Casa Maria Healthcare

Based on observation and interview, the facility failed to complete the following:1. Maintain the ice and water machine in a manner to prevent contamination and foodborne pathogens (a bacterium, virus, or other microorganism that can cause disease), 2. Properly store food items by tracking when to discard, labeling and covering perishable foods, and dating all foods stored in refrigerator, freezer, or pantry.3. Maintain the kitchen environment in a clean and sanitary manner. 4. Temperature tracking sheet on the outside of the refrigerator was dated November 2025. 5. Ensuring food served to residents was sanitary.These failures have the potential to result in cross contamination, the growth of foodborne pathogens, and foodborne illnesses. The findings are:Ice and water machineA. On 12/14/25 at 2:00 pm a random observation of the dining area revealed the ice and water machine had dried residue and what appeared to be dried food particles and splatters covering the outside of the machine and the table the machine sits on.Food storageB. On 12/14/25 at 2:05 pm a random observation 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.

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 for 3(R #6, R #54, and R #98) of 3(R #6, R #54, and R #98) residents reviewed by not: Ensuring Enhanced Barrier Protection (EBP) signage is visibly posted outside resident's room when precautions are in place. Ensuring Personal Protective Equipment is available (PPE) is available,Ensuring EBP signage was posted properly.Infection Control Signs and PPER #6C. Record review of R #6's admission record revealed R #6 was admitted into the facility on [DATE]. D. Record review of R #6's significant change comprehensive assessment dated [DATE] revealed the following:Two, stage three pressure ulcers (involves full-thickness skin loss, where the wound extends through the skin into the fatty tissue), One, stage four pressure ulcer (the most severe type of bedsore, involving full-thickness tissue loss where skin, fat, and underlying muscle, tendon, or bone become exposed and damaged, creating deep,…

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 were provided activities according to their preference for 1 (R #4) of 1 (R #4) resident reviewed for activities of daily living. This deficient practice is likely to result in the residents' personal choices not being honored and loss of dignity. The findings are: A. Record review of R #4 admission record revealed R #4 was admitted on [DATE].B. Record review of R #4's care plan, revised on 06/22/24 revealed R #4 prefers activities that identify with prior lifestyle. She prefers current events, educational programs, movies, sports, and television.C. On 12/14/25 at 3:52 pm during an interview with R #4, she stated she was upset because the facility had taken the power strip that connected her television to the outlet earlier this morning. She stated she could not watch television anymore because the television cord does not reach the outlet. She stated the facility informed her that it was a safety hazard.D. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the resident's current advance directive (a document which provides an individual's wishes for emergency and lifesaving care) and the resident's Electronic Health Record (EHR) revealed the same resident wishes for 3 (R #9, R #79, and R #84) of 6 (R #9, R #10, R #63, R #67, R #79, and R #84) residents reviewed for advance directives. This deficient practice is likely to cause confusion and delay potentially lifesaving procedures. The findings are:R #9A. Record review of the face sheet in R #9's EHR revealed R #9 was admitted into the facility on [DATE], and his current Advance Directive was listed as Attempt Resuscitation/CPR (CPR; a lifesaving emergency measure that combines chest compression with artificial ventilation are desired). B. Record review of R #9's MOST (MOST; a legal document which outlines the care the resident wants when they become incapacitated and unable to speak for themselves) form revealed the form was signed and dated…

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 create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 4 (R #7, R #15, R #79, R #106) of 6 (R #7, R #8, R #15, R #35, R #79, and R #106) residents reviewed for care plans. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission. The findings are:R #7A. Record review of R #7's admission Record revealed she was admitted to the facility on [DATE] with the following diagnoses:1. Metabolic encephalopathy2. End Stage Renal DialysisB. Record review of R #7's Baseline Care Plan revealed the following:1. The Social Services section (section…

