Mother Angeline McCrory Manor

Based on observation, interview, and record review, the facility failed to maintain a clean, sanitary, and homelike environment in multiple resident areas. This affected one (Resident #50) out of six residents reviewed for environmental concerns. Additionally the facility failed to maintain the cleanliness of common areas this had the potential to affect 40 residents (#40, #14, #58, #2, #41, #93, #85, #24, #95, #13, #75, #114, #115, #99, #30, #80, #97, #10, #89, #49, #131, #6, #73, #69, #104, #86, #1, #51, #76, #71, #26, #9, #62, #34, #21, #60, #79, #50, #64, and #74) identified using the affected areas. The facility census was 117. Findings include:1. Review of the medical record for Resident #50 revealed an admission date of 02/28/25 with diagnoses of type two diabetes mellitus, severe protein-calorie malnutrition, morbid obesity, gastro-esophageal reflux disease and gastrostomy status. Review of care plan dated 03/03/25 revealed Resident #50 has potential nutritional problem related to need to mechanically altered diet, need for tube feed due to inadequate oral intake and need…

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

Based on observation, interview, record review and facility policy review, the facility failed to ensure the call light was in reach for Resident #03. This affected one resident (#03) of four residents reviewed for call light accessibility. The facility census was 117.Findings included:Review of the medical record revealed Resident #03 was admitted to facility on 12/14/2024. Pertinent diagnoses included metabolic encephalopathy, adult failure to thrive, heart failure, major depressive disorder.Review of the Minimum Data Set (MDS) 3.0 dated 04/25/25 for Resident #03 revealed she was dependent on staff for toileting, rolling left to right, sit to lying and lying to sitting on side of bed.Review of care plan focus for Resident #03 dated 04/10/25 revealed Resident #03 was at increased risk for falls and intervention suggested was for staff to be sure resident's call light was within reach.Observation and interview on 07/22/25 at 2:22 P.M. of Resident #03 in bed with call light behind the resident, out of sight and out of reach. Resident #03 confirmed she was unable to see or reach the…

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

Based on observation, interview, record review and facility policy review, the facility failed to ensure private medical record information for Resident #03 was not visible to facility visitors. This affected one resident (#03) of four residents reviewed for privacy concerns. The facility census was 117.Findings include:Review of the medical record revealed Resident #03 was admitted to facility on 12/14/2024. Pertinent diagnoses included metabolic encephalopathy, adult failure to thrive, heart failure, major depressive disorder, hyperthyroidism and ileostomy status.Observation on 07/21/25 at 9:35 A.M. on the outside door to room of Resident #03 a sign which said, Synthroid - take whole- no crushing it - 4 hours before breakfast. Place bottom of ostomy bag towards right wall, not over crotch.Observation and interview on 07/22/2025 at 2:45 P.M. the sign remained on outside of door of Resident #03. Certified Nursing Assistant (CNA) #226 confirmed the sign was on the door, confirmed she knew it was HIPAA violation and said the sign had been there since she started in February. CNA #226…

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 review of resident medical record, family interview, staff interviews, dentist interview, review of facility self-reported incident investigation, review of hospital notes, and review of facility policies, the facility failed to complete a thorough investigation of an injury of unknown origin. This affected one resident (Resident #48) that was reviewed for abuse. The facility census was 117 residents. Findings include: Review of Resident #48's medical record revealed that Resident #48 was admitted to the facility on [DATE] and had diagnoses that included cerebral infarction, anxiety disorder and unspecified dementia with mood disturbance. Review of Resident #48's comprehensive admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed that she had modified independence for daily decision making. She was assessed as needing touch assistance for transfers and touch assist for rolling from lying on her back to left and right side. Review of Resident #48's activities of daily living (ADL) care…

