Sapphire Rehabilitation And Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, review of maintenance repair logs, and review of facility policy, the facility failed to maintain a clean and homelike environment regarding temperature, sanitation and condition of residents rooms. This affected 10 (#8, #16, #21, #26, #79, #83, #87, #96, #97, and #108) of 10 residents reviewed for environment. The facility census was 108. 1. Observation on 12/08/25 at 9:30 A.M. of Resident #83 and Residents #96's room revealed a hole exposing the drywall. 2. Observation on 12/08/25 at 9:36 A.M. of Resident #26 and# 87's room revealed exposed wires hanging from the wall.3. Observation on 12/08/25 at 9:39 A.M. of Resident #21 and #97's room revealed dried feces on the floor and wall and privacy curtain with brown stains and dried feces.4. Observation on 12/08/25 at 9:59 A.M. of Resident #79 and #108's room revealed privacy curtain with brown stains.5. Observation on 12/08/25 at 10:00 A.M. of Resident #16 and #08's room revealed Resident #16 with gloves…

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 interview, and review of the facility policy, the facility failed to ensure residents were assisted and supervised with activities of daily living (ADL), and the facility failed to further ensure the necessary supplies were readily available to staff to ensure residents received timely ADL care. This affected three (#33, #78 and #87) residents received for activities of daily living. The facility census was 108. 1. Review of the medical record for Resident #33 revealed an admission date of 04/17/25, diagnoses including unspecified dementia, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, chronic pain, and difficulty in walking.Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 was cognitively intact, required supervision or touching assistance for toileting hygiene, and bed mobility, partial/moderate assistance for shower/bathing, dressing, personal hygiene and transfers, and…

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

Based on observation, staff interview, and review of facility policies, the facility failed to ensure outdoor lighting was maintained and failed to ensure the proper storage of hazardous maintenance equipment and supplies. This had the potential to effect 14 residents with orders for unsupervised leave of absence (#2, #9, #10, #15, #23, #31, #44, #60, #67, #69, #83, #96, #104, and #107) and seven Residents (#21, #28, #62, #65, #94, #97, and #102) who were identified as cognitively impaired but independently mobile. Facility census was 108. 1. Observation on 12/09/25 at 6:30 P.M. revealed a dark night sky and no functioning lights to the right side or around the back of the building, and no functioning lights in the employee parking lot. Only two of six lights were working in the middle grassy and visitor parking area. The two lights that were working only had one of the three bulbs illuminated. Observation and interview on 12/10/25 at 8:35 A.M. with MD #133 confirmed all but two of the front lights were not functioning properly and further confirmed that not having exterior lights…

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, medical record review, staff interview, and review of facility policy, the facility failed to accommodate a resident preference to have an electronic monitoring device (camera) placed in the resident's room. This affected one (#16) of three residents reviewed for accommodation of needs/preferences. The facility census was 108. Review of the medical record for Resident # 16, revealed an admission date of 02/20/20. Diagnoses included chronic respiratory failure with hypoxia, type II diabetes mellitus, need for assistance with personal care, major depressive disorder, and chronic obstructive pulmonary disease. Review of Resident #16's care plan revealed the resident required assistance with activities of daily living (ADL) related to dementia, heart failure, chronic respiratory failure, depression, chronic kidney disease, weakness and cancer. Observation on 12/08/25 at 9:30 A.M. of Resident #16's room revealed no electronic monitoring device (camera). Interview on 12/10/25 at 9:19 A.M. with Social Service Designee #135 revealed there was a request from the family…

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, resident interview, staff interview and policy review, facility failed to ensure residents had privacy when communicating on the phone. This affected one (#35) of three residents reviewed for communication with privacy. Facility census was 108. Review of the medical record for Resident #35 revealed an admission date of 06/06/22. Diagnoses included anxiety, dysphagia, muscle wasting, vascular dementia and Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 00, indicating severe cognitive impairment, and revealed the resident was rarely if ever understood.Review of the medical record for Resident #35 revealed she had a guardian and a family member (son) involved with her care. Observation on 12/10/25 at 2:16 P.M. of the Resident #35's room revealed a corded phone on the nightstand, but not plugged into the wall for service. Resident #35 was unable to be interviewed due to cognitive status. The resident's…

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

Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure medication error rate was less than five percent. There were three medication errors out of 30 opportunities, resulting in a 10 percent medication error rate. This affected one (#58) out of five residents reviewed for medication administration.Review of the medical record for Resident #58 revealed an admission date 08/22/24 ad diagnoses including rhabdomyolysis, type II diabetes mellitus and hypertension.Observation on 12/09/25 at 9:49 A.M. with Licensed Practical Nurse (LPN) #189 completing medication administration for Resident #58 revealed a physician's order dated 08/23/24 for Mucinex 600 milligrams (mg), one tablet twice daily was not administered per order due to not having any supply on hand. A physician's order dated 04/02/25 for Fluticasone Propionate (treats allergies) nasal spray, two sprays in both nostrils was not administered per order due to not having any supply on hand. A physician's order dated 08/24//24 for glipizide (diabetic medication) 5…

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, resident interview, staff interview and review of facility policy, the facility failed to ensure medications were properly stored. This affected one (#79) of three residents reviewed for medication storage. The facility census was 108.Review of the medical record for Resident #79, revealed an admission date of 11/11/16. Diagnoses included: vascular dementia, cerebral infarction, and hypertension.Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #79 had moderate cognitive impairment. Resident #79 required minimal assistance with activities of daily living and ambulates independently.Observation on 12/08/25 at 9:50 A.M. revealed Resident #79's had several medications in a medicine cup sitting on his bedside table. Resident #79 stated he does not know how long they have been there, adding the nurses often leave his medications on the bedside table for him to take.Review of the physician orders revealed Resident #79 did not have an…

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

Based on observation, interview, review of staff time punches, and review of facility policy, the facility failed to have sufficient staffing in the kitchen to maintain a clean kitchen and to serve residents on appropriate dishware. This had the potential to affect all 96 residents residing in the facility who consumed food by mouth from the facility kitchen. Findings include: 1.Observation on 08/25/25 from 9:10 A.M. to 9:28 A.M. revealed the following concerns in the kitchen:a. The wall behind the handwashing sink was covered in food splatter.b. Boxes of food were on the floor, not six inches off the ground. There were 11 boxes piled up in the freezer, over 13 boxes piled up in the walk-in refrigerator, and 17 boxes in dry storage.c. Shelves on all food prep tables, the shelf in the dishwashing area, and the table that had a griddle on it, had a large buildup of food debris and stains. d. The ice machine had a black or gray build up in the back.e. Nine ceiling tiles surrounding a vent were covered in a thick black dust, this went down the wall, which was peeling.f. There were two…

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 revealed the facility failed to maintain a clean and sanitary kitchen and serve beverages in clean cups for the B Unit. This had the potential to affect all 96 residents who consumed food from the kitchen and the 47 residents residing on the B unit (#4, #5, #7, #8, #9, #11, #12, #14, #17, #19, #22, #24, #26, #28, #30, #31, #33, #35, #36, #37, #38, #40, #41, #47, #54, #59, #61, #65, #70, #75, #76, #80, #81, #85, #86, #87, #89, #93, #96, #98, #99, #101, #102, #103, #105, #106, #107). The facility identified all residents received meals/beverages from the kitchen.Findings include:1.Observation on 08/25/25 from 9:10 A.M. to 9:28 A.M. revealed the following concerns in the kitchen:a. The wall behind the handwashing sink was covered in food splatter.b. Boxes of food were on the floor, not six inches off the ground. There were 11 boxes piled up in the freezer, over 13 boxes piled up in the walk-in refrigerator, and 17 boxes in dry storage.c. Shelves on all food prep tables, the shelf in the dishwashing area, and the table that…