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

Based on observation, interview and record review, the facility failed to ensure the medication error rate did not exceed 5 percent (%) when staff performed four medication errors out of 32 opportunities for 1 (R #106) of 6 (R #15, R #35, R #41, R #79, R #101, and R #106) residents reviewed during medication administration. This resulted in a medication error rate of 12.5%. This deficient practice could likely result in the residents receiving incorrect medication, not receiving the desired therapeutic effect, and exposing the residents to a higher risk of side effects. The findings are:A. On 12/17/25 at 8:06 am during an observation of medication administration through R #106's feeding tube, Licensed Vocational Nurse (LVN) #1 prepared [crushing or pouring from a capsule] four different medications for administration and combined all four medications into one medication cup. B. Record review of the facility's policy dated 04/12/23 stated crushed medications are not mixed into the same medicine cup, unless approved by the prescribing physician. C. Record review of physician orders:1.…

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

Based on observation and interview, the facility failed to ensure call lights in the residents' rooms were within reach of the residents while in the room for 1 (R #5) of 5 (R #2, R #5, R #54, R #88 and R #98) residents reviewed for call lights. This deficient practice could likely result in residents being unable to notify staff when they need assistance. The findings are:A. On 12/15/25 at 9:57am during a random observation of R #5's room, his call light was observed to be on the side of his bed between the mattress and bed rail. B. On 12/15/25 at 9:58 am, during an interview with R #5, he confirmed he could not reach his call light. C. On 12/15/25 am at 10:02 am during an interview with Certified Nurse Aide (CNA) #3, she confirmed R #5's call light was not in his reach and should always be within his reach.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for baths or showers for 3 (R #1, R #2, and R #3) of 3 (R #1, R #2, and R #3) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents. The findings are:R #1A. Record review of R #1's admission Record revealed R #1 was admitted to the facility on [DATE] with the following diagnoses:1. History of falling,2. Seizures (convulsions),3. Lack of coordination,4. Cognitive communication deficit (communication problems caused from cognitive impairment),5. Traumatic subdural hemorrhage (a collection of blood between the outer layer and middle layers of the brain's covering due to a traumatic brain injury),6. Generalized muscle weakness (the body's inability to contract muscles properly), 7. Reduced mobility,8. Muscle wasting,9. Difficulty in…

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 a suicide attempt where a potential for serious bodily injury can occur within 24 hours to the State Agency (SA) for 1 (R #2) of 1 (R #2) resident reviewed for abuse. If the facility fails to report these incidents to the State Agency, then the State Agency cannot ensure the residents' safety is protected. The findings are: 1. Record review of the facility's Initial Incident Report for R #1's suicide attempt on 09/01/25 revealed the initial report was submitted to the SA on 09/10/25. 2. On 09/11/25 at 2:15 pm during an interview with the Regional Nurse Consultant, she confirmed that the report was not submitted timely within 24 hours.

Based on interviews the facility failed to ensure residents have ready and reasonable access to their money. This deficient practice could likely affect all 95 residents who reside at the facility. If the facility is not ensuring residents have access to their money, then residents are likely to feel undignified and unworthy. The findings are: A. On 09/17/24 at 8:42 am, during an interview with R #24, she stated she recently received a check for a large amount of money, but the facility will not give her any money. She stated the facility tells the residents that they've [the facility] ran out of money when money is requested. R #24 stated that the facility never gives out money on the weekends. B. On 09/17/24 at 10:00 am, during an interview with the Resident Council members [R #10, R #34, R #40, R #44, R #45, R #55, and R #64], they stated on weekdays, when they request money, staff have constantly told them that the money is not available. The residents further stated that they are never allowed to get money on the weekends. C. On 09/18/24 at 9:50 am, during an interview with the…

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

Based on interviews, the facility failed to ensure that residents are able to receive mail on Saturdays for all 95 residents residing at the facility. This deficient practice is likely to result in residents not receiving timely communication which could result in feelings of isolation. The findings are: A. On 09/17/24 at 10:00 am, during the Resident's Council Meeting [R #10, R #34, R #40, R #44, R #45, R #55, R #64, and R #70], the residents stated mail is not delivered on Saturdays and they would like to receive their mail when it is delivered to the facility. R #44 stated she has never received her mail on a Saturday, even when she is waiting for a package. R #44 stated she has had to wait up to two days to receive packages that contain personal incontinence supplies. B. On 09/18/24 at 11:25 am, during an interview with the Activities Director (AD) she confirmed the mail is not delivered on the weekends. She stated she is the only staff at the facility that delivers the mail to residents. so if she is not at work, the mail does not get delivered. C. On 09/19/24 at 10:24 am…

