Casa De Oro Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide the required transfer information for 1 (R #136) of 2 (R #6 and R #136) residents sampled for hospitalizations when staff failed to: 1. Notify the resident and resident representative(s) of the resident's transfer to the hospital in writing and in a language and manner they understand. 2. Send a written copy of the Transfer Notice to the Ombudsman (an advocate for residents in nursing homes and assisted living facilities). 3. Ensure the resident and their representative received a written notice of the bed hold policy which indicated the duration the bed would be held. These deficient practices could likely result in the residents and/or their representatives not knowing the reason for the transfer, the location of the transfer or discharge, their rights to advocate and make informed decisions regarding the resident's healthcare. The findings are: A. Record review of R #136's face sheet, no date, revealed R #136 was admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to provide activities of daily living (ADL) assistance for 1 (R #33) of 4 (R #10, R #24, R #33, and R #77) residents reviewed for ADL care when staff failed to provide R #33 nail care. This deficient practice is likely to affect the dignity and health of the residents. The findings are: A. Record review of R #33's admission record, no date, R #33 was admitted to the facility on [DATE]. B. On 01/27/26 at 2:25 PM, during an interview and observation, revealed R #33's fingernails were overgrown, yellow, thick and cracked. R #33 stated his fingernails had not been cut in a long time. C. On 01/29/26 at 2:18 PM, during an interview, the DON confirmed R #33's fingernails were overgrown and had not been cut. D. Record review of R #33's, annual MDS, dated [DATE], revealed R #33 is totally dependent on staff to complete ADL care. E. Record review of R #33's medical record, no date, revealed staff did not document providing fingernail care for R #33.…

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 the facility failed to ensure residents received quality treatment and care for 1 (R #106) of 6 (R #2, R #24, R #40, R #47. R #56 and R #106) residents reviewed for accidents when staff failed to ensure resident received follow-up treatment. This deficient practice could likely lead to resident's needs not being met and/or a worsening of their medical condition and prognosis. The findings are: A. Record review of emergency room (ER) visit notes dated 09/18/25 revealed the following: 1. R #106 was seen in the ER. 2. R #106 was diagnosed with olecranon (bony tip of the elbow) fracture. 3. R #106 was placed in a longarm splint (used for injuries requiring immobilization of the elbow) and was to follow up with orthopedic surgeon (medical doctor who specializes in diagnosing, treating, and preventing disorders of the musculoskeletal system, including bones, joints, muscles, ligaments, tendons, and nerves). B. Record review of R #106 provider progress note dated 09/23/25 revealed the following: 1. Diagnosis, assessment and plan: Olecranon fracture followed 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 Based on observation, record review, and interview, the facility failed to provide foot care for 1 (R #33) of 4 (R #2, R #22, R #24, and R #33) resident reviewed for foot care when staff failed to provide nail care for R #33's toenails. This deficient practice could likely cause podiatric complications (foot and toenail health issues such as ingrown toenails, fungal infections, and trauma-related injuries). The findings are: A. Record review of R #33's facesheet, no date, R #33 was admitted to the facility on [DATE]. B. On 01/27/26 at 2:25 PM, during an observation of R #33's foot, and an interview, revealed R #33's toenails were overgrown, yellow, thick and cracked. R #33 stated his toenails had not been cut in a long time. C. Record review of R #33's, annual MDS, dated [DATE], revealed R #33 is totally dependent on staff to complete ADL care. D. Record review of R #33's progress note dated 10/28/25, revealed R #33 had painful mycotic (fungal infection) toenails. The progress note stated to remove all affected…

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 the consultant pharmacist's recommendations were reviewed and implemented by the physician and/or the physician provided documentation of a rationale (a set of reasons or a logical basis for a course of action or a particular belief) for not following the consultant pharmacist's recommendation in the resident's medical record for 1 (R #2) of 5 (R #2, R #3, R #7, R #8, and R #106) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications that are no longer necessary and may cause unnecessary drug interactions (changes to medication action caused by being combined with other foods, beverages, or drugs) or adverse side effects (unwanted, undesirable effects from medication). The findings are: A. Record review of R #2's face sheet, no date, revealed the following: 1. R #2 was admitted to the facility on [DATE]. 2. R #2 had the following diagnoses: a. Essential (primary)…

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 maintain an infection prevention and control program designed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 2 (R #10 and R #77) of 3 (R #10, R #77, and R #127) residents reviewed for pressure wounds and respiratory care when staff failed to: 1. Follow enhanced barrier precautions (EBP, an infection control intervention) for R #127. 2. Change R #10's nasal cannula (a lightweight, flexible, medical-grade tube used to deliver supplemental oxygen (0.5-6 liters per minute) directly into the nostrils for respiratory support, allowing for mobility, eating, and speaking) as ordered. If the facility fails to maintain an effective infection control program, then infections could spread to residents throughout the facility, resulting in illness. The findings are: Enhanced Barrier Precautions R #127 A. Record Review of the [Name of Federal Agency] Enhanced Barrier…

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 the facility failed to report allegations of misappropriation of resident property (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent) to the State Agency within 24 hours of allegation for 3 (R #16, R #17, and R #24) of 3 (R #16, R #17, and R #24) residents reviewed for misappropriation of property, when staff failed to: 1. Report an allegation of misappropriation (diversion of medication) for R #16 with in 24 hours of becoming aware of the allegation. 2. Report the allegations of misappropriation (diversion of medication) for R #17 and R #24 when staff became aware of the allegation. If the facility fails to report allegations of misappropriation of property to the state agency within 24 hours of the allegation, then corrective action may not be taken, and residents may suffer increased anxiety and worsening of their condition. The findings are: A. On 08/19/25 at 12:18 PM, during an interview, the DON stated the following: 1. On 07/30/25, UM #16 and CMA #16…

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 thoroughly investigate an allegation of misappropriation of property (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent) 7 (R #16, R #17, R #18, R #24, R #25, R #26, and R #27) of 7 (R #16, R #17, R #18, R #24, R #25, R #26, and R #27) residents reviewed when staff failed to: 1. Document interviews with residents for the investigation of allegation of misappropriation of resident's narcotic (a substance used to treat moderate to severe pain. Narcotics are like opiates such as morphine and codeine but are not made from opium) medication. 2. Document interviews with staff for the investigation of allegation of misappropriation of resident's narcotic medication. 3. Interview potential witnesses to the allegation of misappropriation of resident's narcotic medication. 4. Review medical records for all residents in the facility with the potential for misappropriation of narcotic medications and potential for missing documentation…

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 meet professional standards of practice for 4 (R #16, R #17, R #18, and R #24) of 4 (R #16, R #17, R #18, and R #24) residents reviewed for misappropriation of property, when staff failed to: 1. Ensure narcotic (a substance used to treat moderate to severe pain. Narcotics are like opiates such as morphine and codeine but are not made from opium) medications were not administered earlier than ordered for R #16 and R #17. 2. Ensure staff notified the provider when R #16 and R #17 required pain medications more frequently than ordered. 3. Ensure R #16 and R #24 did not receive narcotic medications at a higher dose than ordered. 4. Ensure staff document the narcotic medication administration on the MAR for R #16, R #17, R #18, and R #24. 5. Reassess R #16, R #17, R #18, and R #24. These deficient practices could likely lead to the resident having worsening of their medical conditions, adverse (unwanted, harmful, or abnormal result) side effects, or could…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure pharmaceutical services (the direct, responsible provision of medication-related care) were met when staff failed to keep controlled drug records (mandatory documentation required by the Drug Enforcement Agency (DEA))to track the complete life cycle of controlled substances, including their acquisition, administration, dispensing, and disposal. The purpose is to prevent diversion and ensure accountability for potentially addictive and illicitly traded drugs) for controlled medication (drugs or chemicals that the government regulates because they can be easily abused and lead to addiction.) for 4 (R #17, R #24, R #25 and R #27) of 7 (R #16, R #17, R #18, R #24, R #25, R #26, and R #27) residents reviewed for misappropriation of property. This deficient practice could likely lead to a delay in the incident investigation process and lead to potential drug misuse or diversion (medical and legal concept involving the transfer of any legally…

