Westmoreland Place

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure a resident was free from physical restraints. This affected one resident (#94) of three residents reviewed for restraints. The facility census was 84.Findings include:Review of the medical record revealed Resident #94 was admitted to the facility on [DATE] and discharged on 06/05/26. Diagnoses included alzheimer's disease with late onset, mood disorder, disorientation, and unspecified dementia.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #94 had severely impaired cognition, and required substantial assistance with bathing and toileting the assessment coded bed rails and alrams were utilized in the care of Resident #94.Review of the provider orders and care plan for Resident #94 revealed no orders or interventions for side rails.Interview on 07/15/26 at 8:09 A.M. with Certified Nursing Assistant (CNA) #242 revealed side rails were used for Resident #94 on a daily basis. Interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and policy review, the facility failed to report an allegation of resident to resident abuse to the state agency. This affected one resident (#56) of three residents reviewed for abuse. The facility census was 84.Findings include:Review of the medical record revealed Resident #56 was admitted to the facility on [DATE]. Diagnoses included spinal stenosis, psychotic disorder with delusions, visual hallucinations, and paroxysmal atrial fibrillation. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #56 was cognitively intact, and required partial assistance with toileting and bathing. Review of the progress notes for Resident #56 dated 1/7/2026 at 9:05 P.M. revealed this resident was in room and scooted bedside commode next to closet door picked her shoe up and was banging on the closet door with her shoe, when asked what was wrong the resident stated that her roommate has tried to kill her all day and hit and kicked her in the ribs…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy review, the facility failed to ensure discharge planning was in place. This affected one resident (#56) of three residents reviewed for discharge. The facility census was 84.Findings include:Review of the medical record revealed Resident #56 was admitted to the facility on [DATE]. Diagnoses included spinal stenosis, psychotic disorder with delusions, visual hallucinations, and paroxysmal atrial fibrillation. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #56 was cognitively intact, and required partial assistance with toileting and bathing. Review of the Care Conference dated 04/07/26 for Resident #56 revealed the resident was short term with plans for discharge to an Assisted Living.Interview on 07/13/2026 at 2:15 PM with Resident #56 revealed Resident #56 could not recall the last care conference but wants to discharge and the social worker is not assisting with discharge plans. Interview on 07/15/26 at 12:59 P.M. 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 medical record review, staff interview and facility policy review, this facility failed to notify the ombudsman of resident discharge. This affected two residents (#2 and #92) of the three residents reviewed for discharge process. The facility census was 84. Findings include: 1.Review of the medical record for Resident #2 revealed an admission date of 04/03/2026 and a discharge date of 04/22/2026. Diagnosis included generalized anxiety, Thoracic (T) T11-T12 wedge compression fracture, and major depressive disorder. Review of nursing progress notes dated 04/15/2026 revealed Resident #2 was admitted to a local hospital and was set to discharge to another skilled nursing facility to be closer to family. Interview on 07/16/2026 at 10:39 A.M. with the Administrator confirmed the Ombudsman had not been notified of Resident #2's discharge from the facility as required. 2.Review of the medical record for Resident #92 revealed an admission date of 04/30/2026 and a discharge date of 05/04/2026. Diagnosis included dementia, emphysema, and atrial fibrillation. Review of a nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical record review, staff interview, review of residents Pre-admission Screening and Resident Review (PASARR) assessment and facility policy review, this facility failed to ensure the appropriate, State-designated authority was notified of an individuals newly identified or diagnosed intellectual disability or mental disorder. This affected two residents (#4 and #7) of the three residents reviewed for appropriate PASARR assessments. The facility census was 84. Findings include: Review of Resident #4's medical record revealed the resident was admitted [DATE] and had diagnoses that included generalized anxiety disorder, depression, and bipolar disorder. Review of physician's orders revealed the following active orders: Mirtazapine (antidepressant) Oral Tablet 7.5 MG with a start date of 01/30/26 and Duloxetine HCL(antidepressant) Oral Capsule Delayed Release Sprinkle 30 MG with a start date of 01/31/26. Review of Resident #4's Preadmission Screening and Resident Review Identification Screen (PASRR)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interview, and review of the medical record, the facility failed to ensure a care plan was in place for wandering for two residents (#35 and #47) and a care plan for toenail was in place for one resident (#81). This affected three Resident (#35, #47 and #81) of 24 reviewed for the initial sample. Facility census was 84.Findings include:1. Review of the medical record for Resident #47 revealed an admission date of 06/20/26. Diagnoses included unspecified dementia with severe behaviors, diabetes, failure to thrive, and kidney disease.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was cognitively impaired, with a BIMS of 4. Resident was also noted to be dependent with transfers and mobility and used a manual wheelchair.Review of the physician order dated 06/20/26 to 07/04/26 revealed an order for the resident to reside on the secure unit.Review of the dementia assessment dated [DATE] revealed resident was disoriented to time and place with her immediate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy review, the facility failed to ensure one resident (#3), of nine residents the facility identified as needing maximal assistance with eating, receive assistance with eating. Further, the facility failed to ensure toenail care was provided for one resident, (#81) of three residents reviewed for Activities of Daily Living (ADL). The facility census was 84. Findings include: Review of the medical record revealed Resident #3 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, dysphagia, dementia, chronic obstructive pulmonary disease, and cognitive communication deficit. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 had moderately impaired cognition, and required substantial assistance with toileting and bathing. Review of the provider orders for Resident #3 dated 02/18/26 revealed feeding restrictions, resident needs max assist feeding with each meal for nutrition. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, review of the medical record, and review of the facility policy, facility failed to ensure timely communication and care for a resident receiving hospice services. This affected one resident (#35) of one reviewed for hospice services. Facility census was 84.Findings include:Review of the medical record for Resident #35 revealed an admission date of 06/09/25. Diagnoses included polyneuropathy, respiratory failure, hypoxia, Alzheimer's, dementia with behaviors, atrial fibrillation and heart disease.Review of the care plan dated 02/20/26 revealed resident was at risk of developing clinically unavoidable declines secondary to having a terminal prognosis of Alzheimer's disease for which the resident received hospice services. The interventions included follow the hospice plan of care and notify hospice for any changes in condition or significant declines and work cooperatively with the hospice team.Review of the Physician order dated 06/05/26 revealed an order a right arm and hand…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interview, and review of the medical record, the facility failed to ensure residents were properly assessed and interventions were put in place when residents were moved from the secured memory care unit to an unsecured unit. This affected three Resident (#35, #47 and #81) of three reviewed for elopement risk. Facility census was 84.Findings include1. Review of the medical record for Resident #47 revealed an admission date of 06/20/26. Diagnoses included unspecified dementia with severe behaviors, diabetes, failure to thrive, and kidney disease.Review of the Physician order dated 06/20/26 to 07/04/26 revealed an order for the resident to reside on the secure unit.Review of the dementia assessment dated [DATE] revealed resident was disoriented to time and place with her immediate memory intact. The resident was unable to recall most events, receptiveness and had great resistance to care giving.Review of facility progress notes for Resident #47 from 06/24/26 through 07/10/26 reveaeld a note…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff interview, and record review, the facility failed to ensure a medication error rate of less than five percent. This affected two of six residents observed for medication administration (Resident #62 and #72). The facility census was 84.Findings include:Observation of medication pass at the facility on 07/15/26 and 07/16/26 reveaeld 30 opportunities were observed with two errors being made by facility staff. The total medication error rate was 6.67 %.1.Review of Resident #62's medical record revealed the resident was admitted on [DATE] and had diagnoses that included chronic obstructive pulmonary disease (COPD), chronic diastolic heart failure, and acute kidney failure. Review of the medical record revealed intact cognition. Observation on 07/16/26 at 8:09 A.M with Registered Nurse (RN) #408 revealed the nurse preparing Resident #62's Fluticasone Salmeterol Aerosol Inhalation (corticosteroid )Inhaler for administration. Observation revealed RN #408 hand the inhaler to Resident #62.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff interview, and record review, the facility failed to ensure Resident #72 was free from significant medication errors. This affected one of six residents observed for medication administration. The facility census was 84.Findings include:Review of Resident #72's medical record revealed the resident was admitted [DATE] and had diagnoses that included Type II Diabetes Mellitus, respiratory failure, and chronic kidney disease. Review of the medical record revealed intact cognition.Observation on 07/15/26 at 7:32 A.M. with Licensed Practical Nurse (LPN) #203 revealed the LPN put one 20 mg Omeprazole (proton pump inhibitor) Oral Capsule Delayed Release in a medicine cup with multiple other prescribed pills for Resident #72. The LPN preceded to crush all medications together and put the crushed mixture into a small cup of applesauce. The LPN then administered all crushed medications to resident. Interview with LPN #203 at time of medication administration confirmed that delayed release…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff interview and record review, the facility failed to ensure routine dental services were provided for Resident #11. This affected one of two residents investigated for dental concerns. The facility census was 84.Findings include: Review of Resident #11's medical record revealed the resident was admitted [DATE] with intact cognition and had diagnoses that included fibromyalgia, chronic respiratory failure, obstructive sleep apnea, and atherosclerotic heart disease. Review of Resident #11's physician's orders revealed the following active order with a start date of 01/10/26: Audiologist, Podiatrist, Dentist, Optometrist, Psychiatrist may consult and treat PRN. Review of Resident #11's progress notes revealed the following progress note dated 12/10/25 at 6:32 P.M. social worker (SW) made aware that resident needs dentist appointment. Further review of progress notes from 12/10/25 to 07/16/26 revealed no mention of a dentist's appointment being scheduled for or attended by Resident #11. Review of all…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, and review of the facility policy, the facility failed to ensure the residents' medical record was maintained in an accurate manner. This affected one residents (#69) of 24 Resident records reviewed in the initial pool. Facility census was 84.Findings include:Review of the medical record for Resident #69 revealed an admission date of 05/11/26. Diagnoses included cervical disc disorder, diabetes, kidney disease, spinal stenosis, and heart failure.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #69 was cognitively impaired, with a BIMS of 00. Resident was also noted resident required supervision/touching assistance for mobility and transfers.Review of the fall investigation dated 05/30/26 revealed the fall occurred at 3:45 A.M. when resident fell in the bathroom. He suffered bruise to his scalp and the physician was notified on 05/30/26 at 4:32 A.M.Review of the neurological checks completed stated that they began 05/30/26 at 3:40 A.M.Review of the…

