Advanced Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, observation, staff interview, and policy review, the facility failed to ensure incontinence care was provided timely. This affected one (#85) of three residents reviewed for incontinence care. The facility census was 83. Findings include: Review of the medical record for Resident #85 revealed an admission date of 07/13/20. Diagnoses included osteoporosis, urinary incontinence, hypertension, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment. The resident was always incontinent of bladder and frequently incontinent of bowel. The resident was dependent on staff for toileting. Review of the care plan last revised 01/28/25 revealed the resident had urinary and bowel incontinence related to weakness, difficulty ambulating, and cognitive deficits. Interventions included the use of incontinence briefs and incontinence care as needed. Review of the task documentation for toileting 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, review of facility investigations, staff interview, and review of the facility policy the facility failed to ensure medications were administered to the correct resident. This affected one resident (#89) reviewed for medication errors. The facility census was 92. Findings include: Review of the medical record for Resident #89 revealed an admission date of 10/28/24 with diagnoses of follow-up for joint replacement surgery, depression, anxiety, alcohol abuse, and cocaine abuse. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #89 revealed he was cognitively intact and he was not ordered any opioid medication (narcotic pain medication). Review of the current physician orders for April 2025 for Resident #89 revealed no orders for Gabapentin (medication used for nerve pain), Doxycycline (antibiotic), Metoprolol (used to treat high blood pressure), Norco (narcotic (opioid) pain medication), and Oxycodone (narcotic (opioid) pain medication. Review of…

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

Based on review of public social media videos, resident interviews, staff interviews, review of the employee handbook, review of staff schedules, and review of facility policy, the facility failed to ensure residents' right to privacy was honored when State Tested Nurse Aide (STNA) #100 video recorded conversations and interactions with staff and residents (including during personal care) in resident rooms, in common areas, discussed resident care needs and described a resident's malodorous wounds using profanity, while posting the videos to social media and not in accordance with facility policy. This affected four (#13, #31, #62, and #73) of four residents reviewed for privacy and confidentiality. The facility census was 81. Findings Include: Review of STNA #100's public social media account revealed three live recorded videos (meaning the video was posted to the social media page as the video was being recorded) taken at the facility involving residents in the privacy of their home. The live recorded videos were dated 12/22/23, 12/25/23 and 12/30/23, with each video lasting…

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 records review, staff interview and review of facility policy, the facility failed to timely notify the physician of a malfunctioning catheter. This affected one (#53) of one residents reviewed for catheter care. The facility census was 81. Findings include: Review of Resident #53's medical record revealed an admission date of 06/15/23. Diagnoses included osteomyelitis, stage IV pressure ulcer to left buttock, left hip, right hip, right heel, sacral region, venous insufficiency, type II diabetes mellitus, COPD, schizoaffective disorder, chronic pain, contracture left hip, right hip, left knee, major depression, and anxiety disorder. Review of the MDS assessment, dated 11/11/23, Resident #53 was cognitively intact. dependent on staff for activities of daily living (ADLs), including bed mobility, had an indwelling catheter, was incontinent of bowel, and admitted with four stage IV pressure ulcers and one in-house acquired pressure ulcer. Review of the plan of care, revised 07/12/23, revealed Resident #53 had a supra pubic indwelling catheter related 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 observation, medical record review, resident interview, family interview, staff interview, review of the facility contingency box medication list, and review of facility policy, the facility failed to ensure medications were available from the pharmacy for timely administration. In addition, the facility failed to secure available medications from the contingency box for administration when resident's medications were unavailable from the pharmacy. This affected five (#2, #68, #284, #285, #287) of nine residents reviewed for medication administration. The facility census was 81. Findings included: 1. Review of Resident #2's medical record revealed an admission date of 11/17/23. Diagnoses included pancreatic cancer, antiphospholipid syndrome, fibromyalgia, breast cancer, thrombocytopenia, and hemiplegia/hemiparesis following a cerebral vascular accident. Review the admission Minimum Data Set (MDS) assessment, dated 11/24/23, revealed Resident #2 had intact cognition. The resident was independent 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.

