Forest Hills Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and facility policy review, the facility failed to ensure the Physician and family were notified of a change in condition. This affected oneresident, (#36) of one reviewed for change in condition. The facility census was 74. Findings include:Review of the medical record for Resident #36 revealed an admission date of 04/22/26. Diagnoses included metabolic encephalopathy, unspecified dementia with behavioral disturbances, Alzheimer's disease, altered mental status, failure to thrive and edema. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 99 indicating resident was rarely if ever understood. The MDS stated Resident was dependent with most activities of daily living and required moderate to maximum assistance for mobility. Review of the plan of care dated 04/04/26 revealed resident had impaired cognitive process for daily decision making and was at risk for further decline in cognitive status.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical record review the facility failed to ensure indications for use were appropriate for psychotropic medications for two residents, (#49 and #75) and the facility failed to ensure two residents (#2 and #49) were monitored for psychotropic medication side effects. This affected three out of five residents sampled for unnecessary medications. The facility census was 74.Findings include: 1. Review of Resident # 49's medical record revealed an admission date of 06/21/23 with diagnoses that included but were not limited to dementia, anxiety disorder, mood affect disorder, pseudobulbar affect, psychosis, and frontotemporal neurocognitive disorder. Review of Resident # 49's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment and required total assistance from staff with toileting, transfers and hygiene. Further review revealed she received antipsychotics, antianxiety and antidepressant medications with indications for use noted.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff interview and policy review, the facility failed to complete a thorough investigation of injuries of unknown origin. This affected two residents (#20 and #83) of two reviewed for abuse investigations. Facility census was 74. Findings include:1. Review of the medical record for Resident #20 revealed an admission date of 04/10/26. Diagnoses included displaced fracture of lateral left fibula, right femur fracture, wedge compression fracture, dementia without behaviors, kidney disease, muscle weakness, and osteoporosis. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of six indicating impaired cognition and required partial moderate assistance with activities of daily living.Review progress notes dated 04/14/26 revealed during morning rounds resident was observed to be lying in bed holding her right leg and yelling in pain. The resident was unable to state if she had fallen and a stat X-ray was ordered. The X-ray later…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 hospital records, and staff interview, the facility failed to notify the Office of the State Long-Term Care Ombudsman regarding a hospitalization and transfer for one resident (Resident #35) and failed to assist one resident (Resident #8) with discharge planning services. This affected two residents (#35 and #8) of three residents reviewed for discharge planning. The facility census was 74. Findings Include: 1. Review of Resident #35's medical record revealed an admission date of 08/21/24 with diagnoses including Alzheimer's dementia with behavioral disturbance, chronic obstructive pulmonary disease (COPD), essential hypertension, and right hip fracture. Review of hospital records revealed Resident #35 was transferred to the hospital on [DATE] following a fall on 05/12/26 which resulted in right hip pain. Continued review revealed Resident #35 was diagnosed with a right femur fracture and underwent a right hip hemiarthroplasty on 05/14/26. The resident returned to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and resident representative interviews and policy review, the facility failed to ensure a care plan was created for communication and language services for Resident #36, contractures for Resident #55, and physical therapy services for Resident #84. This affected three (#36, #55 and #84) of 20 residents in the sample reviewed for care planning. The facility census was 74. Findings include 1. Review of the medical record for Resident #36 revealed an admission date of 04/22/26. Diagnoses included metabolic encephalopathy, unspecified dementia with behavioral disturbances, Alzheimer's disease, altered mental status, failure to thrive and edema. Review of the plan of care dated 04/04/26 revealed resident had impaired cognitive process for daily decision making and was at risk for further decline in cognitive status with interventions to communicate with staff, family, physician and the resident regarding the resident's needs and obtain input from family and friends. The care plan dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and resident representative interviews and policy review, facility failed to ensure care conferences were completed as required and completed as scheduled. This affected two (#36 and #35) of two residents reviewed for care conferences. The facility census was 74. Findings include: 1. Review of the medical record for Resident #36 revealed an admission date of 04/22/26. Diagnoses included metabolic encephalopathy, unspecified dementia with behavioral disturbances, Alzheimer's disease, altered mental status, failure to thrive and edema. Review of the plan of care dated 04/04/26 revealed resident had impaired cognitive process for daily decision making and was at risk for further decline in cognitive status with interventions to communicate with staff, family, physician and the resident regarding the resident's needs and obtain input from family and friends. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 99 indicating…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, staff and family interviews and policy review, the facility failed to ensure communication and language services were provided to a resident who did not understand or speak English. This affected one (#36) of one residents reviewed for language/communication. The facility census was 74. Findings include:Review of the medical record for Resident #36 revealed an admission date of 04/22/26. Diagnoses included metabolic encephalopathy, unspecified dementia with behavioral disturbances, Alzheimer's disease, altered mental status, failure to thrive and edema. Review of the plan of care dated 04/04/26 revealed resident had impaired cognitive process for daily decision making and was at risk for further decline in cognitive status with interventions to communicate with staff, family, physician and the resident regarding the resident's needs and obtain input from family and friends. The care plan dated 05/01/26 revealed no care plan for communication or language and no interventions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff interview, the facility failed to ensure timely completion of an ordered diagnostic test following a fall for one resident (Resident #35) reviewed for quality of care. This affected one (#35) of one residents reviewed for quality of care. The facility census was 74. Findings include: Review of Resident #35's medical record revealed an admission date of 08/21/24 with diagnoses including Alzheimer's dementia with behavioral disturbance, chronic obstructive pulmonary disease (COPD), essential hypertension, weakness, difficulty walking, unsteadiness on feet, and right hip fracture. Review of Resident #35's most recent Minimum Data Set (MDS) assessment completed prior to the fall revealed the resident required staff assistance with activities of daily living but remained mobile within the facility. The assessment further revealed Resident #35 was able to transfer with staff assistance and ambulate 10 feet. Review of facility documentation revealed Resident #35 sustained a fall 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 medical record review and staff interviews, the facility failed to accurately assess newly identified pressure ulcers. This affected one (#64) out of four residents reviewed for pressure ulcers. The facility census was 74. Findings include: Review of Resident # 64's medical record revealed an admission date of 10/09/23 with diagnoses that included but were not limited to Alzheimer's disease, encephalopathy, anxiety, dementia, mood disorder and intellectual disabilities. Review of Resident # 64's Minimum Data Set 3.0 (MDS) dated [DATE] revealed he had severe cognitive impairment and required assistance from staff with bed mobility, transfers and toileting. Review of Resident # 64's comprehensive care plan dated 01/28/26 revealed a potential for alteration in skin integrity: requiring protective/preventative measures care plan with interventions that included but were not limited to:Place a pillow between legs when in bed to ensure pressure reduction.Encourage to float heels as toleratedPressure reduction…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, staff interviews and policy review, facility failed to ensure a resident was assessed timely by qualified staff after a fall, and before being moved by staff. This affected two (#4 and #47) of four residents reviewed for falls. The facility census was 74. Findings include: 1. Review of the medical record for Resident #4 revealed an admission date of 04/23/26. Diagnoses included left femur fracture, Parkinson's, dementia, muscle weakness, unspecified psychosis, psychotic disorder with hallucinations, heart disease and arthritis. Review of the plan of care dated 04/24/26 revealed resident was at risk for falls with interventions including use assistive device for transfers and ambulation and bed to be in low position with floor mat in place. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 99 indicating impaired cognition and required extensive/dependent assistance from staff members for activities of daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, staff interviews, and facility policy review, the facility failed to properly administer and care for a resident's tube feeding. This affected one (#9) of one residents reviewed for tube feeding care. The facility census was 74.Findings include: Resident #9 was admitted on [DATE] and has diagnoses that include duodenal ulcer, dysphagia following cerebral infarction, and Type 2 Diabetes Mellitus. Review of the Resident's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicates the Resident was rarely/never understood and the Resident used a feeding tube. Review of the medical record for Resident #9 revealed on order on 05/19/26 for enteral nutrition every 24 hours via pump Glucerna 1.2 at 65 milliliters per hour (mL/hr) for 22 hours (9 A.M. to 7 A.M.) via pump per feeding tube