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

Based on observations, staff interview and record review, the facility failed to maintain the substitution log. This had potential to affect all facility residents. Facility census was 94. Findings include Review of the menu revealed chilled pears were to be served for the lunch meal on 01/29/25. Interview on 01/29/25 at 11:31 A.M. with Kitchen staff #287 revealed they ran out of pears so they switched to pineapple for regular texture and applesauce of puree texture for the lunch meal. Interview on 01/29/25 at 11:35 A.M. with Kitchen Manager (KM) #286 revealed the substitution logs should be completed at the beginning of the day or prior to the meal service. Through surveyor interventions KM #286 and Dietician #327 were informed and revealed they were both unaware of the switch in food products. Review of the substitution log revealed no entries were made related to a change for the lunch meal on 01/29/25.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews and record review, the facility failed to maintain a safe and sanitary food storage, ensure food holding temperatures were maintained in a safe range and ensure kitchen staff was trained on proper use of the dishwasher. This had potential to affect all facility residents. Facility census was 94. Findings include 1. Observation and interview 01/27/25 at 10:45 A.M. with Kitchen Manager (KM) #286 revealed in the freezers were crumble (for pies) dated 06/28/24 to 09/28/24. KM revealed 09/28/24 was likely the use by date. Two bags of black olives were dated 12/2024 to an unknown date due to smudging. They appeared to be frostbitten and KM acknowledged they should be thrown out due to finding them frostbitten. In the refrigerator a large bag of ham was undated, five fruit cups were expired from 01/25/25 and a gallon of milk was expired 01/23/25, blueberries had a use by date of 01/24/25, salad dressing had a date of 09/2024, [NAME] sauce had a date of 05/2022. Broccoli leftovers…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident interview, staff interview, and policy review, the facility failed to ensure residents had ready and reasonable access to their personal funds handled by the facility in the evening and on weekends. This could affect 50 of 50 residents whose funds were handled by the facility (Residents #73, #32, #3, #55, #48, #90, #51, #9, #78, #65, #24, #85, #76, #23, #72, #70, #347, #10, #19, #12, #5, #7, #61, #86, #2, #50, #62, #54, #64, #63, #82, #44, #15, #38, #13, #36, #69, #81, #49, #14, #52, #8, #28, #21, #11, #147, #71, #68, #31, and #17). The facility census was 94. Findings include: Interview with Resident #70 on 01/27/25 at 4:49 P.M. revealed he had no access to his money handled by the facility on weekends. He stated he would like to be able to access some of his personal funds on the weekend. Interview with Business Office Manager #266 on 01/30/25 at 9:35 A.M. revealed resident funds handled by the facility are available from her from 9:00 A.M. to 4:00 P.M. Monday through Friday. She further stated funds are available to residents at the 2 East nurses station 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 observations, staff and resident interviews and record review, the facility failed to ensure comfortable water temperatures. This affected 31 Residents (#2, #4, #10, #11, #13, #14, #17, #19, #21, #23, #32, #33, #44, #46, #51, #54, #55 #59, #64, #67, #78, #79, #80, #82, #86, #87, #88, #90, #91, #92, and #146.) Facility census was 94. Findings include 1. Review of the medical record for Resident #19 revealed an admission date of 08/20/24. Diagnoses included dementia, fibromyalgia, cerebral attack, altered mental status, spinal stenosis, diabetes, and emphysema. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 was cognitively intact. Observation and interview on 01/27/25 at 12:08 P.M. with Resident #19 revealed her private bathroom sink had no warm water. She revealed the water was freezing cold and had been cold since she moved into her room several months ago. During resident interview water was left running and was confirmed to be cold to touch with no warm or hot water…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview, and facility policy review, the facility failed to ensure residents were treated in a dignified manner related to an indwelling urinary catheter collection bag. This affected one (Resident #89) of one resident reviewed for indwelling urinary catheter usage. The census was 94. Findings Include: Review of the medical record for Resident #89 revealed an initial admission date of 07/25/24 with the latest readmission of 01/11/25 with the diagnoses including but not limited to cerebral infarction, intervertebral disc degeneration of lumbosacral region, visual loss, acute kidney failure, encephalopathy, slow transit constipation, subdural hemorrhage, history of traumatic brain injury, dementia, anemia, osteoarthritis, obstructive and reflux uropathy, hypertension, hydronephrosis, anxiety disorder, hearing loss, chronic pain, hyperlipidemia, malignant neoplasm of overlapping sites of right female breast. Review of the admit complete admission review dated 07/25/24 revealed…

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

Based on review of personal fund records and staff interview, the facility failed to notify a resident/responsible party when the amount in the resident's account reached $200 less than the resource limit for one person and that, if the amount in the account reached the resource limit for one person, the resident may lose eligibility for Medicaid or Social Security. This affected one (Resident #2) of 50 residents whose funds were handled by the facility. The facility census was 94. Findings include: Review of the facilities record revealed Resident #2's personal funds were handled by the facility. Review of a quarterly statement of Resident #2's account revealed on 09/30/24 the balance was $1778.78. The balance had not been at or above $1800.00 between 07/01/24 and 9/30/24. (The resident was on Medicaid). Interview with Business Officer Manager #266 on 01/30/25 at 10:15 A.M. revealed that she had sent a notification letter to the resident's responsible party 09/30/24 indicating the balance was $1778.78 and that the facility shall provide written notice when the balance is within…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview, and facility policy review, the facility failed to ensure one resident's physician was notified of blood sugars outside of the physician ordered parameters. This affected one (Resident #70) of five residents reviewed for unnecessary medications. The census was 94. Findings Include: Review of the medical record for Resident #70 revealed an initial admission date of 02/07/24 with the latest readmission of 08/28/24 with the diagnoses including but not limited to Rhabdomyolysis, diabetes mellitus, chronic obstructive pulmonary disease (COPD), benign prostatic hyperplasia, hyperlipidemia, pain, dementia, peripheral vascular disease, intellectual disabilities, major depressive disorder, nicotine dependence, legal blindness, schizoaffective disorder, hypertension, acquired absence of left foot, insomnia, major depressive disorder and anxiety disorder. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The…

