Casa Real

Based on observation, interview, and record review; the facility failed to store and serve food under sanitary conditions when staff failed to ensure:1. Food items were labeled and dated in the kitchen refrigerators. 2. Food was stored appropriately and not left open to air in the kitchen refrigerator. 3. Staff personal belongings were not stored next to a food serving line.These deficient practices are likely to affect all 121 residents listed on the resident census list provided by the Administrator on 09/16/25 and are likely to lead to foodborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to. The findings are: A. On 09/22/25 at 10:00 a.m., observation of the kitchen revealed the following: One sheet pan of food item that was not labeled or dated stored in the kitchen refrigerator. One pack of yellow American Sliced Cheese was open to air. One tobacco cigarette and cigarette lighter in the kitchen near the food serving line. B. On 09/22/25 at 10:02 a.m., during an interview, the Dietary Manager (DM) he stated that…

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

Based on observations, record reviews and interviews, the facility failed to maintain a safe, controlled environment for 2 (R #10 and #17) of 2 (R #10 and #17) residents reviewed. The facility failed to:Notify staff of R#10's infection control status by not recognizing R#10's COVID condition and not posting at his doorway a notice of his infectious status.Ensure proper hand hygiene was performed by staff and that a glucometer was cleaned and disinfected which could potentially cause cross-contamination for residents.This deficient practice is likely to result in residents and staff being exposed to infectious diseases that could be transmitted between staff and residents. The findings are: R#10A) On 09/23/25 at 9:59am, observed R#10's call light was on and Licensed Practical Nurse (LPN) #6 went in the room to answer the call light. LPN #6 was wearing a disposable mask the entire time. Observed R#10 telling her that he has COVID-19 (an infectious viral disease that causes flu-like symptoms) and that she has to keep her distance.B) On 09/23/25 at 9:59am, interview with LPN #6 stated…

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 and record reviews the facility failed to ensure its antibiotic stewardship program was implemented and monitored to prevent the unnecessary use of antibiotic. This deficient practice placed residents at risk for developing antibiotic-resistant infections and adverse drug events.The findings are: A) On 09/26/25 at 1:30pm during an interview with the facility's Infection Preventionist (IP) reported not having a system to track residents on antibiotics. The IP was unaware of the overall number of residents on antibiotic therapy in the past 6 months. The IP stated he has all the records on his desk and failed to produce any records and kept pointing to his stack of papers.B) On 09/26/25 at 1:30pm during an interview with the IP, he stated that the facility's antibiotic stewardship program is expected to meet once a month. He stated the last antibiotic stewardship meeting was held in January 2025 when the previous IP was still here. IP confirmed that per facility policy they are to meet once a month.C) On 09/29/25 at 11:00am, facility failed to produce any records…

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 and observation, the facility failed to ensure that a qualified individual was designated as the Infection Preventionist (IP) responsible for the facility's Infection Prevention and Control Program (IPCP). The facility's noncompliance with this requirement has the potential to result in widespread transmission of communicable diseases and infections among residents.The findings are: Cross reference findings from F880 and F881A) On 09/26/25 at 1:30pm, during an interview with the Infection Preventionist (IP), he stated he did not finish the Infection Control class that was offered early this year. He stated he is the facility designated Infection Preventionist. Stated that the previous Infection Control Preventionist left January 2025. IP confirmed that he was required to attend and complete an infection control training to be assigned as the IP but failed to do so due to other non-IP related jobs assigned to him.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to maintain an environment that was clean, in good condition, and free from clutter for 1 (R #9) of 1 (R #9) resident reviewed for a homelike environment by: The facility was storing unused O2 (oxygen) concentrators (medical device used to deliver O2) in R #9's room. Two respiratory spirometers (instrument used to measure the volume of air that a person can inhale and exhale) were not stored in sealed bags and on top of an open tube of Clotrimazole Cream (antifungal medication) on R #9's shelf next to his bed. Failure to maintain the building in a clean and comfortable manner is likely to result in unsafe conditions and prevent residents from enjoying everyday activities. The findings are:A. Record review of R #9's face sheet revealed R #9 was admitted into the facility on [DATE]. B. On 09/23/2025 at 12:19 pm during an observation of R #9's room, two O2 concentrators were not in use and were stored in the corner of R #9's room. C. 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 staff revised the care plan for 5 (R #'s 7, 8, 11, 37 and 60) of 5 (R #'s 7, 8, 11, 37 and 60) residents reviewed by:Staff failed to conduct a quarterly care plan meeting as required and in accordance with their admission date and Minimum Data Set (MDS) assessments for R #7, 8, 11 and 60.Not including use of table during family visits for R #37.This deficient practice is likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are: R #7: A. Record review of R #7's face sheet revealed R #7 was admitted into the facility on [DATE]. B. Record review of R #7's electronic health record (EHR) revealed R #7 had quarterly MDS assessments completed on 12/21/24, 03/20/25, and 06/19/25. C. Record review of R #7's care plan meeting progress notes revealed R #7 had a care plan meeting on 03/06/25, and then not again until 08/28/25 (a care plan meeting should have been conducted between 03/06/25 and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide quality care that meets professional standards for 5 (R #'s 9, 11,32, 97 and 125) of 5 (R #'s 9, 11, 32, 97 and 125) residents when the staff failed to:Obtain physician orders for R #9's use of Clotrimazole Cream (antifungal medication). Follow physician order for enteral feeding maintenance (ongoing process of providing nutrition to the residents who are unable to consume enough nutrients through their normal oral intake) for R #11.Follow physician order for oxygen use for R #32, #97 and #125.These deficient practices are likely to result in residents not maintaining their optimal health as planned by their medical provider. The findings are: R #9: A. Record review of R #9's face sheet revealed R #9 was admitted into the facility on [DATE]. B. Record review of R #9's physician orders revealed an order for the use of Clotrimazole Cream 1% (percent) was not found. C. On [DATE] at 09:30 am during an observation and interview with R…

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

Based on interviews, the facility failed to ensure the facility had sufficient staff to meet the needs of all residents residing in the facility when staff failed to: Offer baths or showers to residents as scheduled.These deficient practices are likely to negatively impact resident safety, comfort, and to impede processes such as timely incontinence care (assisting residents to the bathroom or changing adult briefs), regular turning schedules (moving or turning residents that need assistance and are unable to move on their own), showers, and appropriate assistance with meals.The findings are: A. Refer to F0677 for related findings. B. On 09/26/25 at 11:44 am during an interview with Certified Nursing Assistant (CNA) #1, she stated due to staffing shortages, resident baths and showers are the first things that are missed each day. CNA #1 confirmed residents complain due to missed showers. C. On 09/29/25 at 8:51 am during an interview with CNA #2, she confirmed residents miss baths and showers due to insufficient staffing. D. On 09/29/25 at 9:07 am during an interview with Licensed…

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 interviews, the facility failed to complete the required pharmacy review of resident medications for 2 (R #'s 4 and 7) of 5 (R #'s 2, 4, 7, 64, and 72) residents reviewed for pharmacy reviews when:The facility failed to provide completed pharmacy reviews for every resident in the facility during the months of October 2024, November 2024, and June 2025. The facility provider did not respond to pharmacist recommendations. The facility providers did not respond to pharmacist recommendations for several weeks after the pharmacist's recommendation. This deficiency practice is likely to result in residents receiving medications that are unnecessary for their health. The findings are:A. Record review of the facility pharmacist recommendations dated August 2024 through September 2025 revealed the following: No pharmacist recommendations were provided for any resident in the facility to review for October 2024, November 2024, and June 2025. Pharmacist recommendations dated 05/19/25 through…

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 interviews, the facility failed to complete the required pharmacy review of resident medications for 5 (R #'s 4, 7, 39, 63, and 105) of 8 (R #'s 2, 4, 7, 39, 63, 64, 72, and 105) residents reviewed for pharmacy reviews when:The facility failed to provide completed pharmacy reviews for every resident in the facility during the months of October 2024, November 2024, and June 2025.The facility provider did not respond to pharmacist recommendations.The facility providers did not respond to pharmacist recommendations for several weeks after the pharmacist's recommendation. Initiate a gradual dose reduction (GDR; the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the medication can be discontinued altogether) for an antipsychotic (used to treat psychotic disorders) medication as recommended by the pharmacist and ordered by the physician.If consultant pharmacist recommendations and physicians' orders are not implemented in a…