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

Based on record review and interview, the facility failed to provide documentation confirming on Nurse Aide (NA) #1, employed by the facility, had completed a Nurse Aide Training and Competency Evaluation Program (NATCEP) or a Competency Evaluation Program (CEP) within four months of being employed at the facility. This deficient practice is likely to affect all 95 residents residing in the facility. Residents are likely to experience substandard care because of the use of untrained or unqualified aides providing direct care to residents. The findings are: A. Record review of NA #1's personnel record reviewed the following: 1. NA #1's hire date was 07/17/23. 2. NA #1's date of Certified Nurse Aide certification was 12/08/23. B. On 09/20/25 at 11:55 am, during an interview with the Human Resources Director (HRD), she confirmed NA #1 received her certification late and continued to work shifts during that time. She stated her expectation is for all nurse aides to become certified within four months.

Based on interview and observation, the facility failed: 1. Ensure meals were attractive when served to residents. 2. Ensure foods were palatable (pleasant to taste) and to the resident's satisfaction. 3. Ensure cold and hot foods were served at the appropriate temperatures to prevent scalding and burning. 4. Ensure foods were served timely to each resident and those sharing tables. These deficient practices have the potential to affect all 95 residents' ability to eat and enjoy meals, may decrease their quality of life, and could likely lose weight. The findings are: Food Attractiveness A. On 09/16/24 at 3:51 pm, during an observation of R #90 in his room, he had a partially eaten hamburger on his bedside table. The meat was visibly red in the middle and appeared undercooked. B. On 09/16/24 at 3:51 pm, during an interview, R #90 stated he was asked during breakfast what he wanted for lunch and was offered chicken fried steak. When he arrived for lunch, they served him spaghetti. He was told by the staff that he could not have chicken fried steak, because it is not included on the…

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

Based on record review and interview, the facility failed to ensure the nutritional needs and preferences were met for all 95 residents listed on the facility census provided by the Administrator on 09/16/24 by not having an alternative meal available for residents. If the facility is not providing an alternative meal or offering an alternate meal menu to residents, then residents are likely to experience weight loss, frustration, and depression. The findings are: A. Record review of the posted menu for September 2024, indicated only one meal option for breakfast, lunch and dinner. The facility did not offer an alternative meal/choice (second meal option) for each meal, that is equal in nutritional value to the primary meal being served to all residents. B. On 09/19/24 at 11:17 am during an interview with the VPN (Vice President of Nutrition) she stated there is an always available menu. When asked if it was equivalent to the nutritional value of the main scheduled meal, she stated she feels the everyday menu may have different calories, but feels the resident has the choice to eat…

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

Based on record review, observation and interview, the facility failed to store and serve food under sanitary conditions by not ensuring: 1. Kitchen was clean and sanitary. 2. Food items labeled and dated 3. Refrigeration unit was clean. 5. Food storage and handling. 6. Maintenance of kitchen equipment and plumbing These deficient practices are likely to affect all 95 residents listed on the resident census list provided by the Administrator on 09/16/24 and could likely lead to foodborne illnesses in residents if food is not being stored properly, safe food handling practices are not adhered to and sanitation of equipment preparation areas are not cleaned appropriately. The findings are: A. On 09/16/24 at 12:03 pm, during an observation of the initial tour of the kitchen and pilot kitchen from 12:03 pm through 12:33 pm, the following was revealed: 1. The floor was sticky. 2. The kitchen sink near preparation area had hard water deposits around the spicket. 3. The ice machine had hardwater stains on the outside near door opening. 4. A visibly soiled rag laid in the corner of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure the resident's right to participate in the care planning process for 3 (R #24, R #30, and R #96) of 5 (R #24, R #30, R #90, R #96, and R #294) residents reviewed for care plans. If the facility fails to ensure resident's participation in the care planning process, then residents are likely to feel unimportant and uninformed. The findings are: R #24 A. Record review of R #24's admission Record revealed R #24 was admitted to the facility on [DATE] with multiple diagnosis including: 1. Unspecified Sequelae of Unspecified Cerebrovascular Disease (conditions that impact blood vessels in the brain). 2. Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). 3. Anxiety Disorder. 4. Anoxic Brain Damage (damage to the brain from lack of oxygen), not elsewhere classified. 6. Difficulty in walking B. Record review of R #24's admission Minimum Data Set Assessment (MDS; a federally mandated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews, the facility failed to promote residents' choices for 2 (R #28 and R#96) of 2 (R #28 and #96) residents reviewed for choices when staff failed to: 1. Announce themselves prior to entering R #28's room. 2. Accommodate R #96's choice to have her oxygen tube attached to the rail of her bed. These deficient practices are likely to result in the resident's needs, choices and preferences not being honored. The findings are: R #28 A. Record review of R #28's current physician orders, R #28 was admitted to the facility on [DATE] with multiple diagnosis including: 1. Acute and Chronic Respiratory Failure. 2. Other reduced mobility. 3. Muscle wasting and Atrophy. 4. Morbid obesity. 5. Unspecified Osteoarthris. B. On 09/16/24 at 2:28 pm, during an interview with R #28, she stated that she is frustrated because staff enters her room without knocking. R #28 stated she has reported her concerns to the Administrator, but it continues to occur. C. On 09/19/24 at 10:14 am,…