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 medications were administered as ordered by the physician for 2 (R #3 and R #18) of 3 (R #3, R #17, and R #18) residents reviewed for medication administration when staff failed to: 1. Ensure narcotic (a substance used to treat moderate to severe pain. Narcotics are like opiates such as morphine and codeine but are not made from opium) medications were not administered earlier than ordered for R #3. 2. Ensure R #18 did not receive narcotic medication at a higher dose than ordered. This deficient practice is likely to result in a residents having adverse effects (unwanted, harmful, or abnormal result). The findings are: R #3 A. Record review of R #3's admission record (no date) revealed the following: 1. R #3 was admitted to the facility on [DATE]. 2. R #3 had the diagnosis of Chronic Pain (long standing pain that persists beyond the usual recovery period or occurs along with a chronic health condition). B. Record review of R #3's physician'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 and interview, the facility failed to ensure medical records were complete and accurate for 6 (R #16, R #17, R #18, R #24, R #25, and R #27) of 6 (R #16, R #17, R #18, R #24, R #25, and R #27) residents reviewed for misappropriation of property when staff failed to: 1. Document narcotic medication administration on the MAR for R #16, R #17, R #18, R #24, R #25, and R #27. 2. Ensure R #16's order on his controlled drug record matched the order. These deficient practices have the potential to negatively impact the care staff provide to meet residents' needs due to missing or inaccurate records and resident information. The findings are: R #16 A. Record review of R #16’s admission record, no date, revealed R #16 was admitted to the facility on [DATE]. B. Record review of R #16’s admission MDS, dated [DATE], revealed the following: 1. R #16 had a BIMS of 15. 2. R #16 had pain that was being treated with PRN pain medication. 3. R #16 was receiving opioid (sometimes called narcotics, are a type…

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, record review the facility failed to secure medications in a medication cart and a treatment cart for all 37 residents on the 500 unit (residents were identified by the census list provided by the Administrator on 05/07/25). This deficient practice could result in residents obtaining medication not prescribed to them resulting in adverse side effects. The findings are: A. On 05/12/25 at 3:32 PM, during an observation of the 500 unit revealed the medication cart unlocked. Lancets (to prick their fingers for blood sugar level checks. These devices consist of two parts: a lancet holder that looks like a small pen; and a lancet, which is the sharp point or needle that is placed in the holder.) were in a tray on top of the medication cart. B. On 05/12/25 at 3:34 PM, during an interview RN #3 confirmed that the medication cart was unlocked. C. On 05/12/25 at 3:40 PM, during an observation of the 500 unit revealed the treatment cart unlocked. D. On 05/12/25 at 3:41 PM, during an interview RN #3 confirmed that the treatment cart was unlocked. E. On 05/12/25…

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

Based on interview, the facility failed to report elopements to the State Agency (SA) for 2 (R #1 and R #3) of 3 (R #1, R #2 and R #3) residents sampled for elopement, when they failed to report to the state agency an elopement by R #1 and R #3 on 04/22/25. If the facility fails to report allegations of elopement to the SA, then residents could likely suffer serious bodily injury as a result of the elopement. The findings are: A. On 05/08/25 at 3:00 PM, during an interview, Maintenance Assistant #2 said that on 04/22/25 at approximately 6:30 PM, he saw R #1 and R #3 in the the facility's south parking lot area. C. On 05/08/25 at 3:17 PM, during an interview, R #3 said that he and R #1 went out of the back gate one day. R #3 said that R #1 wanted him to leave with her. R #3 said that staff came out and got them and took them back into the facility (R #3 was not specific about which staff). D. On 05/08/25 at 3:38 PM, during an interview, the Administrator said that she did know that R #1 and R #3 were found out by the dumpsters south of the facility. The Administrator said that she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to have the physician document the required discharge information in the resident's medical records for 1 (R #26) of 1 (R #26) residents reviewed for discharges. This deficient practice could likely cause an unsafe discharge due to a lack of information or documentation. The findings are: A. Record review of R #26's face sheet, undated, revealed R #26 was admitted to the facility on [DATE] and discharged on 01/25/25. B. Record review of R #26's Progress Notes revealed the following: 1. On 01/25/25, staff documented R #26 had a change of condition. The provider ordered R #26 to be sent out for Higher acuity level of care. R #26 was transported to a local hospital. 2. On 01/25/25, the Administrator documented she notified R #26's Power of Attorney (POA: a power of attorney is a legal authorization that gives the agent or attorney the authority to act on behalf of an individual referred to as the principal) that R #26 was being discharged immediately to the…

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

Based on record review and interview, the facility failed to revise the care plan for 3 (R #8, R #9, and R #10) of 3 (R #8, R #9, and R #10) residents reviewed for Resident/Patient/Client Neglect. This deficient practice could likely result in staff being unaware of changes in care to be provided and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: R #8 A. Record review of R #8's Lift Transfer Evaluation dated 02/02/25, revealed R #8 required at least two staff to assist with lift device. B. Record review of R #8's Care plan dated 02/03/25 revealed R #8's need for a lift device and interventions were not documented. R #9 C. Record review of R #9's Lift Transfer Evaluation dated 01/01/25, revealed R #9 required at least two staff to assist with lift device. D. Record review of R #9's care plan dated 02/04/25 revealed R #9's need for a lift device and interventions were not documented. R #10 E. Record review of R #10's Lift Transfer Evaluation dated 01/31/25, revealed R #10 required at least two staff to assist with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a discharge planning process for 1 (R #26) of 1 (R #26) resident reviewed for discharge planning, when they failed to: 1. Develop the R #26's individualized discharge goals and needs. 2. Include R #26 and R #26 PoA/family in the discharge planning. Theses deficient practices are likely to prevent a safe transition from the facility to the resident's post-discharge setting. The findings are: A. Record review of R #26's face sheet, undated, indicated R #26's admission to the facility was on 03/25/23. B. Record review of the Notice of Transfer and discharge date d 01/25/25, revealed R #26 was discharged from the facility on 01/25/25. Staff did not document that R #26 Power of Attorney (POA: a power of attorney is a legal authorization that gives the agent or attorney the authority to act on behalf of an individual referred to as the principal) was informed of the discharge 30 days prior to discharge. C. Record review of R #26'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 and interview, the facility failed to ensure staff completed a discharge summary that included a recapitulation (a summary describing the resident's course of treatment while residing in the facility), and a list of all medication at the time of discharge for 1 (R #26) of 1 (R #26) residents sampled for discharge from the facility. This deficient practice could likely lead to the receiving facility, community agency, or family members not knowing what the current care needs and/or current medications the resident needs. The findings are: A. Record review of R #26's face sheet, undated, revealed R #26's was admitted to the facility on [DATE] and discharged on 01/25/25. B. Record review of R #26's Medical Record, undated, revealed the following: 1. R #26 was discharged from the facility on 01/25/25 to local hospital. 2. Staff did not document a recapitulation of the resident's stay, medication list, or a discharge summary. 3. Staff did not document that R #26 was provided with a discharge…

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 appropriate treatment and services for Foley Catheter tubing (soft plastic or rubber tube that is inserted to the bladder to drain the urine and is connected to a collecting bag) care for 1 (R #13) of 1 (R #13) randomly observed resident. This deficient practice could likely result in residents getting infections. The findings are: A. On 02/26/25 at 2:26 PM, during an observation of the Activity Room on the [NAME] Unit, R #13's catheter tubing dragged on the floor while he self propelled in his wheelchair. B. On 02/26/25 at 1:18 PM, during an interview, LPN #8 confirmed R #8's Foley tubing was dragging on the floor and the catheter tubing should not be on the floor. C. On 02/26/25 at 2:26 PM, during an interview, the DON confirmed R #8's catheter tube is not supposed to be dragging on the floor. The DON said the tubing should be changed after dragging on the floor. D. Record review of the facility's Catheter: Indwelling Urinary Policy dated 02/01/23, revealed to secure catheter tubing keeping the drainage bag below…

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 Noncompliance Based on record review and interview, the facility failed to ensure wound care orders were implemented, wound care was completed, and staff documented that the wound care was performed for 1 (R #1) of 3 (R #1, R #2, and R #17) residents reviewed for pressure ulcers (damage to an area of the skin caused by constant pressure on the area for a long time). These deficient could likely result in the provider being unaware of the resident's current condition, leading to inconsistent interventions and worsening of pressure ulcers. The findings are: A. Record review of R #1's admission record (no date) revealed R #1 was admitted to the facility on [DATE]. B. Record review of the wound care consultation (outside nurse practitioner that provides consultation to the facility for wound treatment) note dated 10/24/24 revealed the following: 1. R #1 presented with a stage 3 pressure (fatty tissue may be visible but bone, tendon or muscle are not exposed) injury to sacrum (triangular bone at the base 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 interview, the facility failed to provide Quality Assurance and Performance Improvement (QAPI) training to staff. This could affect all 127 residents in the facility (residents were identified by the resident matrix provided by the Administrator on 09/16/24). This deficient practice could likely result in staff being unable to identify opportunities for improvement, address gaps in systems or processes, develop and implement an improvement or corrective plan, and continuously monitor the effectiveness of interventions. The findings are: A. On 09/26/24 at 12:58 pm, during an interview, the Administrator stated the facility did not have the QAPI training in place for staff. The Administrator stated they were in the process of implementing the QAPI training.