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

Based on observation, interview, and facility policy review, the facility failed to ensure kitchen trash cans were appropriately contained. This had the potential to affect all residents residing in the facility. The facility census was 96.Findings include: Observation on 09/03/25 at 8:30 A.M. and 11:14 A.M. revealed two large, approximately 20 gallon, trash containers filled with trash. One container was near the handwashing station, and the other one was near the dishwashing area. Both containers were filled with trash and open with no lids or coverings on them. Interview on 09/03/25 at 11:20 A.M. with Dietary Manager (DM) #269 confirmed that the two containers were uncovered and needed lids or covering. DM #269 obtained lids for the trash containers at time of discovery. Review of the policy Sanitization dated October 2008, revealed kitchen wastes that are not disposed of by mechanical means shall be kept in clean, leakproof, nonabsorbent, tightly closed containers and shall be disposed of daily.

Based on staff interview, review of the surety bond, and review of facility resident financial account balances, the facility failed to ensure that their surety bond was sufficient to cover the highest resident daily funds balance. This had the potential to affect 45 resident accounts that were managed by the facility. The facility census was 96.Findings include:Review of the facility surety bond dated 12/27/24 revealed that the facility had a surety bond in the amount of $50,000.00 dollars.Review of the facility's Resident Fund Management Service (RFMS) resident balance sheet, dated 09/03/25, revealed that the total current balance of all resident accounts was $59,786.08 which was $9,786.08 higher than the surety bond amount.Interview on 09/03/25 at 4:10 P.M. with Regional Business Office Manager (RBOM) #267 confirmed that the amount of the surety bond was not enough to cover the 09/03/25 current resident funds balance.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure Minimum Data Set (MDS) assessments were filled out accurately and timely. This affected four residents (#4, #10, #19 and #64) of 40 sampled for the annual survey. The facility census was 96.Findings include:1.Review of Resident #10 's medical record revealed an admission date of 04/18/25 and diagnoses including, but were not limited to, diabetes, dementia, major depressive, hypertension, asthma, and other sequelae of cerebral infarction Review of resident #10's physicians orders revealed an order dated 04/19/25 for aspirin 81 milligrams daily by mouth. Review of Resident #10's quarterly Minimum Data Set (MDS) assessment, dated 06/11/25, revealed a Brief Interview for Mental Status (BIMS) could not be completed because the resident was rarely/never understood. The resident required set-up assistance for eating, was independent for bed mobility, and required supervision for transfers and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to have comprehensive care plans were in place for Residents #5, #14, and #23. This affected three residents (#5, #14, and #23) out of 40 residents reviewed for care planning. The facility census was 96.Findings include: 1. Review of the medical review revealed Resident #5 was admitted on [DATE] with diagnoses that included mood disorder, anxiety disorder, history of traumatic brain injury (TBI), and paraplegia. Review of hospital record dated 07/22/25 revealed an inpatient consult to behavioral health on 07/20/25 for Resident #5. Resident #5 was a [AGE] year-old male with a known intellectual disability and TBI (2019), paraplegia, with chronic pain syndrome. Behavioral health services were consulted to evaluate episodes of agitation and labile encounters with staff. Resident #5 had a history of depression and anxiety which were thought to be related to his TBI. This was complicated by poor frustration tolerance and maladaptive (inappropriate) coping…

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 medical record review, the facility failed to ensure Residents #38 and #93 received medications timely and as ordered, failed to ensure Resident #15's laceration was monitored, and failed to apply Resident #11's ace wraps per physician orders. This affected four residents (#11, #15, #38, and #93) out of 40 residents sampled for quality of care and treatment. The facility census was 96. Findings include:1.Review of Resident #38's medical record revealed an admission date of 04/17/25 with diagnoses including migraine, mild-protein calorie malnutrition, cognitive communication deficit, chronic pain syndrome, major depressive disorder, unspecified dementia, open angle glaucoma bilateral and severe, and retinal neovascularization of the right eye. Review of Resident #38's plan of care dated 09/18/23 revealed the resident was at risk for impaired comfort related to chronic arthritis, wedge compression fracture, chronic pain, and migraines. Interventions included administering 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 and interview, the facility failed to ensure medications were dated and expired medication was discarded. This affected five (Resident #2, #50, #55, #57, and #116) residents but had the potential to affect newly admitted residents. The facility census was 96. Findings include: 1.An observation on [DATE] at 11:49 A.M. revealed two Glargine (long-acting insulin) pens were open and undated for Resident #57. Registered Nurse (RN) #850 verified the insulin pens for Resident #57 were open and undated. 2.An observation on [DATE] at 11:56 A.M. revealed two vials of Admelog (fast acting insulin) were opened and undated for Resident #2. 3.Aspart (fast acting insulin) was open and undated for Resident #50. Resident #50 was admitted on [DATE] and discharged on [DATE]. 4.Lispro (fast acting insulin) and Glargine were open and undated for Resident #55 that was discharged on [DATE]. An unopened box of Cathflo (alfeplase) for Resident #55 was in the medication cart. The Cathflo for Resident #55 had a…

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

Based on observation and interview the facility failed to ensure the floor and air conditioning units were maintained on the B unit, failed to ensure the floor in Resident #4's room was clean, and failed to ensure the floor and walls of Resident #103 room were clean. This had the potential to affect 47 residents residing on the B unit (#4, #5, #7, #8, #9, #11, #12, #14, #17, #19, #22, #24, #26, #28, #30, #31, #33, #35, #36, #37, #38, #40, #41, #47, #54, #59, #61, #65, #70, #75, #76, #80, #81, #85, #86, #87, #89, #93, #96, #98, #99, #101, #102, #103, #105, #106, and #107). The facility census was 96.Findings include: Observation on 08/25/25 at 11:01 A.M. and 4:09 P.M. of Resident #4's room revealed the floor around her tube feeding had brown splatters. The hallway floor on the B unit was observed to have a black, sticky residue throughout the hallway. Observation on 09/04/25 at 10:00 A.M. and 1:20 P.M. revealed Resident #4 had brown splatters on her floor around her tube feeding pole and had black sticky appearing residue under her wheelchair, which was in the same spot as 08/25/25.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to honor Resident #57's and Resident #68's bathing preferences and failed to ensure Resident #12's call light was within reach. This affected three residents (#12, #57, and #68) out of six residents reviewed for accommodations of needs and preferences. The facility census was 96.Findings include: 1.Review of the medical record revealed Resident #57 was admitted on [DATE] with diagnoses that included type one diabetes, rheumatoid arthritis, peripheral vascular disease, hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side. A care plan dated 08/13/25 and revised on 08/28/25 revealed Resident #57 had a self-care performance deficit related to activities of daily living (ADL) abilities. Interventions included one to two persons to assist with bathing, and two persons to assist with transfers. The 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was cognitively intact. An…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and interview, the facility failed to maintain resident privacy during a routine dressing change. This affected one resident (#25) of one resident observed for wound care. The facility census was 96.Findings include: Review of Resident #25's medical record revealed an admission date of 06/23/21 and diagnoses including but not limited to major depressive disorder, generalized anxiety disorder, constipation, vitamin d deficiency, and unspecified dementia. Review of Resident #25's annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was unable to be completed for Resident #25 because the resident was rarely/never understood. Further review of the MDS revealed Resident #25 required supervision for eating, substantial/maximal assistance for bathing, bed mobility, and transfers and was dependent for toileting hygiene, was always incontinent of bowel and bladder, and had a stage two pressure area. An observation on 09/02/2025 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, review of facility self-reported incidents, and review of facility policy the facility failed to ensure Resident #107's injury of unknown origin and an altercation between Resident #5 and a Certified Nursing Assistant (CNA) were reported to the State Agency in a timely manner. This affected one resident (#107) of seven reviewed for accidents and one resident (#5) of one resident reviewed for abuse. The facility census was 96.Findings include: 1.Review of Resident #107's medical record revealed an admission date of 07/20/17 with diagnoses including dysphagia, cognitive communication deficit, type two diabetes mellitus, cerebral infarction, vascular dementia, epilepsy, contracture of left foot and hand, and flaccid hemiplegia affecting left nondominant side. Review of Resident #107's occupational evaluation and plan of treatment dated 06/09/25 revealed he had left upper extremity paralysis with contractures. Review of Resident #107's quarterly Minimum Data Set (MDS) 3.0…