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 review of facility policy, the facility failed to perform oral assessments on a resident. This affected one resident out (Resident #58) out of twenty nine residents reviewed. The facility census was 117 residents. Findings include: Review of the medical record for Resident # 58 revealed that Resident #58 was admitted to the facility on [DATE] with diagnoses that include chronic pain, Alzheimer's disease and chronic kidney disease stage 3. Review of Resident #58's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 11 out of 15, which suggested moderate cognitive impairment. The resident was assessed to require substantial/maximal assistance with oral hygiene and personal hygiene, bed mobility and transfers. She was assessed as having no dental concerns. Review of Resident #58's nursing quarterly assessments on 03/01/25 and 05/02/25 revealed that the nurse did not assess her oral and dental 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 interview and record review the facility failed to ensure documented diagnoses were accurate for Resident #12. This affected one resident (#12) out of five residents reviewed. Facility census was 117.Findings include:Review of the medical record for Resident #12 revealed resident was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE] after a weeklong hospitalization. On 07/24/25 at 8:46 A.M., a review of the medical record via the electronic charting system Point Click Care (PCC) revealed Resident #12 had a primary ICD admitting diagnosis F28 which was listed as, other psychotic disorder not due to a substance or known physiological condition with a start date of 05/07/24 and entry date of 05/09/25. Additional diagnoses included spinal stenosis; unspecified dementia, unspecified severity, with other behavioral disturbance; unspecified mood (affective disorder); adjustment disorder, dementia in other disease classified elsewhere, severe, with agitation; major…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure accurate Preadmission screening and resident review (PASRR) Level I screenings for residents with qualifying mental health diagnoses. This affected one (Resident #90) out of five residents reviewed for PASRR screenings accuracy. The facility census was 117. Findings include:Review of Preadmission screening and resident review (PASRR) identification screen dated 05/12/25 for Resident #90 revealed diagnosis of dementia however no active mental health disorders listed. Review of the medical record for Resident #90 revealed an admission date of 05/14/25 with diagnoses of dementia, bipolar disorder, and history of mental and behavioral disorders. Review of care plan dated 05/16/25 revealed Resident #90 has a mood problem interventions include administer medications as ordered, educate family and resident of treatment and monitor/record mood concerns or changes. Review of admission Minimum Data Set (MDS) 3.0 admission assessment dated [DATE] 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 interview, record review and policy review, the facility failed to ensure care plans reflected resident care needs. This affected three residents (#12, #45, and #114) out of four reviewed for care plans. The facility census was 117.1.Review of the medical record for Resident #12 revealed resident was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE] after a weeklong hospitalization. On 07/24/25 at 8:46 A.M., a review of the medical record via the electronic charting system Point Click Care (PCC) revealed Resident #12 had a primary ICD admitting diagnosis F28 which was listed as, other psychotic disorder not due to a substance or known physiological condition with a start date of 05/07/24 and entry date of 05/09/25. Additional diagnoses included spinal stenosis; unspecified dementia, unspecified severity, with other behavioral disturbance; unspecified mood (affective disorder); adjustment disorder, dementia in other disease classified elsewhere, severe, 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 interviews, observations, record review and facility policy review, the facility failed to ensure shaving needs were completed for two residents (#79 and #120) who required assistance with needs for personal care. Four residents were reviewed for activities of daily living. The facility census was 117.Findings include: 1.Review of the medical record for Resident #120, revealed an admission date of 05/18/18. Diagnoses included but were not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, vascular dementia, weakness and need for assistance personal care. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of rarely/never understood. The resident was assessed to require partial/moderate assistance with bed mobility and transfers with substantial/maximal assistance with shower/bathe self and toilet hygiene. Review of the active plan of care revealed Resident #120 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 medical record review, interview and facility policy review, the facility failed to develop an individualized activity program to meet one resident (#45) needs. This affected one (Resident #45) of two residents reviewed for activities. The facility census was 117.Findings Include:Review of the medical record for Resident #45 revealed an initial admission date of 02/23/25 with the diagnoses including but not limited to diabetes mellitus, chronic kidney disease, dependence on wheelchair, dementia, idiopathic peripheral autonomic neuropathy, atrial fibrillation, hypertension, restless leg syndrome, major depressive disorder, constipation, overactive bladder, insomnia and gastro-esophageal reflux disease. Review of the plan of care dated 02/25/25 revealed the resident was a new long term care resident who pursues independent leisure activities, may benefit from groups for social and recreational needs, assimilation to new surroundings, glasses worn for reading and may require wheelchair assistance when…