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

Based on observation, record review, staff interview, and policy review, the facility failed to maintain personal privacy for a resident during a dressing change. This affected one (Resident #74) of two residents reviewed for wounds. The facility census was 94. Findings include: Record review of Resident #74 revealed an admission date of 12/18/24 with pertinent diagnoses of: sepsis due to streptococcus, type two diabetes mellitus, chronic respiratory failure with hypoxia, encephalopathy, moderate intellectual disabilities, hypertension, heart failure, morbid obesity due to excess calories, type two diabetes mellitus with diabetic neuropathy, acute respiratory failure with hypoxia, benign prostatic hyperplasia, hyperlipidemia, venous insufficiency chronic peripheral, lymphedema, type two diabetes mellitus with foot ulcer, cardiomyopathy, iron deficiency anemia, solitary pulmonary nodule, and unspecified hydronephrosis. Review of the 12/23/24 admission Minimum Data Set (MDS) revealed the resident is moderately cognitively impaired and uses a walker and wheelchair to aid in mobility.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one resident's (#89) comprehensive assessment was accurate. This affected one resident (#89) of one resident reviewed for dental .The facility census was 94. Findings Include: 1. Review of the medical record for Resident #89 revealed an initial admission date of 07/25/24 with the latest readmission of 01/11/25 with the diagnoses including but not limited to cerebral infarction, intervertebral disc degeneration of lumbosacral region, visual loss, acute kidney failure, encephalopathy, slow transit constipation, subdural hemorrhage, history of traumatic brain injury, dementia, anemia, osteoarthritis, obstructive and reflux uropathy, hypertension, hydronephrosis, anxiety disorder, hearing loss, chronic pain, hyperlipidemia, malignant neoplasm of overlapping sites of right female breast. Review of the admit complete admission review dated 07/25/24 revealed the had her own teeth but the question of broken or carious teeth was not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, record review, and staff interview, the facility failed to ensure assessments were accurate in the areas of safe smoking, dental status, and mental health diagnoses. This affected three (Residents #6, #70, and #89) of 24 residents reviewed for comprehensive assessments. The facility census was 94. Findings include: 1. Review of the medical record for Resident #6 revealed an admission date of 09/19/24. He had diagnoses including chronic obstructive pulmonary disease, nicotine dependence, peripheral vascular disease, and bilateral above the knee amputations. Review of a Minimum Data Set (MDS) assessment completed 12/28/24 revealed a brief interview for mental status score of 13 out of 15, indicating intact cognition. The resident used a wheelchair for mobility. Review of a Smoking Safety Evaluation completed 09/23/24 revealed the resident had poor vision, balance problems, and followed the facility's policy on location and time of smoking. Review of a Smoking Safety Evaluation started 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 staff interview, and record review the facility failed to ensure the accuracy of Pre-admission Screening and Resident Review (PASARR) assessments for Residents #7, #32 and #81 for mental health diagnosis. This affected three (Resident #7, #32 and #81) of five residents reviewed for PASARR. The facility census was 94. Findings include: 1. Record review of Resident #7 revealed an admission date of 11/20/18 with pertinent diagnoses of: chronic obstructive pulmonary disease, cerebral infarction, delusional disorders, restlessness and agitation, insomnia due to other mental disorder, sexual dysfunction, schizoaffective disorder bipolar type, major depressive disorder with psychotic symptoms, mild cognitive impairment of uncertain etiology, hypothyroidism, atrial fibrillation, dysphagia following cerebral infarction, type two diabetes mellitus, acute and chronic respiratory failure with hypoxia, aphasia, cardiomyopathy, atherosclerotic heart disease, congestive heart failure, major depressive disorder, hyperlipidemia, hypertension, weakness, repeated falls, and personal history…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Review of the medical record, interview, and facility policy review, the facility failed to complete a Preadmission Screening and Resident Review (PASARR) within 30 days following admission for one resident. This affected one (Resident #18) of five residents reviewed for PASARR. The facility census was 94. Findings Include: Review of the medical record for Resident #18 revealed an initial admission date of 09/16/24 with the diagnoses including but not limited to wedge compression fracture of thoracic 11 and thoracic 12 vertebra, neuropathy, severe morbid obesity, vitamin D deficiency, obstructive sleep apnea, dorsalgia, dipolar disorder, insomnia, overactive bladder, major depressive disorder, anxiety disorder, spinal stenosis, hypertension, hyperlipidemia, diabetes mellitus and restless leg syndrome. Review of the plan of care dated 09/11/24 revealed the resident's discharge plans were undetermined, new/recent admission to facility with possible long term care placement. Interventions include encourage follow…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview, and facility policy review, the facility failed to develop and implement a comprehensive plan of care in the area of smoking, activities of daily living (ADL) and dental. This affected three residents (#6, #75, #89) of 19 sampled residents. The facility census was 94. Findings Include: 1. Review of the medical record for Resident #89 revealed an initial admission date of 07/25/24 with the latest readmission of 01/11/25 with the diagnoses including but not limited to cerebral infarction, intervertebral disc degeneration of lumbosacral region, visual loss, acute kidney failure, encephalopathy, slow transit constipation, subdural hemorrhage, history of traumatic brain injury, dementia, anemia, osteoarthritis, obstructive and reflux uropathy, hypertension, hydronephrosis, anxiety disorder, hearing loss, chronic pain, hyperlipidemia, malignant neoplasm of overlapping sites of right female breast. Review of the admit complete admission review dated 07/25/24 revealed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, and policy review, the facility failed to ensure care plan interventions were updated. This affected two residents (#13 and #67) who were involved in a resident to resident altercation and a third resident (#17) after a fall out of 25 resident careplans reviewed. Facility census was 94. Findings include: 1. Review of the medical record for Resident #13 revealed an admission date of 08/11/21. Diagnoses included chronic obstructive pulmonary disease, diabetes, dysphasia, muscle weakness, schizophrenia and kidney disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was cognitively impaired with a brief interview for mental status (BIMS) of 0 (rarely/never understood) out of 15. Review of the plan of care dated 01/28/25 revealed resident had potential for altered mood pattern related to schizophrenia with interventions for one to one visits as needed, give comfort measures with calm approach, and try different approaches including walk…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview and facility policy review, the facility failed to provide meal assistance for one resident (#9) and provide nail care for one resident (#89), who was dependent on staff. This affected two (Resident #9 and #89) of four residents reviewed for activities of daily living (ADL). The facility census was 94. Findings Include: 1. Review of the medical record for Resident #9 revealed an initial admission date of 12/21/21 with the diagnoses including but not limited to cerebrovascular accident with right sided hemiplegia, anorexia, hyperlipidemia, palliative care, age related physical debility, osteoporosis, hypertension, psychotic disorder with delusions and hallucinations. Review of the plan of care dated 12/27/21 revealed the resident had an activities of daily living (ADL) self care performance deficit related dementia, impaired balance, limited mobility, need for assist/support may fluctuate based on fatigue, time of day and motivation. Interventions included assess to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, family and staff interviews, the facility failed to maintain hospice records. This affected one Resident (#67) of one reviewed for hospice. Facility census was 94. Findings include Review of the medical record for Resident #67 revealed an admission date of 08/13/24. Diagnoses included encephalopathy, chronic obstructive pulmonary disease, respiratory failure, dementia, epilepsy, schizophrenia, muscle weakness and cognitive communication deficit, dysphasia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #67 was cognitively impaired. Review of the plan of care dated 01/27/25 revealed resident was receiving hospice services. Review of the medical record on 01/30/25 found no evidence of hospice notes being uploaded directly to the residents medical record. Review of the hospice binder maintained by the facility, resident was admitted to hospice 06/2024 and only three visit notes were documented. Interview on 01/28/25 at 9:13 A.M. with resident family revealed…