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

Based on observation, and interviews, the facility failed to properly store medications in the facility medication cart by ensuring all expired medications are taken out of the medication cart, and not pre-pouring medications. This deficient practice is likely to result in expired medications and medical supplies being used in resident care resulting in residents being at risk of possible infections and not receiving the full benefits of medication. The findings are: A) On 09/22/25 at 10:06am, during an observation of the medication cart located on the south unit station. The following items were found: - an unlabeled, undated medication cup containing 4 white tablets. - an insulin (insulin is a natural hormone that turns food into energy and manages your blood sugar level) pen for R#71, with no date of first use and no date for when to discard after 28 days. - an insulin pen for R #123, with no date of first use and no date for when to discard after 28 days.B) On 09/22/25 at 10:06am, during an interview with Registered Nurse (RN) #3 stated the following: - that those medications 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure 1 (R #12) of 3 (R #1, 5 and 12) residents reviewed was appropriately discharged when the facility:Provided R #12 a 30-day discharge notice after R #72 wandered into his room and both residents were engaging in sexual behaviors with one another.Requested that R #12 be administered medication to lessen his sexual drive but didn't allow enough time for the medication to take effect before issuing an immediate discharge notice.Ordered for R #12 to have one to one staffing, but while staff stepped away from R #12, R #72 went into R #12's room and both residents were caught engaging in sexual behaviors. Immediately discharged R #12 home with his wife without proper notice, opportunity to prepare for his arrival and option to appeal decision.Discharging a resident without notice and without adequate evidence to justify an immediate discharge, likely puts residents at risk of an unsafe discharge and disruption in care.The findings are: N. On 12/18/25 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon record review and interview, the facility failed to provide written notice of discharge to the resident's representative for 1(R #12) of 3(R #1, 5 and 12) residents reviewed for discharged . If the facility is not providing written notice of discharge of a resident, then residents and their representatives will not have the contact information to appeal the decision without having to ask. The findings are: A. Record review of R #12's face sheet, dated 09/26/25, revealed R #12 was admitted to the facility on [DATE] with the following diagnoses:Dementia (a chronic progressive disease that affects memory) with other behavioral disturbance.Paroxysmal atrial fibrillation (a type of irregular heart rhythm).Restlessness and agitation.Chronic kidney disease (failure of the kidneys to properly function). History of pulmonary embolism (blood clot in the lungs).Encounter for palliative care (medical care that focuses on care and relief from serious illnesses).B. Record review of R #12's daily care notes date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS; a comprehensive review of the resident's health and functional status) assessment was submitted for finalization within 14 days for 1 (R #5) of 1 (R #5) residents reviewed for Minimum Data Set. If MDS assessments are not completed and submitted in a timely manner, then the resident is likely to receive less than optimal care. The findings are:A. Record review of R #5's face sheet revealed R #5 was admitted into the facility on [DATE] and was discharged on 07/10/25. B. Record review of R #5's electronic health record (EHR) MDS Assessments page revealed the following: 06/27/25 Entry MDS submitted within 14 days and accepted.07/10/25 Discharge Return Anticipated MDS was completed but was not submitted within 14 days as required. R #5 did not return to the facility. C. On 09/29/25 at 3:48 pm during an interview with the MDS Coordinator (MDSC), she confirmed R #5's MDS discharge was not submitted and should have been…

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 daily care needs including showers, brief changes and urostomy (a medical device used to collect urine after a urostomy, which is a surgical procedure that creates an opening (stoma) in the abdomen for urine to exit the body) bag changes for 3 (R #'s 4, 11, 36) of 3 (R #'s 4, 11, and 36) residents reviewed for care needs.Failure to provide for resident's daily care needs can result in residents feeling dirty, unclean and ashamed.The findings are: R #4: A. Record review of R #4's care plan dated 09/05/25 revealed R #4 requires assistance for ADL (Activities of Daily Living) care in bathing, grooming, personal hygiene, dressing, eating, locomotion-movement, toileting related to Dementia with behavioral disturbances. B. Record review of R #4's Documentation Survey Report (ADL tracking form) dated 09/08/25 through 09/24/25, revealed the following: Three out of 16 days, R #4 was not toileted/changed for approximately 12 hours. Four out of 16 days, R…

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

Based on interview and record review the facility failed to follow-up on an issue that that was brought up by the family during a meeting with staff for 1 (R #64) of 1 R (#64) resident if the facility is not following up on issues that affect the residents well being and quality of life then it is likely that the resident will feel unheard and that their issues do not matter to the facility. The findings are: A. Record review of R #64's review of MDS section B1000 dated 09/15/25 reveals she wears corrective lenses.B. On 09/23/25 at 9:38 AM during an interview with R #64's Power of Attorney (POA) she stated that she had had a care conference meeting with the facility for R #64. She stated that she had let the facility know that there was a scratch on R #64's glasses and she would like her to be taken to the eye doctor to get new glasses. C. Record review of Care Conference Meeting notes dated 09/04/25 reveals obtain consult as need/indicated and treatment. D. On 09/24/2025 at3:51 PM during an interview with the Social Services Director (SSD) she stated that the family had talked…

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 adequate supervision to prevent resident to resident sexual contact for 2(R #12 and 72) of 2(R #12 and 72) residents reviewed. If the facility is not providing adequate supervision to prevent sexual contact between residents determined to not have the capacity to consent to such contact, then residents are at risk of unwanted contact. The findings are:A. Record review of R #12's face sheet, dated 09/26/25, revealed R #12 was admitted to the facility on [DATE] with the following diagnoses:Dementia (a chronic progressive disease that affects memory) with other behavioral disturbance.Paroxysmal atrial fibrillation (a type of irregular heart rhythm).Restlessness and agitation.Chronic kidney disease (failure of the kidneys to properly function). History of pulmonary embolism (blood clot in the lungs).Encounter for palliative care (medical care that focuses on care and relief from serious illnesses).- R #12's assigned care providers were Medical Director…

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 provide dialysis (a treatment that helps remove waste products and excess fluids from the blood when the kidneys are not functioning properly) services consistent with professional standards for 1 (R#3) of 1 (R#3) resident reviewed for dialysis care. The facility failed to provide a system of communication between the facility and the dialysis provider. This deficient practice is likely to result in resident condition not being communicated between the facility and dialysis center causing residents to receive inadequate care before, during and after dialysis services.The findings are: A) Record review of R #3 face sheet dated 09/24/25, revealed she was admitted to the facility on [DATE] with multiple diagnoses including, but not limited to:Cardiomyopathy (Heart muscle disease)Chronic ulcer of buttock (also known as bedsore that dorms on the buttocks area due to prolonged pressure on the skin and underlying tissues)Hyperlipidemia (a condition in which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, the facility failed to notify the facility providers (Nurse Practitioner, Physician) and the resident's Power of Attorney (POA- medical decision maker), when a resident experienced a new coccyx (tail bone) pressure ulcer (localized damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of usually long-term pressure, or pressure in combination with shear or friction) for 1 (R #3) of 1 (R #3) resident reviewed for a change of condition. This deficient practice is likely to result in a delay in treatment or inadequate treatment. The findings are: A. Refer to F0686 for pertinent findings related to this citation. B. On 03/25/25 at 10:59 am during an interview with R #3's POA, he stated he was not notified of R #3 having a new pressure ulcer located on his coccyx (discovered on 07/03/24) by the facility. R #3's POA confirmed he was made aware of the new pressure ulcer by the hospital on [DATE]. C. On 03/26/25 at 5:08 pm during an interview with the Skin…

