Spring Creek Nursing And Rehabilitation Center LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview, and review of the facility policy, the facility failed to ensure residents who had vision concerns were seen timely by the ophthalmologist. This affected one (#37) resident reviewed for ancillary services. The facility census was 71.Findings include:Review of the medical record for Resident #37 revealed an admission on [DATE]. Diagnoses included traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, subsequent encounter, periodontal diseases, persistent vegetative state, and encephalopathy. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed resident #37 had severe cognitive impairment and was dependent on staff to complete activities of daily living (ADL). Review of the care plan dated 04/09/22 revealed Resident #37 had ADL self-care performance deficit related to traumatic brain injury. Interventions included glasses to be worn during the day.Review of the ancillary vision service provider notes revealed Resident #37 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident interview, staff interview, and policy review revealed the facility failed to ensure a resident with pressure ulcers was provided a high protein diet as prescribed by a physician. This affected one (#25) of two residents reviewed for wounds. The facility census was 71. Findings include:Review of Resident #25's medical record revealed an admission date of 06/07/24. Diagnoses included acute transverse myelitis in demyelinating disease of the central nervous system, paraplegia, and stage three and four pressure ulcers.Review of Resident #25's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had an intact cognition and was documented as having three stage four pressure ulcers and one stage two pressure ulcers.Review of Resident #25's care plan revealed the resident had pressure ulcers to the right buttock, left posterior thigh, and coccyx. Interventions included to administer treatments as ordered, educate the resident/family/caregivers as to causes 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, staff interview, resident interview, and policy review, the facility failed to ensure safety by allowing a space heater in a resident's room. This affected one (#70) of one resident reviewed for resident safety. The facility census was 71. Findings include:Review of Resident #70's medical record revealed an admission date of 11/19/25. Diagnoses included multiple myeloma, malignant neoplasm of bone, anemia, thrombocytopenia, and severe protein calorie malnutrition.Review of Resident #70's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had an intact cognition.Observation on 05/05/26 at 10:35 A.M. revealed there was a space heater sitting on the window ledge in Resident #70's room. The heater was operating and blowing hot air.Observation on 05/05/2026 at 1:40 P.M. revealed Resident #70 was sitting in bed with a visitor at bedside. The heater continued to be in use.Interview with Resident #70 on 05/05/26 at 10:37 A.M. verified the space heater was in working order and she…

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 facility policy, the facility failed to timely identify, assess, and intervene for significant weight loss. This affected one (#5) resident of one resident reviewed for weight loss. The facility census was 71.Findings include:Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included dysphasia, unspecified severe protein-calorie malnutrition, hypokalemia, and vitamin D deficiency.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #5 had cognitive impairment.Record review of the clinical record revealed Resident #5 had a monthly weight of 187.9 pounds on 02/08/26, 177.9 pounds on 03/06/26, and a weight on 04/26/26 of 174.0 pounds for 13.9 pounds or -7.40 percent weight loss.Review of the clinical record Individual Nutrition Recommendations/Response form dated 03/12/26, signed by Nutrition and Dietetic Technician, Registered (NDTR) #900 revealed a recommendation for a mighty shake,…