Based on interview and record review, the facility failed include performance reviews as part of their 12 hours of annual training for 3 (CNA #34, CNA #35, and CNA #36) of 3 (CNA #34, CNA #35, and CNA #36) CNAs sampled for 12 hours of annual training. This deficient practice could likely result in staff being under trained and providing inadequate care. The findings are: A. Record review of CNA #34's training records revealed the record did not contain performance evaluations. B. Record review of CNA #35's training records revealed the record did not contain performance evaluations. C. Record review of CNA #36's training records revealed the record did not contain performance evaluations. D. On 09/26/24 at 2:05 pm, the Staff Development Coordinator confirmed that CNA #34, CNA #35, and CNA #36 had been working in the facility more than a year. E. On 09/26/24 at 2:28 pm, the DON confirmed the facility did the performance reviews but did not use them as part of the 12 hours of annual training.

Based on observation and interview the facility failed to provide a comfortable and homelike environment for 6 (R #4, R #31, R #36, R #45, R #46, and R #110) of 8 (R #4, R #31, R #36, R #45, R #46, R #64, R #109, and R #110) residents sampled for environment, when they failed to: 1. Repaint and match the existing paint from scuff marks and damage on the walls and doors. 2. Keep air/heat vents clean and uncovered with plastic. 3. Keep resident's commode in safe working condition. 4. Keep crash carts (a wheeled container carrying medicine and equipment for use in emergency resuscitations) free of bugs. These deficient practices could likely cause residents to feel like they are not living in a comfortable home-like environment and like they are not valued. The findings are: R # 4 A. On 09/17/24 at 2:25 PM, during an observation of R #4's room, revealed the blinds on the window were broken and in disrepair. Slats were broken and bent, and the blinds could not be lifted or lowered. The blinds were stuck. B. On 09/27/24 at 9:35 AM, during an interview, the Maintenance Director 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.

Based on record review and interview the facility failed to develop and implement a comprehensive person-centered care plan for 2 (R #14 and R #123) of 8 (R #14, R #16, R #29, R #40, R #118, R #123, R #292 and R #293) residents reviewed for care plans. 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 worsening of medical condition. The findings are: R #14 A. On 09/21/24 at 10:21 AM, during an interview with R #14, she stated she had a feeding tube (Percutaneous Endoscopic Gastrotomy Tube/PEG; medical procedure in which a tube is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate) B. Record review of R #14 admission Record (no date) revealed the following. 1. Initial admission date 07/08/24. 2. readmission date 08/06/24. 3. Diagnosis: Gastrostomy status (presence of an artificial opening to the stomach). C. Record review of R #14's physician's orders revealed an order…

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 Recite from 06/20/24 Based on record review, observation, and interview, the facility failed to ensure care plans were reviewed and revised for 9 (R #4, R #12, R #45, R #60, R #81, R #109, R #110, R #111, and R #118) of 9 (R #4, R #12, R #45, R #60, R #81, R #109, R #110, R #111, and R #118) residents reviewed for care plans when they failed to: 1. Have the required Interdisciplinary Team (IDT, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) members participate in the care plan meeting for R #4, R #45, R #60, R #81, and R #109. 2. Have the care plan meeting within seven days after the completion of the Minimum Data Set assessment (MDS, part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid-certified nursing homes. It is a core set of screening, clinical and functional status elements, including common definitions and coding categories, which forms…

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 received treatment and care in accordance with professional standards of practice for 1 (R #23) of 1 (R #23) residents reviewed for hospice services, when they failed to ensure the facility received documentation regarding the services provided to R #23 by hospice staff. This deficient practice could likely lead to staff not being aware of the services that are provided by the hospice staff and residents needs not being met and/or a worsening of their condition. The findings are: A. Record review of R #23's admission record, no date, revealed R #23 was admitted to the facility on [DATE]. B. Record review of R #23's physician's order, dated 06/12/23, revealed an order for hospice services. C. On 09/24/24 at 12:06 PM, during an interview with LPN #16, the following was stated: 1. Hospice staff were supposed to provide a bed bath to R #23 three times a week. 2. The hospice nurse was supposed to come at least once a week. 3. Hospice staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to keep residents free from accidents for 1 (R #12) of 1 (R #12) residents reviewed for falls, when staff failed to identify and implement interventions to prevent R #12 from falling. This deficient practice could likely result in residents being at risk of serious harm or injury. The findings are: A. Record review of R #12's admission record, no date, revealed the following: 1. R #12 was admitted to the facility on [DATE]. 2. R #12 had the following diagnoses: a. Encephalopathy (a broad term for any brain disease that alters brain function or structure). b. Type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). c. Morbid obesity due to excess calories (a disorder that involves having too much body fat, which increases the risk of health problems). d. Unspecified dementia, unspecified severity, with psychotic disturbance (a loss of cognitive functioning, thinking,…

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 ongoing communication and collaboration with the dialysis (clinical purification of blood as a substitute for the normal function of the kidney) facility regarding dialysis care and failed to monitor the resident before and after dialysis treatment for 1 (R #111) of 1 (R #111) residents reviewed for dialysis care. This deficient practice could likely result in the facility being unaware of the resident's condition, possible complications that arise during dialysis treatment, and residents may not receive the appropriate monitoring and care. The findings are: A. Record review of R #111's admission record, no date, revealed R #111 had a diagnosis of end stage renal disease (ESRD; chronic irreversible kidney failure). B. Record review of R #111's physician orders revealed an order, revision date 07/22/24, for resident to have dialysis Monday, Wednesday, and Friday at 09:45 AM. C. Record review of R #111'S Electronic Medical Record (EMR) revealed: 1. Dialysis Communication Record, dated 09/02/23, the facility completed…

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 reviews and interviews, the facility failed to ensure the facility had sufficient staff to meet the needs of 2 (R #12 and R #66) of 2 (R #12 and R #66) residents reviewed for staffing when staff failed to: 1. Get R #12 up and ready on the morning of 09/30/24. 2. Answer R #12's call bell within a timely manner. 3. Offer baths or showers to R #66 as scheduled. These deficient practices are likely to cause residents psychological distress, make them feel as if they are not valued, and negatively impact resident comfort. The findings are: R #12 A. On 09/30/24 at 11:11 AM, during an observation and interview with R #12, the following was revealed: 1. R #12 lay in bed and wore her pajamas. 2. R #12 stated staff did not get her out of bed yet. 3. R #12 stated she pressed the call bell for staff to change her wet brief and get her up (she was unsure how long she had been waiting). 4. R #12's call light was off. 5. She stated sometimes staff turned off the call bell, but did not ask her what she needed (she was unsure if staff had turned off her call light). 6.…

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 did not receive psychotropic medications (antidepressants, anti-anxiety medications, stimulants, antipsychotics, and mood stabilizers) unless the medication was necessary to treat a specific psychiatric diagnosis (mental illness, symptoms or condition that greatly disturbs your thinking, moods, and/or behavior) for 2 (R #6 and R #54, ) of 5 (R #6, R #14, R #26, R #40 and R #54, ) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications without a medical reason and being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result). The findings are: R #6 A. Record review of R #6's physician's order, start date 08/02/24, quetiapine (antipsychotic medicine indicated for the treatment of schizophrenia, bipolar I disorder manic episodes, and bipolar disorder depressive episodes) tablet Give 50 ml by mouth one time a day for depression. B. Record review…

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 properly store medications when they failed to: 1) Document temperatures for the East and [NAME] Unit medication refrigerators. 2) Secure a treatment cart that stored medications on the 500 Unit. These failures had the potential to affect all 127 residents in the facility (Residents were identified by the resident census provided by the Administrator on 09/16/24). These deficient practices could likely result in residents obtaining medications that are no longer effective or that are not prescribed to them resulting in adverse side effects. The findings are: East Unit and [NAME] Unit Medication Refrigerator A. Record review of the medication refrigerator temperature logs on the East Unit, for September 2024, revealed the following: 1. On 09/05/24, the temperature was 41 degrees. 2. On 09/06/24, the temperature was 44 degrees. 3. On 09/10/24, the temperature was 45 degrees. 4. On 09/11/24, the temperature was 42 degrees. 5. On 09/14/24, the temperature was 43 degrees. 6. On 09/25/24, the temperature was 44 degrees. 7. Staff…