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 sufficient preparation for discharge for 1 (R #2) of 2 (R #'s 2 and 3) residents reviewed by not ensuring the referral for services had been received, accepted, and was scheduled to provide care for the resident upon discharge home. These deficient practices could likely result in resident not receiving needed services and having to navigate referral process for services unassisted. The findings are: A. Record review of R #2's face sheet revealed R #2 was admitted into the facility on [DATE] and he was discharged with home health services on 03/12/25. B. Record review of R #2's facility discharge plan dated 03/10/25 revealed R #2 was to receive home health services upon discharge as ordered by a physician. C. On 03/24/25 at 1:57 pm during an interview with the Ombudsman (Resident Advocate), she stated she was aware of several residents being discharged without home health services set up for them upon discharge. D. On 03/26/24 at 1:15 pm during…

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 the necessary treatment and services to prevent the development and worsening of pressure wounds (also called a pressure injury or pressure ulcer; skin damage which results from unrelieved pressure on the body) for 1 (R #3) of 1 (R #3) resident reviewed when staff failed to: 1. Identify R #3's new coccyx (tailbone) pressure wound with measurements of the new pressure wound, while monitoring for changes in the pressure wound. 2. Complete and document weekly skin evaluations that included R #3's new coccyx pressure wound. These deficient practices are likely to lead to residents developing pressure ulcers and wounds worsening. The findings are: A. Record review of R #3's face sheet revealed R #3 was admitted into the facility on [DATE] and discharged to the hospital on [DATE]. B. Record review of R #3's hospital discharge documentation dated 06/20/24 revealed R #3 was sent to the hospital on [DATE] for altered mental status 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 a record review and interview, the facility failed to ensure shower sheets records were complete for 1 (R #1) of 1 (R #1) resident reviewed for complete and accurate shower documentation. This deficient practice is likely to result in staff not having the information they need to provide competent, comprehensive care and services to residents. The findings are: A. Record Review of R #1's face sheet revealed R #1 was admitted to the facility on [DATE]. B. Record review of the facility's shower schedule revealed R #1 was to be offered/given a bath/shower every Monday, Wednesday, and Friday and was not documented that R#1 refused showers on some of those days. C. Record review of R #1's documentation survey report (ADL tracking form on the electronic health record [EHR]) revealed the following: - January 2025, R #1 had seven baths/showers documented out of 21 opportunities and did not have any refusals documented, - February 2025, R #1 had five baths/showers documented out of 23 opportunities with five…

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 a resident's care plan was revised for 1 (R #1) of 1 (R #1) resident reviewed for care plans when staff failed to update the care plan: 1. To accurately reflect the removal of a bathroom door alarm placed to prompt Certified Nurse Aide (CNA) /staff to check on the resident. 2. To reflect the use of a fall mat (a mat placed on the floor beside a resident's bed in case a resident falls out of bed). 3. To reflect the use of an anti-roll back device (a device used prevent a wheelchair from rolling back and away from the user as they attempt to sit down or stand up from the wheelchair) for R #1's wheel chair. This deficient practice is likely to result in staff not being aware of the residents care needs and preferences, and residents not receiving the needed care. The findings are: Door alarm: A. On 01/21/25 at 3:09 PM during an interview with the facility Maintenance Manager (MM), he stated that he installed an alarm on R #1's bathroom door so that staff knows when R #1 goes into the bathroom. B. On…

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

Based on record review and interview, the facility failed to meet professional standards of quality for 1 (R #1) of 1 (R #1) resident reviewed by not obtaining physicians orders to: 1. Install an alarm on R #1's bathroom door. 2. For the use of a fall mat during R #1's seizures. 3. For the use of an anti-roll back device on R #1's wheelchair. If the facility is not ensuring that physician orders are obtained and followed, the residents may not be getting the appropriate treatment and the intended treatment effects. The findings are: A. On 01/21/25 at 3:09 PM during an interview with the facility Maintenance Manager (MM), he stated he had installed an alarm on R #1's bathroom door so that staff would know when R #1 goes into the bathroom. He further stated that he did not remember an exact date of the installation. B. Record review of R #1's Physicians Orders dated 01/23/25 revealed the order did not contain any active or discontinued orders for a door alarm, fall mat and an anti-roll back device. C. On 01/22/25 at 3:15 PM during an interview with the Director of Nursing, she stated…

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

Based on record review and interviews, the facility failed to provide foot care for 1 ( R #1) of 1 ( R #1) resident reviewed for diabetic foot care (involves daily inspection and washing of your feet, keeping toenails trimmed, wearing well-fitting shoes and socks or slippers to protect your feet, getting regular check-ups during healthcare visits to ensure your feet stay healthy and free from complications) If the facility is not ensuring residents toe nails are clipped timely, then residents are likely to experience discomfort or be at risk for infection. The findings are: A. On 01/21/25 at 1:01 PM during an interview with R #1's daughter, she stated her father's toe nails are very long and need to be trimmed. She further stated she had requested a podiatry (medical care and treatment of the human foot) appointment for her father the first week in December of 2024 and an appointment had not been scheduled. B. On 01/22/25 at 10:30 AM during an interview with the scheduler, she stated R #1 was last seen by the podiatric technician on 01/16/25. Podiatry note dated 01/16/25 revealed R…

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

Based on observation and interview the facility failed to provide proper infection control practices for 1 (R #1) of 1 (R #1) resident reviewed for infection control by: 1. Not ensuring R #1's bathroom is clean and sanitary. 2 Not ensuring bathroom floor remained free of feces (waste matter discharged from the bowels after food has been digested). 3. Not ensuring handheld shower head was not on the bare floor. 4. Not ensuring wash bins and cloths for a bed bath were left uncovered under the bathroom sink. 5. Not keeping R #1's room and bathroom free of foul odors. Failure to adhere to an infection control program is likely to cause the spread of infections and illness to residents and staff within the facility. The findings are: A. On 01/14/25 at 9:44 am during observation of R #1's room revealed the bathroom lighting was very dim and the room had a foul odor. Feces was present on bathroom floor, the bathroom floor was sticky, and urine was in the toilet. The shower head laid on the bare floor underneath a raised toilet seat in the shower. Two wash bins were on the bare floor under…

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 allowed a resident to remain in the facility or staff documented the reason for the resident's discharge, the location of the discharge/transfer, the evidence of the facility's efforts to meet the resident's needs prior to discharge, and the instructions for continued care for 1 (R #1) of 1 (R #1) resident reviewed for facility discharges. This deficient practice likely resulted in an unsafe, unplanned discharge in which the facility transferred R #1 to a local shelter without medications and care instructions. The findings are: A. Record review of R #1's face sheet, dated 10/16/24, revealed R #1 was admitted to the facility on [DATE] with the following diagnoses: - Epilepsy (a chronic condition of the brain that causes seizures), - Dysphagia (difficulty swallowing), - Non-st elevated myocardial infarction (heart attack), - Pain. There was no POA or Emergency Contact listed. B. Record review of R #1's Medication Administration 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 provided a written notice to a resident which included the reasons for the discharge and to send a copy of that notice to the Ombudsman (an advocate for the residents) for 1 (R #1) of 1 (R #1) resident sampled for discharges or transfers. Without approporiate notice, the resident likely was not able to adequately advocate for his rights and to ensure that he was not inappropriately transfered or discharged . The findings are: A. Record review of R #1's face sheet, dated 10/16/24, revealed R #1 was admitted to the facility on [DATE] with the following diagnoses: - Epilepsy (a chronic condition of the brain that causes seizures), - Dysphagia (difficulty swallowing), - Non-st elevated myocardial infarction (heart attack), - Pain. B. Record review of R #1's annual Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 06/16/24, revealed staff documented the following: - Brief Interview for Mental…