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

Based on interviews, the facility failed to ensure the grievances identified by the Resident Council (RC) were resolved and the resolutions communicated back to the RC committee. This deficient practice could likely affect all 95 residents who reside at the facility. If the staff is not ensuring RC grievances are responded to and resolutions are communicated back to the RC group, then residents are likely to feel that their concerns do not matter, and do not have any influence over changing issues identified by residents. The findings are: A. On 09/17/24 at 10:00 am, during an interview with the Resident's Council members [R #10, R #34, R #40, R #44, R #45, R #55, R #64, and R #70], they stated the facility discourages them from filing grievances and when they do file grievances the facility does not respond timely, if at all. B. On 09/18/24 at 11:25 am, during an interview with the Activity Director (AD), she stated she fills out the grievance forms and submits the forms to the appropriate department head for completion. She stated that she informs the residents of the outcome of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to complete an accurate comprehensive assessment for 2 (R #22 and R #75) of 2 (R #22 and R #75) residents reviewed for assessments. This deficient practice is likely to result in residents not receiving an accurate assessment which could result in the residents receiving less than optimal care and treatment. The findings are: R #22 A. On 09/17/24 at 11:30 AM during an interview and observation with R #22, she stated she needed dental care but, she has not been offered a dental appointment. R #22 had missing teeth and discoloration. B. Record review of the Minimum Data Set (MDS) assessment dated [DATE], Section L: Oral and Dental Status indicated R #22 did not have any dental problems. C. On 09/20/24 at 1:52 PM during an interview with the MDS coordinator, he confirmed R #22's dental information was entered incorrectly. R #75 D. On 09/17/24 at 9:43 AM during an interview with R #75, he stated he would like dentures, he further stated he has…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide an ongoing program of activities designed to meet the interests for 4 (R #22, R #24, R #30, and R #90) of 6 (R #22, R #24, R #30, R #90, R #242, and R #294) residents reviewed for activities by not providing meaningful individualized activities based upon residents' interests. If residents are not provided or encouraged to attend/participate in activities that meets their interests, then they are likely to experience an increase in boredom, isolation, and depression. The findings are: R #22 A. Record review of R #22's admission Record revealed R #22 was admitted to the facility on [DATE] with multiple diagnoses including: 1. Type 2 Diabetes Mellitus without complications (DM2, a condition results from insufficient production of insulin, causing high blood sugar). 2. Schizophrenia, unspecified (a disorder that affects an individual's ability to think, feel, and behave clearly). 3. Bipolar Disorder, unspecified (a disorder associated 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 record review and interview, the facility failed to ensure residents received proper treatment to maintain vision for 1 (R #24) of 2 (R #24 and R #106) residnets reviewed for vision. This deficient practice could likely result in residents losing some independence if they cannot see, and compromising their quality of life. The findings are: A. Record review of R #24's admission Record revealed R #24 was admitted to the facility on [DATE] with multiple diagnosis including: 1. Unspecified Sequelae of Unspecified Cerebrovascular Disease (conditions that impact blood vessels in the brain). 2. Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). 3. Anxiety Disorder. 4. Anoxic Brain Damage (damage to the brain from lack of oxygen), not elsewhere classified. 5. Difficulty in walking B. On 09/17/24 at 8:51 am, during an interview with R #24, she stated she needs eyeglasses because she can not see very well. R #24 further stated the previous Social…