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

Based on record review and interview, the facility failed to: 1. Keep food in the freezer with dates properly visible. 2. Document the temperature of the snack refrigerators on the East and [NAME] Unit. This failure could potentially affect all residents in the facility who eat food prepared in the kitchen (residents were identified by the census provided by the Administrator on 09/16/24). If the facility fails to adhere to safe food storage, residents could likely be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). The findings are: Food storage A. On 09/20/24 at 11:20 AM, during an observation of the kitchen's walk-in freezer a bag of hash browns was opened with an erased date that was not visible. B. On 09/20/2024 at 11:22 AM, during an interview with the kitchen's District Manager, he confirmed the bag of hash browns was opened with erased date. He stated the dates should be readable on all packaged food. Refrigerator Temperatures C. Record review of the [NAME] Unit snack refrigerator's temperature log, revealed…

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 the medical record for 1 (R #20) of 6 (R #12, R #13, R #20, R #23, R #60, and R #66) residents reviewed for advanced directives when they failed to update the resident's code status. This deficient practice is likely to result in residents not having their wishes honored if a life threatening event occurred. The findings are: A. Record review of R #20's physicians orders, dated [DATE], revealed an order for R #20's code status to be do not resuscitate (DNR, an order that informs healthcare staff not to perform cardiopulmonary resuscitation (CPR) if a person's heart stops beating or their breathing stops). B. Record review of R #20's Medical Orders for Scope of Treatment (MOST; an advanced directive), dated [DATE], indicated the resident's advanced directive was do not resuscitate (DNR). C. Record review of the R #20's care plan, dated [DATE], indicated the resident's advanced directive was DNR. D. Record review of R #20's care plan meeting…

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 the Minimum Data Set Assessment (MDS, part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid-certified nursing homes. It is a core set of screening, clinical and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment) was accurate for 2 (R #12 and R #14) of 10 (R #12, R #13, R #14, R #20, R #23, R #40, R #60, R #81, R #118 and R #292) residents review for MDS assessment accuracy. This deficient practice could likely result in the facility not having an accurate assessment of the residents' needs. The findings are: R #12 A. On 09/17/24 at 10:50 AM, during an interview with R #12, she stated that she had a Urinary Tract Infection (UTI) for the past couple of months. B. Record review of R #12's physician orders revealed the following: 1. Order date 04/16/24, ciprofloxacin HCL (antibiotic) 500 mg every 12 hours for…

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

Based on record review and interview, the facility failed to meet professional standards of care for 1 (R #293) of 1 (R #293) residents reviewed for wound care when they failed to complete wound care as ordered. This deficient practice could likely result in delays in wound healing or worsening of wound condition. The findings are: A. Record review of R #293's admission Record (no date) revealed an admission date of 07/03/24. B. Record review of R #293's physician's orders revealed: Order date 07/03/24 cleanse outer side and bottom of left foot with wound wash, pat dry, apply Skin-prep (liquid or wipe used as part of wound treatment to protect skin and prepare it for medical devices or adhesives) and apply MediHoney (medical-grade honey dressing used to treat wounds) and calcium alginate (highly absorbent wound dressing made from a natural polymer derived from brown seaweed that helps wounds heal) to wound bed (base or open area of a wound), cover with non-adherent (non-stick)dressing, cast padding, kerlix (gauze bandage rolls) and ace bandage long, stretchable cloth that's used to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure residents received care and treatment for pressure ulcers (an injury to skin and underlying tissue resulting from prolonged pressure on the skin) in accordance with professional standards of care (reasonable degree of care a person should provide to another person, typically in a professional or medical setting) for 1 (R #12) of 2 (R #12 and R #23) residents reviewed for pressure ulcers, when staff failed to: 1. Notify the provider that R #12 had a pressure injury to her right heel. 2. Document in the medical record interventions, staff provided to heal or prevent worsening of the pressure injury to R #12's right heel. These deficient practices could likely result in the provider being unaware of the resident's current condition leading to inconsistent interventions and worsening of pressure ulcers. The findings are: A. Record review of R #12's medical record, no date, revealed the following: 1. R #12 was admitted to the facility…

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 proper management of enteral tubes (a device utilized to provide liquid nutrition, hydration and medications via a tube into the stomach or intestine) for 2 (R #13 and R #14) of 2 (R #13 and R #14) residents reviewed for tube feeding when they failed to: 1. Administer R #13's feeding during the times ordered by the physician. 2. Provide care for R #14's enteral tube insertion site (percutaneous endoscopic gastrostomy/PEG; medical procedure in which a tube is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate). These deficient practices could likely lead to malnutrition, weight loss, and infection. The findings are: R #13 A. Record review of R #13's admission record, no date, revealed the following: 1. R #13 was admitted to the facility on [DATE]. 2. R #13 had the following diagnoses: a. Multiple sclerosis (a disease in which the immune system eats…

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 pharmaceutical services (the direct, responsible provision of medication-related care) were met for 1 (R #133) of 3 (R #6, R #31, and R #133) residents reviewed for medications when they failed to provide routine medication for a resident. This deficient practice could likely lead to unresolved medical issues. The findings are: A. Record review of R #133's Physician orders revealed the following: 1. An order, dated 08/06/24, for Lyrica ( used to treat fibromyalgia, diabetic nerve pain, spinal cord injury nerve pain, and pain after shingles in adult patients) Give 50 mg by mouth one time a day for pain. 2. An order, dated 08/06/24, for Nephro-Vite oral tablet (B-Complex with Vitamin C, and folic acid), 1 MG. Give one tablet by mouth one time a day for dietary supplement. B. Record review of R #133's MAR, dated August 2024, revealed staff did not document they administered Lyrica and Nephro-Vite to R #133 as ordered from 08/02/24 through 08/07/24.…

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

Based on record review and interview, the facility failed to ensure the consultant pharmacist's recommendations were reviewed and implemented by the physician or the physician provided a rationale for not following the consultant pharmacist's recommendation for 2 (R #6 and R #54) of 2 (R #6 and R #54) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications that are no longer necessary and may cause unnecessary drug interactions (changes to medication action caused by being combined with other foods, beverages, or drugs) or adverse side effects (unwanted, undesirable effects from medication). The findings are: R #6 A. Record review of R #6's pharmacy consultation report, dated 09/08/24, revealed R #6 had an as needed (PRN) order for lorazepam (medication used to treat anxiety), which was in place longer than 14 days without a stop date. The recommendation was for a clinical rationale for continuation. B. Record review of R #6's physician's orders, dated 08/02/24, no end date, revealed an order for lorazepam 0.5…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 1 (R #40) of 8 (R #14, R #16, R #29, R #40, R #118, R #123, R #292 and R #293) residents reviewed for documentation accuracy. This deficient practice has the potential to negatively impact the care staff provide to meet residents' needs due to missing or inaccurate records and resident information. The findings are: A. Record review of R #40's admission Record, no date, revealed the following: 1. R #40 was admitted to the facility on [DATE]. 2. R #40's diagnoses as follows: protein-calorie malnutrition (not consuming enough protein and calories to meet the body's needs), bipolar disorder (serious mental illness characterized by extreme mood swings, that can include extreme excitement episodes or extreme depressive feelings), and major depressive disorder (mental health condition characterized by persistently low or depressed mood). B. Record review of R #40's physician's orders revealed: 1. Order…

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 safeguard resident medical record information for all 126 residents (residents were identified by the census provided by the Administrator on 06/17/24). This deficient practice could likely result in the residents' information being viewed by unauthorized residents, visitors, and staff. The findings are: A. On 06/17/24 at 9:16 AM, during an observation of the 500 Unit at room [ROOM NUMBER] and 507, a computer on the medication cart was open, and the screen was not locked and staff were not present. Resident information was visible. All 126 resident's information can be accessed from this computer. B. On 06/17/24 at 9:18 PM, during an interview, CMA #11 confirmed that the computer was left open with resident information visible. CMA #11 confirmed that the computer is not supposed to be left unlocked. CMA #11 said that he just stepped away real fast because he had to take care of something.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure there was a functional system in place to ensure staff could initiate / not initiate cardiopulmonary resuscitation (CPR; any medical intervention used to restore circulatory and/or respiratory function that has ceased) during an emergency for all 73 residents who were Full Code (individual wants resuscitation and all life saving measures during a medical emergency) when they failed to: 1) Check pulse and air way on R #1 2) Ensure staff knew what procedure to follow in an emergency. 3) Track staff's CPR certification to ensure the certification was up to date. Residents were identified by the resident code list provided by the Administrator on [DATE]. This deficient practice could likely cause confusion among the nursing staff who may not be aware of what to do for residents who are Full Code and those residents who were coded Do Not Resuscitate (DNR; do not perform life saving measures, allow natural death), resulting in residents not receiving…