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, observation, and record review, the facility failed to ensure treatment for a contracture and plan of care was in place for one Resident (#95) of one that was reviewed for position and mobility. The facility census was 117.Findings include:Review of the medical record for Resident #95, revealed an admission date of 08/09/24. Diagnoses included but were not limited to cerebral infarction, cognitive communication deficit, other abnormalities of gait and mobility, and dementia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of the resident is rarely/never understood. The resident was assessed to require total dependence on toilet hygiene, shower/bathe self, bed mobility and transfers. Review of the active plan of care for Resident #95 revealed none for care and treatment of the contracture to her left hand. Review of the hospice note dated 01/14/25 for Resident #95 revealed a contracture to the left hand upon…

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 nutritional supplements were provided as ordered by the physician for one (Resident #48) of four residents reviewed for nutritional support. The facility also failed to obtain weekly weights as ordered for two (Residents #9 and #13) of four residents reviewed for nutritional support. The facility census was 117. Findings include:1. Review of the medical record for Resident #13 revealed an admission date of 09/17/21 with diagnoses of Alzheimer's disease, vascular dementia, weakness, muscle wasting and atrophy, type two diabetes mellitus, and abnormal weight loss. Review of care plan dated 09/21/21 revealed Resident #13 has a potential nutritional problem related to dementia, hypertension, alcohol dependence, variable oral intake, unintentional weight loss, and use of an appetite stimulant. Interventions include obtaining and monitoring lab and diagnostic work as ordered, obtaining weights as ordered, providing and serving…

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 resident record review, observations, staff interview, and review of facility policy, the facility failed to administer an enteral feeding per physician's orders. The facility also did not date the enteral formula container with the hang date and/or time. This affected one (Resident #72) out of two residents reviewed for tube feedings. The facility census was 117 residents. Findings include: Resident #72 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, dysphagia, hemiplegia and hemiparesis and gastrostomy status. Review of Resident #72's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed that his cognitive skills for daily decision making were moderately impaired. He was assessed as being dependent for his oral hygiene, personal hygiene and for sit to stand positioning. He was assessed as being substantial to maximal assistance for bed mobility. He was assessed as having a feeding tube and receiving 51% or more of his total calories from his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure the nebulizer medication delivery system as stored in a manner to prevent contamination. This affected one (Resident #116) of one resident reviewed for respiratory care. The facility census was 117.Findings Include:Review of the medical record for Resident #116 revealed an initial admission date of 06/01/21 with the diagnoses including but not limited to polyosteoarthritis, zoster, atrial fibrillation, chronic kidney disease, anemia, congestive heart failure, asthma, dry eye syndrome, myopia, presbyopia, constipation, abdominal aortic aneurysm, seasonal allergic allergies, hyperlipidemia, aortic valve stenosis, overactive bladder, insomnia, presence of cardiac pacemaker, peripheral vascular disease, hypertension and obstructive sleep apnea. Review of the plan of care dated 06/02/21 revealed the resident experienced and was at risk for respiratory insufficiency related to asthma, obstructive sleep apnea, seasonal allergies, 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 Based on closed record review, interview and facility policy review, the facility failed to ensure long-acting narcotic pain medication was available for administration. This affected one resident (Resident #15) out of five residents reviewed for pain. The facility census was 117. Findings include:Review of the closed medical record for Resident #15 revealed an initial admission date of 6/02/25 with the diagnoses including but not limited to dementia, weakness, need for assistance with personal care, dependence on wheelchair, history of falling, pain in right hip, anemia, chronic kidney disease, hypertension, hyperlipidemia, depression, anxiety disorder, obesity and low back pain. The resident was discharged home on [DATE]. Review of the resident's admission pain assessment dated [DATE] revealed the resident denied any pain. Review of the plan of care dated 06/03/25 revealed the resident was at risk for alteration in comfort. Interventions included complete pain evaluation upon admission and as needed, give pain…