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, review of facility self-reported incidents, facility investigation review and review of facility policy the facility failed to ensure Resident #107's injury of unknown origin and an altercation between Resident #5 and a Certified Nursing Assistant CNA) were thoroughly investigated. This affected one resident (#107) of seven reviewed for accidents and one resident (#5) of one resident reviewed for abuse. The facility census was 96.Findings include: 1.Review of Resident #107's medical record revealed an admission date of 07/20/17 with diagnoses including dysphagia, cognitive communication deficit, type two diabetes mellitus, cerebral infarction, vascular dementia, epilepsy, contracture of left foot and hand, and flaccid hemiplegia affecting left nondominant side. Review of Resident #107's occupational evaluation and plan of treatment dated 06/09/25 revealed he had left upper extremity paralysis with contractures. Review of Resident #107's quarterly Minimum Data Set (MDS) 3.0…

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 timely complete a Preadmission Screening and Resident Review (PASARR) for Resident #9 and failed to ensure an accurate PASARR was completed for Resident #23. This affected two residents (#9 and #23) out of six residents reviewed for PASARR assessments. The facility census was 96.Findings include: 1. Resident #23 was admitted on [DATE], readmitted on [DATE], and discharged [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), moderate protein-calorie malnutrition, anemia, alcohol abuse, hypertensive heart disease, adult failure to thrive, chronic viral hepatitis C, osteoarthritis, cutaneous abscess of right lower limb, and multiple myeloma. Review of the 5-day Medicare Minimum Data Set (MDS) dated [DATE] Revealed Resident #23 was cognitively intact. Review of the Preadmission Screening and Resident Review (PASARR) identification screen dated 07/07/25 revealed Resident #23 had no mental disorders or substance use related…

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 update the preadmission screening and resident review (PASARR) when Resident #15 received a new diagnosis. This affected one (Resident #15) out of six residents reviewed for PASARR assessments. The facility census was 96. Findings include: Review of the medical record revealed the Hospital Exemption from Preadmission Screening Notification dated 02/06/25 revealed Resident #15 had a mood disorder and paranoia. A disability of blindness was not marked. Review of the medical record for Resident #15 revealed he was admitted to the facility on [DATE] with diagnosis of unspecified psychosis, blindness, and delirium. A pharmacy recommendation dated 05/27/25 revealed a new diagnosis for Risperdal (an antipsychotic medication) was needed. A new diagnosis of delirium due to a known physiological condition was added on 06/06/25. A Preadmission Screening and Resident Review (PASARR) dated 08/28/25 was completed due to the Hospital Exemption from Preadmission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and policy review, the facility failed to provide nail care for Resident #62 and failed to provide bathing as scheduled for Resident #68. This affected two (Resident #62 and #68) of nine residents reviewed for activities of daily living (ADL). The facility census was 96.Findings include: 1. Review of the medical record revealed Resident #62 was admitted on [DATE] with diagnoses that included dementia, type 2 diabetes, and chronic kidney disease. A care plan dated 08/13/25 revealed Resident #62 had an ADL self-care performance deficit with interventions to check nail length and trim and clean (nails) on bath day and as necessary. An admission Functional abilities and goals form dated 08/14/25 revealed Resident #62 was dependent on staff for bathing. An observation and interview on 08/26/25 at 8:27 A.M. with Resident #62 revealed Resident #62 had long fingernails with a dark substance under the nails. Resident #62 verified he would like his fingernails trimmed and cleaned. An…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure Resident #11 and #38 were offered activities and had activity plans of care in place. This affected two residents (#11 and #38) of three residents reviewed for activities. The facility census was 96.Findings include: 1.Review of Resident #38's medical record revealed an admission date of 04/17/25 with diagnoses including cognitive communication deficit, chronic pain syndrome, major depressive disorder, unspecified dementia, open angle glaucoma bilateral and severe, and retinal neovascularization of the right eye. Review of Resident #38's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #38's recreational therapy assessment dated [DATE] revealed the resident had interest in jazz, reading, and watching television and movies. Review of Resident #38's plan of care on 08/25/25 revealed it did not address her activities preferences. Review of Resident #38's medical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility policy review, the facility failed to implement interventions to prevent pressure ulcer development for Resident #21 and failed to ensure Resident #85's pressure ulcer was treated as ordered. This affected two residents (#21 and #85) of four residents reviewed for pressure ulcers. The facility census was 96. Findings include:1. Review of Resident #21's medical record revealed an admission date of 07/29/25 with diagnoses including obstructive and reflux uropathy, spinal stenosis, severe protein-calorie malnutrition, colostomy status, pressure ulcer of sacral region, heart failure, and anal abscess. Review of the Braden scale for Predicting Pressure ulcer risk for Resident #21, dated 07/29/25, revealed the resident was at moderate risk for developing pressure ulcers. This was related to a very limited sensory perception, very limited mobility, and friction and shearing risk. Review of the comprehensive Minimum Data Set (MDS) assessment 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 and interview, the facility failed to ensure documented evidence of Resident #15's bowel movements and failed to ensure documented evidence of Resident #21's catheter care. This affected two (Residents #15 and #21) out of four residents reviewed for bowel and bladder. The facility census was 96.Findings include: 1. Review of the medical record revealed Resident #15 was admitted [DATE] with diagnoses that included unspecified psychosis, left side rib and right lower leg fracture, blindness, and delirium. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had cognitive impairment. The MDS also revealed Resident #15 was always continent of bowel and bladder. Review of the bowel documentation revealed Resident #15 did not have documentation of a bowel movement from 08/07/25 until 08/16/25. An interview on 09/03/25 at 9:17 A.M. with the Director of Nursing (DON) verified the facility did not have a bowel protocol, but stated a residents' name would show…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide documented evidence that Resident #9's ileostomy/urostomy bag was routinely changed. This affected one (Residents #9) out of four residents reviewed for bowel and bladder. The facility census was 96.Findings include: Review of the medical record for Resident #9 revealed an admission date of 03/03/25. Diagnoses included acute kidney failure, hypertension, colostomy, and ileostomy. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/24/25, revealed the resident had slightly impaired cognition. It also noted the resident required staff assistance with managing her colostomy and ileostomy, including changing of the bags. Review of Resident #9's physician orders for March 2025 revealed no orders for ensuring the resident's ileostomy or urostomy bag was changed. Review of Resident #9's medical record revealed no documented ileostomy or urostomy bag changes from her admission [DATE] until she was hospitalized on [DATE]. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to appropriately supervise and position Resident #107 during meals, and timely implement dietitian recommendations for Resident #4 and #21. This affected three residents (#4, #21, and #107) of seven residents reviewed for nutrition. The facility census was 96.Findings include:1.Review of Resident #107's medical record revealed an admission date of 07/20/17 with diagnoses including dysphagia, cognitive communication deficit, type two diabetes mellitus, cerebral infarction, vascular dementia, peripheral vascular disease, epilepsy, sickle-cell disease, contracture of left foot and hand, and flaccid hemiplegia affecting left nondominant side. Review of Resident #107's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. He required substantial to maximal assistance with eating. Review of Resident #107's occupational evaluation and plan of treatment dated 06/09/25 revealed he had left…