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 Certified Nurse Aide (CNA) #1 failed to report a resident's fall with injury to the facility nurse for 1 (R #2) of 1 (R #2) residents reviewed for falls. Failure to report a fall immediately to the nurse to conduct an assessment could likely result in the resident not receiving the necessary care needed for injuries sustained or for prolonged pain and discomfort. The findings are: A. Record review of R #2's Care Plan, dated 09/16/24, revealed R #2 was admitted to the facility on [DATE] and the following: - Diagnoses: - Muscle weakness, - Dysphasia (trouble swallowing), - Right sided hemiplegia following cerebral infarction (paralysis of right side following a stroke), - Hypotension (low blood pressure), - Unspecified dementia (a group of symptoms affecting memory). - R #2 was at risk for falls due to impaired mobility (lack of strength to walk, grasp or lift objects), poor safety awareness (impaired ability to judge safety), and psychosis with behaviors (changes in a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure 1 (R #3) of 1 (R #3) resident was free from accidents when staff failed to provide adequate supervision while the resident used the toilet. If the care plan is not followed according to the resident's needs then the resident is not likely to get the proper assistance needed which places the resident at an increased risk for injury. The findings are: A. Record review of R #3's face sheet revealed R #3 was admitted to the facility on [DATE] with the following diagnoses: - Non-traumatic interceder hemorrhage, unspecified (bleeding in the brain), - Cerebral edema (swelling in the brain), - Cognitive communication deficit (difficulty communicating), - Other lack of coordination (can affect balance, speech, and fine motor skills), - Muscle weakness (generalized: lack of strength in one or more muscles), - Difficulty in walking, not elsewhere classified, - Need for assistance with personal care. B. Record review of R #3's care plan, dated 03/15/24,…

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 observation and interview, the facility failed to safeguard clinical record information when staff disclosed private health information (PHI) to unauthorized persons for 1 (R #1) of 1 (R #1) resident reviewed. This deficient practice likely resulted in R #1's clinical information not being sufficiently safe guarded. The findings are: A. Record review of R #1's face sheet, dated 09/24/24, revealed the resident was admitted to facility on 03/26/24 with multiple diagnoses to include dementia (a chronic, progressive condition of the brain that causes mental and memory decline) and Parkinson's disease (a chronic progressive condition of the nervous system that causes tremors). Further review revealed R #1's contact persons included his daughter, son, and other (niece). B. Record review of R #1 daily care note, dated 09/15/24, revealed R #1 experienced a decline in health that resulted in his death. C. On 09/20/24 at 4:21 pm during phone interview with R #1's daughter-in-law (DIL), she stated she was a former employee of the facility. She stated she was familiar with many 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 observation, record review, and interview, the facility failed to ensure an allegation of staff-to-resident abuse was reported within two hours to the State Agency for 1 (R #1) of 1 (R #1) resident reviewed. If the facility is not immediately reporting allegations of abuse and conducting an investigation, residents are likely to be at risk of further abuse. The findings are: A. Record review of R #1's face sheet, dated 09/24/24, revealed the resident was admitted to facility on 03/26/24 with multiple diagnoses to include dementia (a chronic, progressive condition of the brain that causes mental and memory decline) and Parkinsonism (a chronic progressive condition of the nervous system that causes tremors). B. On 09/20/24 at 2:37 pm during interview and record review with the Administrator (ADM), he stated he was contacted by telephone between 9:00 pm and 10:00 pm on 09/14/24 and was informed CNA #1 used loud profane language while working with R #1 on the memory care unit. He stated staff heard CNA #1 yelling and cussing loudly at R #1 and then CNA #1 left the area and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to meet professional standards of quality for 1 (R #) of (R #1) residents reviewed by not administering medications in accordance with the physician's orders. If the facility is not administering medications as prescribed, the resident is likely to not get the therapeutic benefits of medications needed to maintain resident health and well-being. The findings are: A. Record review of R #1's face sheet, dated 08/07/24, revealed she was admitted to facility on 07/19/24 with multiple diagnoses including: -Seizures (a sudden attack, spasm or convulsion). -Mood disorder (a mental change from normal feelings). -Dysphagia (difficulty swallowing). -History of transient ischemic attack (brief blockage of blood flow to a small area of the brain). B. Record review of R #1's hospital transfer orders, dated 07/15/24, revealed R #1: - Past medical history of second degree atrioventricular block (a condition of the heart in which the heartbeat signal is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews the facility failed to ensure the facility had sufficient staff to meet the needs of all 109 residents residing in the facility when staff failed to: 1. Offer baths or showers to residents as scheduled; 2. Supervise residents during residents smoking times. These deficient practices are likely to negatively impact resident safety, comfort, and to impede processes such as timely incontinence care (assisting residents to the bathroom or changing adult briefs), regular turning schedules (moving or turning residents that need assistance and are unable to move on their own), showers, and appropriate assistance with meals. The findings are: Baths/Showers: A. Record review of R #41's face sheet revealed R #41 was admitted into the facility on [DATE]. B. Record review of R #41's care plan dated 05/07/24 revealed, Focus: [Name of R #41] requires assistance with ADL care/ transfers and mobility r/t [related to] dx [diagnosis] of seizures/ epilepsy/ ESRD [end stage renal…

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 staff provided residents with a nourishing bedtime snack to ensure there were no more than 14 hours between a substantial evening meal and breakfast the following day for 6 (R #21, R #53, R #36, R #20, R #99, and R #97) of 6 (R #21, R #53, R #36, R #20, R #99, R #97) residents reviewed for snacks. This deficient practice could likely cause frustration and lead to unnecessary hunger. The findings are: A. Record review of Meal Times, no date, revealed staff served dinner at 5:00 PM and breakfast at 7:30 AM (14.5 hours between meal services.) All meals are served at the same time, hall trays will go out and then they will serve any residents that are seated in the dining room. B. On 06/24/24 at 3:11 PM, during an interview with the Resident Council, R #21, R #53, R #36, R #20, R #99, and R #97 stated they were not provided with a snack at bedtime and dinner was served at 5:00 PM. Residents stated that they would like to have snacks at bedtime because it is a long night and some residents get hungry. Snacks used 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 observation, interview, and record review, the facility failed to: 1. Ensure unknown food storage containers were labeled and stored appropriately. 2. Ensure a garbage bin was covered and away from ready to eat foods on the food preparation area. 3. Ensure one gallon plastic jug of salsa open to air. 4. Ensure a tray of what appeared to be cake was not labeled or dated. 5. Ensure Dietary Aide serving lunch line was wearing a hair restraint. 6. Ensure one can of chili con carne was not stored on bare floor in dry storage area. 7. Ensure back door of the kitchen area was not propped opened These deficient practices are likely lead to foodborne illnesses and have the potential to affect all 109 residents who eat food prepared in the kitchen identified on the census list provided by the Administrator on 06/23/2024. The findings are: A. On 06/23/24 at 11:30 am, during an observation of the kitchen, the following was reveavled: 1. Storage containers in the refrigerator with unidentified food were not appropriately stored or dated. 2. A large garbage bin was next to the food…

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 adequately maintain and implement an infection prevention and control program for all residents by: 1. Not covering laundry carts when in hallway when delivering resident laundry. 2. Staff placing personal protective equipment (respiratory equipment, garments, and barrier materials used to protect rescuers and medical personnel from exposure to biological, chemical, and radioactive hazards.) (PPE) in resident trash cans without liners and resident's room did not have PPE bins resident's room to doff (remove) PPE. These deficient practices are likely to affect all 109 residents in the facility as identified on the census list provided by the Assistant Director of Nursing on 06/22/24. Failure to follow and implement an infection control program is likely to cause the spread of infections and illness to residents and staff within the facility. The findings are: A. On 06/24/24 at 10:57 am during random observation of a housekeeper #1 pushed a rolling rack of clothing down the hallway. A bed sheet laid on the top of the rolling…

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 promote resident self-determination through support of resident choice for 2 (R #'s 36 and 89) of 2 (R #'s 36 and 89) residents reviewed for choices by not accommodating R #36 and R #89's choice to have privacy with each other. If the facility is not honoring resident's choices, then residents are likely to have an increase in frustration and depression. The findings are: A. On 06/24/24 at 2:18 PM during an interview with R #89, she stated it is hard to find privacy here. I have a friend (male) and we were told that we could have privacy but it's yet to happen. We are not even allowed to nap together. B. On 06/26/24 at 9:17 PM during an interview with R #36, he stated the he was in a relationship with R #89, and they cannot go into each other's room. We were told they were going to have a private space for us, but the facility has not provided one. We like to take naps together. When R #36 was asked how it made him feel when they don't have private…