Based on observation, medical record review, staff interview, and facility policy, the facility failed to ensure medications were administered as ordered by the physician, within prescribed time frames, and in accordance with manufacturer instructions for use, resulting in a medication error rate above five percent (%). A total of 10 medication errors were observed out of 43 opportunities for a medication administration error rate of 23.26%. This affected four (Residents #16, #52, #1, #53) of six residents observed during medication administration. The facility census was 81. Findings include: 1. Review of Resident #16's medical record revealed a physician order dated 11/17/23 for Hydrocodone-Acetaminophen (pain medication) 5-325 milligrams (mg) one tablet four times a day for pain scheduled 9:00 A.M., 12:00 P.M., 6:00 P.M., 9:00 P.M. An order dated 06/22/23 for as needed (PRN) Acetaminophen 325 mg two tablets every six hours for pain. Observation on 12/12/23 at 7:17 A.M. noted Licensed Practical Nurse (LPN) #121 obtained Resident #16's medications from the medication cart and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure signage and Personal Protective Equipment (PPE) were posted and available to a COVID-19 positive room. This affected one (Resident #17) of one resident observed for isolation. Additionally, the facility failed to ensure staff took off used PPE and practiced hand hygiene when exiting a COVID-19 positive room. This affected two (Residents #38 and #40) of two residents observed in contact with the staff member. The facility census was 81. Findings include: 1. Review of Resident #17's medical record revealed an admission date of 08/31/23. Diagnoses included peripheral vascular disease, chronic obstructive pulmonary disease, nicotine dependence, and COVID-19. Resident #17's COVID-19 diagnosis was added 12/08/23. Review of Resident #17's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #17 was cognitively intact. Resident #17…

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 interview, staff interview, and facility policy review revealed the facility failed to ensure residents lighting was in working condition and within reach. This affected one (#287) of one residents reviewed for accommodation of needs. The facility census was 81. Findings include: Review of Resident #287's medical record revealed an admission date of 12/08/23. Diagnosis included basal cell carcinoma of the scalp and neck, myasthenia gravis, diabetes mellitus, acute respiratory failure, adult failure to thrive, and osteomyelitis. Review of the Minimum Data Set (MDS) revealed it was in process. Review of Resident #287's care plan revealed the resident had complaints of acute/chronic pain. Interventions were to follow physician orders for complaint of pain. Observation on 12/11/23 at 3:24 P.M. revealed Resident #287 was lying in bed in a brightly lit room. The resident was unable to reach the wall switches to be able to control the ceiling light nor the overhead bed light. Observation of the bedside lamp revealed it was out of reach and did not contain a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, resident interview, review of the air mattress user manual, and review of facility policy, the facility failed to ensure interventions were consistently implemented to promote skin integrity. This affected one (#53) of three residents reviewed for pressure ulcers. The facility census 81. Findings include: Resident #53 admitted to the facility on [DATE] with the diagnoses including osteomyelitis, stage IV pressure ulcer to left buttock, left hip, right hip, right heel, and sacral region, venous insufficiency, type II diabetes mellitus, chronic obstructive pulmonary disease, schizoaffective disorder, chronic pain, contracture left hip, right hip, and left knee, major depression, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment, dated 11/11/23, revealed Resident #53 was cognitively intact, dependent on staff for activities of daily living (ADLs), had an indwelling catheter, was incontinent of bowel, and admitted with four stage IV…

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, and staff interview, the facility failed to ensure interventions were implemented to timely address bowel incontinence and related indwelling urinary catheter malfunction. This affected one (#53) of two residents reviewed for incontinence and catheter care. The facility census was 81. Findings include: Resident #53 admitted to the facility on [DATE] with diagnoses including osteomyelitis, stage IV pressure ulcer to left buttock, left hip, right hip, right heel, sacral region, venous insufficiency, type II diabetes mellitus, chronic obstructive pulmonary disease, schizoaffective disorder, chronic pain, contracture left hip, right hip, left knee, major depression, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment, dated 11/11/23, revealed Resident #53 was cognitively intact, dependent on staff for activities of daily living (ADLs), utilized an indwelling catheter, was incontinent of bowel, and admitted with four stage IV pressure ulcers and had one…