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

Based on observation, record review, and interview, the facility failed to ensure the medication error rate was 5% or less when six medication errors occurred out of 43 opportunities, which resulted in an error rate of 13.95% for 4 (R #19, R #24, R #55, and R #76) of 7 (R #19, R #24, R #38, R #41, R #55, R #62, and R #76) residents observed during medication administration. This deficient practice could likely result in the residents receiving the incorrect medication, not receiving the desired therapeutic effect, and exposing the resident to a higher risk of side effects. The findings are: Incorrect Administration A. Record review of the physician's order dated 09/17/24 for R #55, revealed an order for Lantus Subcutaneous solution (long-acting insulin that starts to work several hours after injection and keeps working evenly for 24 hours and is used to improve blood sugar control) 100 UNIT/ML (100 units of insulin per milliliter of solution) (insulin glargine [bioengineered (man-made) injectable form of long-acting insulin that is used to regulate sugar/glucose levels]) Inject 46…

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

Based on record review, observation and interview, the facility failed to ensure a resident was free of a significant medication error by not administering medications as ordered for 1 (R #55) of 1 (R #55) resident reviewed for administration of insulin (hormone produced in the pancreas which regulates the amount of glucose in the blood). This deficient practice could likely have severe negative effects on the resident, such as hypoglycemia (too little sugar in the blood) and lead to symptoms of trouble talking, confusion, loss of consciousness, seizures, or death. The findings are: A. Record review of R #55's admission Record (no date) revealed the diagnosis of Type 2 Diabetes Mellitus (condition characterized by high blood glucose levels caused by either a lack of insulin or the body's inability to use insulin efficiently) with foot ulcer. B. Record review of R #55's Physician's Orders revealed an order dated 09/17/24 at 8:00 am Lantus Subcutaneous solution (long-acting insulin that starts to work several hours after injection and keeps working evenly for 24 hours and is 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 obtained routine dental care for 3 (R #22, R #24 and R #75) of 3 (R #22, R #24 and R #75) residents reviewed for dental services. This failure is likely to result in the resident experiencing pain, embarrassment over condition of teeth, and potential weight loss. The findings are: R#22 A. Record review of R #22's face sheet revealed R #22 was admitted into the facility on [DATE]. B. On 09/17/24 at 11:30 AM during an observation and interview with R #22, she had missing teeth, tooth decay and discoloration on the remaining teeth. R #22 stated, she had not been offered dental care. She stated she had some of her teeth pulled in the past and she wanted to get dentures. C. On 09/18/24 at 2:36 PM during an interview with Medical Records/Scheduler, she stated she schedules specialty services only and Social Services will make all other appointments for needs that are requested during care plan meetings or interdisciplinary team…

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 administer medications in a manner to prevent cross contamination for 3 (R #19, R #24, and R #76) of 7 (R #19, R #24, R #38, R #41, R # 55, R #62, and R #76) residents. The failure has the potential to cause residents to be exposed to pathogens (organisms that can cause disease) and increased risk of infection. The findings are: A. On 09/18/24 at 8:05 am, during an observation of the medication administration pass, Licensed Practical Nurse (LPN) #1 prepared and gave R #19's medication and went back to the medication cart after administering medications. LPN #1 did not sanitize or wash her hands before or after resident contact. B. On 09/18/24 at 8:18 AM, during continued medication administration observation, LPN #1 prepared medications for R #76. R #76's medications included a subcutaneous (just under the skin) injection. LPN #1 entered the resident's room, donned (to put on) gloves and administered the resident her medications. LPN #1 removed gloves and exited the room. LPN #1 went back to the medication cart…