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

Based on observation, record review, interview, and facility policy review, the facility failed to ensure safe smoking for two residents (#6, #75). Additionally the facility failed to ensure safe hot water temperatures for three residents (#9, #79, #89). This affected two ( Resident #6 and #75) of three resident reviewed for smoking and three ( Resident #9, #79, and #89) of 19 sampled residents for water temperatures. The facility census was 94. Findings Include: 1. On 01/27/25 at 12:38 P.M., observation of Resident #9's room water temperature revealed a temperature of 131.2 degrees. On 01/27/25 at 12:45 P.M., interview with Maintenance Director (MD) #228 verified the water temperature was above the maximum 120 degree limit. 2. On 01/27/25 at 12:23 P.M., observation of Resident #89's water temperature in the bathroom revealed a temperature of 125.7 degrees. On 01/27/25 at 12:45 P.M., interview with Maintenance Director (MD) #228 verified the water temperature was above the maximum 120 degree limit. 3. On 01/27/25 at 12:34 P.M., observation of Resident #79's room water temperature…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview and facility policy review, the facility failed to ensure residents had access to fluids and bedside. Additionally, the facility failed to ensure one resident received beverages with meals. This affected three ( #8, #9, and #89) of four residents reviewed for hydration. The facility census was 94. Findings Include: 1. Review of the medical record for Resident #8 revealed an initial admission date of 11/11/23 with the diagnoses including but not limited to fibromyalgia, chronic respiratory failure, chronic pulmonary edema, cerebrovascular accident (CVA) with hemiplegia, dorsalgia, congestive heart failure, diabetes mellitus, chronic obstructive pulmonary disease (COPD), spinal stenosis, obstructive sleep apnea, restless leg syndrome, hypertension, chronic kidney disease, peripheral vascular disease, irritable bowel syndrome with constipation, spondylosis, dementia, osteoarthritis, hyperlipidemia, anxiety disorder, gout, hypothyroidism, osteoporosis and depressive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 monitor one resident's blood pressure prior to the administration of the medication Hydralazine (a medication used to lower blood pressure). This affected one ( Resident #70) out of five residents reviewed for unnecessary medications. The facility census was 94. Findings Include: Review of the medical record for Resident #70 revealed an initial admission date of 02/07/24 with the latest readmission of 08/28/24 with the diagnoses including but not limited to Rhabdomyolysis, diabetes mellitus, chronic obstructive pulmonary disease (COPD), benign prostatic hyperplasia, hyperlipidemia, pain, dementia, peripheral vascular disease, intellectual disabilities, major depressive disorder, nicotine dependence, legal blindness, schizoaffective disorder, hypertension, acquired absence of left foot, insomnia, major depressive disorder and anxiety disorder. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff interview, record review, and policy review, the facility failed to obtain Physician ordered labs for residents. This affected two (Resident #70, and #81) of five residents reviewed for medications. The facility census was 94. Findings include: 1. Record review of Resident #81 revealed an admission date of 08/13/24 with pertinent diagnoses of: dementia with psychotic disturbance, malignant neoplasm of prostate, deficiency of B group vitamins, hyperlipidemia, hypertension, gastro-esophageal reflux disease, edema, anxiety disorder, and psychotic disorders with delusions. Review of the 11/22/24 modification of quarterly Minimum Data Set (MDS) revealed the resident is rarely or never understood. Review of a Physicians Order dated 08/13/24 revealed complete blood count (CBC, a lab to check blood cells) and basic metabolic panel (BMP, a lab to check chemical balance and metabolism) laboratory values one time only for new admit. Review of a Physicians Order dated 08/23/24 revealed complete blood count…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview and facility policy review, the facility failed to ensure one resident received dental services. This affected one resident (#89) of two residents reviewed for dental. The facility census was 94. Findings Include: Review of the medical record for Resident #89 revealed an initial admission date of 07/25/24 with the latest readmission of 01/11/25 with the diagnoses including but not limited to cerebral infarction, intervertebral disc degeneration of lumbosacral region, visual loss, acute kidney failure, encephalopathy, slow transit constipation, subdural hemorrhage, history of traumatic brain injury, dementia, anemia, osteoarthritis, obstructive and reflux uropathy, hypertension, hydronephrosis, anxiety disorder, hearing loss, chronic pain, hyperlipidemia, malignant neoplasm of overlapping sites of right female breast. Review of the admit complete admission review dated 07/25/24 revealed the resident had her own teeth but the question of broken or carious teeth was…