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. Ensure facesheet matched the advanced directives document [legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions] in the medical record for R #86. 2. Ensure R #100's advanced directive document was available and in her medical chart. 3. Ensure advanced directive that was in the advanced directive book at the nurses station matched what was in the medical record for R #114. If the facility is not ensuring that each resident has the opportunity to execute an advanced directive, then residents are likely not to have their wishes carried out if there is a time when they are not able to make their own healthcare decisions. The findings are: R #86 A. Record review of MOST form (Medical orders for scope of treatment) for R #86 dated 04/18/24 revealed Full Code (attempt resuscitation). B. Record review of the Physician's order dated 05/09/24 revealed R #86 had Do not Resuscitate (DNR) C. On 06/24/24 at 3:50 PM during an interview with Minimum Data…

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 2 (R #'s 1 and 7) of 2 (R #'s 1 and 7) residents reviewed when staff failed to: 1. Update the care plan to include oxygen (O2) usage for R #1. 2. Update the care plan to remove restorative nursing services (person-centered nursing care designed to improve or maintain the functional ability of residents, so they can achieve their highest level of well-being possible) for R #7. These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are: R #1: A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE]. B. Record review of R #1's physician order dated 08/19/23 revealed R #1 had an order to wear O2. C. On 06/25/24 at 10:48 am during an interview with R #1, R #1 was observed wearing O2. R #1 stated she wears O2 often. D. Record review of R #1's care plan dated 06/17/24 revealed R #1 did not have O2 use…

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 activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for baths and showers for 4 (R #'s 41, 50, 69 and 71) of 4 (R #'s 41, 50, 69 and 71) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents. The findings are: R #41: A. Record review of R #41's face sheet revealed R #41 was admitted into the facility on [DATE]. B. Record review of R #41's care plan dated 05/07/24 revealed, Focus: [Name of R #41] requires assistance with ADL care/ transfers and mobility r/t [related to] dx [diagnosis] of seizures/ epilepsy/ ESRD [end stage renal disease]/ Hemiplegia [paralysis of one side of the body] R [right]/ Weakness, dialysis, liver cirrhosis, HTN [hypertension- high blood pressure] and generalized weakness. Interventions: One staff assist with showers per schedule and prn [as needed].…

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 an ongoing activity program for 4 (R #12, #51, #66 and #86) of 4 (R #12, #51, #66 and #86) residents reviewed for activities. If the facility is not ensuring that all residents are receiving an ongoing activity program, documenting resident refusals and making in room activity accommodations, then residents are likely to demonstrate an increase in isolation and depression. The findings are: A. Record review of the one on one room visit log provided by the Activities Director (AD) revealed R #12, R #51, R #66, and R #86 were residents that were to receive room visits (activity staff visits) three times a week for social interaction. R #12, R #51, R #66, and R #86 did not like to participate in group activities. B. Record review of R #12's activity attendance logs for April 2024, revealed staff had documented that R #12 had two room visits out of 13 opportunities. In May 2024, R #12 had six room visits with three refusals, one actively involved in activity and two R #12 was asleep, out of 14 opportunities. In June…

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 3 (R #'s 7, 63, and 68) of 3 (R #'s 7, 63, and 68) residents reviewed were free from accidents and hazards by staff not: 1. Completing a fall risk assessment and placing a fall mat (specially designed floor mats placed on the floor at the bed or chair to protect the elderly from serious physical trauma) per physician orders for R #7. 2. Completing smoking assessments quarterly for R #'s 63 and 68. 3. Having staff present during smoking times for R #'s 63 and 68. These deficient practices are likely to put residents at risk of unsafe situations. The findings are: R #7: A. Record review of R #7's face sheet revealed R #7 was admitted into the facility on [DATE]. B. Record review of R #7's physician orders dated 02/15/24 revealed, Place fall mat on floor. C. Record review of R #7's care plan dated 05/19/24 revealed, Focus: [Name of R #7] is at risk for falls: cognitive loss, lack of safety awareness, Impaired mobility, pain and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure ongoing communication forms were completed and collaboration (different persons/groups working together) with the dialysis (clinical purification of blood as substitute for normal kidney functioning) facility regarding dialysis care and services for 1 (R #41) of 1 (R #41) residents reviewed for dialysis. If the facility is unaware of the status, condition, or complications that arise during dialysis treatment, then residents are likely to not receive the appropriate monitoring and care they need. The findings are: A. Record review of R #41's face sheet revealed R #41 was admitted to the facility on [DATE] with multiple diagnoses including: End Stage Renal Disease (a progressive disease of the kidneys) Dependence of Renal Dialysis (use and dependence on dialysis to clean and purify blood) B. Record review of R #41's electronic medical record revealed a physician order for R #41 to attend dialysis on Mondays, Wednesdays and Fridays. C. 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 for 1 (R #55) of 1 (R #55) resident reviewed for behavioral health concerns received necessary behavioral health care to meet their needs by staff not: 1. Ensure R #68's behavioral health/psychiatric (psych) progress notes were documented for facility staff in R #68's Electronic Health Record (EHR). 2. Referred R #70 to a psych services provider per physician orders. These deficient practices are likely to result in the residents not receiving the behavioral or mental health care and assistance needed to improve mood and reduce depression and anxiety. The findings are: R #68: A. Record review of R #68's face sheet revealed R #68 was admitted into the facility on [DATE]. B. Record review of R #68's physician orders dated 09/15/22 revealed, Please refer to [Name of Psych Services Provider] for psychiatric eval [evaluation] and treatment. C. Record review of R #68's care plan dated 06/21/24 revealed, Focus: [Name of R #68] exhibits or is at risk…

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

Based on record review and interview, the facility failed to ensure that the consultant pharmacist recommendations were reviewed and considered each month for 1 (R #97) of 5 (R # 12, 39, 45, 66, and 97) residents reviewed for medication regimen. If consultant pharmacist's recommendations are not reviewed by the facility and health care provider monthly, residents are likely to experience unnecessary drug interactions and adverse side effects. The findings are: A. Record review of R #97 face sheet dated 06/30/24 revealed R #97 was admitted to facility on 02/17/24 with multiple diagnoses including: -Alcoholic Cirrhosis of Liver (damage of the liver due to past alcohol intake) -Alcohol Dependence (a perceived need to consume alcohol) with Alcohol Induced Disorder (unspecified disorder that is caused by past or present use of alcohol) -Anxiety Disorder (unusual nervousness) -Repeated Falls B. Record review of R #97's pharmacist consultation report dated April 1, 2024 to April 23, 2024 revealed a recommendation by the consulting pharmacist to monitor R #97 for involuntary movements now…

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

Based on record review and interview, the facility failed to ensure that 1 (R #97) of 5 (R #12, 39, 45, 66, and 97) resident's prescription for a PRN (as needed) psychotropic medication was reviewed and renewed every 14 days by the prescriber. This deficient practice is likely to result in residents receiving medications without regular review or oversight causing over-sedation and other negative side effects. The findings are: A. Record review of R #97 face sheet dated 06/30/24 revealed R #97 was admitted to facility on 02/17/24 with multiple diagnoses including: -Alcoholic Cirrhosis of Liver (damage of the liver due to past alcohol intake) -Alcohol Dependence (a perceived need to consume alcohol) with Alcohol Induced Disorder (unspecified disorder that is caused by past or present use of alcohol) -Anxiety Disorder (unusual nervousness) -Repeated Falls B. Record review of R #97's physician orders dated 03/24/24 revealed an order to administer Lorazepam (a anti-anxiety psychotropic medication) 2 MG (milligram) give 1 tablet by mouth every 5 hours as needed for increased anxiety with…