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 report injuries of unknown source within two hours to the State Agency (SA) for 1 (R #11) of 1 (R #11) residents sampled for abuse. If the facility fails to report allegations of abuse or neglect to the SA within two hours, then residents could likely continue to be abused or suffer serious bodily injury. The findings are: A. On 06/17/24 at 10:52 AM, during an interview, R #11's son said he went to visit R #11 about two and a half months ago (R #11's son was unsure of the date). R #11's son said R #11 had a bruise on her forehead. R #11's son said he asked LPN #11 what had happened to R #11, and she told him that she did not know. R #11's son said he asked R #11 what happened. He stated he touched R #11's bruise, and R #11 winced at the touch. B. On 06/17/24 at 11:30 AM, during an interview, LPN #11 said she remembered R #11's family visited and asked about a bruise on R #11's forehead. LPN #11 said she assessed R #11 and did not think it was a bruise, she said it was a discoloration. LPN #11 did not feel a lump. LPN #11…

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 that residents, their representatives, and the Ombudsman received a written notice of transfer as soon as practicable for 1 (R #21) of 1 (R #21) residents reviewed for hospitalization. This deficient practice could likely result in the resident or their representative not knowing the reason or location the resident was discharged . The findings are: A. Record review for R #21's nursing progress note, dated 05/29/24, revealed the facility transferred R #21 to the hospital on [DATE]. B. Record review of R #21's transfer notification form, dated 05/29/24, revealed the following: 1. The form had family member #2 (FM #2) on the form for the notification. 2. The section of the form that stated Copy of this notice was mailed to the resident/family, and Ombudsman on _________(date) was blank. C. Record review of R #21's nursing progress note, dated 05/30/24, revealed the facility transferred R #21 to the hospital on [DATE]. D. Record review of R #21'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 and interview, the facility failed to ensure residents and their representatives received a written notice of the bed hold policy which indicated the duration the bed would be held for 1 (R #21) of 1 (R #21) residents reviewed for hospitalization. This deficient practice could likely result in the resident and/or their representative being unaware of the bed hold policy upon return from the hospital. The findings are: A. Record review of R #21's nursing progress note, dated 05/29/24, revealed R #21 was transferred to the hospital on [DATE]. B. Record review of R #21's Bed Hold Policy Notice and Authorization form, dated 05/29/24, revealed the form was blank on the section for the signature of the resident or representative, which indicated they received a copy of the notice. C. Record review of R #21's nursing progress note, dated 05/30/24, revealed R #21 was transferred to the hospital on [DATE]. D. Record review of R #21's Bed Hold Policy Notice and Authorization form, dated 05/30/24,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to ensure staff revised the care plan for 1 (R #1) of 3 (R #1, R #2, and R #11) residents to reflect R #1 ate independently and did not need supervision/cue/assistance with meals. This deficient practice could likely result in staff being unaware of changes in the care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: A. Record review of R #1's care plan, dated 01/28/24, revealed R #1 required supervision/cue/assistance with meals. B. Record review of R #1 Occupational Therapy (OT) (a form of therapy for those recuperating from physical or mental illness that encourages rehabilitation through the performance of activities required in daily life) Discharge summary, dated [DATE], revealed the resident could eat independently. C. Record review of R #1's quarterly Minim Data Set (MDS) (a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and…

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

Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 1 (R #11) of 3 (R #1, R #2, and R #11) residents reviewed for documentation accuracy. This deficient practice has the potential to negatively impact the care staff provide to meet residents' needs due to missing or inaccurate records and resident information. The findings are: A. On 06/17/24 at 10:52 AM, during an interview, R #11's son said he went to visit R #11 about two and a half months ago. R #11's son said R #11 had a bruise on her forehead. R #11's son said he asked LPN #11 what had happened to R #11, and she told him that she did not know. R #11's son said he asked R #11 what happened. He stated he touched R #11's bruise and she winced and said it hurt a little. B. On 06/17/24 at 11:30 AM, during an interview, LPN #11 said she remembered R #11's family visited and asked about a bruise on R #11's forehead. LPN #11 said she assessed R #11 and did not think it was a bruise, she did not feel a lump. LPN #11 said she believed that R #11 had a discoloration and not 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 record review and interview, the facility failed to ensure residents were treated with respect and dignity for 1 (R #22) of 1 (R #22) residents randomly sampled, when the facility failed to allow R #1 to close her door for privacy. This deficient practice could likely result in residents feeling insecure, angry, and that their feelings and right to privacy are unimportant to the facility staff. The findings are: A. Record review of R #22's admission record revealed she had an admission date of 06/06/23. B. Record review of the facility Complaint Narrative Investigation report, no date, revealed the following: 1. On 12/28/23, R #22 was identified as an alleged victim of resident to resident abuse. Alleged abuser was identified as R #22's roommate/husband. 2. The allegations were not substantiated. C. On 02/26/24 at 2:44 PM, during an interview with the DON, she stated that after the allegation of abuse was investigated, R #22 and her roommate (R #22's husband) were instructed not to close the door unless they are changing, to ensure R #22 was safe due to the allegation of…

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

Based on interview and record review, the facility failed to provide written notice for room/roommate change for 1 (R #22) of 2 (R #22 and R #23) residents sampled for notification of change. This deficient practice could likely cause residents to become anxious and depressed if they are not given written room/roommate change notices. The finding are: A. Record review of R #22's admission record revealed she had an admission date of 06/06/23. B. Record review of the facility Complaint Narrative Investigation report, no date, revealed the following: 1. On 12/28/23, R #22 was identified as an alleged victim of resident to resident abuse. Alleged abuser was identified as R #22's roommate/husband. 2. The facility separated the residents until the investigation was completed. Staff did not document a completion date. 3. The allegations were not substantiated. 4. The residents were returned to the same room. Staff did not document a date. C. Record review of R #22's census report revealed the following: 1. R #22 was moved into the secure unit on 12/28/23. 2. R #22 was moved back to 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 notify the resident or the resident representative of a transfer to the hospital and room for 2 (R #13 and R #22) of 2 (R #13 and R #22) residents reviewed for change of condition, when they failed to: 1. Notify R #13's representative of R #13's change in condition which required hospital transfer. 2. Notify R #23 about the reason for transferring her from one room in the facility to another room in the facility. These deficient practices could likely result in the resident and the resident representative being unable to provide advocacy and make medical decision when needed, cause residents to become anxious, depressed, and believe that their feelings and preferences are unimportant to the facility staff. The findings are: R #13 A. Record review of R #13's medical record revealed the following: 1. R #13 was transferred to the hospital on [DATE]. No reason was documented for the transfer. 2. R #13 was discharged from the facility on 02/26/24. [R #13…

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 keep residents free from involuntary seclusion for 1 (R #23) of 1 (R #23) residents sampled for elopement (an act or instance of leaving a safe area or safe premises, done by a person with a mental disorder or cognitive impairment) risk, when they failed to implement and document the following: 1. The clinical criteria (rules or standards on which a decision or judgment is made to determine medical necessity) met for placement in the secured/locked area by the resident's physician along with information provided by members of the interdisciplinary team (IDT team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities). 2. Whether placement in the secured/locked area was the least restrictive approach that was reasonable to protect the resident and assure her health and safety. 3. The IDT consideration of the impact and reaction of the resident, if any, regarding placement on the unit. 4. Ongoing review and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to report to the State Survey Agency within five (5) days of the incident for 11 (R #3, R #5, R #6, R #7, R #8, R #9, R #12, R #21, R #22, R #23, and R #24) of 11 (R #3, R #5, R #6, R #7, R #8, R #9, R #12, R #21, R #22, R #23, and R #24) residents sampled for abuse when they failed to report the results of all investigations of abuse or accidents within five days to the State Agency. If the facility fails to report the results of the investigations to the State Agency within five days, then corrective action may not be taken and residents could likely continue to be abused and/or suffer serious bodily injury. The findings are: R #6 A. Record review of the facility's 5 day report (no date) revealed the following: 1. R #6 was observed with a black eye on 12/13/23, it was unknown what caused the injury. 2. The record did not contain documentation that the follow up report was submitted within five days. R #8 B. Record review of the facility's 5 day report…