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 a medication error rate was below 5%. This affected two (Resident #6 and #48) out of four residents observed during medication administration. 27 opportunities of medication administration were observed and 2 of the 27 medications were not administered in accordance with physician's orders, resulting in a medication error rate of 7.41%. The facility census was 117.Findings include: 1. Review of the medical record for Resident #48 revealed an admission date of 06/05/25 with diagnoses of encephalopathy, hyperlipidemia, cerebral infarction and hypercholesterolemia.Review care plan dated 06/06/25 indicated Resident #48 has altered cardiovascular status related to hypertension and cardiomegaly. Interventions include assessing for chest pain and shortness of breath, monitoring lung sounds and reporting changes, and monitoring, documenting, and reporting any signs or symptoms of coronary artery disease.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 closed record review, interview and facility policy review, the facility failed to ensure the transfer was documented in the resident's medical record. This affected one resident (#49) of three residents reviewed. The facility census was 117.Findings Include:Review of the closed medical record for Resident #49 revealed an initial admission date of [DATE] with the diagnoses including but not limited to dementia with psychotic disturbances, dysphagia, cerebrovascular accident with left sided hemiplegia, gastro-esophageal reflux disease, hypertension, congestive heart failure, insomnia, major depressive disorder, presence of cardiac pacemaker, hyperlipidemia, anemia, constipation, chronic pain, atrial fibrillation and hypothyroidism. The resident expired on [DATE] at the facility. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the resident's change in condition evaluation dated [DATE] revealed the resident had…

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 NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview and policy review, the faciliy failed to ensure residents were free from abuse. This affected one (Resident #8) of seven residents reviewed for abuse. The facility census was 116. Findings include: Record review revealed former Resident #8 was admitted on [DATE]. Diagnoses included diabetes mellitus, dementia, hypertension, and end stage renal disease. The resident was discharged [DATE] to the hospital. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/28/25, revealed Resident #8 had impaired cognition. The resident required maximum staff assistance for bed mobility, transfers, bathing, and ambulation. Review of the facility's investigation file revealed on 05/15/25 former Certified Nursing Assistant (CNA) #22 admitted to having a picture of Resident #8 on his personal cell phone. During an interview on 06/03/24 at 1:40 P.M., 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, staff interview, record review, document review, and policy review the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of disease and infections when they failed to follow droplet precautions for Resident #90 and failed to properly clean a blood glucose monitoring machine for Resident #3. This had the potential to affect four (Resident #3, #76, #78, and #79) Residents who received blood glucose monitoring on the two East hallway The facility census was 106. Findings include: 1. Record review of Resident #90 revealed an admission date of [DATE] with pertinent diagnoses of: congestive heart failure, hypothyroidism, atherosclerotic heart disease, atrail fibrillation, and hypertension. Review of the [DATE] admission Minimum Data Set (MDS) assessment revealed the resident is cognitively intact and uses a walker and wheelchair to aid in mobility. Review of a Physician Order dated [DATE] revealed Isolation Precautions: Droplet, for…

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 hospital reports, review of facility investigation, and interview, the facility failed to ensure a safe and proper wheelchair transport resulting in a fall. This affected one resident (#7) of three residents reviewed for falls. The facility census was 113. Findings include: 1. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including dementia, chronic kidney disease, protein-calorie malnutrition, weakness, failure to thrive, and atrial fibrillation. Review of the fall risk assessment, dated 05/03/24, revealed Resident #7 was determined to be at an increased risk for falls. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/08/24, revealed the resident was severely cognitively impaired. The assessment further revealed the resident was dependent on staff for activities of daily living and mobility. The resident's mobility device was a wheelchair. Review of the Care Plan dated 12/22/17 revealed the resident had…

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, policy review and interview, the facility failed to ensure a medication error rate of not 5 percent or greater. This affected four (Resident #67, #111, #113 and #131) of six residents observed for medication administration. Five errors were observed out of 35 opportunities resulting in a medication error rate of 14.2%. The census was 111. Findings include: 1. Medical record review revealed Resident #67 was admitted on [DATE] with diagnoses including depression, high blood pressure and pain. Review of the Order Summary dated March 2024 revealed medications to administer included Tylenol Extra Strength 500 milligrams (mg) twice a day for osteoarthritis and Sertraline HCL 50 mg give 1.5 tablet by mouth in the morning for depression. On 03/28/24 at 8:13 A.M., observation of Resident #67's medication administration revealed Licensed Practical Nurse (LPN) #2 administered medications including acetaminophen 500 mg with diphenhydramine 25 mg and Sertraline 50 mg. LPN #2…

