Horizon Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to ensure enteral feeding orders administered through the gastrostomy tube were followed as ordered, and total volume delivered was monitored and documented for 1 of 26 sampled residents (Resident 34). This deficient practice had the potential to result in inadequate nutritional and fluid intake, leading to malnutrition, dehydration, electrolyte imbalances, impaired wound healing and increased susceptibility to infections. Findings include: Resident 34 (R34) R34 was admitted on [DATE], with diagnoses including risk for malnutrition due to impaired food and fluid intake, diabetes mellitus, dementia and gastrostomy. On 06/10/2025 at 10:10 AM, R34 was observed in bed with the head of bed elevated 30 to 45 degrees. Nepro 1.8 (a liquid therapeutic nutritional supplement specifically designed to help meet nutritional needs) was hung on a pole, with the tube feeding (TF) bag approximately full at 1000 milliliters (mL). The bag was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review, the facility failed to ensure 1) a resident's yelling and disruptive behaviors were communicated to the psychiatric provider and 2) the resident was referred to the behavioral services provider for psychotherapy services for 1 of 26 sampled residents (Resident 55). The deficient practice potentially had a negative impact on the resident of concern's overall well-being and deprived other residents of the right to live in a peaceful environment free from disruptive noise. Findings include: Resident 55 (R55) R55 was admitted on [DATE] and readmitted on [DATE], with diagnoses including insomnia, anxiety disorder and major depressive disorder. Psychiatric provider not informed On 06/10/2025 at 9:45 AM, R55 was overheard from the hallway yelling, help! help! help! A Licensed Practical Nurse (LPN1) entered R55's room. Upon leaving R55's room, the LPN indicated R55 yelled all the time. On 06/10/2025 at 9:52 AM, R55 was seated in wheelchair and reported…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, document review, and record review, the facility failed to ensure target behaviors were monitored for a resident receiving medication to treat Post Traumatic Stress Disorder (PTSD) for 1 of 26 sampled residents (Resident #26). This deficient practice had the potential to cause the residents to use unnecessary medication, which may result in possible adverse effects. Findings include: Resident 26 (R26) R26 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including chronic respiratory failure with hypercapnia and post-traumatic stress disorder (PTSD). A physician's order dated 04/02/2025 documented Prazosin capsule two milligrams (mg) by mouth every 12 hours for PTSD, target behaviors: night terrors. The psychotropic consult report dated 01/20/2019 documented R26 had a history of being abused as a child and witnessing a violent crime. R26 experienced night terrors related to the incident and had trouble sleeping. R26's medical record lacked documented…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, document review, and record review, the facility failed to ensure a medication error rate of less than 5% was obtained during medication pass. There were 31 opportunities observed, which revealed three errors. The medication error rate was 9.68%. Failure to follow physician orders during medication administration had the potential to cause harm or injury to residents. Findings include: Resident 82 (R82) R82 was admitted on [DATE], with diagnosis including hemiplegia affecting left nondominant side, major depressive disorder recurrent severe without psychotic features, and generalized anxiety disorder. On 06/12/2025 at 7:17 AM, a Licensed Practical Nurse (LPN) prepared and administered R82 six medications including Aspirin 81 milligrams (mg) one tablet by mouth and Vistaril (hydroxyzine pamoate) 25 mg (a medication used to treat anxiety), one capsule by mouth. R82's medical record lacked a physician order for Aspirin 81 mg one tablet by mouth. A Physician order dated 11/15/2024,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review, the facility failed to ensure a Quality Assurance Performance Improvement (QAPI) plan was in place. This deficient practice has the potential to negatively affect the outcomes of resident care and the quality of each resident's life. Findings include: On 06/13/2025 at 1:20 PM, the Administrator acknowledged the facility did not have a specific QAPI plan in place. The Administrator explained the facility was using their QAPI