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 notify the resident and resident's representative(s) of the transfer in writing for 2 (R #12 and R #13) of 2 (R #12 and R #13) resident sampled for hospitalizations when they failed to: 1. Notify the resident and the resident's representative(s) of the transfer to the hospital in writing and in a language and manner they understand for R #13. 2. Include in the notice a statement of the R #12 and R #13's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. 3. Include in the R #12 and R #13's notice the address (mailing and email) of the Office of the State Long-Term Care Ombudsman. 4. Document that the Transfer Notices for R #12 and R #13 was sent to the Ombudsman. These deficient practices could likely result in the resident and/or 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents or their representatives received a written notice of the bed hold policy which indicated the duration the bed would be held for 1 (R #13) of 1 (R #13) residents reviewed for hospitalization. This deficient practice could likely result in the resident and/or their representative being unaware of the bed hold policy upon return from the hospital. The findings are: A. Record review of R #13's medical record revealed the following: 1. The facility transferred R #13 to the hospital on [DATE] for a fall. 2. The record did not contain a written notice of the bed hold policy. B. On 02/28/24 at 1:37 PM, during an interview, R #13's POA (the authority to act for another person in specified or all legal or financial matters) said he did not know that the resident was currently not at the facility. R #13's POA said he did not get a bed hold notice. R #13's POA said the facility did not contact him. C. On 02/28/23 at 1:55 PM, during an interview,…

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 R #11's refusals for Physical Therapy (PT; the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery), Occupational Therapy (OT; a form of therapy for those recuperating from physical or mental illness that encourages rehabilitation through the performance of activities required in daily life), and Speech Therapy (ST; training to help people with speech and language problems to speak more clearly) for 1 (R #11) of 1 (R #11) resident reviewed for care plans. This deficient practice could likely result in staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: A. Record review of R #11's medical record revealed R #11 had an order for the following: 1. Physical Therapy dated 10/06/23 for to increase strength. 2. Occupational Therapy dated 10/06/23 for five times a week for 30 days. 3. Speech Therapy…

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 did not receive unnecessary psychotropic drugs (any drug that affects brain activities associated with mental processes and behavior) for 1 (R #2) of 1 (R #2) residents reviewed for unnecessary psychotropic medications. When the facility failed to: 1. Follow the Mental Health Nurse Practitioner's recommendation to complete a gradual dose reduction (GDR; gradually lowering the dosage of medication over a period of time) or discontinue lorazepam for R #2. 2. Ensure that R #2's antipsychotic medication order was limited to 14 days. 3. Consistently monitor R #2's behaviors to determine the continued need for lorazepam (medication used to treat severe agitation, trouble sleeping and especially anxiety and anxiety disorders). The findings are: A. Record review of R #2's admission Record revealed: 1. R #2 was admitted to the facility on [DATE]. 2. Principal diagnosis of unspecified dementia (group of symptoms that affects memory, thinking and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 2 (R #13 and R #22) of 2 (R #13 and R #22) residents reviewed for accuracy of documentation. This deficient practice has the potential to negatively impact the care staff provide to meet residents' needs due to missing or inaccurate records. The findings are: R #13 A. Record review of R #13's medical record revealed the following: 1. R #13 was transferred to the hospital on [DATE]. 2. R #13 was discharged from the facility on 02/26/24. B. Record review of R #13's medical record revealed the record did not contain documentation of why R #13 was sent to the hospital. C. On 02/28/24 at 12:32 PM, during an interview, the DON said she expected the record to contain a note documenting why the resident was admitted to the hospital. The DON said R #11's discharge should be documented. R #22 D. Record review of R #22's admission record revealed she had an admission date of 06/06/23. E. Record review 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 interviews, the facility failed to maintain appropriate staffing levels to meet the needs of the residents,when they failed to: 1) answer call lights timely, 2) have more than one CNA for 700 unit for 13 residents where 5 residents were on contact precautions. 3) Not able to honor resident preference when to get out of bed for R #103 and shower preference for R #76 This deficient practice has the potential to affect all 127 residents (residents were identified by the resident matrix as provided by the Administrator on 11/13/23). This deficient practice could likely affect direct resident care and limit residents' abilities to obtain the best possible care while in the facility. The findings are: Call Light Wait Times A. On 11/13/23 at 1:18 PM, during an interview with R #47, she stated that it sometimes took staff 30 minutes to answer her call button. B. On 11/13/23 at 2:06 PM, during an interview with R #50, she stated there was not enough CNA's on the weekends. The resident stated there were two CNAs for 45 residents. C. On 11/14/23 at 8:56…

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 maintain proper infection prevention measures by not: 1. Properly doffed (removed) personal protection equipment (PPE; clothing, gloves, face shields, goggles, facemasks, gowns and/or respirators or other equipment designed to protect the wearer from injury or the spread of infection or illness) after they exited the room of a resident on transmission-based precautions (TBP; residents who are known or suspected to be infected or colonized with infectious agents). 2. Ensuring a trash can for doffed PPE was available inside of resident's room. 3. Ensuring contract staff properly wore their N95 masks (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles). 4. Keeping the door closed for residents on airborne precautions (used to prevent the spread of germs through the air or dust). Failure to adhere to an infection control program is likely to cause the spread 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 provide reasonable accommodations of resident needs and preferences for 1 (R #28) of 1 (R 28) residents reviewed for choices, by not letting R #28 return to his room when he asked. This deficient practice could likely result in the resident's life style, personal choices, needs, and preference not being met which could result in loss of dignity and resident rights. The findings are: A. On 11/13/23 at 11:32 AM, an observation of 500 Unit, R #28 sat in the common area and repeatedly asked to go to his room. The Wound Care Nurse (WCN) told R #28 he could not go to his room, because he might fall. The WCN told the resident that he needed to be watched so that he would not fall. B. On 11/13/23 at 11:34 AM, during an interview, RN #11 stated R #28 could go to his room, but they would have to help him do it in a safe manner. C. On 11/13/23 at 12:12 PM, during an observation of the 500 Unit, R #28 continued to sit in the common area and asked repeatedly to go back to his room. R #28 asked anyone that walked by him.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide quarterly statements for resident's personal funds entrusted to the facility for 1 (R #106) of 2 (R #13, and R #106) residents sampled for personal funds. If residents are not provided quarterly statements for their personal funds accounts, then residents could experience anxiety and depression, because they don't know how much money they have. The findings are: A. On 11/14/23 at 10:34 AM, during an interview with R #106, he stated he did not receive any statements for his personal funds account that he had with the facility. B. Record review of R #106's medical record revealed he was admitted on [DATE]. C. On 11/16/23 at 9:45 AM, during an interview with the Business Office Manager (BOM), she stated she did not send the quarterly statement to R #106. The BOM stated that she sent the statements to R #106's responsible party. The BOM was not aware of any reason R #106 would not be able to receive the quarterly statement. The BOM also 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.

Based on record review and interview, the facility failed to notify the physician for 1 (R #237) of 1 (R #237) reviewed for insulin, when they failed to notify the physician about R #237's frequent refusal of insulin. This deficient practice could likely result in the physician being unaware of residents' current condition resulting in delay in treatment. The findings are: A. On 11/13/23 at 2:56 PM, an interview with R #237 revealed sometimes she did not receive her insulin. B. Record review of R #237's physician's orders revealed 08/21/23 Humulin R Insulin (is a type of short-acting medical insulin) sliding scale (varies the dose of insulin based on blood glucose level) before each meal and bedtime. C. Record review of R #237's MAR for October 2023, revealed R #237 refused sliding scale Humulin R Insulin (is a type of short-acting medical insulin) on the following dates and times: 1. Before breakfast on 10/04/23, 10/06/23, 10/23/23, and 10/24/23. 2. Before lunch on 10/01/23, 10/14/23, 10/24/23. 3. Before dinner on 10/10/23, 10/13/23, and 10/24/23. 4. Before bed on 10/01/23,…

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.