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 review of facility policy, the facility failed to ensure the satellite kitchens were maintained in a sanitary manner. This had the potential to affect 113 of 113 residents who consumed food from the kitchen. Findings include: Observation on 09/27/23 from 2:05 P.M. to 2:20 P.M. of the satellite kitchens revealed the following concerns: a. Observation of the second-floor kitchen revealed three food carts that had a buildup of food debris and splatters. Additionally, in the refrigerator there was a stack of cheese wrapped in plastic wrap. The cheese was poorly wrapped, the plastic wrap was wet with an unidentifiable substance, and was not labeled or dated. b. Observation of the third-floor kitchen revealed two food carts with a buildup of food debris and splatter. Additionally, observation of the steam table revealed the wells had a build up of calcium and food debris. The water in the steam table was brown. c. Observation of the fourth-floor kitchen (which was additionally observed during meal service at 11:30 A.M.) revealed two food carts with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interviews the facility failed to ensure pharmacy recommendations were dated and appropriate rationale was provided regarding gradual dose reductions. This affected three residents (Resident #43, #74 and #85) of five residents reviewed for unnecessary medications. The facility census was 116. Findings include: 1. Review of Resident #74 medical record revealed the resident was admitted to the facility on [DATE] with the following diagnoses including Alzheimer's disease, hemiplegia to the right side, psychosis, seizures, and weakness. A further review revealed Resident #74 was cognitively impaired and required assistance from staff for Activities of Daily Living (ADL) tasks. Review of Resident #74 physician orders revealed the resident received anti-anxiety medication lorazepam 0.5 milligrams (mg) daily for anxiety, anti-psychotic medication perphenazine 2 mg at bedtime for psychosis, and anti-seizure medication levetiracetam 100mg per milliliter (ml) give 5 ml every twelve…

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 maintain complete and accurate medical records. This affected five residents (#23, #88, #71, #66, and #85) of 24 resident records reviewed. The facility census was 116. Findings include: 1. Review of the medical record for Resident #66 revealed an admission date of 05/27/22 with diagnoses including chronic obstructive pulmonary disease, cerebral infarction, bipolar disorder, anxiety disorder, dysphagia, dementia, and fibromyalgia. Review of the quarterly MDS dated [DATE] revealed Resident #66 had severely impaired cognition. She was totally dependent for bathing. Review of the plan of care dated 06/27/22 revealed Resident #66 had an activity of daily living self-care performance deficit related to weakness, abnormal gait, dementia. Resident #66 had noted fluctuations with level of assistance. Interventions included fluctuations with level of assistance, preferring to stay in bed most days, extensive to dependent with staff assistance for dressing, 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 medical record review and staff interview, the facility failed to provide skilled nursing facility advanced beneficiary notices (SNFABN) with estimated costs upon discharge from Medicare Part A skilled services for two (#101 and #87) of three residents reviewed for beneficiary protection notification review. The facility census was 116. Findings included: 1. Review of Resident #101's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of atherosclerotic heart disease and transient cerebral ischemic attack. The resident was discharged from Medicare Part A skilled services on 06/30/23, and remained in the facility. The medical record did not contain an SNFABN with remaining estimated costs for Resident #101. 2. Review of Resident #87's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of attention and concentration deficit following cerebral infarction. The resident was discharged from Medicare Part A skilled services 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, resident and staff interviews, medical record review, review of shower sheets, and facility policy review, the facility failed to ensure one resident's (Resident #85) hair was washed and one resident's (Resident #88) unwanted facial hair was removed. This affected two (Residents #85 and #88) of eight residents reviewed for activities of daily living (ADLs). The facility census was 116. Findings Include: 1. Review of the medical record for Resident #85 revealed an initial admission date on 03/22/21 and a readmission date on 04/09/21. Medical diagnoses included chronic obstructive pulmonary disease (COPD), Type II diabetes mellitus with polyneuropathy, stroke, essential hypertension (high blood pressure), colostomy status, fibromyalgia, other chronic pain, major depressive disorder, anxiety disorder, and drug induced subacute dyskinesia (abnormal movements). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #85 had intact cognition and scored 15 out…