policy as their plan. A facility policy titled, Quality Assurance and Performance Improvement Program Committee Guidelines, revised on 12/03/2019, did not identify the requirement of developing a QAPI Plan containing the processes that will guide the nursing home's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved. However, it did document the QAPI Plan is used to guide the organizational and facility performance improvement efforts. According to the state operations manual, the facility is required to develop a QAPI plan and present its plan to federal 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, interview, and document review, the facility failed to 1) procure a clean food preparation environment and 2) ensure food products that needed to be refrigerated were kept in a safe temperature range by accurately monitoring the temperature of the walk-in refrigerator. The deficient practice could potentially expose residents to foodborne illnesses. Findings included: On 07/09/24 in the morning, an inspection was conducted with the kitchen manager in the kitchen area. The following issues were identified: 1) Cleanliness: - The exhaust hood over the stove was greasy and visibly dusty outside. - The oven was visibly soiled with greasy matter and dust outside and greasy with food debris inside. - Food debris was observed on the floor behind the oven, stove, and pressure cook. - The floor in the room preparation area was visibly soiled with food debris. A fan was on the floor, blowing air to the table where hamburger patties were being prepared. - The air conditioning (AC) vents were visibly dusty. - An AC vent in the dishwashing area was visibly corroded, with the…

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

Based on observation, interview, and document review, the facility failed to ensure a walk-in refrigerator was maintained in working condition to keep refrigerated food products in a safe range of temperature. The deficient practice could potentially endanger the safety of the food, exposing residents to foodborne illnesses. Findings included: On 07/09/24 at 9:40 AM, the temperature reading in the external thermometer of the walk-in refrigerator indicated 44 degrees Fahrenheit (°F). The temperature log located at the door of the walk-in refrigerator documented a temperature of 40 °F was obtained in the morning. The two thermometers situated inside the refrigerator read 58 °F each. The kitchen manager indicated that the door of the walk-in refrigerator was opened several times during meal preparation, which could be the reason the temperature dropped. It was suggested the temperature be checked in one hour. On 07/09/2024 at 11:09 AM, the temperature of the walk-in refrigerator was rechecked. The two internal thermometers read 54 °F. The kitchen manager confirmed the observation 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, interview, record review, and document review, the facility failed to ensure the signs and symptoms (s/s) of bleeding for a resident on anticoagulants were monitored for 1 of 25 sampled residents (Resident 2). This deficient practice had the potential to result in hemorrhage, an increased risk of severe anemia, and harm to the resident. Findings include: Resident 2 (R2) R2 was admitted on [DATE], with diagnoses including anoxic brain damage and iron deficiency anemia. A physician order dated 06/10/2024, documented Heparin Solution 5,000 units/milliliters (ml) to be administered subcutaneously every 12 hours for deep vein prophylaxis. The Medication Administration Record (MAR) from June to July 2024, documented the Heparin solution injections were administered as ordered. R2's medical records lacked documented evidence the s/s for bleeding were monitored until 07/11/2024. On 07/09/2024 at 9:34 AM, R2 was in bed, awake, non-verbal and obtunded. The family was at the bedside. A 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 observation, interview, record review, and document review, the facility failed to provide care to prevent a stage 4 pressure ulcer for 1 of 25 sampled residents (Resident 72). The deficient practice caused a wound to develop and not be identified until it had progressed into a stage 4 pressure ulcer. Findings include: Resident 72 (R72) R72 was admitted on [DATE], and readmitted on [DATE], with diagnosis including unspecified injury level of cervical spinal cord, paraplegia, muscle wasting and atrophy. Braden Scale for Predicting Pressure Sore Risk dated 01/15/2024, documented total Braden Scale score of 15, which determined