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 administer a fentanyl patch as ordered for Resident #38 and failed to ensure parameters were in place for Resident #105's pain medications to administer them appropriately. This affected one resident (#105) of five reviewed for unnecessary medications and one resident (#38) of four people reviewed for pain. The facility census was 96.Findings include: 1. Review of Resident #38's medical record revealed an admission date of 04/17/25 with diagnoses including migraine, osteoarthritis, cognitive communication deficit, chronic pain syndrome, major depressive disorder, unspecified dementia, open angle glaucoma bilateral and severe, and retinal neovascularization of the right eye. Review of Resident #38's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition, almost constantly had pain that occasionally affected day to day activities and the worst pain over the last five days was an eight 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 interview and record review, the facility failed to appropriately document the disposal of fentanyl patches for Resident #38. This affected one resident (#38) of five residents reviewed for pain. The facility census was 96.Findings include: Review of Resident #38's medical record revealed an admission date of 04/17/25 with diagnoses including migraine, osteoarthritis, cognitive communication deficit, chronic pain syndrome, unspecified dementia, open angle glaucoma bilateral and severe, and retinal neovascularization of the right eye. Review of Resident #38's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. almost constantly had pain that occasionally affected day to day activities. The worst pain over the last five days was an eight. Review of Resident #38's plan of care dated 09/18/23 revealed the resident was at risk for impaired comfort related to chronic arthritis, wedge compression fracture, chronic pain, and migraines. Interventions included…

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 #15's medication was ordered with the proper diagnosis. This affected one (Resident #15) of five residents reviewed for appropriate diagnosis for medications. The facility census was 96.Findings include: Review of the medical record revealed Resident #15 was admitted on [DATE] with diagnoses of unspecified psychosis, left side rib and right lower leg fracture, blindness bilateral category 3, delirium, and acute embolism and thrombosis of deep veins of right lower extremity. Review of physician orders revealed from 04/17/25 until 09/03/25 Resident #15 was ordered Clonidine (to treat high blood pressure) 0.1 milligram transdermal patch weekly for deep vein thrombosis. Review of the medication administration record revealed the resident received the medication as ordered. An interview on 09/03/25 at 9:17 A.M. with the Director of Nursing (DON) verified a diagnosis of deep vein thrombosis was an incorrect diagnosis for Clonidine and there…

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 prevent Resident #8 from experiencing a significant medication error when he missed his immunosuppressant medication related to a kidney transplant. This affected one resident (#8) of seven residents reviewed for accidents. The facility census was 96.Findings include: Review of Resident #8's medical record revealed an admission date of 06/06/19 with diagnoses including brief psychotic disorder, bipolar disorder, schizoaffective disorder, kidney transplant status, unspecified mood disorder, chronic kidney disease stage three, and immunodeficiency. Review of Resident #8's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #8's plan of care, revised 06/08/23, revealed the resident had renal insufficiency related to stage three kidney disease and immunodeficiency due to a kidney transplant. Interventions included monitoring and reporting changes in mental status, monitoring for signs…

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

Based on record review and interview, the facility failed to ensure Resident #10's physician-ordered laboratory testing was completed as ordered. This affected one resident (#10) of five residents reviewed for unnecessary medications. The facility census was 96.Findings include: Review of Resident #10 's medical record revealed an admission date of 04/18/25 and diagnoses including, but not limited to, diabetes, dementia, major depressive, hypertension, asthma, and other sequelae of cerebral infarction Review of Resident #10's quarterly Minimum Data Set (MDS) assessment, dated 06/11/25, revealed a Brief Interview for Mental Status (BIMS) could not be completed because the resident was rarely/never understood. The resident required set up assistance for eating, was independent for bed mobility, and required supervision for transfers and ambulation. Resident #10's MDS indicated he was occasionally incontinent of bladder and frequently incontinent of bowel and was working with physical therapy at the time of the assessment. Review of Resident #10's physicians orders revealed an order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility policy, the facility failed to ensure enhanced barrier precautions were in place as ordered for Resident #4, failed to appropriately sanitize a blood pressure cuff for the B Hall, and failed to maintain infection control procedures by changing Resident #64's incontinence brief in Residents #71's bed. This affected three residents (#4, #64, and #71) out of 10 residents reviewed for infection control, and had the potential to affect 47 residents residing on the B hall, that utilized the facility blood pressure cuff, at the time of the survey. The facility census was 96.Findings Include:1.Review of Resident #64's medical record revealed an admission date of 11/25/24 and diagnoses including, but not limited to, depression, anxiety disorder, Vitamin D deficiency, hypertension, diabetes, and unspecified dementia. Review of Resident #64's quarterly Minimum Data Set (MDS) assessment, dated 06/02/25, revealed a Brief Interview for Mental Status (BIMS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to ensure Resident #107's topical antibiotic cream was not provided antibiotic cream past its physician-ordered end date. This affected one resident (#107) of seven residents reviewed for accidents. The facility census was 96.Findings include: Review of Resident #107's medical record revealed an admission date of 07/20/17 with diagnoses including dysphagia, cognitive communication deficit, type two diabetes mellitus, cerebral infarction, vascular dementia, epilepsy, contracture of left foot and hand, and flaccid hemiplegia affecting left nondominant side. Review of Resident #107's progress note dated 05/29/25 revealed the resident was noted to have several liquid filled blister like areas on the back of his hand. Two of the areas were seeping and two were completely opened. There was a yellowish drainage with a mild odor and the resident had pitting edema to his hand. The physician was notified, and they received orders to send…

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, resident, resident family member, and staff interview, and medical record review, the facility failed to maintain a homelike environment for one (#13) of three residents reviewed for environment. The facility census was 99. Findings include: Review of the medical record for Resident #13 revealed an admission date of 10/17/24. Diagnoses included dysphasia, muscle disorder, mobility abnormalities, diabetes with foot ulcer, respiratory failure, and dependence on renal dialysis. Interview and observation on 02/26/25 at 1:35 P.M. with Resident #13 and Resident #13's family member revealed the resident's furniture was typically covered in medical supplies, pillows, wound vacuum care supplies, gloves, incontinence briefs, and blankets. Observation of the resident's room during the interview revealed a pile of items was three feet high and taller than the back of the armchair. Resident #13's family stated the resident did not have current orders for a wound vacuum and the resident typically had pillows for off loading, but did not need the six that were piled up.…