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

Based on observation, record review, policy review ,and staff interview, the facility failed to maintain an infection prevention and control program to help prevent the transmission of infections when they failed to use proper hand hygiene during a dressing change, and failed to follow enhanced barrier precautions. This affected one (Resident #74) of two residents reviewed for wounds. The facility census was 94. Findings include: Record review of Resident #74 revealed an admission date of 12/18/24 with pertinent diagnoses of: sepsis due to streptococcus, type two diabetes mellitus, chronic respiratory failure with hypoxia, encephalopathy, moderate intellectual disabilities, hypertension, heart failure, morbid obesity due to excess calories, type two diabetes mellitus with diabetic neuropathy, acute respiratory failure with hypoxia, benign prostatic hyperplasia, hyperlipidemia, venous insufficiency chronic peripheral, lymphedema, type two diabetes mellitus with foot ulcer, cardiomyopathy, iron deficiency anemia, solitary pulmonary nodule, and unspecified hydronephrosis. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an adequate resident call system to allow residents to call for staff assistance. This affected two residents (Residents # 48 and #20) of the 30 residents reviewed for call light function in the facility. The facility census was 94. Findings include: 1. Record review of Resident #48 revealed an admission date of 12/26/21 with diagnoses that included inflammatory neuropathy, heart failure, paraplegia and chronic obstructive pulmonary disease. 2. Record review of Resident #20 revealed an admission date of 03/13/23 with diagnoses of radiculopathy, polyneuropathy, type II diabetes mellitus and chronic obstructive pulmonary disease. Interview on 01/29/25 at 2:30 P.M. with Residents #48 and #20 revealed that the call light system was not functioning properly and had not been for months. Resident #48 reported that when the call light was activated the light in the hallway did not come on and did not alert staff of need for assistance. 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 observation, staff interview, and resident interview, the facility failed to provide a functional comfortable environment when the walls were in disrepair. This affected one (Resident #65) of two residents reviewed for environmental issues. The facility census was 94. Findings include: Record review of Resident #65 revealed an admission date of 02/16/22 with pertinent diagnoses of: atrial fibrillation, type two diabetes mellitus, peripheral vascular disease, congestive heart failure, and insomnia. Observation and Interview with Resident #65 on 01/27/25 at 11:28 A.M. revealed his room has multiple wall marks that need sanded and painted over by the bed. Resident #65 stated the walls have been like that since he was in the room. Observation on 01/30/25 at 02:38 P.M. with Maintenance Director #228 verified the wall marks in Resident #65 room that need sanded and painted.

Based on observation, staff and resident interview, and review of the facility menu, the facility failed to follow weekly menus and have requested items available. This had the potential to affect 90 residents who receive their meals from the kitchen. The facility census was 94. Findings include: Observation on 12/18/23 at 11:42 A.M. of the lunch meal revealed Resident #67 was served a shredded chicken sandwich, hash browns, a piece of chocolate cake and two six-ounce glasses of orange colored juice. Resident #67 told State Tested Nursing Assistant (STNA) #95 he did not like chicken, and he wanted the alternate entree. STNA #95 stated the substitute was a bratwurst on a bun, and Resident #67 stated that would be fine. STNA #95 then returned to the dining room and told Resident #67 the kitchen did not have bratwurst available and that the only alternative available on 12/18/23 was a peanut butter and jelly sandwich. Observation on 12/18/23 at 11:45 A.M. revealed Resident #11 was served a grilled chicken sandwich, hash browns, a piece of chocolate cake and two six-ounce glasses 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, staff interview, and policy review, the facility failed to ensure foods were stored in at appropriate temperatures in order to prevent foodborne illness. This had the potential to affect all 109 residents who consumed foods prepared and stored in the kitchen. The facility identified one resident (#97) who did not receive foods prepared/stored in the kitchen and was to receive nothing by mouth. The census was 110. Findings include: Observations with [NAME] #151 during the tour of the kitchen on 07/25/22 at 8:15 A.M., revealed the reach in refrigerator #2's internal thermometer read 48 degrees Fahrenheit, and contained three large trays of portioned pudding as well as three large pans of raw chicken. Reach in refrigerator #3's internal thermometer read 50 degrees Fahrenheit, and contained a half pan of very hot oatmeal and small pan of hot sausage gravy. There were three cases of liquid eggs stored in reach in refrigerator #3. [NAME] #151 confirmed the internal thermometer readings of reach in refrigerators #2 and #3 at that time. Observations on 07/26/22 at 7:25…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, medical record review, review of facility census, review of COVID tracking log, review of the facility staff and visitor COVID-19 screening questionnaire log and policy reviews, the facility failed to ensure staff used the proper personal protective equipment (PPE) when providing care to residents who were either positive for COVID-19 or in quarantine for possible COVID-19; failed to ensure staff sanitized or wash their hands after removing gloves; failed to ensure proper signage was posted for residents in isolation/quarantine; failed to properly quarantine residents with possible COVID-19 exposure; and failed to properly screen residents and visitors for symptoms of COVID-19. This had the potential to affect 110 of 110 residents residing at the facility. The facility census was 110. Findings include: 1. Review of the medical record for Resident #405 revealed an admission date of 07/22/22. Review of hospital records revealed the resident tested positive for COVID-19 by…