or until 1,430 mL infused. An order written 05/11/26 states every shift for enteral feeding to check feeding tube placement before initiation of formula, medication administration, and flushing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, staff and resident interviews and policy review, the facility failed to ensure drinks were provided regularly and upon resident request. This affected one (#26) of one residents reviewed for hydration. The facility census was 74. Findings include:Review of the medical record for Resident #26 revealed an admission date of 01/05/24. Diagnoses included dementia without behaviors, psychotic disturbance, vascular dementia, dysphagia and pulmonary disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 99 indicating impaired cognition. Review of the plan of care dated 01/20/26 for alteration in nutrition with interventions to provide favorite foods and fluids. Further review of Resident #26's medical record revealed there was no order for fluid restrictions. Observation and interview on 06/01/26 at 11:28 A.M. with Resident #26 revealed he had no drinks or hydration in his room and he requested a drink from staff,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interviews, review of facility investigations, review of facility Self Reported Incidents (SRI) and review of facility policy, the facility failed to report injuries of unknown sources in a timely manner to the State agency. This affected four of four residents (Residents #7, #11, #14, and #18) reviewed for injuries of unknown sources. The facility census was 72 residents.Findings include: 1. Review of Resident #7's medical record revealed that Resident #7 was admitted to the facility on [DATE] and had diagnoses that included senile degeneration of the brain, schizoaffective disorder, bipolar disorder and dementia. Review of Resident #7's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 00, indicative of severe cognitive impairment. Resident #7 was assessed as being dependent for mobility and for activities of daily living. Review of Resident #7's care plan dated 03/16/24 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, medical record review, staff interviews, review of facility investigations and review of facility policy, the facility failed to thoroughly investigate injuries of unknown sources. This affected three (Residents #7, #11, and #14) of four residents reviewed for injuries of unknown sources. The facility census was 72 residents.Findings include: 1. Review of Resident #7's medical record revealed that Resident #7 was admitted to the facility on [DATE] and had diagnoses that included senile degeneration of the brain, schizoaffective disorder, bipolar disorder and dementia. Review of Resident #7's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 00, indicative of severe cognitive impairment. Resident #7 was assessed as being dependent for mobility and for activities of daily living. Review of Resident #7's care plan dated 03/16/24 and revised on 03/29/24 revealed that Resident #7 had an impaired cognitive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, this facility failed to ensure residents were able to receive care and services from approved physicians only. This effected one (Resident #161) of the four residents reviewed for the right to choose their own care provider. The facility census was 70. Findings include: Review of the medical record for Resident #161 revealed an admission date of 07/11/25 and a discharge date of 09/03/25. Diagnosis included Alzheimer's disease, heart disease, and obstructive sleep apnea. Review of Resident #161's medical profile face sheet revealed under Instructions: For acute changes, resident will need to go to the emergency room. Do not contact facility physicians. Resident does not have an attending physician due to refusal for consent for treatment. Review of Resident #161's Care Conference Summary dated 07/14/25 with a lock date of 07/15/25 revealed the resident's legal guardian was present and indicated that the only ancillary service selected was dental and it indicated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility Self-Reported incident review, hospital record review, staff interview, observation, and review of facility policies, the facility failed to ensure residents were free from resident-to-resident altercations resulting in injury as well as ensuring ordered stop signs in doorway openings were in place. This affected two (Resident #159 and #63) of the seven residents reviewed for abuse. The facility census was 70.Findings include: 1. Review of the facility's Self-Reported Incident (SRI) tracking number #263862 dated 08/10/25 revealed there was an allegation of physical abuse between two residents. Per the nurse, two residents were heard screaming, the nurse quickly ran to the scene (in from of Resident #63 doorway) and immediately separated Resident #63 and #159. Enhanced supervision was provided for both residents, including one-on-one care for Resident #63. During Neurological checks and the head-to-toe assessment, the nurse discovered Resident #159 had a cut to her nose…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Emergency Medical System (EMS) run report, review of the Certification and Licensure System (CALS), and facility policy review, the facility failed to timely report injuries of unknown origin to the state agency for Residents #153 and #155 and failed to report a resident to resident incident