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, resident, resident family, and staff interview, medical record review, and policy review, the facility failed to ensure residents received assistance with bathing and nail care. This affected three (#13, #21, and #102) of four residents reviewed for activities of daily living (ADLs) for dependent residents. The facility census was 99. Findings include: 1. Review of the medical record for Resident #102 revealed an admission date of 11/04/24 and discharge date of 01/19/25. Diagnoses included amputation of the right foot, diabetes, muscle disorder, end stage renal disease, epilepsy, and heart failure. Review of the plan of care dated 11/04/24 revealed Resident #102 had a self-care deficit with interventions to assist with bathing and shower as needed, and assist with hygiene, grooming, dressing as needed. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #102 was cognitively intact and required substantial maximum assistance for toileting, bathing, and personal…

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, resident, resident family, and staff interview, policy review, the facility failed to ensure physical therapy was provided as ordered. This affected two (#13 and #102) of three residents reviewed for therapy services. The facility census was 99. Findings include: 1. Review of the medical record for Resident #13 revealed an admission date of 10/17/24. Diagnoses included dysphasia, muscle disorder, mobility abnormalities, diabetes with a foot ulcer, respiratory failure, and dependence on renal dialysis. Review of Resident #13's physician orders dated 11/07/24 to 02/10/25 revealed physical therapy was recommended for skilled treatment five times weekly until 12/11/24. Resident #13 had an order dated 12/06/24 to 02/10/25 for physical therapy recommended for skilled treatment five times weekly until 01/04/25. Further review reveled a third order for 02/19/25 with no end date for a physical therapy recommended for skilled treatment five times weekly. Review of Resident #13's therapy…

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 infection control logs, and policy review, the facility failed to ensure COVID-19 infections were adequately monitored. This affected one (#102) of three reviewed for COVID-19 infections. The facility census was 99. Findings include: Review of the medical record for Resident #102 revealed an admission date of 11/04/24. Diagnoses included amputation of the right foot, diabetes, muscle disorder, end stage renal disease, epilepsy, and heart failure. The resident was discharged on 01/19/25. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #102 was cognitively intact. Review progress notes dated 01/08/25 revealed Resident #102 was evaluated for a transfer to an assisted living facility, and a COVID-19 test was requested. Resident #102 tested negative and all parties were updated. Review of a subsequent progress note dated 01/10/25 revealed Resident #102's family was concerned about a change in condition and a COVID-19 test was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, resident interview, guardian interview, record review, policy review, and review of Self-Reported Incident (SRI), the facility failed to timely notify the resident representative following a change in condition. This affected one (#69) of three residents reviewed for notification of change in condition. The facility census was 95. Findings include: Review of the medical record for Resident #69 revealed an admission date of 08/16/22. Medical diagnoses included hemiparesis and hemiplegia following cerebrovascular accident (stroke), lack of coordination, and anxiety. Review of Resident #69's Minimum Data Set (MDS) annual assessment, dated 06/05/24 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #69 had no recorded behaviors or rejection of care. Review of Resident #69's interdisciplinary progress notes revealed a note dated 07/24/24 at 2:00 P.M., which indicated the resident sustained a wound to her left…

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, hospital record review, orthopedic follow-up note review, and staff interview, this facility failed to ensure follow-up appointments were implemented as scheduled and/or ordered. This affected one (Resident #36) of the six residents reviewed for follow-up care. The facility census was 98. Findings include: Review of the medical record for Resident #36 revealed an initial admission date of 02/09/24 and a re-entry date of 05/08/24. Diagnoses included dehiscence of amputation stump, need for assistance with personal care, peripheral vascular disease, and acquired absence of the right leg below the knee. Review of the hospital after visit summary dated 02/09/24 revealed an order for the resident to follow-up with her orthopedic physician in two weeks. Review of Resident #36's scheduled appointments for February 2024 revealed a scheduled follow-up appointment with orthopedic office in two weeks or on February 20 th, 2024 at 12:00 P.M. Review of progress note dated 02/19/24 at 4:53 P.M.…

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, staff interview, and fall investigation report review, this facility failed to ensure safety measures were in place during mechanical lift transfers to prevent a fall. This affected one (Resident #108) of three residents reviewed for accidents while receiving staff assistance. Facility census was 98. Findings Include: Review of the medical record for Resident #108 revealed an initial admission date of 10/20/10 and a re-entry date of 03/06/23. Diagnoses included contracture of the left and right ankle, lack of coordination, muscle spasms, and dependence on enabling machines and devices. Review of Resident #108's Fall assessment dated [DATE] revealed a score of 10 indicating a low risk for falls. Review of Resident #108's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had a Brief Interview for Mental Status (BIMS) score of 14 out 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 medical record review, observations, staff interview, and facility policy review, this facility failed to ensure proper hand hygiene after glove removal and implement Enhanced Barrier Precautions during wound care and dressing change. This affected one (Resident #36) of the four residents reviewed for wound care. Facility census was 98. Findings include: Review of the medical record for Resident #36 revealed an admission date of 02/09/24 and a re-entry date of 05/08/24. Diagnoses included dehiscence of amputated stump, need for assistance with personal care, and absence of right leg below the knee. Review of the care plan dated 02/13/24 revealed Resident #36 has actual impairment to skin integrity of the right below the knee amputation (RBKA) related to a surgical wound. Interventions include to follow facility protocols for treatment of injury, weekly treatment documentation to include measurement of each area of skin breakdowns width, length, depth, type of tissue and exudate and any other notable…

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

Based on observation, staff interviews, resident interviews, and review of the facility meal schedule, the facility failed to ensure meals were served at the scheduled time. This affected all of the residents residing in the facility. The facility census was 102. Findings include: Observation on 01/29/24 from 8:44 A.M. to 9:15 A.M. revealed the residents were waiting for breakfast to be served. Observation on 01/29/24 at 9:10 A.M. revealed Regional Dietary Manager (RDM) #305 and Dietary Aide (DA) #202 were preparing scrambled eggs and toast for breakfast. Interview on 01/29/24 at 9:30 A.M. with Dietary Manager (DM) #199 confirmed the cook had called off work on 01/29/24 and no one had notified him of the call off until he arrived at the facility. Observation on 01/29/24 at 9:31 A.M. revealed the dietary staff began delivering breakfast meal trays to the residents. Interviews on 01/29/24 from 10:30 A.M. to 11:00 A.M. with Residents #12, #14, #18 and #20 confirmed breakfast was not served on 01/29/24 until after 9:30 A.M. Residents further confirmed they preferred to receive breakfast…

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

Based on observations, staff interviews and review of the facility policy the facility failed to ensure food was stored, prepared and distributed in a sanitary manner to prevent food borne illnesses. This had the potential to affect all of the residents residing in the facility. The census was 102 residents. Findings include: 1.Observation of the kitchen 01/29/24 at 8:44 A.M. revealed the ice machine's shield had a residue of brown and black particles which were observable when staff wiped the shield with a paper towel. Interview on 01/29/24 at 8:44 A.M. with Dietary Aide (DA) #202 confirmed the ice machine shield located inside the ice machine had a residue of brown and black particles. 2. Observation on 01/29/24 at 8:46 A.M. revealed the shelf above the prep table contained an undated sealed bag of brown sugar. Interview on 01/29/24 at 8:46 A.M. with Administrator in Training (AIT) #102 confirmed the bag of brown sugar was not dated. 3. Observation on 01/29/24 at 8:48 A.M. revealed the door to the dry storage room was propped open with a plastic gallon container of mayonnaise on…