R72 was at risk for pressure ulcers. A Skin Risk Analysis and Interventions dated 01/15/2024, documented skin was to be inspected daily, especially bony prominences, repositioned at least every hour and increased frequency of turning. A Wound Information Observation History dated 02/27/2024, documented an unstageable (the stage of the wound was unclear) right buttock ulcer was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to ensure a physician order for splint application was obtained and implemented to treat a resident's contracture for 2 of 35 sampled residents (Residents 2 and R77), and the care plan was updated following the resident's readmission for 1 of 35 sampled resident (Resident 77). The deficient practice could potentially lead to worsening contractures, decreased mobility, increased pain, and a reduced quality of life for the affected residents. Findings include: R2 was admitted on [DATE], with diagnoses including contracture of the left and right hands and atrophy. The Joint Mobility Screen dated 06/10/2024, documented the inability of R2 to flex and extend the fingers. The Restorative Nursing Care Plan dated 06/10/2024, documented R2's goal of maintaining the current level of function with the use of bilateral upper extremities palm protection or a hand roll for 3-6 hours per day. The Minimum Data Set with R2's functional…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, and document review, the facility failed to ensure: 1) the nutritional assessment for a resident on percutaneous endoscopic gastrostomy (PEG) was completed upon readmission per policy for 1 of 25 sampled residents (Resident 2), and 2) care orders to manage the PEG tube were obtained and transcribed for 1 of 25 sampled residents (Resident 2). The deficient practice could have the potential to compromise resident safety and well-being, leading to inadequate nutritional support and an increased risk of complications related to PEG tube management. Findings include: Resident 2 (R2) R2 was admitted on [DATE] and readmitted on [DATE], with diagnoses including anoxic brain injury, dysphagia (difficulty swallowing) and gastrostomy. 1) On 07/09/2024 at 9:34 AM, R2 was in bed, awake, non-verbal, and obtunded. Tube feeding (TF) Jevity 1.2 was hanging by the bedside and not infusing. The label on the TF bag dated 07/08/2024, indicated a flow rate of 70 milliliters per hour…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review the facility failed to post daily staffing information in a place accessible to residents and visitors. The deficient practice had the potential to result in a lack of awareness for residents and visitors regarding the type and number of staff on duty on any given day. Findings include: On 07/12/2024 at 8:10 AM, a tour of the facility was conducted with the Director of Nursing (DON). Licensed nurses and Certified Nurse Assistant assignments were posted on an 8 and 1/2 by 11-inch sized paper near each of the two nursing stations, affixed to the corridor wall about four or five feet above floor level. The posting verbiage was in approximately size-14 font, difficult to read unless close up, and room assignments were hand-written. The staffing documents lacked the total Patient Per Day (PPD) hours information for the facility. The DON verbalized the staffing posting as observed was what the facility customarily posted daily. On 07/12/2024 at 8:20 AM, the Administrator, verbalized knowledge of the requirement to post daily staffing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, and document review, the facility failed to ensure their medication error rate was below five (5) percent (%) when two errors were identified with 30 opportunities observed, calculating an error rate of 6.67%. Failure to follow physician orders and timely administer medications posed a potential risk of injury or harm to the resident. Findings include: Resident 55 (R55) R55 was admitted on [DATE], with diagnoses including muscle weakness and spasms. On 07/11/2024 at 8:26 AM, a Licensed Practical Nurse (LPN) prepared R55's eight medications except B12 and the Refresh eye drop. A Physician order dated 04/19/2024, documented B12 tablets, chewable daily, at 9:00 AM. A Physician order dated 05/13/2024, documented Refresh Classic, one drop in both eyes four times daily. The Medication Administration Record (MAR) dated 07/11/2024, documented R55 refused the B12 and the eye drops. On 07/12/2024 at 11:26 PM, R55 indicated the vitamin B12 and the eye drops had not 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.