involving Resident #63. This affected three residents (#63, #153, and #155) of seven residents reviewed for abuse. The facility census was 70.Findings include:1a. Review of the medical record revealed Resident #153 was initially admitted to the facility on [DATE]. His diagnoses included metabolic encephalopathy, cerebral amyloid angiopathy, type II diabetes, unspecified mood disorder, depression, and cognitive communication deficit. Review of the Care Plan entry dated 05/09/24 noted Resident #153 had the potential risk for falls related to cognitive function, decreased physical function, incontinence and medication. A goal was established for Resident #153 to be free…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility investigation report review, staff interview, and policy review, the facility failed to ensure a thorough investigation was completed for injuries of unknown origin for residents #153 and #155, and failed to complete an investigation into a resident to resident altercation involving Resident #63. This affected three residents (#63, #153 and #155) of seven residents reviewed for abuse. The facility census was 70.Findings include:1a. Review of the medical record revealed Resident #153 was initially admitted to the facility on [DATE]. His diagnoses included metabolic encephalopathy, cerebral amyloid angiopathy, type II diabetes, unspecified mood disorder, depression, and cognitive communication deficit. Review of the Care Plan entry dated 05/09/24 noted Resident #153 had the potential risk for falls related to cognitive function, decreased physical function, incontinence and medication. A goal was established for Resident #153 to be free from injury. Interventions included to…

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

Based on facility staff schedule review and staff interviews, the facility failed to provide registered nurse (RN) coverage as required. This had the potential to affect all 70 residents residing in the facility. Findings Include: Review of facility staff schedule, dated 07/14/24 to 08/31/24, revealed the following days did not have the proper RN coverage: 07/14/24 (no RN), 07/16/24 (no RN), 07/17/24 (no RN), 07/20/24 (no RN), 07/21/24 (no RN), 07/22/24 (no RN), 07/23/24 (no RN), 07/24/24 (no RN), 07/27/24 (only seven hours of RN coverage), 07/28/24 (no RN), 07/30/24 (no RN), 07/31/24 (no RN), 08/05/24 (only 5.25 hours of RN coverage), 08/07/24 (no RN), 08/10/24 (no RN), 08/14/24 (no RN), 08/19/24 (no RN), 08/20/24 (no RN), 08/21/24 (no RN), 08/24/24 (no RN), 08/25/24 (no RN), 08/27/24 (no RN), and 08/28/24 (no RN). Interview with Director of Nursing (DON) on 05/01/25 at 11:00 A.M. confirmed the dates listed above did not have proper RN coverage.

Based on observation and interview, the facility failed to maintain the kitchen in a clean and sanitary manner and failed to obtain food temperatures in a sanitary manner. This had the potential to affect all 69 residents who consumed food from the kitchen. Resident #3 consumed nothing by mouth. The facility census was 70. Findings include: 1. Observation on 04/28/25 at 9:30 A.M. and on 04/30/25 at 11:45 A.M. revealed a large grate (about two feet by one foot) in front of the oven; the area under this grate was four to six inches deep. The area had a very thick layer of multiple black and brown substances, and the whole area appeared moist. All walls and surfaces underneath the grate were covered in this. Additionally, observation revealed the floor under equipment and around the edges of the kitchen had a buildup of dirt, food debris, and other items. A plastic cup was observed under the reach-in refrigerator on both occasions. Interview on 04/28/25 at 11:15 A.M. with [NAME] #175 revealed the area under the grate sometimes emitted a smell. Interview on 04/28/25 beginning at 11:45…

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

Based on observation and interview, the facility failed to maintain the laundry room in a clean and sanitary manner. This had the potential to affect all 70 residents residing in the facility. Findings include: Observation on 05/01/25 at 10:05 A.M. of the laundry room with Maintenance Director #117 revealed the washers were about a foot and a half to two feet from the back wall. All along the back wall were polyvinyl chloride (PVC) pipes and water lines leading from the washer to a drain. Everything from the wall to the pipes were covered in lint. On the floor were multiple wet spots including two puddles that had turned green. The floor around this area was black. In the dirty side of the laundry room, there was a sink with a buildup of dust, lint, and other debris. There were multiple areas of this floor that were cracked and peeling. Along the wall where the flooring was peeling, there was a buildup of dirt and leaves. Interview on 05/01/25 at 10:05 A.M. with Maintenance Director #117 verified the observation, and stated the area needed cleaned. The facility provided policy 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 medical record review, interview and facility policy review, the facility failed to ensure residents had appropriate diagnoses for psychological medications. This affected five residents (#35, #48, #50, #53, and #63) of nine residents reviewed for unnecessary medications or behavioral-emotional health services. The facility census was 70. Findings include: 1. Review of Resident #63's medical record revealed an admission date of 03/05/25 with diagnoses including dementia, unspecified mood disorder, hypertension, unspecified fracture of first, second, third, and fourth lumbar vertebra, restlessness and agitation, and muscle weakness. Review of Resident #63's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed severely impaired cognition. No behaviors were indicated. Review of Resident #63's physician order dated 03/06/25 revealed an order for escitalopram oxalate 10 milligrams (mg), selective serotonin re-uptake inhibitors (SSRIs) antidepressant, one tablet by mouth in the morning for depression.