the facility around the kitchen, storage areas, dining area, and within the walls. The complainant stated that the kitchen also had many areas mice could 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 record review, observation and interview, the facility failed to provide training and maintain a sufficient amount of dietary staff to meet the needs of all residents listed on the census that was provided on by the Center Executive Director on 07/31/23. This deficient practice could likely result in residents not receiving food on time or food that was stored and prepared safely to the industry standard. A. Record review of the dining services policy titled Department Staffing. last revised 09/2017, revealed: The Dining Services department will employ sufficient staff, with appropriate competencies and skill sets to carry out the functions of food and nutrition services in a manner that is safe and effective. Further review revealed the following: 3. Adequate staffing will be provided to prepare and serve palatable (pleasant to taste), attractive, nutritionally adequate meals, at proper temperatures, at appropriate times, and to support proper sanitary techniques being utilized. B. Record review of the dining services policy titled Education and Training, last revised…

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: 1. Serve food according to the presented menu 2. Communicate menu changes with residents; and 3. Maintain a process that would allow residents to communicate their preferences regarding menu options one (1), two (2) or the always available menu options. 4. Offered enough fresh fruits and vegetables to all residents and enough healthy choices for dialysis and diabetic residents. This deficient practice has the potential to affect all residents listed on the census presented by the Center Executive Director on 07/31/23. These deficient practices could likely result in resident frustration and/or unsatisfaction with meal options. The findings are: A. On 07/31/23 at 11:14 am, during an interview, R #39 stated The food is weird. I am not on any special diet but the food is sometimes mushy and chopped up. Its confusing, what you can have; option one (1) or option two (2). Often, when you get your tray, the food on the tray is not what's on the paper [meal ticket/menu]. They never serve milk [contradicting what'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 record review, observation, and interview, the facility failed to maintain a snack program that would include all residents for snack preferences and diet textures; and failed to maintain consistent meal service times. This deficient practice has the potential to affect all residents listed on the census presented by the Center Executive Director on 07/31/23. This deficient practice could likely result in residents not receiving a snack and/or receiving a snack that does not meet their diet and/or diet texture; and residents may not receive meals if they have scheduled appointments and meals are not served at posted meal times. The findings are: A. Record review of the dining service's policy titled Snacks,, last revised 09/2017, revealed Snacks and beverages will be provided as identified in the individual plans of care. Bedtime snacks will be provided for all residents . 1. The dinning Services department will collaborate with the residents/patients, nursing and management team to identify necessary…

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 store and serve food under sanitary conditions by not ensuring: 1. Proper handling techniques were used when handling cups and glasses when soup and drinks were distributed to residents served in the dining room. 2. Food was not stored properly, not discarded at their expiration date. These deficient practices are likely to affect all 116 residents listed on the resident census list provided by Center Executive Director (CED) on 07/31/23; and could likely lead to foodborne illness in residents if safe food handling practices are not adhered to. The findings are: A. On 07/31/23 at 12:20 pm, during observation #1, Licensed Practice Nurse (LPN) #1 was observed to be handling the cups and bowls by the rim of the dish, with her bare hand covering the opening of the dish as she was serving meals to residents. B. On 07/31/23 at 12:25 pm, during an observation #2, LPN #1 was observed to be handling the cups and bowls by the rim of the dish, with her bare hand covering the opening of the dish as she was serving meals…

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: 1. Foods being held for meals maintain a temperature of at least 135 degrees Fahrenheit; and 2. Equipment is serviced to maintain it's regular functional capacity These deficient practices have the potential to affect all residents listed on the censes provided by the Center Executive Director on 07/31/23. This deficient practice could likely result in residents feeling frustrated if they receive cold food and safe food handling measures not being met due to malfunctioning equipment. The findings are: A. Record review of the dining service's policy titled Food: Preparation, last revised 09/2017, revealed: All foods are prepared in accordance with the FDA (The Food and Drug Administration- a government entity that is responsible for protecting the public health by assuring the safety, efficacy, and security of human and veterinary drugs, biological products, medical devices, food supply, cosmetics, and products that emit radiation) Food Code. Further review revealed: 13. All foods will be held 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 and interview, the facility failed to maintain the cleanliness of the ceiling vents and the condition of the ceiling in the kitchen area. This deficient practice has the potential to affect all residents listed on the census provided by the Center Executive Director on 07/31/23. This deficient practice could likely result in the contamination of resident food. The findings are: A. Record review of the dining service's policy titled Environment, last revised 09/2017, revealed: 1. The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation. B. On 08/07/23 at 3:50 pm, during an observation, the vent above the prep table near the walk-in refrigerator was observed to be dusty with debris hanging from the vent edges. Further observation of the vents in the kitchen revealed that 3 out of 5 vents were dusty. C. On 08/07/23 at 3:55 pm, during an observation of the ceiling, swelling of the ceiling panel was noted and paint was chipping off and hanging. D. On 08/07/23…