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, interview, and review of the facility policy the facility failed to ensure a resident on dialysis who frequently refused due to nausea and vomiting was monitored, and that the physician was notified. This affected one (#64) resident reviewed for dialysis. The facility census was 71.Findings include:Review of the medical record for Resident #64 revealed an admission on [DATE]. Diagnoses included end stage renal disease, encephalopathy, hypo-osmolality and hyponatremia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #64 had cognitive impairment and was dependent on staff for activities of daily living (ADLs). Further review of the MDS revealed Resident #64 received dialysis. Review of the care plan dated 11/05/25 revealed Resident #64 had pain related to decreased mobility and end stage renal disease (ESRD). Interventions included monitoring and documenting probable cause of each pain episode. Further review of the care plan revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure provider orders were carried out as prescribed. This affected one (#5) of one resident reviewed for the implementation of provider orders. The facility census was 71.Findings include:Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included dysphasia, unspecified severe protein-calorie malnutrition, hypokalemia, and vitamin D deficiency.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #5 had cognitive impairment.Record review of the clinical record revealed Resident #5 had a monthly weight of 187.9 pounds on 02/08/26, 177.9 pounds on 03/06/26, and a weight on 04/26/26 of 174.0 pounds for 13.9 pounds or -7.40 percent weight loss.Review of the clinical record Individual Nutrition Recommendations/Response form dated 03/12/26, signed by Nutrition and Dietetic Technician, Registered (NDTR) #900 revealed a recommendation for a mighty shake, appetite stimulant, to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure dental services were provided for one (#37) resident reviewed for dental services. The facility census was 71.Findings include:Review of the medical record for Resident #37 revealed an admission on [DATE]. Diagnoses included traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, subsequent encounter, periodontal diseases, persistent vegetative state, and encephalopathy. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed resident #37 had severe cognitive impairment and was dependent on staff to complete activities of daily living (ADL). Further review of the MDS revealed Resident #37 had inflamed or bleeding gums.Review of the care plan dated 04/09/22 revealed Resident #37 had an ADL self-care performance deficit related to traumatic brain injury. Interventions included glasses to be worn during the day, and staff to perform oral care. Review of the dental health service 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, staff interview, police officer interview, review of Self-Report Incident (SRI) #269318, review of the facility investigation, and review of the facility policy, the facility failed to protect a resident from misappropriation. This affected one resident (#2) of three reviewed for misappropriation. The facility census was 71.Findings include: Review of the medical record for Resident #2 revealed an admission date of 12/04/13. Diagnoses included Multiple Sclerosis (MS), diabetes mellitus type two, chronic obstructive pulmonary disease (COPD), heart failure, chronic kidney disease (CKD) stage three, atrial fibrillation (A-fib), hypertension, and peripheral vascular disease (PDV). Review of the quarterly Minimum Data Set (MDS) dated [DATE] for Resident #2 revealed the resident had mild cognitive impairment. Review of the statement submitted by Resident #2, dated 01/02/26, revealed the resident reported she reviewed her most recent bank statement and it had charges…

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 and staff interview, review of resident shower sheets and shower schedules, and facility policy review, the facility failed to ensure residents who were dependent on staff for bathing received showers on their scheduled days per their preference. This affected three (#17, #25, and #67) of four residents reviewed for showers. The facility census was 68. Findings include: 1. Review of the medical record for Resident #17 revealed an original admission date of 12/04/13 with re-admission to the facility on [DATE]. Diagnoses included multiple sclerosis, chronic obstructive pulmonary disease (COPD) and atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. The resident was assessed to require maximal assistance with showers and was dependent on staff to transfer into the shower. Review of the care plan dated 07/26/22 revealed…

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

Based on observation, resident and staff interviews, and review of the facility policy, the facility failed to ensure the resident's call devices were functioning in their bathroom and/or bedrooms and failed to ensure the residents had accessibility and/or functionality of call devices in the shower rooms. This affected three (#22, #23, and #24) of five residents reviewed for call lights and had the potential to affect the residents who utilize the showers on first and third floor. The facility census was 74.1. Observation and interview on 08/14/25 at 8:45 A.M. revealed Resident #22's bathroom call light did not work. Resident #22 stated he would just wait for staff to come back after he was toileted. He could not recall if he used his call light or not. Interview on 08/14/25 at 11:10 A.M. with Plant Operation Director (POD) #102 confirmed Resident #22's bathroom call light did not work. 2. Observation and interview on 08/14/25 at 8:30 A.M. revealed Resident #23's bathroom call light was in the pulled position and the light was not functioning. Interview on 08/14/25 at 8:30 A.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 Based on observation, resident and staff interviews, record review, and review of the facility policy, the facility failed to ensure the residents had a homelike environment. This affected three (#22, #23,and #24) of four residents reviewed for homelike environment. The facility census was 72.1. Review of the medical record for Resident #22 revealed a re-admission on [DATE]. Diagnoses included chronic obstructive pulmonary disease and seizures. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had severe cognitive impairment.Observation and interview on 08/14/25 at 8:45 A.M. of Resident #22's bathroom revealed a sink with a built in soap dispenser holder without a soap container in the holder. There was not any soap or paper towels available. Interview on 08/14/25 at 8:45 A.M. with Resident #22 stated she ambulates with one assist to the restroom. Resident #22 stated to wash his hands, the Certified Nursing Aide (CNA) would have to get a washcloth and soap from outside…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to develop a care plan based on Resident #23's medical needs. This affected one (#23) of one resident reviewed for care plans. The facility census was 72.Review of the medical record for Resident #23 revealed an admission on [DATE]. Diagnoses included type I diabetes mellitus (DM). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively intact. Review of Resident #23's physician orders dated 06/05/25 revealed an order for insulin aspart injection solution 100 units (u) per milliliter (ml). Inject 100 units subcutaneously as needed for type I DM, administered through insulin pump. Review of the care plan for Resident #23 dated 06/25/25 revealed there was no care plan developed for Resident #23's diagnosis of type I DM, use of insulin for DM and management of Resident #23's insulin pump. Interview on 08/14/25 at 8:30 A.M. with Resident #23 revealed there have been times when she has low…