Based on interview, and document review, the facility failed to ensure the facility had a Director of Nursing (DON) in accordance with the facility assessment. The deficient practice had the potential to compromise supervision of nursing care and oversight. Findings include: The Facility Assessment tool reviewed on 01/18/2023, described staffing resources needed to provide care to the population based on care analysis would include one Director of Nursing, two Assistant Directors of Nursing (ADONs) and one Infection Preventionist/Director of Staff Development. The Facility Assessment tool was re-reviewed on 07/10/2023, which revealed the facility did not have a DON and the DON position had not been filled. On 08/04/2023 at 12:29 PM, the Human Resources (HR) Director explained the DON resigned on 06/02/2023 and the facility had been unsuccessful at hiring a new DON. The HR Director indicated the two ADONs who were Licensed Practical Nurses and the Infection Preventionist who was a Registered Nurse worked their best to perform the DON's duties but collectively, the three employees…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review, the facility failed to ensure 1) the walk-in freezer was free from ice build-up, 2) rotten vegetables were discarded, 3) opened food items were labeled and dated, 4) kitchen equipment was in working condition, 5) food preparation area and equipment were maintained in a sanitary manner and 6) the sanitation compartment of the three-compartment sink was not too hot. The deficient practice had the potential to serve foods to residents at an increased risk of food safety. Findings include: On 08/02/2023 at 8:20 AM, an initial tour of the kitchen revealed the following: 1) Walk-in freezer had significant ice build-up -freezer pipes were covered in ice -frozen ice covered the door frame and strip curtains from inside the freezer -heavy ice buildup on freezer floor and on top of boxes containing food items 2) Rotten vegetables were discarded -a box filled with rotten cucumbers approximately 25 pieces or more were in the walk-in refrigerator 3) Opened food items were dated and labeled -an opened container of salsa was one-third full 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, record review and document review, the facility failed to complete a comprehensive assessment in a timely manner for 1 of 25 sampled residents (Resident 3). The deficient practice placed the resident at risk for receiving inappropriate care. Findings include: Resident 3 (R3) R3 was admitted on [DATE] with diagnoses to include anoxic brain damage and muscular dystrophy (group of diseases that cause progressive weakness and loss of muscle mass). R3's medical record revealed the last annual Minimum Data Set (MDS) assessment was dated 07/19/2022. On 08/04/2023 in the afternoon, two MDS Coordinators explained an annual MDS assessment should be conducted a year following the last annual date, with a grace period of seven days. The two MDS Coordinators confirmed R3's medical record lacked an annual MDS assessment for July 2023 due to an oversight. The Centers for Medicare & Medicaid Service Resident Assessment Instrument (version 3.0 manual; dated October 2019) documented an annual assessment was 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 Resident 7 (R7) R7 was admitted on [DATE] with diagnoses including cognitive communication deficit, anorexia, and dysphagia (swallowing difficulties). A Nutrition care plan initiated on 06/26/2017, revealed R7 was at risk for weight loss due to current body weight, disease state, advanced age, and increased needs due to therapy and healing. Interventions included offering snacks twice a day. On 08/02/2023 at 12:12 PM, three Certified Nursing Assistants (CNA) verbalized R7 ate snacks brought in by a family member. On 08/03/2023 at 09:10 AM, a CNA indicated R7 had a snack drawer which R7 could access when they wanted a snack. The CNA indicated the snacks in R7 snack drawer was provided from a family member and not by the facility. The CNA noted R7 did not like the sandwiches the facility provided for a snack. On 08/03/2023 at 09:24 AM, with permission, the same CNA opened R7's snack drawer and a couple of cookies, an individual pudding, and a banana on top of the drawer, were observed. The CNA informed they did…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a psychiatry evaluation was provided per the physician's order for 1 of 25 sampled residents (Resident 31). The deficient practice had the potential for the facility not providing the appropriate care and services to the resident. Findings include: Resident 31 (R31) R31 was admitted on [DATE], with diagnoses including post-traumatic stress disorder, major depressive disorder, unspecified mood (affective) disorder, insomnia due to medical condition, and anxiety disorder. The physician's order dated 04/17/2023, documented consult: psychiatry evaluation and treat. R31's Quarterly Minimum Data Set (MDS) dated [DATE], documented psychological therapy (by any licensed mental health professional) was not administered to the resident for at least 15 minutes a day in the last seven days. The physician's order dated 07/31/2023, documented psychiatry consult for refusal of wound care due to depression. R31's Wound Treatment Administration