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 promote care with dignity and respect for 2 (R #36 and #162) of 2 ( R #36 and #162) residents interviewed and during random observation by entering R #36 and R #162 rooms without first knocking on the door. This deficient practice likely resulted in residents feeling embarrassed, ashamed, and as if their feelings and preferences are unimportant to the facility staff. The findings are: R #162 A. Record review of R #162's medical record indicated that resident went to dialysis on Tuesday, Thursdays and Saturdays. She had been admitted to the facility initially on 07/09/23 and was readmitted on [DATE]. B. On 08/02/23 at 7:42 am, during an interview with R #162, she stated that she goes to dialysis every Tuesday, Thursday and Saturday. She stated that her chair time (appointment time) is at 11:00 am. She is always ready to go for her appointments. She stated that one time (couldn't recall when) it was really early like 9 am. She stated that 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.

Based on observation and interview the facility failed to safeguard clinical record information by leaving Private Health Information (PHI) unattended. This has the potential to affect all 28 residents on hallway 100 and all 30 residents on hallway 300 (residents were identified by the Resident census list provided by the Administrator on 07/31/23). If resident's clinical information is not sufficiently safe guarded, resident's PHI is likely to be viewed by unauthorized residents, visitors, and staff. The finding are: A. On 08/01/23 at 1:27 pm, an observation was made of the computer on the 100 hall medication cart being open to a resident's page indicating what medications she was receiving and the Certified Medication Assistant (CMA) #1 was not observed at the cart or on the hall. Three family members of a resident on that hall were also observed to walk past the open computer screen showing the unknown residents information. Open to a presidents a page while the med tech was delivering the medications. B. On 08/01/23 at 1:29 pm, an interview and observation was conducted 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.

Based on interview, the facility has failed to maintain a process of returning laundered clothing articles. This has the possibility to affect all residents listed on the census that was provided by the ADON (Assistant Director of Nursing) on 07/31/23. This deficient practice could likely result in residents feeling frustrated due to their belongings not being returned. The findings are: R #39 A. On 07/31/23 at 10:50 am, during an interview with R #39, she stated They [the facility] needs a better laundry system. I have had some missing laundry. She also stated Sometimes when I am getting bathed, they run out of washcloths. R #22 B. On 07/31/23 at 3:21 pm, during an interview with R #22, she stated I'm missing black pants, a pink top, a pink print top, and 3-4 night gowns. I reported it to the CNAs (Certified Nursing Assistants), they are supposed to pass on the word. No one seems to want to help. R #43 C. On 08/01/23 at 10:09 am, during an interview with R #43, she stated I've had clothes go missing. I reported my missing cloths and they said they would look for them. My sister 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 This is a repeat deficiency Based on record review and interview, the facility failed to ensure that residents or their representatives were invited and able to participate in care plan meetings for 2 (R #'s 29 and 35) of 5 (R #'s 10, 14, 29, 35 and 65) residents reviewed for participation in care planning. If residents are not able to participate in their care plan development, then residents are likely not get the care and treatment that they need or want. The findings are: A. Record review of the facility's policy titled Person-Centered Care Plan, last revised 10/24/22, revealed the following: 7. Care plans will be: 7.2 Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals . 9. The Center has the responsibility to assist patients to participate by: 9.1 Extending invitations to patient . in advance; . 9.3 Facilitating the inclusion of 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, record review and interview, the facility failed to ensure that dialysis residents received a meal, snack or sack lunch prior to leaving to their appointment for 2 (R #60 and #162) of 2 (R #60 and #162) residents reviewed for nutrition. This deficient practice is likely to result in weight loss and deterioration of overall health and wellbeing for dialysis residents. The findings are: R #162 A. On 07/31/23 at 10:39 am, during an interview with R #162, she stated that when she goes out to Dialysis on Tuesday, Thursday and Saturday her appointment time is at 11:00 am. She stated that breakfast will come in the morning before she leaves but she is never provided a meal before leaving for her appointment or a sack lunch or snacks. She stated that no one has asked or offered her anything before she leaves, or after she returns from her appointment. B. Record review of R #162's medical record indicated the following: Dialysis on Tuesday, Thursday, and Saturday at 11:00 am at (name of location). R #60 C. On 08/02/23 at 1:36 pm, during an observation of R #60's room. 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 This is a repeat deficiency Based on record review, observation and interview, the facility failed to ensure that 2 (R #35 and #160) of 2 (R #35 and 160) residents reviewed for behavioral health concerns were receiving necessary behavioral health care to meet the resident's need. This deficient practice could likely cause the residents to not receive the mental health care and assistance that they need exacerbating (increasing in severity) anger, depression and other negative feelings . The findings are: R #35 A. Record review of R #35's face sheet indicated that he was admitted to the facility on [DATE] and had the following diagnoses': Anxiety (persistent and excessive distress that affects daily life), Major Depression (is a common and serious mental illness that affects your mood and interest in life), Parkinson's Disease (is a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), Traumatic Brain Injury (TBI head injury causing damage to the brain 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This is a repeat deficiency. Based on interview and record review, the facility failed to ensure for 4 (R #s 9, 108, 161 and 162 ) of 4 (R #s 9, 108, 161 and 162) residents reviewed for medication administration; had their medications administered correctly by: 1. Giving the resident the wrong antibiotic R #162; 2. Giving two doses of oxycodone causing an overdose R #108; 3. Two residents not receiving their medications consistently and as the physician ordered for R #9 and R #161. These deficient practices caused an overdose for one resident, and could likely have caused any of the following: allergic reaction, infections to worsen, and a potential for the resident to develop a blood clot causing significant and unnecessary harm. The findings are: R #9 A. Record review of the Medication Administration Record (MAR) for June 2023, indicated the following: Amoxicillin-Pot Clavulanate Tablet 875 (an antibiotic used to treat a wide variety of bacterial infections)125 mg (milligram) give one tablet by mouth every 12…