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

Based on observation and staff and family interviews, the facility failed to maintain a clean homelike environment. This affected 22 residents (#08, #18, #35, #50, #56, #58, #80, #86, #26, #43, #35, #52, #51, #53, #88, #39, #01, #61, #69, #77, #03, and #207) of 110 residents environment observed. The facility census was 110. Findings include: 1. Observation of Resident #50's room on 07/25/22 at 1:48 P.M. revealed the windows have what appears to be dark paint dripping down the panes and appeared hazy. An empty resident bed with no mattress in place was observed. Plastic and metal silverware, cups, and bowls were observed on the windowsill, on the small chair ledge around the room, on the floor of the closet, and on the bathroom floor. 2. Observation of Resident #18's room on 07/25/22 at 1:58 P.M. revealed scratches on the wall by the bed were grooved into the dry wall. The windows had what appeared to be dark paint dripping down the panes and were hazy. The floor was sticky when walked across and dark pieces of debris were observed on the floor. 3. Observation of Resident #35's room…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical record review, observation, resident and staff interview, and policy review, the facility failed to ensure staff transferred a resident who was non weight bearing on one leg safely. This affected one resident (#404) of five residents reviewed for falls. In addition, the facility failed to ensure adequate supervision of smoking materials for resident's who smoked. This affected three residents (#30, #66, and #451) of three residents reviewed for smoking. The facility identified 27 residents (#02, #09, #10, #12, #14, #16, #21, #30, #33, #38, #47, #48, #64, #65, #67, #70, #74, #76, #77, #78, #79, #83, #88, #89, #94, #100, and #457) who smoked at the facility. Residents #66 and #451 were not identified by the facility as smokers. In addition, the facility failed to provide adequate supervision of medication administration to ensure medications were not left at bedside. This affected one resident (#95) of one residents reviewed for accidents related to medications. The facility census was 110.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical record review, observations, resident and staff interview, the facility failed to maintain acceptable parameters of nutritional status, which included monitoring weight status and following up on nutritional recommendations. This affected five residents (#25, #33, #61, #97, and #404) of 11 residents reviewed for nutrition. The facility census was 110. Findings include: 1. Review of the medical record for Resident #404 revealed an admission date of 07/17/22. The resident had diagnoses including chronic kidney disease with dialysis three times weekly, diabetes mellitus, and positive for COVID-19. The resident had physician's orders on 07/17/22 for a regular diet and daily weights. Review of weight records revealed Resident #404 had a weight of 258.5 pounds on 07/18/22. Review of a dietary progress note by the dietetic technician on 07/20/22 at 1:43 P.M. revealed Resident #404 was receiving a regular diet. Weight fluctuations expected due to dialysis. A recommendation was made to add a house liquid…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff interviews and policy review, the facility failed to follow the policy of disposing of food waste in the kitchen in containers with tight fitting lids. The finding potentially affected 109 residents who consumed foods prepared in the kitchen except for Resident #97 who consumed nothing by mouth. The census was 110. Findings include: Kitchen observation on 07/25/22 at 8:30 A.M. revealed two trash containers half full of food waste in dish room and production areas with no lids to cover the trash. The trash containers were not in use by staff at that time. Interview with Dietary Manager #100, at that time of the observation, verified the two trash containers with garbage and no lids. Observation on 08/02/22 at 8:45 A.M., revealed two trash containers half full of food waste in dish room and production areas with no lids to cover the trash. The trash containers were not in use by staff at that time. Interview with Dietary Manager #100, at that time of the observation verified the two trash containers with garbage and no lids. Review of the policy titled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical record review, review of the Resident COVID-19 Vaccination Log, staff interview, and review of facility policy, the facility failed to ensure residents and/or their representatives were offered COVID-19 vaccines and/or boosters and were provided education regarding the COVID-19 vaccines. This affected 11 (Residents #25, #30, #33, #34, #35, #50, #56, #58, #86, #95, and #453) out of 11 residents reviewed for COVID-19 vaccinations. The facility census was 110. Findings include: 1. Review of the Resident COVID-19 Vaccination Log revealed it contained 105 resident names. Of those 105 residents, 56 residents were documented as receiving a primary vaccination series. Of the 56 residents who had received a primary vaccination series, only 11 residents had received one booster vaccine. No resident had received two booster vaccines. The following five residents had not received any COVID-19 vaccination: Resident #30 was was admitted on [DATE], Resident #35 who was admitted on [DATE], Resident #50 who was…