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

Based on observation, staff interview, and resident interview, the facility failed to maintain a safe, functional, and homelike environment for residents and staff. This had the potential to affect all residents residing in the facility. The census was 102 residents. Findings include: 1.Observation on 01/29/24 at 8:02 A.M. of the parking lot revealed there were two garbage dumpsters with eight large clear bags of garbage sitting on the ground. Interview on 01/29/24 at 8:30 A.M. with the Director of Nursing (DON) confirmed the bags had been sitting there since 01/28/24 and should be placed inside the dumpster. 2. Observation on 01/29/24 at 8:31 A.M. revealed there was a low air mattress, a slender box approximately three feet long and several large boxes sitting out in the lobby of the facility, an area which was accessible to residents. Interview on 01/29/24 at 8:31 A.M. with the DON confirmed the low air loss mattress and boxes were being stored in the lobby and should be stored in an appropriate storage location. 3. Observation on 01/29/24 at 8:33 A.M. revealed there was a geri…

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, observation, resident interview, and staff interview, the facility failed to ensure staff treated residents with dignity and respect by knocking on the resident door and waiting to be invited in before entering the room. This affected one (Resident #16) of four residents reviewed for dignity and respect. The facility census was 102. Findings include: Review of the medical record for Resident # 16 revealed an admission date of 03/28/22 with diagnoses including alcohol cirrhosis, kidney failure, heart failure, diabetes, and legal blindness. Review of the Minimum Data Set (MDS) assessment for Resident #16 dated 12/29/23 revealed the resident was cognitively impaired and required staff assistance with activities of daily living (ADLs). Observation on 01/30/24 at 2:45 P.M. revealed State Tested Nursing Assistant (STNA) #112 entered Resident #16's room without knocking on the door. The Surveyor was interviewing Resident #16 at the time and told STNA #112 they were having a private conversation. STNA #112 did not acknowledge Resident #16 or the Surveyor and…

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

Based on medical record review, resident interview, review of facility grievance log, staff interview, and review of the facility policy, the facility failed to ensure resident complaints and concerns were documented and followed up on in a timely manner. This affected one (Resident #16) of three residents reviewed for follow up on resident concerns. Resident census was 101. Findings include: Review of the medical record for Resident #16 revealed an admission date of 03/28/22 with diagnoses including alcohol cirrhosis, kidney failure, heart failure, diabetes, and legal blindness. Review of the Minimum Data Set (MDS) assessment for Resident #16 dated 12/29/23 revealed the resident was cognitively impaired and required set up assistance for lower and upper body dressing and shower and bathing required partial or moderate assistance. Interview on 01/29/24 at 2:21 P.M. with Resident #16 confirmed he was legally blind and required assistance with certain activities of daily living (ADLs.) Resident #16 confirmed he had reported many concerns including issues with staff and dietary issues…

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 interviews and review of the facility policy the facility failed to ensure a complete and thorough investigation was completed for allegations of abuse, neglect and misappropriation. This affected one (Resident #16) of three residents reviewed for abuse and neglect. The facility census was 101. Findings include: Review of the medical record for Resident # 16 revealed an admission date of 03/28/22 with diagnoses including alcohol cirrhosis, kidney failure, heart failure, diabetes, and legal blindness. Review of the Minimum Data Set (MDS) assessment for Resident #16 dated 12/29/23 revealed the resident was cognitively impaired and required set up assistance for lower and upper body dressing and shower and bathing require partial or moderate assistance. Review of a progress note for Resident #16 dated 11/29/23 per the Administrator revealed staff reported Resident #16 was being aggressive and using foul language and impeding care of his roommate. Staff had reported resident spoke disrespectfully to them and called them profane names. Staff informed…

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, observation, resident interview, staff interview, and review of the facility menu, the facility failed to ensure residents received foods that accommodated resident preferences. This affected two (Residents #16 and #22) of six residents reviewed for dietary services. The facility census was 102. Findings include: Review of the medical record for Resident # 16 revealed an admission date of 03/28/22 with diagnoses including alcohol cirrhosis, kidney failure, heart failure, diabetes, and legal blindness. Review of the Minimum Data Set (MDS) assessment for Resident #16 dated 12/29/23 revealed the resident was cognitively impaired and required staff supervision and set up help with eating. Review of the January 2024 physician orders for Resident #16 revealed the resident received a regular diet with regular textures and thin liquids. Review of the breakfast tray ticket for Resident #16 dated 01/30/24 revealed the resident requested toast, four pieces of bacon and two hard boiled eggs for breakfast. Interview on 01/29/24 at 2:21 P.M. with Resident #16…

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

Based on observations, staff interview, and facility policy review, the facility failed to ensure one resident's (Resident #74) call light was kept within reach. The deficient practice affected one (Resident #74) of 21 residents observed for call lights. The facility census was 87. Findings include: Review of the medical record for Resident #74 revealed an initial admission date on 04/03/23 and a readmission date on 05/05/23. Medical diagnoses included senile degeneration of the brain, type two diabetes mellitus, chronic obstructive pulmonary disorder (COPD), dysphagia (difficulty swallowing), dementia, and history of falling. Review of the Medicare Five Day Minimum Data Set (MDS) 3.0 assessment, dated 05/12/23, revealed Resident #74 had impaired cognition and scored an 11 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #74 required extensive assistance from one to two staff to complete Activities of Daily Living (ADL), except eating. Resident #74 required supervision with set up help only from staff with eating. Resident #74 was totally dependent 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, resident interviews, review of resident council meeting minutes, staff interview, and facility policy review, the facility failed to ensure repeated concerns expressed during resident council were adequately addressed. This affected three (Residents #28, #61, and #68) of five residents reviewed for staffing concerns. The census was 87. Findings include: Review of the medical record for Resident #28 revealed Resident #28 was admitted to the facility on [DATE]. Resident #28's diagnoses included congestive heart failure, chronic respiratory failure, cerebral infarction, type two diabetes. Review of Resident #28's Minimum Data Set (MDS) assessment, dated 06/12/23, revealed Resident #28 was cognitively intact. Review of the medical record for Resident #61 revealed Resident #61 was admitted to the facility on [DATE]. Resident #61's diagnoses included paraplegia, congestive heart failure, cerebral infarction, insomnia, and chronic pain syndrome. Review of Resident #61's MDS assessment,…

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 ensure meals intakes were consistently recorded and monitored as well ensure resident weights were routinely obtained upon admission. This affected one (Resident #87) of four residents reviewed for nutrition. The census was 87. Findings include: Review of the medical record for Resident #87 revealed Resident #87 was admitted to the facility on [DATE]. Her diagnoses included but were not limited to type two diabetes, hypertension, and edema. Review of Resident #87's Minimum Data Set (MDS) assessment, dated 05/19/23, revealed Resident #87 was cognitively intact. Review of Resident #87 weights since 05/12/23, revealed the following weights and dates they were taken: 05/13/23 (292 pounds), 05/31/23 (287 pounds), and 06/12/23 (286 pounds). There was no evidence additional weights were obtained for Resident #87. Review of Resident #87's nutritional notes and assessments since 05/12/23, revealed one nutritional…