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 This is a repeat deficiency Based on observation and interviews the facility failed to: 1. Properly store medications in a medication cart. 2. Properly label alcoholic beverages in the medication refrigerator. 3. Document the daily medication refrigerator internal temperatures and daily medication storage room temperatures. 4. Provide a separately locked, permanently affixed compartments for storage of controlled drugs in the medication refrigerator. 5. Properly label two open multidose vials (vials used for multiple patient) with the open date. 6. Personal items should not be stored in the medication cart. These deficient practices have the likelihood to result in 116 residents that were identified on the census list provided by the Centers Executive Director (CNE) on 07/31/23, to receive expired or improperly temperature-controlled medications that have either lost their potency, or effectiveness; medications that were undated continued to be accessed and stored with active medications; allow a controlled…

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, the facility failed to coordinate dental services for 2 (R #10 and R #43) of 3 (R #'s 10, 14, and 43) residents reviewed for dental care. This deficient practice could likely result in residents experiencing oral pain or discomfort. The findings are: A. Record review of the facility's policy titled Consult Agreements and Responsibilities, last revised 03/01/22, revealed Agreements pertaining to services furnished by outside resources must specify in writing that the Center assumes responsibility for: - Obtaining services that meet professional standards and principles that apply to professionals providing services in the Center; and - The timeliness of the services. Findings for R #10: B. On 08/01/23 at 1:30 pm, during an interview, R #10 stated that she currently needs to have her teeth cleaned. Findings for R #43: C. On 08/01/23 at 10:02 am, during an interview, R #43 explained that she needs work done on her bottom teeth. She currently has two (2) cracked teeth on her bottom left side. She then explained that it can cause pain because she sometimes bites 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 interview, record review, and observation, the facility failed to ensure that meals were served at an appetizing temperature and were attractive and palatable (pleasant to taste) for 9 (R #'s 4, 7, 28, 33, 34, 41, 49, 52 and 70) of 10 (R's #'s 4, 7, 28, 33, 34, 41, 49, 50, 52 and 70) residents reviewed for meal quality. This deficient practice reduces residents' ability to eat and enjoy meals, may decrease their quality of life, and could likely lose weight. The findings are: A. Record review of the dining service's policy titled Food: Quality and Palatability, last revised 09/2017, revealed Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature. Resident #4 B. On 08/01/23 at 3:09 pm, during an interview, R #4 stated, The food is not good, they serve too much food that is greasy and I get a stomach ache if it's too greasy. Resident #7 C. On 08/08/23 at 10:00 am during an interview, R #7 stated, The food is not good. I have complained about it and my daughter…

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.

This is a repeat deficiency Based on interview, observation, and record review, the facility failed to provide proper infection control practices by not performing hand hygiene between resident care and getting ice from the ice cooler for 2 (R #36 and resident unknown) 2 (R#36 and resident unknown) residents. This deficient practice could likely result in the spread of infectious agents (Viruses and bacteria) between the residents and/or staff. The Findings are: A. Record review of the facility's policy control titled, Hand hygiene, revealed Adherence to hand hygiene practices is maintained by all Center personnel. Purpose: To improve hand hygiene practices and reduce the transmission of pathogenic microorganisms (of bacterium, virus, or other microorganisms). Process: 1. Perform hand Hygiene: 1.1 Before patient/resident care; 1.4 After patient care; 1.5 After contact with the patient's environment. B. On 08/01/23 at 09:31 am, during an observation in the 300 halls. Restorative recreation (staff member who is activity and restorative) was seen walking into R #36's room to push 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to update a resident's end-of-life treatment for 1 (R #65) of 2 (R #65 and R #53) residents reviewed for advanced directives (a written document stating how you want medical decisions to be made if you lose the ability to make them for yourself). This deficient practice could likely result in residents not having their preferences honored during an end of life event. The findings are: A. Record review of the facility's policy titled Health Care Decision Making, last revised 03/01/22, revealed the following: centers must: - Inform and provide written information to all patients concerning the right to accept or refuse medical or surgical treatment and, at the patient's option, formulate an advanced directive. - Inquire with the individual's patient representative if the patient is incapacitated at the time of admission as to whether an advanced directive has been completed/executed in accordance with state law . B. Record review of R #65's face sheet…