History for July…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review and document review, the facility failed to ensure a pack of cigarettes and lighter were not kept inside a resident's room for 1 of 25 sampled residents (Resident 221); and failed to monitor the residents who were smoking for 1 of 25 sampled residents (Resident 221) and one unsampled resident (Resident 68). The deficient practice had the potential for the residents, and the facility in general, to be at risk for accidents. Findings include: Resident 221 (R221) R221 was admitted on [DATE], with diagnoses including restlessness and agitation, traumatic subdural hemorrhage without loss of consciousness, and acute pain due to trauma. The Focused Observation form dated 07/29/2023, documented R221 was alert and oriented to person, place, time, and situation. On 08/02/2023 at 9:04 AM, R221 was not inside the resident's room. There was a pack of cigarettes observed on top of the resident's bedside table. On 08/02/2023 at 9:58 AM, R221 confirmed keeping the cigarettes 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, interview, record review and document review, the facility failed to 1) provide three fortified meals a day as ordered and offer snacks as care planned for 1 of 25 sampled residents (Resident 7) and 2) obtain weights per facility policy for 1 of 25 sampled residents (Resident 3). The deficient practice placed the residents at risk for malnutrition. Findings include: Resident 7 (R7) R7 was admitted on [DATE] with diagnoses including cognitive communication deficit, anorexia, and dysphagia (swallowing difficulties). The quarterly Minimum Data Set (MDS) dated [DATE], documented the Brief Interview for Mental Status (BIMS) score as 99 (unable to complete the interview) and required supervision with set up assistance for eating. A physician's order dated 07/03/2017, documented to give fortified food, one serving with meals three times a day. A physician's order dated 07/11/2023, documented to give Super soup (fortified) once a day at 9 AM, to provide extra nutrients to compensate for low 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY gastrostomy tube (G-tube) feeding and water flush bag were labeled with the name of the resident, room number, infusion rate, and date and time the feeding and water flushes started; the correct amount of G-tube water flush was provided, and G-tube placement was verified prior to starting the feeding for 1 of 6 sampled residents (Resident 222). The deficient practice had the potential for the resident receiving expired or incorrect G-tube feeding, inaccurate rate of feeding and water flushes, and develop complications from incorrect amount of water flush and incorrect placement of the G-tube. Findings include: Resident 222 (R222) R222 was admitted on [DATE], with diagnoses including hypo-osmolality and hyponatremia, nausea with vomiting, and cognitive communication deficit. The physician's order dated [DATE], documented check feeding tube placement per facility policy. The physician's order dated [DATE], documented Jevity 1.2 at 85 milliliters (ml) per hour for 18 hours (2:00 PM - 8:00 AM) or until full volume…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review and document review, the facility failed to ensure there was proper coordination of care with the dialysis provider regarding the resident's persistent refusal of dialysis treatments and care of the resident's central venous catheter (CVC) during non-use for 1 of 25 sampled residents (Resident 45). The deficient practice placed the resident at risk for a CVC infection, sepsis up to and including death. Findings include: R45 was admitted on [DATE] and readmitted on [DATE], with diagnoses including diabetes mellitus, end stage renal disease and acute kidney failure. On 08/02/2023 at 10:23 AM, R45 laid in bed while having casual conversation with roommate. The resident's gown was slightly pulled down which revealed a right CVC with an exposed insertion site. The resident indicated the CVC was for the dialysis clinic's use. On 08/03/2023 at 12:26 PM, a Certified Nursing Assistant (CNA) and a Licensed Practical Nurse (LPN) were in R45's room when R45 pulled down frontal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, and document review, the facility failed to ensure an unnecessary medication (duplicative anti-psychotic order) was discontinued per the physician orders for 1 of 25 sampled residents (Resident 79) and an Abnormal Involuntary Movement Scale (AIMS) was completed on admission for a resident who was receiving anti-psychotic medication (R31). The deficient practice had the potential to result in adverse consequences for the resident's health and well-being. Findings include: Resident 79 (R79) R79 was admitted on [DATE] with diagnoses including schizoaffective disorder, bipolar type, and post-traumatic stress disorder. The medical record revealed an after-visit note from a specialty clinic on 07/14/2023, documented to discontinue the bedtime dose of Nuplazid (20mg) after one more dose. A prescription order from the specialty clinic dated 07/14/2023, documented Nuplazid 10 mg tablets, give 2 tablets at bedtime for one dose and discontinue medication. The medical record indicated R79…

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