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff interview and facility policy review, the facility failed to ensure accurate advanced directive information was present throughout the medical record for Resident #3. This affected one resident (#3) out of three residents reviewed for advanced directives. The facility census was 70. Findings include: Resident #3 was admitted on [DATE] with diagnoses that included neurocognitive disorder with Lewy bodies, encephalopathy, aphasia, dysphagia, atherosclerosis, gastrostomy, major depressive disorder and psychosis not due to a substance or known physiological condition. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 was severely cognitively impaired with a Brief Interview for Mental Status score of zero out of 15. Review of the current active orders for Resident #3 revealed an order for Full Code dated [DATE]. The banner on the electronic medical record indicated Resident #3 was a Full Code. Review of the care plan for Resident #3 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview and facility policy review, the facility failed to assess Resident #53 prior to utilizing a physical restraint. This affected one resident (#53) out of one resident reviewed for physical restraints. The facility census was 70. Findings include: Review of Resident #53's medical record revealed that she was admitted on [DATE] with diagnoses that included dementia, pseudobulbar affect (PBA), anxiety, frontotemporal cognitive disorder, psychosis, major depressive disorder and mood disorder. Review of Resident #53's progress note, dated 01/12/25, revealed that Resident #53 started running and screaming in the hallway, and staff redirected her to her room. Review of physician's visit consult, dated 01/15/25, revealed that the physician dictated she has these very quick onset hyper episodes where she will run up and down the hallways, curse, push, shove, tear, pound on anything that comes in her way. These episodes usually last 30 minutes and then fade off. Sometimes just put…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and facility policy review, the facility failed to properly monitor resident bruises. This affected one (Resident #37) of three residents reviewed for skin conditions. Also, the facility failed to implement wound orders in a timely manner. This affected one (Resident #70) of three residents reviewed for skin conditions. The facility census was 70. Findings include: 1. Resident #37 was admitted to the facility on [DATE]. Her diagnoses were malignant neoplasm of unspecified part of unspecified bronchus or lung, dementia, hemiplegia and hemiparesis, epilepsy, mood disorder, hyperlipidemia, hypothyroidism, aphasia, anxiety disorder, insomnia, major depressive disorder, vitamin D deficiency, lack of coordination, muscle weakness, cerebral infarction, low back pain, dysphagia, hypertension, psychosis, cognitive communication deficit, and urinary incontinence. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #37 had a significant…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview, and review of the facility policy, the facility failed to ensure fall interventions were in place for Resident #13. This affected one resident (#13) of six residents reviewed for falls. The facility census was 70. Findings include: Review of Resident #13's medical record revealed an admission date of 06/20/23 with diagnoses including Alzheimer's disease, peripheral vascular disease, aphasia, bipolar disorder, generalized anxiety, unspecified psychosis, cognitive communication deficit, and dysphagia. Review of Resident #13's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had severely impaired cognition. He had one fall without injury during the lookback period. Review of Resident #13's plan of care dated 03/08/24 revealed he had the potential risk for falls related to cognitive function, decreased physical function, and medication use. Interventions included attempting to redirect with food and fluids, encourage frequent rest periods,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pain medication as ordered for Resident #70 and notify the physician when the medication was unavailable. This affected one resident (#70) of two residents reviewed for pain management. The facility census was 70. Findings include: Review of Resident #70's medical record revealed an admission date of 04/03/25 with diagnoses including hemiplegia and hemiparesis affecting right dominant side, aphasia, type two diabetes mellitus, chronic obstructive pulmonary disease, burn of unspecified region of body, vascular dementia, malignant neoplasm, acquired absence of right breast and nipple, and anxiety. Review of Resident #70's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition. Review of Resident #70's physician order dated 04/04/25 revealed an order for Butrans Transdermal Patch Weekly (Schedule III controlled substance for