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 have weekend activities and daily independent activities available. This affected two residents (#41 and #62) of two residents reviewed for activities. The facility census was 116. Findings include: 1. Review of the medical record for Resident #41 revealed an admission date of 02/02/17 with diagnoses including dementia, type II diabetes, dysphagia, psychotic disorder with delusions, moderate protein-calorie malnutrition, and memory deficit following cerebral infarction. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #41 was rarely or never understood. Review of the plan of care dated 07/27/23 revealed Resident #41 required structured activities due to diagnoses, need for verbal or tactile cueing, and need for assistance for mobility. Interventions included involving the resident in daily facility routine, reminding, and encouraging to attend activities of interest, providing leisure supplies…

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 pharmacy delivery receipts, and facility policy review, the facility failed to ensure hospice notes were kept on-site and readily available to staff for one resident (Resident #89). The facility failed to administer as needed (PRN) blood pressure medication as ordered to one resident (Resident #67). The facility failed to timely treat tardive dyskinesia (involuntary, repetitive movements often caused by long-term use of some psychiatric medications) for one resident (Resident #85). This affected one (Resident #89) of two residents reviewed for hospice services and two (Residents #67 and #85) of five residents reviewed for medications. The facility census was 116. Findings Include: 1. Review of the medical record for Resident #89 revealed an original admission date on 06/17/22 and a readmission date on 07/13/23. Diagnoses included Parkinson's Disease, dementia, pneumonia (07/14/23), esophageal obstruction (07/14/23), type II diabetes mellitus without…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure pressure reducing interventions were in place for Resident #41. This affected one resident (#41) of two residents reviewed for pressure ulcers. The facility census was 116. Findings include: Review of the medical record for Resident #41 revealed an admission date of 02/02/17 with diagnoses including dementia, type two diabetes, dysphagia, psychotic disorder with delusions, moderate protein-calorie malnutrition, and memory deficit following cerebral infarction. Review of the physician order dated 05/10/23 revealed Resident #41 was to be encouraged to lay down after meals due to wounds on the sacrum. Review of the Medication Administration Record (MAR) for September 2023 revealed this was marked as completed on 09/25/23, 09/26/23, and 09/27/23. Review of the plan of care dated 05/12/23 revealed Resident #41 was at risk for development of pressure injuries and other skin impairments related to weakness, impaired mobility, diagnoses,…