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 keep residents free from physical restraints for 1 (R #163) of 1 (R #163) resident observed during random observations. This deficient practice could likely result in physical restraints being used for discipline or staff convenience; unnecessarily preventing residents from freedom, movement, or activity. The findings are: A. On 07/31/23 at 10:41 am, during an observation of R #163, resident was in her room, she had a mattress on the floor, her bed on one side was against the wall, and there was long rectangle support cushion approximately 2 to 3 feet long under R #163's mattress. There were three pillows under the fitted sheet on the bed creating a barrier. The bed was observed to be angled/slopped towards the wall. R #163 was observed to be awake and had her arm extended and appeared frustrated. Resident was not able to get out of bed or move around on the mattress because the support cushion and pillows were keeping the resident from doing these things. Resident was trying to move herself with no success. B. On 08/01/23…

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 coordinate vision and hearing service for 3 (R#'s 10, 14, and 43) of 3 (R #'s 10, 14, and 43) residents reviewed for outside services. This deficient practice could likely result in residents not being able to see or hear to their fullest extent. The findings are: A. Record review of the facility's policy titled Consult Agreements and Responsibilities, last revised 03/01/22, revealed Agreements pertaining to services furnished by outside resources must specify in writing that the Center assumes responsibility for: - Obtaining services that meet professional standards and principles that apply to professionals providing services in the Center; and - The timeliness of the services. R #14: B. On 07/31/23 at 10:03 am, during an interview, R #14 explained that he needs to make an appointment to get glasses as he has readers but needs to get glasses to wear all the time. He also stated that he needs some help with his hearing aids. He is unsure if he only…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation , and record review, the facility failed to provide podiatry services for 1 (R #14) of 2 ( R #14 and R #65) residents reviewed for toenail care. This deficient practice could likely result in toenail infections going untreated. The findings are: A. Record review of the facility's policy titled Foot Care, last reviewed 08/07/23, revealed Centers will provide foot care and treatment in accordance with professional standards of practice and state scope of practice, as applicable, including to prevent complications from the patient's medical condition(s) such as diabetes, peripheral vascular disease, or immobility Further review revealed Patients who have complicating disease processes requiring foot care including, but not limited to, infections/fungus, ingrown toenails, diabetes mellitus . must be referred to qualified professionals such as podiatrists or other qualified providers. B. On 07/31/23 at 10:03 am, during an interview, R #14 explained I need my toenails cut. I have fungus…

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.

This is a repeat deficiency Based on observation, record review, and interview, that facility failed to maintain oxygen according to professional standards for 1 (R #33) of 1 (R #33) residents reviewed for respiratory care by not ensuring the resident always had access to portable oxygen. This deficient practice could likely result in the resident not having oxygen when he needs it. The findings are: A. Record review of physician's orders for R #33 revealed the following orders related to oxygen use: Physician order, dated 03/14/23, Oxygen at 1-6 liters per minute via nasal cannula (a device used to deliver supplemental oxygen). Every day and night post evaluate pulse oximetry (oxygen percentage in your blood). B. On 08/01/23 at 9:43 am, during an interview with R #33, he said he was on oxygen, but that they (the facility) couldn't give him a portable (one that goes with him out of his room) oxygen tank. R #33 stated he feels out of breath when he moves down the hallway. A staff member was looked for to take an oxygen saturation (oxygen levels in the blood) but one could not 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 record review and interviews, for 1 (R #81) of 3 (R #48, R #70, and R #81) residents reviewed that were receiving hospice services. This deficient practice of not ensuring that were was an appropriate collaboration between the facility and hospice services could result in the residents not receiving the services that they need. The Finding are: A. Record review of the facility's policy titled Hospice, last revised 03/01/18, revealed the following: The hospice and center must communicate, establish, and agree upon a coordinated plan of care which reflects the hospice philosophy, and is based on an assessment of the patient's needs. The plan of care must include: Directives for managing pain and other uncomfortable symptoms and be revised and updated as necessary to reflect the patient's current status; The most recent hospice plan of care; and the care and services that the Center will provide in order to be responsive to the unique needs of the patient and his/her expressed desire for hospice care. The Center and hospice are responsible for performing each of their…

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.