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 policy review, the facility failed to maintain a clean environment in the shower rooms. This had the potential to affect all residents residing One South and One [NAME] (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, and #74). The facility census was 73. Findings include: Observation on 05/28/25 from 1:31 P.M. to 2:21 P.M. revealed the shower room on One [NAME] with a brown substance observed on the back of the shower chair seat. Shower bed with brown residue underneath on the drip cloth running the length of the bed and peg-tube cap under the shower bed mattress. Observation on 05/29/25 at 4:15 P.M. of One South shower room revealed brown sticky substance on the floor in the shower area, one tile missing on the shower wall, brown/black substance on the ceiling above the foot washer, brown substance on the wall of the foot washer, three dirty washcloths in the tub, and standing water…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility policy, the facility failed to notify a resident representative of a change of condition. This affected one (Resident #41) of three residents reviewed for notification of change. The facility census was 69. Findings include: Review of the medical record revealed Resident #41 was admitted on [DATE]. Diagnoses included acute and chronic respiratory failure, unspecified combined systolic (congestive) and diastolic (congestive) heart failure, lymphedema, chronic kidney disease stage three, acute respiratory failure with hypoxia, bilateral primary osteoarthritis of knee, fibromyalgia, essential primary hypertension, and hyperlipidemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of the nursing note dated 11/18/24 at 12:29 A.M. revealed Resident #41 complained of shortness of breath and her chest feeling heavy. The resident's oxygen saturation was in the 70's and 80's at two liters of…

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

Based on review of the facility's billing statements, review of email communication, vendor interviews, and staff interviews, the facility failed to operate the facility in a manner to ensure facility bills were being paid in a timely manner. This had the potential to affect all 73 residents in a facility with a census of 73. Findings include: 1. Review of the facility's electric invoice dated 07/29/24 revealed an amount of $438,869.15 was due by 09/19/24 with a disconnection notice provided which states the facility's electric service payment is past due and the electric service could be disconnected unless payment of $409,334.97 is made by 08/19/24. Review of the facility's electric invoice dated 08/30/24 revealed an amount of $436,010.41 was due by 09/20/24 with a disconnection notice provided which stated the facility's electric service is payment is past due and the electric service could be disconnected unless payment of $403,795.52 is made by 09/20/24. Review of the facility's payments to the electric service provider revealed payments in the amount of $25,000 on 03/20/24,…

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, medical record review, the facility failed to ensure the electronic medical record (EMR) accurately reflected physician orders and treatments provided to residents. This affected four (#49, #71, #74, and #77) of 20 residents reviewed for an accurate medical record. The facility census was 75. Findings include: 1. Review of the medical record revealed Resident #77 was admitted on [DATE]. Diagnoses included encounter for other orthopedic aftercare, other fracture of the left lower leg, subsequent encounter for closed fracture with routine healing, nontraumatic subarachnoid hemorrhage, unspecified fracture of the sacrum initial encounter for closed fracture, lesion of the radial nerve of the left upper limb, and cutaneous abscess of the left lower limb. Review of the Minimum Data Set (MDS) assessment, dated 01/17/24, revealed the resident was cognitively intact. Review of Resident #77's physician order, dated 01/10/24 to 02/13/24, revealed an order 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 observation, medical record review, staff interview, and review of a facility policy, the facility failed to ensure resident dignity was maintained. This affected one (#24) of one residents reviewed for dignity. The facility census was 75. Findings include: Review of the medical record revealed Resident #24 was admitted on [DATE]. Diagnoses included Parkinson's disease without dyskinesia, hypertensive heart and chronic kidney disease with heart failure, peripheral vascular disease, chronic kidney disease stage three, unspecified dementia, major depressive disorder, and lymphedema. Review of the Minimum Data Set (MDS) assessment, dated 11/08/23, revealed the resident was moderately cognitively impaired. Resident #24 was always incontinent of bowel and bladder and required substantial/maximal assistance with toileting. Observation on 02/13/24 at 1:39 P.M. revealed Resident #24 was observed from the hallway with the door to the room open. Resident #24 was laying on her left side with her backside facing…