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

Based on medical record review, review of the menu, review of the substituation log, review of the dietary spreadsheet, observation, staff interview, and facility policy review, the facility failed to serve the appropriate dessert according to the menu. The deficient practice affected two (Residents #10 and #29) of three residents who were on a pureed diet in the facility. The facility census was 87. Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 11/04/21. Resident #10's medical diagnoses included dementia, generalized anxiety disorder, and rheumatoid arthritis. Review of the order summary report of active physician orders as of 06/22/23 revealed Resident #10 had a diet order for a regular diet, pureed texture, and nectar thick liquids. The order was dated 04/05/23. 2. Review of the medical record for Resident #29 revealed an initial admission date on 01/30/23 and a readmission date on 02/12/23. Medical diagnoses included acute and chronic respiratory failure with hypoxia, diffuse traumatic brain injury, protein-calorie malnutrition,…

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, observation, staff interview, review of the pureed green beans recipe, and review of facility policy, the facility failed to serve palatable pureed green beans. This affected three (Resident #10, #29, and #40) out of three residents who received a pureed diet. The facility census was 87. Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 11/04/21. Resident #10's medical diagnoses included dementia, generalized anxiety disorder, and rheumatoid arthritis. Review of the order summary report of active physician orders as of 06/22/23 revealed Resident #10 had a diet order for a regular diet, pureed texture, and nectar thick liquids. The order was dated 04/05/23. 2. Review of the medical record for Resident #29 revealed an initial admission date of 01/30/23 and a readmission date of 02/12/23. Resident #29's medical diagnoses included acute and chronic respiratory failure with hypoxia, diffuse traumatic brain injury, protein-calorie malnutrition, and dysphagia (difficulty swallowing). Review of the order summary…

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, observation, staff interview, and facility policy review, the facility failed to ensure residents received dessert that was the appropriate texture and consistency. The deficient practice affected one (Resident #40) out of three residents who received a pureed diet. The facility census was 87. Findings include: Review of the medical record for Resident #40 revealed an initial admission date of 04/19/18 and a readmission date of 05/22/18. Resident #40's medical diagnoses included Alzheimer's Disease, dysphagia, and protein-calorie malnutrition. Review of the order summary report of active physician orders as of 06/22/23 revealed Resident #40 had a diet order for a regular diet, pureed texture, and thin liquids. The order also stated to feed drinks to Resident #40 with a spoon, provide a divided plate for all meals, and provide one on one for all meals. The order was dated 05/19/21. Observation on 06/20/23 at 12:10 P.M. of Resident #40 during the lunch meal revealed the resident was sitting in a broda chair in the common area, in front of the nurse's…

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

Based on observation and staff interview, the facility failed to ensure the environment was maintained in a safe, sanitary, and comfortable manner. This affected two (Residents #12 and #50) out of three residents reviewed for environment. The facility census was 87. Findings include: Observation on 06/12/23 at 10:47 A.M. revealed drywall tape and plaster was hanging from the ceiling by the window over the wardrobe in the room shared by Resident #50 and Resident #12. Observation on 06/14/23 at 2:15 P.M. revealed drywall tape and plaster was still hanging from the ceiling by the window over the wardrobe in the room shared by Resident #50 and Resident #12. Observation on 06/20/23 at 3:00 P.M. revealed drywall tape and plaster was still hanging from the ceiling by the window over the wardrobe in the room shared by Resident #50 and Resident #12. Interview on 06/20/23 at 5:00 P.M. with the Administrator verified there was drywall tape and plaster hanging from the ceiling over the wardrobe in Resident #50 and Resident #12's room. The Administrator stated there needed to be a work order…

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

Based on observation, staff interview and review of the facility's policy, the facility failed to maintain a sanitary kitchen and ensure food proper food storage. This affected 83 of 87 residents who receive food from the kitchen (Residents #4, #23, #68 and #245 receive nothing by mouth). The facility census was 87. Findings include: Observation of the kitchen's bread rack on 02/24/20 at 9:28 A.M. revealed all thawed facility bread was undated as to when it was thawed. Interview with Assistant Dietary Manager (ADM) #554 at the time of the observation revealed the dietary staff were supposed to date the bread when they pull it out of the freezer to thaw, and the bread was good for seven days. If is not used within seven days, then it was to be thrown away. The ADM verified the bread was not dated as to when it was thawed. Observation of the range hood over the stove on 02/24/20 at 9:30 A.M. revealed grayish fuzzy substance hanging off the range hood over the stove. Interview with ADM #554 at the time of the observation verified there was grayish fuzzy substance hanging off the range…

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 facility record review, staff interview, interview with the county health department, review of the memorandum from the Center for Clinical Standards and Quality/Quality, Safety and Oversight Group and review of the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) guidance, the facility failed to develop an adequate water management plan. In addition, the facility failed to ensure proper signage was located on the door of a resident on isolation precautions. This had the potential to affect all 87 residents residing in the facility. Findings include: 1. Review of the facility's undated water management plan revealed the facility failed to accurately describe its building water system and failed to follow the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) guidance. The facility's water management plan did not establish control limits and failed to establish response protocols when the control limits were not met. Further 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 record review, observation, staff and resident interviews and review of the facility's policy, the facility failed to promote dignity by not removing a hospital band containing private information from Resident #68's wrist and failed to provide dignity to Resident #6, #28 and #51 by standing over the residents and feeding the residents. This affected four (#6, #28, #51 and #68) of six residents reviewed for dignity. The facility identified nine residents who require feeding assistance. The facility census was 87. Findings include: 1. Review of Resident #68's medical record revealed an admission date of 08/04/19. Diagnoses included cerebral palsy, anxiety disorder, acute respiratory failure, acute kidney failure and unspecified intellectual disabilities. Review of the Minimum Data Set (MDS) assessment, dated 01/22/20, revealed the resident was significantly cognitively impaired and required the extensive assistance of one person for dressing and hygiene care needs Review of the progress notes, 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.

Based on record review, staff interview and review of the facility's policy, the facility failed to ensure the code status in the electronic medical record was accurate for Resident #36 and failed to obtain a do not resuscitate (DNR) consent nt for Resident #68. This affected two (#36 and #68) of 25 residents reviewed for advanced directives. The facility census was 87. Findings include: 1. Review of Resident #36's medical record revealed an admission date of 12/16/17. Diagnoses included chronic obstructive pulmonary disease, vascular dementia with behavioral disturbance and chronic kidney disease stage three. Review of the Minimum Data Set (MDS) assessment, dated 12/31/19, revealed the resident was moderately cognitively impaired. Review of the physician order, dated 01/28/20, revealed a Do Not Resuscitate- Comfort Care (DNR-CC) code status order. (A DNR-CC requires that only comfort measures be provided when a resident's heart stop beating or they stop breathing). Review of the resident's code status consent form, undated, revealed the resident consented to a DNR-CC Arrest code…