pain) one patch applied transdermally one time a day every…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to monitor, thoroughly document, and prevent Resident #48's behaviors. This affected one resident (#48) of four residents reviewed for mood and behavior. The facility census was 70. Findings include: Review of Resident #48's medical record revealed an admission date of 05/31/23 with diagnoses including dementia with other behavioral disturbance, vascular dementia with agitation, atherosclerotic heart disease, generalized anxiety disorder, major depressive disorder, delirium due to known physiological condition, restlessness and agitation, history of traumatic brain injury, and alcohol abuse. Review of Resident #48's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition. He experienced behaviors of wandering and rejection of care during one to three days of the seven-day assessment reference period. Review of Resident #48's physicians order dated 05/10/24 revealed an order 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 observations, resident and staff interviews, review of temperature logs, review of a Packaged Terminal Air Conditioner (PTAC) facility audit, and facility policy review, the facility failed to ensure the Third Street Unit and one room on the First Street Unit (room [ROOM NUMBER]) were maintained at a comfortable temperature for the residents who resided in those areas. The deficient practice affected one resident (Resident #40) who resided in room [ROOM NUMBER] and had the potential to affect one additional resident (Resident #2) who also resided in room [ROOM NUMBER] and all 28 residents who resided on the Third Street Unit (Residents #10,#15, #35, #43, #44, #45, #46, #47, #48, #49, #51, #52, #54, #56, #58, #61, #62, #64, #66, #68, #71, #73, #75, #77, #79, #85, #87, and #89). The facility census was 74. Findings Include: Review of the facility PTAC unit audit completed on 07/22/24 and 07/25/24 revealed there were three PTAC units which needed to be replaced. The units in room [ROOM NUMBER] and 311 were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of a facility-reported incident (FRI) investigation, staff interviews, and facility policy review, the facility failed to follow abuse policies and procedures when Residents #10 and #15 were left alone after a potential observation of abuse. The deficient practice affected two (Residents #10 and #15) of three residents reviewed for abuse. The facility census was 74. Findings Include: Review of the medical record for Resident #10 revealed an original admission date of 11/15/21 and a readmission date on 12/12/22. Diagnoses included unspecified psychosis, restlessness and agitation, mood (affective) disorder, cognitive communication disorder, anxiety disorder, and Alzheimer's Disease. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 was rarely or never understood. Per staff assessment, the resident had severely impaired cognition. Resident #10 was totally dependent on staff to complete Activities of Daily Living (ADLs). Review of…

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

Based on record review, interview, and facility policy review the facility failed to implement comprehensive care plans to include activities and preferences. This affected two residents (Resident #17 and #66) of four residents reviewed for comprehensive care plans. The facility census was 73. Findings Include: 1. Review of Resident #17's medical record revealed an admission date of 05/17/24 with diagnoses including diabetes mellitus type two, dementia, chronic kidney failure, and paranoid personality disorder. Resident #17 had severely impaired cognition with a Brief Interview of Mental Status (BIMS) score of zero out of 15 and required assistance from staff for activities of daily living (ADL) tasks, including transfers and mobility. Review of Resident #17's comprehensive care plan dated 05/17/24 revealed there was not an activity care plan or activity preferences completed for Resident #17. Interview on 06/25/24 at 11:53 A.M. with the Administrator confirmed Resident #17 did not have an activity care plan or activity preferences completed as part of the comprehensive care plan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, observations, staff and resident interviews, review the National Weather Forecast, and review of facility policies, the facility failed to prevent Resident #25 from eloping. This affected one (Resident #25) of three reviewed for elopement. The facility census was 74. Findings include: Record review revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including encephalopathy, alzheimer's disease, type II diabetes mellitus, and anxiety disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #25 revealed severe cognitive impairment. Resident #25 required supervision for Activities of Daily Living (ADLs) and did not not require any mobility devices. Review of the admission Assessment with Baseline Care Plan dated 04/26/24 revealed Resident #25 had impaired cognition and impaired cognition or decision…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 closed medical record review, resident representative interview, staff interviews, review of the grievance log, review of a missing items concern form, and facility policy review, the facility failed to protect Resident #74's belongings from being lost. This affected one resident (#74) of three reviewed for missing items. The facility census was 72. Findings Include: Review of the former Resident #74's closed medical record revealed an admission date on 11/21/23 and a discharge date on 12/14/23. Medical diagnoses included anxiety disorder, unsteadiness on feet, chronic kidney disease Stage 3, dementia with behavioral disturbance, and metabolic encephalopathy. Review of the Five-Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #74 had impaired cognition and scored nine out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #74 required set-up or clean-up assistance with self-care activities of daily living (ADL), except bathing required partial to moderate…