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

Based on observation and interview, the facility failed to provide a safe, functional, and comfortable environment for all 109 residents by: 1. Not emptying trash bins on a regular basis and allowing them to overflow. 2. Not replacing a broken washer machine and having only one washer which was leaking in laundry room. 3. Leaving cigarette butts on the ground and allowing other residents to pick them up. These deficient practices could likely effect all 109 residents in the facility as identified on the census list provided by the Assistant Director of Nursing on 06/22/24. Failure to have a sanitary facility is likely to cause the spread of infections and illness to residents and staff within the facility. The findings are: A. On 06/23/24 at 2:59 pm during observation of facility grounds revealed the following: 1. Three large trash bins were in the back of the facility, the trash bins were uncovered and overflowing with their contents falling onto the ground around them. 2. One extra large trash bin was uncovered and filled to capacity, with four mattresses sitting on the ground…

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 1(R #21) of 1 (R #21) resident with their medical records when requested. By not providing the resident with his medical record, the facility is not supporting resident's right to access their records, preventing them from knowing about their medical care and obtaining necessary services. The findings are: A. Record review of R #21's face sheet dated 07/2/2, revealed R #21 was admitted to the facility on [DATE]. The face sheet also revealed that R #21 was responsible for himself. B. On 06/24/24 at 3:11 PM during an interview with R #21, he stated that he had contacted the facility's Director of Nursing(DON) and requested a copy of his medical records approximately two months prior (05/24). R #21 stated that as of the date of this conversation (06/24/24), R #21 had not received his medical records. R #21 stated he has had several conversations with the past Administration. , C. On 06/24/24 at 4:30 PM during an interview with the Administrator he…

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

Based on record review and interview, the facility failed to ensure that 1 (R #34) of 1 (R #34) resident reviewed for urinary tract infections (UTI) had a sufficient change assessment (a major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions) completed within 14 days of determining the status change was significant. This deficient practice could likely result in residents not receiving the care and assistance needed. The findings are: A. Record review of R #34's admission record indicated an original admission date of 03/29/2018. with the following diagnosis: 1. Chronic Kidney Disease(CKD), Stage 4 (Stage 4 kidney disease is the last stage before kidney failure). 2. Type 2 Diabetes (a chronic condition where the pancreas produces little or no insulin) 3. Hypercalcemia (a condition in which the calcium level in the blood becomes too high). 4. Hyperthyroidism (when the thyroid gland makes too much thyroid hormone speeding up the body'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.

Based on record review and interview, the facility failed to ensure that 3 (R #45, 85 and 100) of 3 (R #s 45, 85 and 100) residents reviewed for Pre-admission Screening and Resident Review (PASRR) (assessment screen performed prior to admission to evaluate resident for mental illness or intellectual disability) identified as having a primary diagnosis of Dementia, received a Dementia waiver. The waiver would exclude these residents from needing a Level 2 screen (an in depth assessment for mental health illness). The Dementia waivers were not obtained by the facility and Level 2 PASRR screenings were not completed. This deficient practice could likely result in residents with physical or intellectual disabilities not receiving appropriate services after admission to the facility. The findings are: R #45 A. Record review of R #45's medical record revealed a Level II PASRR was not completed due to diagnosis of dementia. This indicated that R #45 needed a Dementia waiver, the record did not contain a Dementia waiver. B. On 06/28/24 at 12:25 pm during interview with Social Services…

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 1 (R #75) of 1 (R #75) resident 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 care plan for R #75 revealed R #75 was at risk for falls due to impaired mobility and weakness related to recent surgery of right knee and history of polytrauma secondary to motor vehicle accident. B. Record review of R #75's clinical orders indicated that R #75 was discharged from physical therapy (PT) on 04/26/2024. C. Record review of R #75's clinical orders indicated resident will be on restorative program to continue with strengthening and endurance. 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.

Based on observation and interview the facility failed to: 1. Ensure all medications were stored properly and in the original, labeled packaging. 2. Ensure medical supplies in the medication carts were not expired. 3. Ensure medication carts were locked when unattended. 4. Ensure medications were labeled with open date These deficient practices are likely to negatively impact the health of all residents, if staff administered or used potentially compromised or contaminated medications. The findings are: Findings for loose medications: A. On 06/23/24 at 12:15 PM during observation of the medication cart, two unidentified loose pills were on the bottom of the second drawer of the cart. B. On 06/23/24 at 12:16 PM during interview Licensed Practical Nurse (LPN) #3 confirmed that there were two loose unidentified pill in the drawer of the cart and they should not be there and should be destroyed. Findings for expired medical supplies in the Medication Cart: C. On 06/26/24 at 8:57 PM during observation of the medication cart revealed a bag with approximately ten 16 mm (millimeter-unit 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 ensure dental services were obtained for 1 (R #114) of 1 (R #114) residents reviewed for dental care and services. This deficient practice could likely result in the residents not receiving dental care and services to meet their needs. The findings are: A. On 06/25/24 at 10:37 AM during an observation and interview with R #114, R #114's lower dentures were not in his mouth at the time of interview. R #114 stated that his bottom denture has been missing for a couple months, (unsure of the exact dater) He further stated that he and his brother had reported it missing and nothing has been done. B. Record review of R #114's care plan dated 6/27/24 revealed R #114 is at risk for oral health or dental care problems as evidenced by missing teeth and resident has a hard time keeping track of dentures. Resident has upper and lower dentures, but does not always wear them. C. On 06/28/24 at 11:27 AM during interview with Social Services Director (SSD) she stated she was aware that R #114 was missing his bottom dentures…

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 interviews, the facility failed to ensure residents obtained routine dental care for 1 (R #50) of 1 (R #50) resident reviewed for dental services. This failure is likely to result in the resident experiencing pain, embarrassment over condition of teeth, and potential weight loss. The findings are: A. Record review of R #50's face sheet revealed R #50 was admitted into the facility on [DATE]. B. Record review of R #50's nursing progress notes dated 02/26/24 revealed R #50 had a dental appointment scheduled on 03/07/24 at 8:15 am. C. Record review of R #50's care plan dated 02/29/24 revealed R #50 was edentulous (lacking teeth) and staff were to assist R #50 with brushing and cleaning R #50's dentures and monitor for change in fitting of dentures. D. On 06/24/24 at 12:13 pm during an observation and interview with R #50, R #50 did not have dentures present. R #50 stated her dentures do not fit and she needed another dentist appointment because she could not attend her…

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

Based on record review and interview, the facility failed to ensure Certified Nurse Aides (CNAs) received the required in-service training of no less than 12 hours per year for 2 (CNAs #7 and #8) of 5 (CNAs #7, #8, #9, #10, and #11) CNAs randomly reviewed for required in-service training. This deficient practice is likely to result in the nurses aides not receiving the necessary training to meet the care needs of the residents. The findings are: CNA #7: A. Record review of the facility staffing list revealed CNA #7 was hired on 10/01/18. B. Record review of CNA #7's facility in-services and training's dated 10/01/22 through 10/01/23 revealed CNA #7 had only completed 8 hours out of the 12 required hours of training. C. Record review of the facility staffing schedule dated 07/01/24 through 07/03/24 revealed CNA #7 had worked three out of three shifts. D. On 07/03/24 at 4:30 pm during an interview with the Director of Nursing (DON), she confirmed CNA #7 had only 8 hours of training completed and was out of compliance. DON stated CNA #7 should not have been working the floors without…