Based on observation and interview the facility failed to provide a comfortable and homelike environment for 20 (R #12, R #19, R #26, R #28, R #36, R #37, R #39, R #42, R #49, R # 56, R #59, R #67, R #72, R #75, R #79, R #96, R #103, R #104, R #126, & R #237) of 20 (R #12, R #19, R #26, R #28, R #36, R #37, R #39, R #42, R #49, R # 56, R #59, R #67, R #72, R #75, R #79, R #96, R #103, R #104, R #126, & R #237) residents sampled for environment, when they failed to: 1. Repaint and match the existing paint from scuff marks and damage on the walls and doors. 2. Keep air/heat vents uncovered with trash bags. 3. Serve residents lunch on tableware. 4. Protect residents against the loss of personal property. This deficient practice could likely cause the resident and/or the resident's family frustration with the loss of personal belongings, and cause them to feel like they are not valued. The findings are: A. On 11/15/23 at 2:58 PM, an observation of R #28's and R #26's room revealed the wall by the window had drywall damage which revealed the material under the drywall, and the paint on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the Ombudsman received a written notice of transfer as soon as practicable for 2 (R #37 and R #131) of 2 (R #37 and R #131) residents reviewed for hospitalization. This deficient practice could likely result in the Ombudsman not knowing the reason or location the resident was discharged . The findings are: R #37 A. Record review of R #37's medical record revealed R #37 was sent to the hospital on [DATE]. B. On 11/20/23 at 9:59 AM, during an interview, the Business Office Manager and Unit Manager #2 stated they were unaware the transfer notices needed to be sent to the Ombudsman. R #131 C. Record review of R #131's medical record revealed R #131 was sent to the hospital on [DATE]. D. On 11/20/23 at 11:22 AM, during an interview, the DON confirmed the staff did not send the transfer notices to the Ombudsman.

Based on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (R #89) of 7 (R #28, R #31, R #44, R #75, R #89, R #106 and R #184) residents reviewed for comprehensive care plans. Failure to develop a comprehensive person-centered care plan could likely result in staff's failure to understand the needs, preferences, and treatments for residents to achieve their highest level of well-being. The findings are: A. Record review of R #89's Change in Condition Minimum Data Set (MDS; comprehensive assessment completed by staff when residents have either a major improvement or decline in health status), dated 05/15/23, revealed: 1. Section B, hearing, speech, and vision as follows: a. Resident was usually able to make self understood if prompted or given time but had difficulty communicating some words or finishing thoughts. b. Resident was usually able to understand and comprehend most conversations but missed some part or intent of the message. 2. Section V, Care Area Assessment (CAA; triggered areas indicating a care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to revise the care plan for 5 (R #31, R #59, R #82, R #49, and R #237) of 6 (R #28, R #31, R #59, R #82, R #49, and R #237) residents reviewed for care plan revisions. This deficient practice could likely result in staff being unaware of changes in care being provided and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: R #31 A. Record review of R #31's Minimum Data Set (MDS; comprehensive assessment), dated 06/27/23, Section G: Functional Status revealed: 1. Question G0110.A Bed Mobility; resident required extensive physical assistance of one staff for bed mobility. 2. Question G0110.H Eating; resident required staff supervision for eating, to include set up help. B. Record review of R #31's MDS dated [DATE], Section G: Functional Status revealed: 1. Question G0110.A Bed Mobility; resident required extensive physical assistance of two staff for bed mobility. 2. Question G0110.H Eating;…

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

Based on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (R #49) of 1 (R #49) resident reviewed for skin conditions, when they failed to remove R #237's hemodialysis catheter (HD) (catheter is an access point, meaning an entrance and exit point, for the blood during hemodialysis treatment) dressing when the provider ordered it on 05/30/23. This deficient practice could likely lead to residents needs not being met and/or a worsening of their condition. The findings are: A. On 11/14/23 at 9:04 am, an observation of R #49 revealed he had a hemodialysis catheter in place. B. On 11/14/23 at 9:04 am, during an interview with R #49, he stated he had the hemodialysis catheter because he went to dialysis. R #49 confirmed he stopped going to dialysis in May, 2023. C. Record review of R #49's dialysis progress notes revealed the resident discharged from dialysis on 05/04/23. D. Record review of R #49's physican's orders revealed an order to remove the HD catheter on 05/30/23. E. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure that residents received appropriate treatment and services to prevent further decrease in range of motion for 1 (R #76) of 1 (R #76) residents reviewed for restorative therapy, when they failed to initiate a restorative nursing program (RNP; nursing service that often follows skilled rehabilitation services provided by physical or occupation therapists with the goal to maximize function and prevent functional decline in residents dependent on staff for certain actions). This deficient practice could likely result in decreased mobility or a decrease in residents' abilities to participate or perform their own activities of daily living (ADLs). The finding are: A. On 11/14/23 at 10:13 AM, during an interview with R #76, she stated she asked for rehabilitation, but the staff had not done anything about it. B On 11/14/23 at 10:13 AM, an observation of R #78 revealed she had contractures (a condition of shortening and hardening of…

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

Based on interview and record review, the facility failed to complete performance reviews at least every 12 months for 1 (CNA #35) of 3 (CNA #35, CNA #36, and CNA #37) CNAs sampled for 12 hours of annual training. This deficient practice could likely result in staff being undertrained and providing inadequate care. The findings are: A. Record review of employee files revealed CNA #35's last performance review was completed on 03/14/22. B. On 11/17/23 at 1:03 PM, during an interview, the DON confirmed the facility completed the last performance review for CNA #35 on 03/14/22.

Based on record review and interview, the facility failed to ensure staff received the appropriate training and skills to provide services for 3 staff (LPN #1, CNA #1, and CNA #2) of 3 staff (LPN #1, CNA #1, and CNA #2) reviewed for behavioral health training. This deficient practice is likely to result in residents not getting the care and assistance needed and may trigger behaviors that lead to injuries or mental anguish. The findings are: A. Record review of R #75's admission Record revealed an admission date of 09/11/23 and included a diagnosis of Post-Traumatic Stress Disorder (mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations). B. Record review of nurse progress note, dated 11/06/23 at 4:21 PM, revealed R #75 had an altercation with staff. Staff redirected R #75 to her room to cool down (getting away from situation and allowing time to calm down) after yelling at staff in the hallway. In her room, R #75 hit CNA #1 in the face and…

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

Based on record review and interview, the facility failed to act upon the pharmacy recommendations for 1 (R #72) of 5 (R #28, R #29, R #72, R #79, and R #82) residents reviewed for unnecessary medications. This deficient practice could likely result in residents being at a higher risk of adverse side effects and residents receiving medications that are no longer necessary. The findings are: A. Record review of Pharmacy Consultation Report for R #72, dated 10/13/23, revealed the following recommendations: 1. Discontinue famotidine [medication used to treat stomach ulcers, erosive esophagitis (heartburn or acid indigestion) and gastroesophageal reflux disease (GERD; a condition where the acid in the stomach washes back up into the esophagus]. 2. Consider discontinuing docusate [a medication utilized for managing and treating constipation] and, if a routine laxative is deemed necessary, initiate alternative therapy with Miralax (used to treat occasional constipation). 3. Reevaluate this combination and reduce the dose of buspirone [a medication used to treat anxiety disorders] from 5…

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

Based on record review and interview, the facility failed to ensure residents did not receive antipsychotic medications unless the medication was necessary to treat a specific psychiatric condition or diagnosis and was documented in the medical record for 1 (R #29) of 5 (R #28, R #29, R #72, R #79, and R #82) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications without a medical reason and being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result). The findings are: A. Record review of R #29 Physician's orders, dated 09/01/23, revealed an order for haloperidol (an antipsychotic used to treat nervous, emotional, and mental conditions) tablet, 0.5 mg. Give 0.25 mg one time a day for anxiety. B. Record review of R #29's medical record revealed the record did not contain a psychiatric diagnosis to indicate the need for an antipsychotic. C. On 11/17/23 at 10:22 AM, during an interview, the DON confirmed R #29 did not have a psychiatric diagnosis on file for the antipsychotic medication.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to properly store medications for all 54 residents on 400 and 500 unit (residents were identified by the resident matrix provide by the Administrator on [DATE]), when they failed to: 1) Secure a medication cart on 500 Unit, 2) Have an expiration date for R #15's medication, 3) Log the temperatures in the medication refrigerator on the 400 Unit. This deficient practice could likely result in residents receiving medications that are expired, not stored at the proper temperature, or not prescribed to them resulting in adverse side effects. The findings are: Medication Cart 500 Unit A. On [DATE] at 8:34 AM, an observation of 500 Unit revealed the medication cart unlocked, and staff were not present. B. On [DATE] at 8:36 AM, during an interview, RN #11 confirmed the medication cart was unlocked, and it should not be unlocked. C. On [DATE] at 2:3 PM, during an interview, the DON confirmed the medications cart should be locked when not in line of site. Medication…