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

Based on record review and interview, the facility failed to properly track infections to identify infectious trends or patterns to prevent transmission. This had the potential to affect all 76 residents in the facility. Findings included: Record review revealed facility's infection control log did not contain a category regarding the type of organism in infections or whether the infection was facility acquired or the resident had the infection upon admission. The facility map for infections for each month did specify type of infection, such as urinary tract infection, skin infection, or respiratory infection but it did not detail which organism was growing in the infection. Interview on 07/27/23 at 1:10 P.M. with Assistant Director of Nursing (ADON) #460 confirmed the facility did not keep information of whether an infection was in house acquired or present upon admission on the log or the facility map. ADON #460 also stated trends in infections were only reviewed once a month during a quality assurance meeting. ADON #460 confirmed the facility does not list which type of organism…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure Resident #14's skin was monitored appropriately for bruising or signs of abnormal bleeding related to anticoagulant use. This affected one resident (Resident #14) out of one resident reviewed for non-pressure skin conditions. Findings include: Record review revealed Resident #14 admitted to the facility on [DATE] with diagnoses including atrial fibrillation, anemia, congestive heart failure, coronary artery disease, dementia, hypertension, and diabetes. Review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/17/23 revealed Resident #14 had a brief interview for mental status (BIMS) score of six, indicating moderate cognitive impairment, and required limited assistance of one person physical assistance for transfers and bed mobility. Review of Resident #14's medication list revealed the resident received Eliquis (blood thinner) 5 milligrams twice a day for treatment of coronary artery disease. Observation on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Resident #14 and Resident #48 neurological checks were properly completed to assess for injury after falls. This affected two (Resident #14 and #48) of two residents reviewed for head injuries. Findings included: 1. Record review revealed Resident #14 admitted to the facility on [DATE] with diagnoses including atrial fibrillation, anemia, congestive heart failure, coronary artery disease, dementia, hypertension, and diabetes. Review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/17/23 revealed Resident #14 had a brief interview for mental status (BIMS) score of six, indicating moderate cognitive impairment, and required limited assistance of one person physical assistance for transfers and bed mobility. Review of Fall Assessment from 04/07/23 revealed Resident #14 was at minimal risk for falls. Review of Resident #14's medication list revealed she took Eliquis (blood thinner) 5 milligrams twice a day for treatment of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Resident #69 received medication timely to manage pain. This affected one resident (Resident #69) of one resident reviewed for pain. Findings include: Review of the closed medical record for Resident #69 revealed an original admission date on 10/23/20, a readmission date on 02/03/21, and a discharge date on 05/26/23. Medical diagnoses included pain in left hip, Alzheimer's Disease, dislocation of left hip, fracture of left femur (thigh bone), cognitive communication deficit, anxiety disorder, delusional disorder, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #69 had severely impaired cognition and scored a three out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #69 required extensive assistance from one staff to complete Activities of Daily Living (ADLs). Review of the physician orders for April 2023 revealed Resident #69 had the following…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff interview, the facility failed to explicitly grant the resident or resident representative the right to rescind Binding Arbitration Agreements within 30 days of signing the agreement. This affected three residents (#17, #19, and #36) of three residents reviewed for Binding Arbitration Agreements. Findings include: 1. Review of medical record for Resident #17 revealed an admission date of 05/02/23. Diagnoses included Alzheimer's disease, depression, cerebral infarction, dysphagia, and dementia. Review of Resident #17's admission Minimum Data Set (MDS) dated [DATE] indicated Resident #17 was significantly cognitively impaired. Review of Resident #17's Voluntary Arbitration Agreement revealed the agreement was signed on 05/02/23 by Resident #17's legal representative. The