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 the facility failed to ensure the medical records contained documentation that each resident received, or staff offered the pneumococcal (a bacteria that can cause pneumonia infection of the respiratory tract) or influenza (flu) vaccines for 1 (R #74) of 6 (R #2, R #17, R #22, R #39, R #74, and R #75) residents reviewed for immunizations. If residents are not vaccinated as appropriate against pneumonia and influenza, they have a higher likelihood of contracting that illness and spreading it to other 95 residents on the census list provided by Administrator (ADM) on 09/16/24 and staff in the facility. The findings are: A. Record review of R #74's medical record revealed the following: 1. admission record for R #74 indicated she was admitted to the facility on [DATE]. 2. Review of the EHR (Electronic Health Record) did not contain consent forms or declination forms for either vaccination. 3. Record review of the facility's policy titled Influenza Prevention and Control (no date) are to be…

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

Based on record review and interview, the facility failed to ensure Certified Nurse Aides (CNAs) received the required in-service training of 12 hours per year for 1 (CNA #1) of 2 (CNA #1 and CNA #2) CNAs reviewed for required in-service training. This deficient practice is likely to result in the CNAs not receiving the necessary training to meet the care needs of the residents. The findings are: A. Record review of CNA #1's personnel file revealed CNA #1 was hired on 06/27/23. B. Record review of CNA #1's in-service training Transcript Report revealed CNA #1 did not complete any of the required 12 hours trainings from 06/27/23 to 09/20/24. C. On 09/20/24 at 11:55 am, during an interview with the Human Resources Director (HRD), she confirmed CNA #1 has not completed any trainings during her employment at the facility. She confirmed CNA #1 continues to work shifts providing care for residents in the facility even though she has not completed any of the trainings. The HRD stated she expected all CNAs to complete at least 12 hours of training per year.

Based on observation and interview, the facility failed to promote care with dignity and respect for 4 (R #3, R #44, R #56, and R #70) of 6 (R #3, R #12, R #44, R #56, R #64, and R #70) residents reviewed during a random dining observation when the facility failed to serve lunch at the same time to all the residents who sat at the same dining table. This deficient practice could likely result in residents feeling frustrated and disappointed. The findings are: A. On 09/16/24 at 12:04 pm, during a lunch observation in the dining room, revealed the following: 1. R #12 and R #56 sat at the same table waiting for lunch to be served: a. R #12 was served his meal at 12:22 pm and R #56 watched R #12 eat his meal. b. R #56 was served his meal at 12:29 pm. 2. R #3, R #44, R #64, and R #70 sat at the same table waiting for lunch to be served: a. R #64 was served his meal at 12:34 pm and R #3, R #44, and R #70 watched R #64 eat his meal. b. R #3 was served her meal at 12:36 pm and R #44 and R #70 watched R #3 eat her meal. c. R #70 was served his meal at 12:40 pm and R #44 watched R #70 eat his…

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 interviews, the facility failed to ensure all treatment carts were locked while unattended. This deficient practice had the potential to affect all 94 people residing in the facility by allowing unauthorized persons access to their medical supplies and personal health information. The findings are: A. On 08/23/24 at 8:23 am, during a random observation of the facility, the treatment cart located in the short hallway between the dining room and the nurse's station was unlocked, and facility employees were not in the area. B. On 08/23/24 at 8:24 am, during an interview with Certified Nursing Assistant (CNA) #1, she confirmed the treatment cart was unlocked, and facility employees were not in the area. C. On 08/23/24 at 8:26 am, during an interview with Assistant Director of Nursing (ADON) she stated the treatment cart should be locked and secured while not in use.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure grievances (complaints over something believed to be wrong or unfair) were acted upon for 3 (R #3, R #6, and R #12) of 3 (R #3, R #6, and R #12) residents reviewed for grievances. This deficient practice could likely result in residents feeling unimportant and unsatisfied with the results of the grievance process. The finding are: R #3 A Record review of R #3's face sheet revealed that R #3 was admitted to the facility on [DATE]. B. On 04/24/25 at 3:15 pm during an interview with R #3, she stated that the facility continues to 1. Send cold food. 2. Send improper eating utensils (fork for oatmeal, spoon for pork chops). 3. Sends bread on her tray when she asks for no carbs. 4. During church service on Sunday's its very noisy and loud in the kitchen. R #3 stated these complaints have been brought up at the Resident Council meetings and they have not been addressed with her or the Resident Council. The dates of the Resident Council meetings took…