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, and staff interview, the facility failed to ensure timely response to activated call lights and failed to ensure call lights were within reach of residents who were capable of using the call light and were dependent for care. This affected two (#1 and #4) of three residents reviewed for call lights. The facility census was 75. Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 05/16/95 with diagnoses of hemiplegia and morbid obesity. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had intact cognition and was dependent on staff for toileting. Review of the current care plan revealed Resident #1 had an activities of daily living (ADL) self-care deficit due to left side hemiplegia. Interventions included to provide a bedpan or bedside commode. Interview and observation on 02/12/24 at 7:30 P.M. with State Tested Nurse Aide (STNA) #315 confirmed the call light…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure advanced directives were consistent throughout the medical record. This affected one (#49) of 24 residents reviewed for advanced directives. The facility census was 75. Findings include: Review of the medical record for Resident #49 revealed an admission date of 12/08/23 with diagnoses of Alzheimer's disease and vascular dementia. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 had severely impaired cognition. Review of the electronic medical record (EMR) revealed Resident #49 had a physician order for Do Not Resuscitate Comfort Care (comfort measures to be administered before, during, or after the time of cardiac or respiratory arrest). Interview on 02/13/24 at 4:39 P.M. with Registered Nurse (RN) #297 confirmed there was a paper copy of Resident #49's advance directive in her paper medical record. The paper copy revealed Resident #49's code status was Do Not Resuscitate Comfort…

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 and staff interview, medical record review, and review of a facility policy, the facility failed to ensure only physician ordered tracheostomy supplies were readily available to staff for respiratory needs, and failed to ensure supplemental oxygen tubing was changed as ordered. This affected three (#71, #74, and #76) of four residents reviewed for respiratory care. The facility census was 75. Findings include: 1. Review of the medical record for Resident #76 revealed an admission date of 11/16/23. Diagnoses included cerebral palsy, spastic quadriplegia, hypertension, dysphagia, end stage renal disease with dependence on dialysis, and respiratory failure with hypercapnia and dependence on a respirator. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #76 was assessed with cognitive impairment with memory loss. Resident #76 was dependent on staff for all care and required oxygen therapy and suctioning via tracheostomy (a surgical airway passage…

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

Based on medical record review, staff interview, pharmacy staff interview, and review of a pharmacy agreement document, the facility failed to ensure irregularities were identified during monthly drug regimen reviews and those irregularities were reported to the facility. This affected one (#20) of six residents reviewed for pharmacy monthly drug regimen reviews. The facility census was 75. Findings include: Review of the medical for Resident #20 revealed an admission date of 03/24/20 with a diagnosis of hypokalemia (low potassium). Review of Resident #20's physician orders revealed the resident was ordered the supplement potassium tablet 20 milligrams (mg) in December 2023, January 2024, and currently in February 2024. Review of the monthly physician progress notes for Resident #20 for December 2023 and January and February 2024 the physician reviewed the medication list for Resident #20 which included an order for potassium tablet 20 mg and contained a plan to continue the potassium supplement. Review of the monthly medication regimen review (MRR) documents for Resident #20 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 observation, staff interview, medical record review, review of pharmacy packing slips, review of a pharmacy provider agreement, and review of a facility policy, the facility failed to ensure medications were available and administered as ordered by the physician resulting in significant medication errors. This affected one (#77) of two residents observed during medication administration and two (#76 and #331) of five residents reviewed for medications. The facility census was 75. Findings included: 1. Review of the medical record for Resident #76 revealed an admission date of 11/16/23. Diagnoses included cerebral palsy, spastic quadriplegia, hypertension, dysphagia, end stage renal disease with dependence on dialysis, and respiratory failure with hypercapnia with dependence on a respirator. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #76 was assessed with cognitive impairment with memory loss, was dependent on staff for all care, was dependent on supplemental…