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 who submitted written grievances were informed of the facility's findings and were given a written summary of the grievance conclusion for 8 (R #s 2, 3, 4, 5, 6, 7, 8, 9) of 22 (R #s 1, 2, 3, 4, 5, 6, 7, 8, 9,10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22) residents and or resident's representatives who submitted a grievance to the facility. This deficient practice is likely to result in residents believing the facility did not take their grievances seriously and did nothing to respond to their grievances. The findings are: A. Record review of facility policy OPS204 Grievance/Concern, dated 01/08/24, revealed the following: - Facility leadership will investigate, document, and follow-up on all concerns and grievances registered by any resident or representative. - Social Services personnel will serve as resident advocates in the grievance/concern process. - The Administrator will serve as the Grievance Officer who is responsible for overseeing the grievance process. The Administrator will receive 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 1 (R #1) of 3 (R #'s 1, 2, and 3) residents reviewed for elopement (an unauthorized departure of a patient from an around-the-clock care setting) was free from accidents/hazards by not providing adequate supervision. The findings are: A. Record review of R #1's Face Sheet revealed 07/03/23 as her initial admission date and included the following diagnoses: Alzheimer's Disease (a brain disorder that causes the brain to shrink and brain cells to eventually die), Type 2 Diabetes (high blood sugar), Palliative Care (specialized medical care for people who have a serious or life-threatening illnesses), Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (intense, excessive and persistent worry and fear about everyday situations). B. Record review of hospice Physician's Progress Notes, dated 05/02/23, for R #1 revealed, Per daughter, she (R #1) has had behavioral issues. Sometimes physically combative and tends to run away from the house . C. Record review of…

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

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 1 (R #4) of 3 (R #s 1, 3 and 4) residents reviewed for medications. This deficient practice can result in a resident failing to obtain maximum wellness and/or suffer prolonged illness/pain. The findings are: A. Record review of face sheet dated 09/09/23 for R #4 revealed this as an initial admission date and a discharge date of 09/11/23. B. Record review of nursing progress notes dated 09/09/23 at 4:00 pm revealed, Patient new admission with diagnosis CKD (chronic kidney disease) stage 3 (three), Chronic Achalasis (rare swallowing disorder), Essential Tremor (movement disorder that causes uncontrollable shaking of your hands, arms and other body parts), chronic pain (pain that is persistent or long-lasting), HDL (high levels of fats in the blood), BPH (enlarged prostate - gland located beneath the bladder) UTI (infection of any part of the urinary system), Urinary retention (inability…

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: 1) Ensure that opened and accessed (has been opened or accessed the pen should be dated with the last date that the product should be used {expiration date} and discarded within 28 days unless the manufacturer specifies a different {shorter or longer}) for a flexpen (is pre-filled with insulin so you don't have to load it) weren't dated as to when they were initially opened/assessed, by the nursing staff. 2) Ensure that undated medications were not stored with dated medications, that were readily available for resident use, 3) Ensure that expired supplies were not stored with unexpired supplies in the storage rooms, and 4) To properly store medications in medication carts. These deficient practices have the likelihood to result in 103 residents that were identified on the census list provided by the Centers Executive Director on 05/15/23, to receive expired medications that have either lost their potency, or effectiveness; medications that were undated continued to be accessed and stored with active medications. 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, interview, and record review, the facility failed to follow safe food handling practices and proper sanitation practices by: 1. Not labeling food items, in the refrigerator, with dates, 2. Placing uncovered, prepared glasses of juice under a hand sanitizing dispenser, and 3. Not maintaining complete documentation (i.e. temperature log) of refrigerator temperatures located in the nutrition room on the facility's south unit. These deficient practices could likely affect all 105 residents listed on the resident census list provided by the Administrator on 05/15/23, by leading to foodborne illnesses if safe food handling practices are not adhered to. The findings are: A. On 05/15/23 at 9:22 am, during an observation and interview, an initial tour of the facility's kitchen was conducted with the Dietary Manager (DM). In the refrigerator, opened, canned tuna was observed in a serving pan. The opened tuna was covered but it had no date. Also observed was a serving pan of prepared tuna salad. It was covered but not labeled with the date it was prepared. During an…

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

Based on interviews the facility failed to show dignity and respect resident rights to eat in the dining room for 5 (R #6, 29, 73, 74 and 93) of 5 (R #6, 29, 73, 74, and 93) residents interviewed for Resident Council. This deficient practice likely caused residents to feel frustrated and disrespected when the dining room was closed and the residents were given no choice, but to eat in their rooms without any warning or explanation from staff. The findings are: A. On 05/15/23 at 10:51 am, during an interview with R #93, he stated that there have been times when the dining room is closed and the staff make them eat in their rooms. B. On 05/17/23 at 2:00 pm, during the resident council meeting all five residents (R #6, 29, 73, 74, and 93) agreed that sometimes on weekends they are told to eat in the rooms. They are never given a reason why they aren't able to eat in the dining room. It was stated in the Resident Council meeting that it has happened twice in one week before. The residents also stated that it is a time to socialize for some residents and they should be given a choice 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 maintain inventory sheets of personal belongings upon entry to the facility, and a laundry process that would track unclaimed laundry or claims of missing clothes for 4 (R #'s 5, 13, 55, & 81) of 4 (R #'s 5, 13, 55, & 81) residents reviewed for personal property. This deficient practice could likely result in residents experiencing frustration due to missing clothes when sent out for laundering and when personal items have gone missing. The findings are: A. Record review of the facility's policy OPS208 Personal Property: Patient's, last revised 09/01/22, revealed: 6. The patient and/or patient representative will be notified of the loss or breakage of personal items, and advised if the loss or breakage will or will not be replaced or repaired at the Center's expense. 6.1 Any loss or breakage of a patient's personal item will be properly documented on the property loss form (obtain from Claims Department) by the person receiving the report, and then…

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 develop and implement a comprehensive person-centered care plan for 6 (R #'s 31, 36, 49, 56, 68, and 103) of 6 (R #'s 31, 36, 49, 56, 68, and 103) residents. Failure to develop and implement a resident centered care plan may result in staff's failure to understand and implement the needs and treatments of residents possibly resulting in decline in abilities and a failure to thrive. The findings are: Findings for R #56 A. Record review of the face sheet for R #56, indicated that resident was originally admitted in 08/22 and was re-admitted on [DATE]. He had a diagnosis of Traumatic Brain Injury (TBI head injury causing damage to the brain by external force or mechanism. It causes long term complications or death), Epilepsy (neurological disorder that causes seizures or unusual sensations and behaviors), Diabetes Mellitus (metabolic disorder in which the body has high sugar levels for prolonged periods of time), Chronic Viral Hepatitis…

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 an ongoing activity program for 4 (R #7, 31, 68, and 91) of 4 (R #7, 31, 68, and 91) residents reviewed for activities. If the facility is not ensuring that all residents are receiving an ongoing activity program, documenting resident refusals, making in room activity accommodations, and completing an activity assessment (a questionnaire designed to collect information about resident likes, interests, and capabilities); then residents are likely to demonstrate an increase in isolation and depression. The findings are: Findings for R #7 A. On 05/15/23 at 11:35 am, during an interview with R #7, he stated that he wants more activities. He can't see and is limited with the activities he can do. Resident #68 B. On 05/16/23 at 12:36 pm, during an interview with R #68, she stated that it would be nice to do something when referring to activities C. While on survey at the facility between 05/15/23 through 05/24/23 no observations were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to follow physician orders related to nutritional needs for 2 (R #'s 18 and 96) of 3 (R #'s 18, 96, and 104) residents reviewed for dialysis care and weight management. This deficient practice could likely result in residents not receiving the required nutritional support needed. The findings are: Findings for R #18 A. Record review of the EHR (Electronic Health Record) revealed that R #18 was admitted to the facility on [DATE] with the following pertinent diagnoses: Type 2 Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar), Chronic Kidney Disease- stage V (End Stage Renal Disease- stage 5 is when the kidneys begin to fail), Peripheral Vascular Disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), Pressure Ulcer (Injury to skin and underlying tissue resulting from prolonged pressure on the skin) of Left Heel, and Pressure Ulcer of Sacral Region (bottom of the spine), 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 observation, record review, and interview, the facility failed to maintain oxygen equipment according to the professional standards for 6 (R#'s 23, 24, 25, 36, 64, and 103) of 6 (R#'s 23, 24, 25, 36, 64, and 103) residents reviewed for respiratory care. This deficient practice could likely result in oxygen tubing not being changed according to the date of install or previous replacement, and not ensuring the resident is wearing oxygen as per the physician's order. The findings are: A. Record review of the facility procedure: Oxygen: Nasal Cannula, last reviewed 06/15/22, revealed Replace disposable set-up every seven days. Date and store cannula in a treatment bag when not in use. Findings for R #25 B. On 05/15/23 at 10:24 am, during an observation of R #25's oxygen tubing, it was noted that the oxygen tubing was not labeled as to the date it was changed or installed. Per the facilities Procedure titled, Oxygen: Nasal Cannula, #22, reads Replace disposable set-up every seven days. Date and store cannula in treatment bag when not in use. C. On 05/22/23 at 3:56 pm, during an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to maintain a process to monitor resident behavior after prescribing psychotropic medication (a medication that alters the chemical makeup of the brain and nervous system) to determine effectiveness for 4 (R#25, R #36, R #40, and R #89) out of 4 # R (R #25, R #36, R #40, and R #89) residents reviewed for unnecessary medications. This deficient practice could likely result in residents being administered psychotropic medications they do not need, experience potential unnecessary drug and/or adverse side effects. The findings are: A. Record review of the facility's policy: Behavior's: Management of Symptoms, last reviewed 10/24/22, Staff will monitor for and document in the medical records any exhibited behavioral symptoms which include but are not limited to: Verbally aggressive behaviors , Physically aggressive behaviors , Sexually inappropriate behaviors , touching, rummaging, or removing other's property and wondering that places the resident in at…