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 residents' ability to perform activities of daily living (ADLs) was maintained for 2 (R #10 and R #11) of 4 (R #1, R #4, R #10 and R #11) residents reviewed for restorative therapy (Restorative services refers to nursing interventions that promote the resident ' s ability to adapt and adjust to living as independently and safely as possible). If the facility does not ensure that residents receive restorative services, then the residents are likely to experience a decrease in their ability to walk, transfer, and do other activities of daily living. The findings are: A. Record review of R #10's Therapy Records indicated that R #10 was discharged from physical therapy (PT), occupational therapy (OT), and speech therapy (ST) on 04/10/2024. B. Record review of care plan for R #10 dated 04/10/24 revealed that PT was to evaluate for fall prevention. C. Record review of R #11's Therapy Records indicated that R #11 was discharged from PT and OT services on 04/03/2024 and was discharged from ST on 03/27/2024. D. Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure staff revised and updated the care plan for 1 (R #5) of 1 (R #5) residents reviewed for care plans when staff failed to add R #5's behavior to refuse diabetic management practices (insulin and blood sugar level checks). This deficient practice is likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are: A. Record review of R #5's face sheet revealed R #5 was admitted into the facility on [DATE] with a diagnosis of type 2 diabetes mellitus with hyperglycemia (high blood sugar). B. Record review of R #5's physician order, dated 08/28/23, revealed Insulin Lispro Injection Solution 100 unit/milliliter (ml), insulin lispro. - Inject as per the following sliding scale, subcutaneously (under the skin) before meals and at bedtime for diabetes mellitus: - If blood glucose level is 70 to149, give 0 units; - 150 to 199, give 2 units; - 200 to 249, give 3 units; - 250 to 299, give 4 units; - 300 to…

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

Based on observation, record review, and interview, the facility failed to post Nurse Staffing Information in an accurate manner and at the beginning of each shift, This deficient practice could likely prevent the 71 residents on the facility census list provided by the Administrator on 06/25/23, and any visitors to have access to accurate daily staffing information. The findings are: A. On 07/06/23 at 8:00 am during an observation the facility, the posted nurse staffing daily schedule at both nurses stations was dated 07/05/23, and the Registered Nurse (RN) staffing section was left blank. An additional posted nursing staff daily schedule located on the 200 hallway was dated 06/29/23. B. Record review of the prior two months of posted nursing staff schedules revealed the following: 1. Posted nursing staff schedule dated 06/01/23 had two different postings for the same date, with different numbers of staff posted 2. Posted nursing staff schedule dated 06/02/23 had two different postings for the same date, with different numbers of staff posted 3. Posted nursing staff schedule dated…

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 an alternate meal menu for residents that preferred not to eat the meal served on the menu. By failing to post an alternate meal, all 71 residents listed on the census provided by the Administrator, may not be aware that they have choices. This deficient practice could lead to residents having less than optimal nutritional health outcomes, and suffer unwanted weight loss. The findings are: A. On 06/25/23 at 11:30 am, during observation of the facility it was noted that the menu displayed in the hallways bulletin boards did not show an alternate meal choice. B. On 06/25/23 at 12:00 pm, during observation of the main dining room, the displayed menus for breakfast, lunch, and dinner did not list an alternate meal choice. C. On 06/26/23 at 11:50 am, during observation of the main dining room, it was noted that the displayed menus did not contain an alternate menu listing. D. Record review of the facility meal menu revealed that the facility did not offer alternate meal choices for breakfast, lunch, or…