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

Based on interview and observation, the facility failed to ensure meals were served at an appetizing temperature and were palatable (pleasant to taste) for 7 (R #23, R #51, R #71, R #72, R #103, R #111, and R #237) of 7 (R #23, R #51, R #71, R #72, R #103, R #111, and R #237) residents reviewed for meal quality. This deficient practice could likely reduce residents' ability to eat and enjoy meals, decreasing their quality of life. The findings are: R #72 A. On 11/13/23 at 2:05 PM, during an interview, R #72 stated she stated the food was sometimes cold, especially in the mornings. R #111 B. On 11/13/23 at 2:20 PM, during an interview, R #111 stated the food was his biggest complaint. He said it was low quality and was always cold. He said he will not eat the chicken. R #237 C. On 11/13/23 at 2:42 PM, during an interview, R #237 stated the food was always cold when it arrived, and the taste was terrible. R #51 D. Record review of the meal time document (provided by the Administrator on 11/14/23) revealed the following: a. Breakfast was scheduled at 7:00 am - 8:30 am. b. Lunch was…

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

Based on observation, interview, and record review, the facility failed to accommodate resident's food preferences for 1 (R #49) of 3 (R 49, R #76, and R #237) reviewed for food. If residents are unable to have their food preferences, then they could suffer weight loss, depression, and/or anxiety. The findings are: A. On 11/14/23 at 8:58 am, during an interview, R #49 stated he requested not to have eggs for breakfast, but he still received them. B. On 11/14/23 at 10:05 am, an observation of the R #49's meal tray revealed R #49's meal had eggs. CNA #35 came into the room. R #49 stated to CNA #35 that he did not want eggs for breakfast. CNA #35 confirmed the resident's meal ticket stated no eggs.

Based on observation and interview, the facility failed to store and serve food under sanitary conditions in accordance with professional standards of food service safety for all 127 residents who ate food prepared in the kitchen in the facility (residents were identified by the resident matrix provided by the Administrator on 11/13/23), when they failed to: 1. Serve meal trays covered, 2. Have staff wear a hairnet on while in the kitchen. If the facility fails to adhere to safe food handling practices and hygiene practices, residents could likely to be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). The findings are: A. On 11/13/23 at 8:36 AM, during an observation of the kitchen, Dietary Assistant (DA) #11's hair was not covered with a hairnet while he was in the kitchen and prepared food. B. On 11/13/23 at 8:36 AM, an interview DA #11 confirmed he did not have a hairnet on. C. On 11/13/23 at 8:36 AM, during an interview, the Dietary Manager (DM) confirmed that DA #11 did not have a hairnet on. She also confirmed a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the Therapy Department of a referral for 1 (R #31) of 2 (R #31 and R #76) residents reviewed for physical therapy (PT; the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise) and occupational therapy (OT; a form of therapy that encourages rehabilitation through the performance of activities required in daily life such as eating dressing). This deficient practice could likely result in residents not receiving therapy services as needed or ordered to improve or maintain their physical functional ability. The findings are: A. On 11/14/23 at 8:50 AM, during an interview, R #31's sister stated she is not able to walk or move around like she used to. She said, I hope they are doing some type of therapy for her still. B. Record review of R #31's Annual Minimum Data Set (MDS; comprehensive assessment), dated 06/27/23, Section G: Functional Status revealed: 1. Question G0110.A Bed Mobility; The…

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

Based on record review and interview, the facility failed to ensure documents were complete and accurate for 2 (R #27 and R #44) of 2 (R #27 and R #44) residents who were reviewed for documentation, when they failed to accurately document: 1. Showers for R #27. 2. Wound Care for R #44. This deficient practice could likely result in staff not having the information they need to provide competent, comprehensive care and services if vital information is missing from the documents. The findings are: R #27 A. Record review of R #27's Activities of Daily Living (ADL) sheet for showers, dated September 2023 and October 2023, revealed staff documented the resident received showers on 09/06/23 and 10/27/23. B. Record review of R #27's shower sheets, dated September 2023 and October 2023, provided by Unit Manager #2 revealed R #27 received a shower on 10/07/23. C. On 11/16/23 at 12:50 PM, during an interview with the DON, she confirmed the following: 1. Two showers were documented in Electronic Medical Record (EMR) for R #27, in September 2023 and October 2023. One shower occurred on…

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

Based on interview and record review, the facility failed complete 12 hours of annual training that included the performance reviews and the facility assessment for 2 (CNA #36 and CNA #37) of 3 (CNA #35, CNA #36, and CNA #37) CNAs sampled for 12 hours of annual training. This deficient practice could likely result in staff being under trained and providing inadequate care. The findings are: A. Record review of CNA #36's personnel records revealed: 1) CNA #36 completed 11 hours and 33 minutes of annual training within the past 12 months. B. Record review of CNA #37's personnel records revealed: 1) CNA #37 completed 10 hours and 51 minutes of annual training within the past 12 months. C. On 11/17/23 at 11:02 AM, during an interview, the Nurse Educator confirmed CNA #36 and CNA #37 did not complete 12 hours of annual training within the past 12 months.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents or their representatives received a written notice of their bed hold policy which indicated the duration the bed would be held for 1 (R #37) of 2 (R #37 & R #131) residents reviewed for hospitalization. This deficient practice could likely result in the resident and/or their representative being unaware of the bed hold policy upon return from the hospital. The findings are: A. Record review of R #37's medical record revealed the following: 1) R #37 was sent to the hospital on [DATE]. 2) The written bed hold notice did not contain the number of hospital days and therapeutic leave days the facility would hold a bed for the resident. B. On 11/20/23 at 10:03 AM, during an interview, Unit Manager #2 confirmed the bed hold notice for R #37 did not have the number of days filled in to indicate the number of days the facility would hold a bed for the resident. She confirmed the expectation was for staff to complete this information prior to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop a comprehensive person-centered care plan for 2 (R #1, and R #11) of 3 (R #1, R #11, and R #12) residents reviewed for Resident/Patient/Client Neglect. Failure to develop a person-centered care plan could likely result in staff's failure to understand the needs, preferences, and treatments for residents to achieve their highest level of well-being. The findings are: R #1 A. Record review of R #1's MDS (Minimum Data Set/comprehensive assessment), dated 07/11/23, revealed: Section G- functional status: Activities of daily living (ADL; Daily self-care activities that include bathing, grooming, oral care, dressing, eating and toileting): 1. Bed mobility; requires extensive assistance of 1 staff. 2. Dressing; requires extensive assistance of 1 staff. 3. Eating and drinking; independent, assistance only required for meal set up. 4. Toilet use; requires extensive assistance of 1 staff. 5. Personal hygiene (combing hair, brushing teeth); requires…

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

Based on record review and interview, the facility failed to revise the care plan for 1 (R #11) of 3 (R #1, R #11, and R #12) residents reviewed for Resident/Patient/Client Neglect. This deficient practice could likely result in staff being unaware of changes in care being provided and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: A. On 08/15/23 at 1:40 PM, during an interview, LPN #11 stated even though R #11 was not able to communicate due to her health and diagnosis, staff noticed R #11's discomfort with male care givers. LPN #11 said that when male staff were providing care that R #11 would become more vocal and agitated. LPN #11 said that R #11's POA told staff that R #11 is more comfortable and prefers female caretakers because of R #11's past trauma. LPN #11 said that they changed staff to accommodate R #11's preference for female caregivers. B. Record review of R #11's care plan, dated 02/18/23 revealed that R #11's preference for female care staff due to trauma was not updated in the resident's care…

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

Based on observation, and interview, the facility failed to keep residents free from accidents for all 11 residents on the 700 hallway, when they failed to secure a treatment cart on 700 hallway. This deficient practice could likely result in residents obtaining medical equipment that could be harmful to them resulting in injury. The findings are: A. On 08/15/23 at 9:40 AM, observation of the 700 unit revealed a treatment cart unlocked. No staff were present. B. On 08/15/23 at 9:41 AM, during an interview RN #12 confirmed that the treatment cart was unlocked. RN #12 could not get the crash cart to lock.

Based on record review and interview, the facility failed to ensure documents in resident records were complete and accurate for 2 (R #11 and R #12) of 3 (R #1, R #11, and R #12) residents, when they failed to accurately document resident's nutritional and fluid intake. This deficient practice could likely result in staff not having the information they need to provide competent, comprehensive care and services if vital information is missing from the resident's medical documents. The findings are: A. Record review of R #12's Care Plan revision date 05/23/22 revealed the following: 1. Encourage her to consume all fluids during meals; 2. Monitor for changes in nutritional status. B. Record Review of R #12's ADL (Activities of Daily Living; daily self-care activities that include bathing, grooming, oral care, dressing, eating and toileting): sheets revealed the following for the month of August 2023: 1. Drink/Snack- other than with meals, intake revealed no documentation for the following days and shifts: a. August 5, 2023 all shifts, b. August 6, 2023 all shifts, c. August 12, 2023…

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.