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 policy review the facility failed to complete assessments for continuation of an appropriate restorative program. This affected two residents (Resident #43 and Resident #74) of two residents reviewed for Restorative Therapy. The facility census was 116. Findings include: Review of Resident #74 medical record revealed the resident was admitted to the facility on [DATE] with the following diagnosis including Alzheimer's disease, hemiplegia to the right side, psychosis, seizures, and weakness. A further review revealed Resident #74 was cognitively impaired and required assistance from staff for Activities of Daily Living (ADL) tasks. Review of Resident #74 assessments revealed the last Restorative Therapy Assessments was completed on 08/05/19. Review of Resident #74 physician orders revealed an order dated 08/15/22 for a Restorative ambulation therapy program to ambulate up to 135 feet with Resident #74 pushing the wheelchair with assist of a staff member six 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, staff interviews, and facility policy review, the facility failed to conduct a thorough investigation following a choking episode for one resident (Resident #89). This affected one (Resident #89) of three residents reviewed for accidents. The facility census was 116. Findings Include: Review of the medical record for Resident #89 revealed an original admission date on 06/17/22 and a readmission date on 07/13/23. Diagnoses included Parkinson's Disease, dementia, pneumonia (07/14/23), esophageal obstruction (07/14/23), type II diabetes mellitus without complications, heart disease, and encounter for palliative care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #89 has impaired cognition and scored six out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #89 required extensive assistance to total dependence on one to two staff to complete Activities of Daily Living (ADLs). Resident #89 received hospice services.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure physician orders were in place for an indwelling urinary catheter. This affected one resident (Resident #361) of one residents reviewed for indwelling urinary catheter. The facility census was 116. Findings include: Review of Resident #361 medical record revealed the resident was admitted to the facility on [DATE] with the admitting diagnoses including rectal cancer, encephalopathy, weakness, hallucinations, urinary tract infection, and high blood pressure. Further review revealed Resident #361 had intact cognition and required assistance from staff for Activities of Daily Living (ADL) tasks. Review of Resident #361 admission and current physician orders revealed no indication for the use of the indwelling urinary catheter and no orders for the care and/or maintenance of the resident's indwelling urinary catheter. Review of Resident #361 care plan dated 09/08/23 revealed Resident #361 had an indwelling urinary catheter and 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 medical record review, staff interview, review of medication administration records, and facility policy review, the facility failed to attempt a variety of non-pharmacological interventions and did not include parameters for administering as needed (PRN) pain medications to one resident (Resident #85). The facility also failed to ensure appropriate monitoring for antipsychotic medication side effects was completed. This affected two residents (Resident #5 and #85) of five residents reviewed for unnecessary medications. The facility census was 116. Findings Include: 1. Review of the medical record for Resident #85 revealed an initial admission date on 03/22/21 and a readmission date on 04/09/21. Medical diagnoses included chronic obstructive pulmonary disease (COPD), Type II diabetes mellitus with polyneuropathy, stroke, essential hypertension (high blood pressure), colostomy status, fibromyalgia, other chronic pain, spondylosis without myelopathy or radiculopathy lumbosacral region, major 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 resident interview, observation, and staff interview the facility failed to ensure one resident (#71) with a documented lactose intolerance received food free from dairy products containing lactose. This affected one resident (#71) out of one resident reviewed for food allergies or food intolerances. The facility census was 116. Findings include: Review of the medical record for Resident #71 revealed the resident was admitted on [DATE] with diagnoses that included osteomyelitis of left foot and ankle, type 2 diabetes mellitus, acute kidney failure, acquired absence of right leg below knee, osteoarthritis, hypertension, and congestive heart failure. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #71 was cognitively intact and independent for eating. On 09/26/23 at 9:12 A.M. interview with Resident #71 revealed she had some food allergies and was lactose intolerant. Resident #71 shared her menu had her allergies and lactose intolerance listed but she was often served foods…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to maintain accurate resident influenza and pneumonia immunization records. This affected two residents (Resident #88 and Resident #361) out of five residents reviewed for accurate immunization documentation. The census was 116. 1. Review of Resident #88 medical record revealed Resident #88 was admitted to the facility on [DATE] with the admitting diagnosis including dementia, type two diabetes mellitus, depression, anxiety, dysphagia, and weakness. Further review revealed Resident #88 had impaired cognition and impaired hearing. Review of Resident #88 immunization record revealed there was no current influenza vaccine received date or a signed refusal consent by Resident #88 or Power of Attorney (POA) for Resident #88. 2. Review of Resident #361 medical record revealed Resident #361 was admitted to the facility on [DATE] with the admitting diagnoses including rectal cancer, encephalopathy, weakness, hallucinations, urinary tract infection, and high blood…

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 provide all necessary and reasonable accommodations for a resident with mobility impairments. This affected one (Resident #63) of two residents reviewed for mobility. Findings Include: Record review revealed Resident #63 was admitted to the facility on [DATE]. Her diagnoses were unspecified fracture of left humerus, moderate protein calorie malnutrition, peripheral vascular disease, venous insufficiency, chronic kidney disease, unspecified dementia, tremor, anxiety disorder, anemia, osteoarthritis, hypertension, hypothyroidism, hypokalemia, and glaucoma. Her Brief Interview for Mental Status (BIMS) score was not calculated due to her inability to answer the questions, which indicated she had a severe cognitive impairment. The assessment was completed on 04/21/21. Review of Resident #63 medical records revealed she needed the use of a walker for ambulation. She had three falls from 04/18/21 to 05/30/21. After her fall on 05/30/21, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to update and submit new Preadmission Screening and Resident Review (PASRR) screenings when one resident (Resident #82) was diagnosed with additional mental health diagnoses. Additionally, the facility failed to ensure an accurate PASRR screening was completed for one resident (Resident #43). This affected two residents (Residents #43 and #82) out of four residents reviewed for PASRR screenings. Findings include: 1. Review of the medical record for Resident #82 revealed an original admission date on 02/02/15 and a readmission date on 04/24/19 with the following medical diagnoses: presence of cardiac pacemaker, gastro-esophageal reflux disease without esophagitis (GERD), and chronic systolic (congestive) heart failure upon admission on [DATE]. Additional medical diagnoses: chronic obstructive pulmonary disease (COPD), weakness, vitamin D deficiency, polyneuropathy, glaucoma, osteoarthritis, history of falling, and presence of automatic (implantable)…