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

Based on observation and interview, the facility failed to ensure food was labeled and dated in the refrigerators and dry storage areas. This deficient practice could affect the 71 residents, as listed on the facility census provided by the Administrator on 06/25/23, that receive food or meals from the kitchen. If the facility does not ensure food storage is conducted using proper procedures, residents have the potential to receive food that is expired, or potentially exposed to food contamination resulting in foodborne illness. The findings are: A. On 06/25/23 at 9:08 am, the following items were observed during the kitchen tour: Preparation Area: 1. (1) tortilla chips bag was open and sitting on top of a preparation table 2. (1) egg carton containing eggs was left on preparation counter/table uncovered and unrefrigerated 3. (1) marshmallow bag was opened and unlabeled laying on shelf under the preparation table 4. (4) eggs left in bowl on table with yellow substance on/under them 5. (1) container of basil leaves, only labeled with FIFO (first in first out) date 6. (1) container 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 and interview, the facility failed to ensure trash/garbage cans were closed and in good repair. This deficient practice has the potential to affect all 71 residents, as listed on the facility census provided by the Administrator on 06/25/23, by attracting insects, rodents and animals to the facility. The findings are: A. On 06/25/23 at 9:08 am, during observation of the kitchen, four garbage cans (located outside of the kitchen) were observed to be without lids. B. On 06/29/23 at 11:00 am, during observation of the kitchen, the following was observed: 1. Three garbage cans had only partial lids, with part of the lid broken off. 2. One garbage can had no lid. 3. One rolling garbage can, contained a plastic liner that was filled to the top and untied, had no lid. C. On 06/29/23 at 11:18 am, during an interview with the Director of Dietary Services (DDS), she acknowledged that the garbage cans listed above were missing lids or had broken lids and unable to be closed completely.

Based on record review and interview, the facility failed to ensure that the consultant pharmacist reviewed each resident's drug regimen for irregularities on a monthly basis for 5 (R #15, 34, 44, 48 and 172) of 5 (R #15, 34, 44, 48 and 172) residents reviewed for unnecessary medications. If the facility fails to conduct monthly reviews, there is potential for residents to experience unnecessary drug interactions and potentially adverse side effects. The findings are: Resident #15: A. Record review of R #15's facility face sheet, dated 07/05/22, indicated the following diagnoses: Muscle Wasting And Atrophy (loss of muscle), Hypotension (low blood pressure), Lack Of Coordination, Seizures (involuntary muscle spasms), Iron Deficiency Anemia (low iron and red blood cell count), Type 2 Diabetes Mellitus (high blood sugar), Hyperlipidemia (high cholesterol), Dementia (memory loss), Depressive Episodes (feeling of sadness), Hypertensive (high blood pressure) With Heart Failure (heart attack), Heart Failure, Gastro-Esophageal Reflux Disease (acid reflux), Gastrointestinal Hemorrhage…

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

Based on observation, record review, and interview, the facility failed to ensure that 1 (R #18) of 1 (R #18) resident reviewed for falls was free from accidents and hazards by not providing the necessary equipment. This deficient practice could likely result in injuries and/or hospitalizations. The findings are: A. Record review of facility face sheet for R #18, dated 06/01/23, revealed admitting diagnoses which included: Fracture Of Left Femur (broken upper left leg), Heart Failure, Hypothyroidism (underactive thyroid), Extended Spectrum Beta Lactamase (ESBL) Resistance (difficulty in resistance to certain infections), Presence Of Left Artificial Hip Joint (new left hip), Urinary Tract Infection (bladder infection), Dementia (memory loss), Chronic Kidney Disease (low functioning kidneys), Hypertension (high blood pressure), Blindness in Left Eye, and History Of Falling. B. On 06/26/23 at 9:26 am, during an observation of R #18 revealed that she had a small bandage to the left upper forehead/temple area. C. Record review of R #18's 5 day Minimum Date Set (MDS) assessment, dated…

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 provide services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. This deficient practice could affect all 71 residents, as identified on the facility census list provided by the Administrator on 06/25/23, if the residents cannot maintain their highest achievable status of health, mobility, and mental functioning. The findings are: A. Record review of the posted nursing staff schedule for 07/05/23, revealed that the facility failed to schedule an RN to provide nursing care for that day. B. On 07/06/23 at 1:30 pm, during an interview with the Director of Nursing (DON), she stated that there was RN coverage for 07/05/23 but that the facility had failed to document that on the posted nursing staff schedule. DON was unable to provide documentation to support this.