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 a facility policy, the facility failed to ensure medications were stored in a safe and secure manner. This affected two (#8 and #53) of four residents reviewed for medication storage. The facility census was 75. Findings include: 1. Review of the medical record revealed Resident #8 was admitted on [DATE]. Diagnoses included unspecified injury at the C5 level of cervical spinal cord, quadriplegia, chronic obstructive pulmonary disease, essential (primary) hypertension, hypertensive heart disease with heart failure, and type two diabetes mellitus without complications. Review of the Minimum Data Set (MDS) assessment, dated 12/22/23, revealed Resident #8 was cognitively intact. Review of the most recent care plan revealed Resident #8 had depression due to physical limitations. Interventions included to administer medications as order and monitor/document for side effects and effectiveness. The resident declines medications due to paranoia…

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 the physician visited residents every 60 days. This affected one (Resident #87) of three residents reviewed for physician services. The facility census was 79. Findings include: Review of Resident #87's medical record revealed an admission date of 06/09/21. Diagnosis included quadriplegia, stage four pressure ulcer to the sacral and buttocks, and chronic obstructive pulmonary disease. Review of Resident #87's quarterly Minimum Data Set (MDS) dated [DATE] revealed his cognition was intact. Review of Resident #87's medical record revealed the resident was seen by the Certified Nurse Practitioner (CNP) monthly and as needed. The medical record had only one physician progress note dated 09/21/23. During interview on 11/29/23 at 8:44 A.M., interview with Resident #87's family revealed they were not aware of any physician visits, but that the CNP visited regularly and as needed. During interview on 11/29/23 at 3:48 P.M., the Director of Nursing (DON)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, review of the Resident Council meeting minutes, family and staff interview and review of the facility policy, the facility failed to allow one (#8) resident to have visitors at the time of the resident and visitor's choosing. This deficient practice had the potential to affect 59 of 59 residents who reside in the facility. Findings include: Review of Resident #8's medical record revealed an admission date of 09/05/11. Diagnoses included hemiplegia and hemiparesis, cerebral vascular accident, dysphagia, diabetes mellitus, epilepsy, lymphedema and a history of breast cancer. Review of Resident #8's quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident was rarely or never understood. The resident was totally dependent on toilet use, personal hygiene, bed mobility, transfers, Interview with Resident #8's family on 10/26/21 at 10:47 A.M., revealed the facility did not allow visitors after 5:00 P.M. The family stated due to their work schedule, they had limited…

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 reviews, observations, staff interviews, review of the facility policy, review of the Legionella guide, and review of the map and census, the facility failed to maintain standards of infection control practices during a clean dressing change for one (#14) resident. The facility failed to ensure resident care equipment was clean and stored in an appropriate manner for one (#32) resident to prevent potential infections. The facility also failed to implement the Legionella guide to ensure the water supply was adequate. In addition, the facility failed to ensure staff and visitors wore proper personal protective equipment (PPE) during a COVID-19 outbreak in the facility, including the staff swabbing for COVID-19 tests of unvaccinated staff. This deficient practice had the potential to affect 59 of 59 residents who reside in the facility. Findings include: 1. Review of the record for Resident #14 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic respiratory…