agreement stated the agreement could be canceled by notifying the Facility in writing. Such notice must be sent via certified mail to the attention of the Administrator of the Facility, and the notice must be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, facility failed to ensure Resident #26 and #324 met the criteria for antibiotic use before antibiotics were administered. This affected two (Resident #26 and #324) of two residents reviewed for antibiotic stewardship. Findings included: 1. Record review revealed Resident #26 admitted to the facility on [DATE] with diagnoses including hypertension, aphasia, diabetes, dysphagia, anemia, anxiety disorder, and Alzheimer's disease. Review of a Minimum Data Set (MDS) with an assessment reference date (ARD) of 02/22/23 revealed Resident #26 had a brief interview for mental status (BIMS) staff assessment completed showing severe cognitive impairment, bladder assessment revealed Resident #26 is always incontinent of bladder, and requires total dependence of one person assist for toileting. Review of infection control log revealed Resident #26 was treated for a urinary tract infection (UTI) on 03/11/23 with one dose of Ceftriaxone injection 1 gram. Review of nursing notes from…

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

Based on observation, interview, and record review, the facility failed to ensure the kitchen, dishwasher, and nectar thick fluid dispenser were maintained in a clean and sanitary manner. This had the potential to affect all 70 residents who receive meals from the kitchen. The census was 70. Findings Include: Observation on 05/24/21 at 10:15 A.M. revealed the a large amount of a yellowish brown solid substance all over the top of the dishwasher. Interview with Dietary Manager (DM) #505 on 05/24/21 at 10:15 A.M. verified there was a large amount of a yellowish brown solid substance all over the top of the dishwasher. The interview further revealed the dishwasher was supposed to be cleaned every day. Observation on 05/24/21 at 10:17 A.M. revealed there was a build up of a reddish substance along the inner part of the nozzle to the nectar thickened liquids dispenser. Interview with DM #505 on 05/24/21 at 10:15 A.M. verified there was a build up of a reddish substance along the inner part of the nozzle to the nectar thickened liquids dispenser. The interview further revealed the juice…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and staff interview, the facility failed to ensure resident room doors were not blocked. This affected one resident (Resident #39) of one residents reviewed for homelike environment. The census was 70. Findings Include: Review of the medical record for Resident #39 revealed an admission date of 03/16/21 with diagnoses including dementia, psychosis, and depression. Review of the admission minimum data set assessment dated [DATE] revealed Resident #39 had moderate cognitive impairment and required supervision assistance with activities of daily living. Observation on 05/24/21 at 1:08 P.M. revealed a treatment cart and a cart with coffee and plastic utensils were in front of the door to Resident #39's room. No staff were observed actively using either the treatment cart or the cart with coffee and plastic utensils. Observation on 05/25/21 at 2:03 P.M. revealed a treatment cart was in front of the door to Resident #39's room. No staff were observed actively using the treatment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff interview, the facility failed to notify the ombudsman of resident hospitalizations. This affected two (Resident #41 and #69) of three residents reviewed for hospitalizations. The census was 70. Findings Include: 1. Review of the medical record for Resident #41 revealed an admission date of 09/01/20 with diagnoses including dementia, chronic kidney disease stage three, and depression. Review of quarterly minimum data set assessment dated [DATE] revealed Resident #41 had sever cognitive impairment and required supervision/limited assistance with activities of daily living. Review of a nurses note dated 04/21/21 revealed Resident #41 x-ray results were obtained and showed a fracture of the left femoral neck. Further review of the note revealed the certified nurse practitioner gave a new order for Resident #41 to be sent to the emergency room. Review of second nurses note dated 04/21/21 revealed Resident #41 was transferred to the emergency room on [DATE]. Review of the nurses 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, review of the facility's Foley Catheter care policy, and review of the Hand Washing policy, the facility failed to ensure infection control was maintained while completing care. This affected one (Resident #27) of one residents observed for Foley catheter care. The facility census was 70. Findings include: Review of the medical record for Resident #27 revealed an admission date of 10/09/20. Diagnosis included Parkinson's disease, hypertension, and neuromuscular dysfunction of the bladder. Review of Resident #27's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 indicating a moderately impaired cognition for daily decision making ability. Resident #27 required extensive assistance from two staff members for bed mobility, transfers and extensive assistance from one staff member for ambulation, dressing, toilet use, and personal hygiene. Resident #27 was noted to require the use of a indwelling…

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