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

Based on observation, interview and record review the facility failed to ensure the glactometer's (a medical device to measure glucose {sugar} levels in the blood) utilized by the facility for more than one resident, was disinfected per manufacturer's instructions after each time one is used, for 4 (R #64, #67, #68 and #103 ) of 18 (R #4, #7, #10, #18, #43, #56, #58, #60, #62, #64, #66, #67, #68, #69, #91, #102, #103, and #104 ) residents observed for capillary (small blood vessels) blood glucose (CBG capillary blood glucose) monitoring with glucometers. This deficient practice may likely result in the spread of infection agents (viruses and bacteria) between residents and or staff who utilize glucometers. These findings are: A. On 05/16/23 at 10:32 am, during an observation of Registered Nurse (RN) #2 checking R #67 CBG, after the CBG was completed RN #2 was observed dropping the glucometer in a small caddy (this is where all the supplies were stored to check the resident's CBG's) without disinfecting the glucometer. The glucometer was not observed to be disinfected prior to use.…

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 the correct notification(s) for 1 (R #21) of 1 (R #s 21) resident reviewed for timely and specific Beneficiary Protection Notification. This deficient practice can likely result in confusion for the resident or their representative as to what services they receive or do not have financial coverage for under Medicare. The findings are: A. Record review of electronic health record for R #21, revealed the R #21 was admitted to the facility on [DATE] for skilled physical therapy and occupational therapy related to a wedge compression fracture of her thoracic and lumbar vertebra (when the bones of the spine crushes or collapses, forming a wedge in the upper and lower back). B. On 05/23/23 at 3:23 pm during an interview with the Director of Rehabilitation (DOR), she stated that R #21 worked on activities of daily living in occupational therapy, however R #21 was non-compliant with wearing her back brace unless she was walking. At the time of…

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

Based on record review and interview, the facility failed to develop and implement a baseline care plan within 48 hours of a resident's admission for 1 (R #106) of 1 (R #106) resident. If the facility is not developing a care plan for newly admitted residents, then residents are likely to not get the specific care and assistance they need. The findings are: A. Record review of the face sheet for R #106 revealed an initial admission date on 02/03/23. He was admitted to the facility with a hospice evaluation pending. He had an admitting diagnosis of Hepatic Encephalopathy (a loss of brain function as a result of failure in the removal of toxins from the blood due to liver damage), End Stage Renal Disease (disease or condition impairs kidney function, causing kidney damage to worsen over several months or years), Hepatitis B (a serious liver infection caused by the hepatitis B virus), and a stage II pressure ulcer (involves partial thickness skin loss involving epidermis (outer layer of skin), dermis (is a layer of skin between the epidermis (with which it makes up the cutis) 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 good communication was in place for care coordination between the hospice company and the facility staff for 1 resident (R #'s 56) of 1 (R #56) reviewed for hospice services. This deficient practice is likely to result in staff uncertainty over resident care needs and affected residents not receiving appropriate care. The findings are: A. Record review of the face sheet for R #56, indicated that resident was originally admitted in 08/22 and was re-admitted on [DATE]. He had a diagnosis of Traumatic Brain Injury (TBI head injury causing damage to the brain by external force or mechanism. It causes long term complications or death), Epilepsy (neurological disorder that causes seizures or unusual sensations and behaviors), Diabetes Mellitus (metabolic disorder in which the body has high sugar levels for prolonged periods of time), Chronic Viral Hepatitis (either transmitted through contaminated food or water or via blood and body fluids), NSTEMI…

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 provide podiatry services for 1 (R #43) of 1 (R #43) residents reviewed for diabetic nail care. This deficient practice could likely result in residents feeling uncomfortable with the feel and appearance of their toenails and/or result in medical complications. The findings are: A. Record review of facility policy NSG217 Foot Care, last revised 09/01/22, revealed Patients who have complicated disease processes requiring foot care including, but not limited to, infection/fungus, ingrown toenails, diabetes mellitus, neurological disorders, renal failure, and peripheral vascular disease must be referred to qualified professionals such as podiatrists or other physicians. The Center is responsible for assisting patients in making appointments and arranging transportation to obtain services. B. On 05/16/23 at 10:30 am, during an observation and interview, R #43 was observed sitting at the edge of his bed with one boot off, leaving his left foot…

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 safe environment that was free of hazards for 1 (R #158) of 1 (R #158) resident looked at during the initial pool sample. This deficient practice has the potential to cause an accident when there is no light in the bathroom. The findings are: A. On 05/15/23 at 10:37 am, during an interview with R #158, he stated that everything was pretty good except he had been without his bathroom light since Friday 05/12/23. He had told the nurse (didn't know who it was) right away (Friday). He stated that he is independent with using the bathroom. B. On 05/15/23 at 10:37 am, an observation was made of the light in the bathroom no working. C. On 05/15/23 at 11:38 am, during an interview with the Maintenance Director (MD), he stated that the process is that staff (any staff member) can fill out a TELS form (building maintenance request) and the work order goes in. When staff enter a work order they need to indicate on it whether it is emergent (is an emergency), mid-emergent (not emergency but needs to be corrected quickly) 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, interview and record review, the facility failed to properly maintain records of controlled substances (drugs that are subject to strict government control because they may cause addiction) on each cart medication cart. This deficient practice could cause the likelihood of controlled substances being diverted (a medical and legal concept involving the transfer of any illegal prescribed controlled substances from the individual for whom it was prescribed to another person for any illicit use). The findings are: A. On 05/12/23 at 9:49 am, during an observation on the North Hall medication cart Narcotic Book (This is a book used to manually track inventories of prescription medications. This tracks resident prescription intake. It will record when the facility receives the medication for each schedule 2 controlled substance from the pharmacy, and shift pages to count at the beginning and end of each shift), the medication blister pill cards (single dose pack that has the medication name, pill information, expiration dates, and a number next to each blister that…

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

Based on record review and interview, the facility failed to ensure medications were administered as ordered by the physician for 1 (R #157) of 3 (R #s 67, 84 and 157) residents reviewed for medications. This deficient practice can result in a resident failing to obtain maximum wellness and/or suffering prolonged illness. The findings are: A. Record review of the nursing progress notes dated 04/05/23 at 11:01 am, indicated the following: Resident arrived to facility @ 10:50 a.m. Via ambulance. Resident is non-verbal. Resident make moaning sounds and grunts. Resident does not appear to be in any pain or distress at this time . B. On 05/23/23 at 12:22 pm, during an interview with Center Nursing Executive (CNE), she stated that R #157 came from a LTAC (Long Term Acute Care) step down unit. She stated that residents that come from those units are more critical than what they offer at a skilled nursing facility. She stated that their CAD's (Corporate admission Director) reviewed the paperwork and indicated that R #157 was ok to come here. On the way over here on 04/05/23, R #157 had 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.