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 review of the facility's policy, the facility failed to notify the physician of Resident #68's abnormal lab values. This affected one (#68) of two residents reviewed for notification of change. The facility census was 87. Findings include: Review of Resident #68's medical record revealed an initial admission date of 08/04/19 with diagnoses including cerebral palsy, anxiety disorder, acute respiratory failure, acute kidney failure, and unspecified intellectual disabilities. Review of the Minimum Data Set (MDS) assessment, dated 01/22/20, revealed the resident was significantly cognitively impaired. Review of the physician order, dated 01/16/20 revealed to have lab Complete Metabolic Panel (CMP) preformed each Friday. Review of the hospital Discharge summary, dated [DATE], revealed the resident was admitted to the hospital for abnormal lab values (Sodium 168) and was admitted to the Intensive Care Unit for free water replacement and the resident was diagnosed with…

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

Based on record review and staff interview, the facility failed to complete a pre-admission screening and resident review (PASARR) after a new mental health diagnosis for Resident #17. This affected one (Resident #17) of five reviewed for PASARR. The facility census was 87. Findings include: Record review of Resident #17 revealed an admission date of 07/23/19. Diagnoses included visual hallucinations and delusional disorder. Review of Resident #17's pre-admission screening and resident review (PASARR), dated 07/23/19, revealed diagnosis of mental disorders included mood disorder and delusional disorder only. Schizophrenia was not marked. Review of the resident's diagnosis sheet revealed a diagnosis of schizoaffective disorder was given to the resident on 08/14/19. There was not a new PASARR after the resident's new diagnosis of schizophrenia. Interview with Licensed Social Worker (LSW) #648 on 02/26/20 at 3:25 P.M. verified the new diagnosis of schizoaffective disorder on 08/14/19 and a new PASARR was not completed after the new diagnosis as required.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, review of the facility's policy and observation, the facility failed to develop and implement fall interventions for Resident #7, an oxygen administration care plan for Resident #24, and a wandering care plan for Resident #66. This affected three (#7, #24 and #66) of 23 resident's care plans reviewed during the annual survey. The facility census was 87. Findings include: 1. Review of the medical record for Resident #7 revealed the resident was admitted to the facility on [DATE]. Diagnoses included lack of coordination, repeated falls, heart failure, unspecified, arteriosclerotic heart disease of native coronary artery without angina pectoris, Parkinson's disease, bilateral primary osteopathic of knee and Alzheimer's disease. Review of the care plan, dated 06/13/19, revealed the resident was at risk for pressure related skin alteration injury to rule out decreased strength, decreased mobility, surgical incision to the right knee, decreased muscle mass and co-mobilities. An…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff and resident interviews and review of the facility's policy, the facility failed to provide timely personal hygiene care to a resident who required extensive assistance from staff for personal hygiene. This affected one (#68) of seven residents reviewed for activities of daily living (ADL). The facility census was 87. Findings included: Review of Resident #68's medical record revealed an admission date of 08/04/19. Diagnoses included cerebral palsy, anxiety disorder, acute respiratory failure, acute kidney failure, gastrostomy, and unspecified intellectual disabilities. The resident was noted to be hospitalized on [DATE] and returned to the facility on [DATE] for an upper gastrointestinal bleed. Review of the Minimum Data Set (MDS) assessment, dated 01/22/20, revealed the resident was significantly cognitively impaired and the resident required the extensive assistance of one person for hygiene care needs and was totally dependent on the assistance for bathing needs.…

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

Based on observation, staff interviews and record review, the facility failed to implement fall interventions as indicated in a resident's care plan by not adding non-slip strips to the floor next to the resident's bed or in front of the resident's toilet. This affected one (Resident #61) of three residents reviewed for falls. The facility census was 87. Findings include: Review of Resident #61's medical chart revealed an admission date of 01/06/18. Diagnoses included osteoarthritis, dementia with behavioral disturbance, restlessness and agitation, generalized anxiety disorder, abnormalities of gait and mobility, lack of coordination, muscle wasting and atrophy, history of falling, and fracture of unspecified part of neck of left femur. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/22/20, revealed the resident had severely impaired cognition and required assistance from two staff persons with activities of daily living. Review of the Incident Report, dated 01/10/20, revealed Resident #61 had a fall in her room after the resident attempted to transfer herself…

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, observation, staff interview and review of the facility's policy, the facility failed to administer Resident #68's tube feeding per physicians order. This affected one (#68) of one residents reviewed with a tube feeding care need. The facility identified seven residents receiving tube feed. The facility census was 87. Findings include: Review of Resident #68's medical record revealed an admission date of 08/04/19. Diagnoses included cerebral palsy and acute respiratory failure. Review of the Minimum Data Set (MDS) assessment, dated 01/22/20, revealed the resident was significantly cognitively impaired and was totally dependent on the assistance of another person for eating. Review of the physician orders, dated 02/18/20, revealed an order to administer enteral feed order one time a day from 9:00 A.M. to 7:00 A.M. at 50 milliliters per hour for 22 hours. Review of the care plan, dated 02/19/20 revealed the resident required tube feeding due to dysphagia and an intervention to provide treatment as ordered to gastrostomy tube, provide medications as ordered, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interviews and facility policy, the facility failed to obtain an oxygen order and then follow the physician for Resident #24 and failed to properly date and label the oxygen tubing for Resident #24 and Resident #77. This affected two (#24 and #77) of five residents reviewed for respiratory care. The facility identified 14 residents who receive respiratory care. The facility census was 87. Findings include: 1. Review of Resident #24's medical record revealed an admission date of 12/10/19. Diagnoses included chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, asthma, shortness of breath and dependence on supplemental oxygen. Review of the Minimum Data Set (MDS) assessment, dated 12/17/20, revealed the resident was cognitively intact and the resident used oxygen therapy. Review of the progress notes, dated 02/04/20, revealed the resident was on three liters of oxygen continuously via nasal cannula. Review of Resident #24's physician orders…

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, review of the facility's policy and staff interview, the facility failed to address monthly pharmacy recommendations in a timely manner. This affected one (Resident #53) of five residents reviewed for unnecessary medications. The facility census was 87. Findings include: Review of the medical record for Resident #53 revealed an admission date of 05/10/19. Diagnoses included anxiety, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/19/19, revealed the resident was cognitively intact. Review of the pharmacy recommendation, dated 11/18/19, revealed Resident #53 had an order for hydroxyzine, an antihistamine medication that can be used to treat anxiety, 25 milligrams (mg.) every eight hours as needed for anxiety, which was in place for greater than 14 days, and Resident #53 had not received a dose in the past 60 days. The pharmacist recommended the medication be discontinued due to non-use. The pharmacy recommendation was never addressed by the physician. Review of a second pharmacy recommendation, dated 11/18/19,…

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, review of the facility's policy and staff interview, the facility failed to ensure drugs and biological were stored in locked compartments when they left a medication cart unlocked on unit A. This had the potential to affect four residents (Resident #6, #37, #81 and #238) who were cognitively impaired and self mobile. The facility census was 87. Findings include: Observation on 02/24/20 at 12:33 P.M. on unit A revealed an unlocked medication cart sitting by the nurse's station. No staff member was around the nurse station. Interview with Licensed Practical Nurse (LPN) #653 on 02/24/20 at 12:35 P.M. verified the medication cart was unlocked. LPN #653 stated she was not working on the floor today and LPN #577 was in charge of the unit A medication cart. Review of the facility's list of resident who were cognitively impaired, self mobile and resided on unit A revealed Resident #6, #37, #81 and #238 were cognitively impaired, self mobile and resided on unit A. Review of the facility's storage of medication policy, dated 04/01/07, revealed compartments including 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.