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 review of the facility policy, the facility failed to maintain resident rooms and the resident smoking area in a sanitary and comfortable manner. This affected eight (#12, #20, #32, #36, #38, #50, #53, and #54) of 59 residents who reside in the facility. The total facility census was 59. Findings include: Observation on 10/25/21 at 11:22 A.M., revealed a heavy build up of dust on the television entertainment stand, unfolded clothes piled on the bed, four soiled clothing protectors laying on the bed, and the sliding closet doors were off the track. Resident #38 was not able to use the closet as the doors will not open or close. This was verified with the Director of Environmental Services (DES) #500. Observation on 10/25/21 at 11:25 A.M. of Resident #32's bathroom, revealed a dirt and grime build up on the bathroom floor and a dried brown substance on the toilet seat. This was verified with State Tested Nursing Assistant (STNA) #200. Observation on 10/27/21 at 11:48 A.M. of the outside smoking area, revealed cigarette butts laying on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and resident interviews, review of the facility policy and review of the facility Self-Reported Incidents (SRI's), the facility failed to report an allegation of verbal abuse involving one resident to the State Agency. This affected one (#47) of one resident reviewed for abuse. The total facility census was 59. Findings include: Review of Resident #47's medical record revealed an admission date of 12/04/20. Diagnoses included congestive heart failure, chronic obstructive pulmonary disease, diabetes mellitus, coronary bypass, chronic pain syndrome, malnutrition, and a history of falls. Review of Resident #47's quarterly Minimum Data Set, dated [DATE]. revealed the resident had a high cognitive function and required a one person assist for bathing. Interview with Resident #47 on 10/25/21 at 11:02 A.M., revealed the resident stated a nurse was verbally abusive to her on 10/23/21, regarding showers. She indicated the nurse told her they did not have time to do showers and was verbally…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and staff interview, the facility failed to properly position one resident during a meal to ensure she was able to feed herself appropriately. This affected one (#46) of one resident observed for meals. The total facility census was 59. Findings include: Review of the Resident #46's record revealed the resident was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, diabetes, seizure disorder, peripheral vascular disease, and schizophrenia. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE], revealed Resident #46 scored a 13 on the Brief Interview for Mental Status (BIMS), indicating she had moderate cognitive deficits. The resident required extensive assistance of two staff for bed mobility and transfers and required setup for eating and can feed herself. Review of the plan of care updated 09/03/21, indicated Resident #46 had an activities of daily living (ADL) self-care performance deficit due to fatigue, muscles impairment,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and staff interviews, the facility failed to ensure compression stockings were applied as ordered for one resident. This affected one (#46) of two residents reviewed for assistive devices. The total facility census was 59. Findings include: Review of Resident #46's record revealed the resident was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, diabetes, seizure disorder, peripheral vascular disease, and schizophrenia. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE], revealed Resident #46 scored a 13 on the Brief Interview for Mental Status (BIMS), indicating she had moderate cognitive deficits and required extensive assistance of two staff for bed mobility, dressing, and transfers. Review of the plan of care updated 09/03/21, revealed Resident #46 had an activities of living (ADL) self-care performance deficit due to fatigue, muscles impairment, activity intolerance, and limited mobility. The goal was for the resident to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and staff interviews, the facility failed to implement interventions that included a palm protector for one resident to ensure his hand contractures did not worsen. This affected one (#19) of one resident observed for contractures. The total facility census was 59. Findings include: Review of the record for Resident # 19 revealed the resident was admitted to the facility on [DATE]. Diagnoses included traumatic brain injury, right dominate side hemiplegia aphagia, and contracture of the right hand. Review of the quarterly Minimum Data Set (MDS) assessment dated 10 06/21, revealed the residents short and long term memory was in tact. His decision making was severely impaired and he wsa totally dependent on staff for all activities of Daily living (ADL's) including eating. Review of the plan of care updated 10/6/21, revealed Resident #19 had an activity of daily living (ADL) self-care performance deficit due to decline in fine motor skills, balance, and contractures. The goal…

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 review of the facility policy, the facility failed to ensure the medication was stored properly and in locked compartments. This affected one (#257) of one residents medication that was not secured. The total facility census was 59. Findings include: Observation of the first floor nurses station on 10/26/21 at 9:46 A.M., revealed a blistered package of Mycophenolic Acid (immunosuppressive for organ transplant resident) 360 milligram tablets were on the counter unattended. The package contained eight pills. Further observation revealed there was no staff at the nurses station or the hallways surrounding the area. Interview with Registered Nurse #200 on 10/26/21 at 9:58 A.M., verified the medication was left unattended and was accessible to residents. Review of the facility policy titled, Storage of Medications, dated April 2019, revealed the facility stores all drugs and biological's in a safe, secure, and orderly manner. Drugs and biological's used in the facility were stored in locked compartments under proper temperature, light 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 observations, staff interview and review of the facility policy, the facility failed to maintain one residents bed in safe manner. This affected one (#257) of one residents bed observed during the environmental tour. The total facility census was 59. Findings include: Observation of Resident #21's bed on 10/26/21 at 8:48 A.M., revealed the resident's bed control was laying on the floor and was noted to have frayed and exposed wires. The frayed and exposed wires were approximately six inches from the remote down the cord with red and blue wires exposed. Interview with Registered Nurse #200 on 10/26/21 at 9:01 A.M., verified the frayed and exposed wires on Resident #21's bed remote were a danger and she would alert maintenance immediately. Review of the undated facility policy titled, Red Tagging of Equipment Policy, revealed if equipment was not functioning properly or the sticker was out of date, place a red tag on the item with the description of what the issue was.