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

Based on observation, staff interview, and family interview, the facility failed to maintain a safe and comfortable environment on the Three [NAME] Unit. This had the potential to affect all 22 residents (#8, #11, #15, #18, #19, #26, #31, #35, #42, #43, #45, #50, #56, #58, #68, #72, #80, #81, #85, #86, #96, and #351) residing on the Three [NAME] Unit. The facility census was 110. Findings include: Observation on 07/27/22 at 9:03 A.M. revealed two large gray trash cans in the middle of hallway on the Three [NAME] Unit outside of the medication room with blankets wrapped around the bottom of each trash can. A clear fluid was dripping from a vent in the ceiling above the trash cans and was dripping from the metal supports of the ceiling. Observation on 07/27/22 at 11:05 A.M. revealed a small black trash can in the hallway of the Three [NAME] Unit outside of the medication room with clear fluid dripping from the ceiling into the trash can. The large gray trash cans observed on 07/27/22 at 9:03 A.M. remained in place. Further observation of hallway area revealed an electrical panel cover…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical record review and staff interview, the facility failed to complete a comprehensive assessment using the resident assessment instrument (RAI) within 14 calendar days after admission. This affected one resident (#404) of three residents reviewed who were admitted within the past 30 days. The facility census was 110. Findings include: Review of the medical record for Resident #404 revealed an admission date of 07/17/22. The resident had diagnoses including fracture of right tibia, chronic kidney disease with dialysis three times a week, diabetes mellitus, rheumatoid arthritis, hypertension, and positive for COVID-19. Review of a Minimum Data Set (RAI) assessment dated [DATE], which documented it was in progress, revealed it only had sections C, D, E, and K completed. The other sections were not complete. The assessment had an assessment reference date of 07/30/22 and the facility system stated the assessment was two days past due. A comprehensive RAI had not been completed since admission.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical record review, observation, and interview, the facility failed to accurately document a residents assessment on the resident assessment instrument. This affected one resident (#03) of 35 resident assessments reviewed. The facility census was 110. Findings Include: Review of Resident #03's medical record revealed an admission date of 09/25/18. Diagnoses included Parkinson's disease, dementia without behaviors, congestive heart failure, osteoporosis and history of falls. Review of the physician orders for July 2022 revealed Resident #03 received passive range of motion for movement and prevention of contractures, admitted to hospice services, a regular pureed texture diet with thin liquids, double portions for weight loss and a Boost (supplement) 240 milliliters by mouth three times daily for weight loss. Review of the recorded monthly weights revealed Resident #03 weighed 150 pounds on 12/02/21, 145 pounds on 12/08/21, 148 pounds on 01/08/22, 138 pounds on 03/08/22, 133 pounds on 04/18/22, 128…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical record review and staff interview, the facility failed to accurately complete the Preadmission Screening and Resident Review (PASRR) for an individual with a mental disorder. This affected one resident (#25) of five residents reviewed for PASRR. The facility census was 110. Findings include: Review of the medical record for Resident #25 revealed an admission date of 12/30/21. The resident had a diagnosis of Schizophrenia (08/07/16) upon admission. An admission Minimum Data Set assessment completed 01/06/22 included a diagnosis of Schizophrenia. Review of a PASRR result notice dated 12/29/21 revealed a section for indications of serious mental illness, which included Schizophrenia. Schizophrenia had not been marked as a diagnosis for Resident #25. The result notice stated the resident had no indications of serious mental illness. Interview with Social Service Director #103 on 07/26/22 at 2:15 P.M. confirmed the PASRR review had not been accurately completed by the previous admission director. She confirmed Resident #25 had a diagnosis of Schizophrenia upon admission,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical record review, review of the self-reported incident (SRI), interview, and policy review, the facility failed to ensure residents were discharged to a safe location. This affected one resident (#73) of four residents reviewed for discharge. The facility census was 110. Findings include: Review of the medical record for Resident #73 revealed an admission date of 03/05/22 from acute hospital and was discharged on 07/06/22 to the local emergency department. Diagnoses included cerebral infarction, dissection of vertebral artery, type one diabetes mellitus with neuropathy, hypertension, anxiety, depression, chronic viral hepatitis C, hemiplegia affecting left non dominant side, ataxia, hypothyroidism, hyperlipidemia, muscle weakness, abnormalities of gait and mobility, needs assistance with personal care and other psychoactive substance abuse. Review of the unplanned discharge return not anticipated Minimum Data Set (MDS) dated [DATE] indicated Resident #73 was cognitively intact and independent with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff and resident interview, the facility failed to provide assistance with adequate nail care, hair care and bathing. This affected one resident (#95) of three residents reviewed for activities of daily living. The facility census was 110. Findings include: Review of the medical record for Resident #95 revealed an admission date of 09/30/19 with diagnosis of exacerbation of chronic obstructive pulmonary disorder, weakness, congestive heart failure and hypertension. Review of the annual Minimum Data Set (MDS) dated [DATE] indicated Resident #95 had mild cognitive impairment with behaviors. Resident #95 required extensive assistance of two persons for bed mobility, transfers, dressing, and toilet use. Resident #95 required extensive assistance of one person for bating and limited assistance of one person for personal hygiene. Review of Resident #95's shower/bathing documentation from 07/01/22 through 07/26/22 revealed the resident refused a shower/bath on 07/01/22…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical record review, review of personal finances, resident and staff interviews, the facility failed to provide medically-related social services for a resident who needed assistance with financial matters. This affected one (#70) of 35 sampled residents. The facility census was 110. Findings include: Review of the medical record for Resident #70 revealed an admission date of 09/24/20 and a readmission date of 09/29/21. Review of the Minimum Data Set (MDS) assessment completed on 06/07/22 revealed a Brief Interview for Mental Status score of 12, indicating moderately impaired cognitive status. The resident had diagnoses including vision loss in both eyes and anxiety disorder. Review of Social Service note on 06/29/22 at 5:30 P.M.,stated Resident #70 was alert and oriented and required assistance with activities of daily living related to his blindness and receives hospice services. Interview on 07/25/22 at 10:47 A.M., with Resident #70 revealed he had not received his pension check for several months. He stated he had asked to see social services, who had not visited.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, resident and staff interview, and policy review, the facility failed to provide an effective pest control program. This affected two (Resident #17 and #41) out of three residents reviewed for pest control. The census was 110. Findings include: 1. Observation on 07/25/22 at 11:35 A.M. of Resident #17's room revealed multiple flying insects in the room and around the Resident #17. At that time, Resident #17 stated the flies bothered him while he ate his meals. Observation on 07/28/22 at 8:13 A.M. of Resident #17's room revealed there were multiple flying insects in the room. Interview with Housekeeping Supervisor #101 at the time of the observation revealed there were multiple flies in Resident #17's room while he was eating breakfast. 2. Observation on 07/25/22 at 12:23 P.M. revealed multiple flying insects in Resident #41's room. Interview with Resident #41 at that time revealed the flies bothered him especially when he was trying to sleep. Observation on 07/28/22 at 8:41 A.M. revealed there were multiple flying insects in Resident #41's room. Interview 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.