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 thoroughly investigate a resident fall. This affected one (Resident #63) of two residents reviewed for falls. The census was 100. Findings Include: Medical record review revealed Resident #63 was admitted to the facility on [DATE]. Her diagnoses were unspecified fracture of left humerus, moderate protein calorie malnutrition, peripheral vascular disease, venous insufficiency, chronic kidney disease, unspecified dementia, tremor, anxiety disorder, anemia, osteoarthritis, hypertension, hypothyroidism, hypokalemia, and glaucoma. Her Brief Interview for Mental Status (BIMS) score was not calculated due to her inability to answer the questions, which indicated she had a severe cognitive impairment. The assessment was completed on 04/21/21. Review of Resident #63 medical records revealed she had falls on 04/18/21, 05/18/21 and 05/30/21. While reviewing the documentation for these falls, the investigations as to the surroundings of the falls 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 medical record review, staff interview, and facility policy and procedure review, the facility failed to ensure medications were administered without significant medication errors when one resident (Resident #20) was administered an improper dosage of Coumadin (a blood thinning medication) which resulted in a critically high international normalized ratio (INR). This affected one resident (Resident #20) out of five residents reviewed for unnecessary medications. Findings Include: Review of the medical record for Resident #20 revealed the resident had an original admission date on 08/18/19 and a readmission date on 01/04/20 with medical diagnoses including heart failure, essential hypertension, atrial fibrillation, polyneuropathy, weakness, insomnia, lymphedema, polyosteoarthritis, major depressive disorder, anxiety disorder, unspecified tremor, personal history of urinary tract infections, and presence of cardiac pacemaker. Review of the annual Minimum Data Set (MDS) 3.0 assessment for Resident #20 dated 01/07/21 revealed the resident had intact cognition. The resident…

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, policy review, and staff interview the facility failed to ensure insulin was discarded appropriately after being opened. This affected three residents (Residents #1, #6 and #79) and had the potential to affect fifteen residents (#1, #6, #13, #15, #20, #35, #42, #50, #52, #55, #59, #60, #79, #294, #347) who receive insulin in the facility. The facility census is 100. Findings include: Observation on [DATE] from 10:30 A.M. of the medication cart on the third floor revealed Resident #79's Novolog injection vial had an opened date of [DATE]. Observation on [DATE] at 10:32 A.M. of the medication cart on the third floor revealed Resident # 1's Novolog injection vial had an opened date of [DATE]. Resident #1's Lantus injection vial was observed with an opened date of [DATE]. Observation on [DATE] at 10:35 A.M. of the medication cart on the third floor revealed Resident #6's insulin Lispo Kwik pen with an opened date of [DATE]. Interview on [DATE] at 10:44 A.M. with Licensed Practical Nurse (LPN)…

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 resident diets, review of dietary spreadsheets, observation, staff interview, and facility policy review, the facility failed to follow the dietary spreadsheet when plain chicken with brown gravy instead of barbeque chicken was served to residents who were prescribed a pureed or mechanical soft diet. This had the potential to affect 26 residents (Residents #2, #3, #4, #9, #10, #12, #13, #16, #26, #27, #31, #33, #34, #35, #43, #47, #50, #51, #54, #57, #62, #65, #75, #83, #86, #92) who received a pureed diet, a mechanical soft diet, or ground/pureed meats. The facility census was 100. Findings Include: Review of the Diet Order Tally Report-All Special Diets, dated 06/01/21, revealed there were 13 residents on a mechanical soft diet (Residents #2, #3, #9, #13, #16, #26, #33, #34, #43, #47, #50, #57, and #62). Two residents (Residents #75 and #83) were on a mechanical soft diet with pureed meat. Eight residents (Residents #4, #12, #27, #35, #51, #54, #86, and #92) were on a pureed diet. Two residents (Residents #10 and #31) were on a regular diet with ground meats.…

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.