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, policy review and staff interviews, the facility failed to ensure a resident was free from significant medication error, when insulin orders were erroneously discontinued from the medication record. This affected one (#2) of three residents reviewed for medication administration. The current census is 78. Findings include: Record review of Resident #2 revealed the resident was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Diagnoses for Resident #2 included cerebral edema, bipolar disorder, diabetes, heart failure, and morbid obesity. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and was a two-person assist for Activities of Daily (ADL). Resident #2 received 3 insulin injections out of 7 days in the review period. Per the assessment there were 0 times the physician changed the order for the insulin. The assessment was documented as signed on 09/19/23 after the 09/13/23 discharge.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, review of the medical record, and review of policy, the facility failed to ensure the functioning of wandering devices to prevent elopement was monitored. This affected two (#30 and #31) of two residents reviewed for wandering devices. Additionally, the facility failed to ensure hot water temperatures did not exceed 120 degrees Fahrenheit (F). This affected two (#11 and #115) of seven residents reviewed for hot water temperatures. The facility census was 78. Findings include: 1. Review of Resident #30's medical record revealed an admission date of 06/27/17, with a diagnosis of dementia. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 had impaired cognition. Review of a physician order dated 11/17/22 revealed Resident #30 required staff to check the function of his wandering device on day and night shifts. Review of the Treatment Administration Record (TAR) for the evening shift on 09/02/23 revealed Licensed Practical Nurse…

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, review of facility identified diet list, review of the facility temperature logs, and review of the facility policies, the facility failed to ensure refrigerator and freezer temperatures were monitored daily. This had the potential to affect all residents in the facility except 10 residents (#38, #57, #58, #59, #61, #62, #68, #69, #86, and #102) identified to receive no food from the kitchen. Additionally, the facility failed to ensure staff followed proper hand hygiene when serving meals to residents in the dining room. This affected 13 residents (#11, #13, #14, #17, #22, #23, #25, #27, #30, #31, #46, #51, and #53) in the dining room who received cheese ravioli. The facility census was 78. Findings include: 1. Observation on 09/05/23 at 10:05 A.M., revealed the August 2023 temperature logs were incomplete from 08/24/23 through 08/31/23 for the milk refrigerator, the reach-in refrigerator, and walk-in refrigerator and the walk-in freezer. Interview on 09/05/23 at 10:05 A.M., with the Dietary Manager #286 confirmed the temperature logs were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Review of the resident medical records, facility documentation of Ombudsman notification, and staff interview, the facility failed to ensure required notification to the Ombudsman's office. This affected three (#58, #60, and #101) of three resident records reviewed. The facility census was 78. Findings include: 1. Review Resident #58's medical record revealed an admission date of 07/27/22, with diagnoses including: nontraumatic subarachnoid hemorrhage, chronic obstructive pulmonary disease, type two diabetes mellitus without complication, dysphagia oropharyngeal neuromuscular dysfunction of bladder, essential primary hypertension, schizophrenia, hyperlipidemia, and adjustment disorder with mixed anxiety and depressed mood. Review of the Minimum Data Set (MDS) assessment, dated 08/02/23, revealed the resident was moderately cognitively impaired. Review of the census documentation revealed Resident #58 was hospitalized overnight from 07/23/23 to 07/24/23. 2. Review of Resident #60's medical record revealed 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 review of the medical record review, staff interview, and review of policy, the facility failed to ensure the comprehensive care plan included discharge planning. This affected two (#8 and #9) of three former residents reviewed for discharge care plans. The facility census was 78. Findings include: 1. Review of Resident #8's closed medical record revealed an admission date of 04/26/23 and discharged on 08/23/23. Diagnoses for Resident #8 included pulmonary hypertension, type two diabetes mellitus with hyperglycemia, hypoxemia, heart disease, essential (primary) hypertension, hypothyroidism, and hyperlipidemia. Review of the Minimum Data Set (MDS) assessment, dated 08/23/23, revealed a discharge assessment was completed. Review of the care plan, initiated on 05/02/23 and closed on 09/05/23, revealed Resident #8's care plan did not include a discharge goal. 2. Review of Resident #9's closed medical record revealed an admission date of 03/07/23 and discharged on 08/24/23. Diagnoses for Resident #9 included muscle wasting and atrophy, interstitial pulmonary disease, ulcerative…

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, medication insert review, and policy review, the facility failed to ensure medications were administered timely and per manufacturer recommendations. This affected two residents (#17 and #40) of three residents observed for medication administration. The facility census was 78. Findings included: 1. Review of Resident #40's medical record revealed an admission date of 06/29/20, with diagnoses including asthma, spina bifida, and seasonal allergies. Review of Resident #40's quarterly Minimum Data Set (MDS), dated [DATE], revealed he had an intact cognition and required one person supervision for eating. Review of Resident #40's most recent care plan revealed he had an alteration in respiratory status related to asthma. Interventions were to administer medications per medical provider's orders and observe for side effects and effectiveness. Review of Resident #40's medical record revealed a physician's order dated 06/28/23 for Advair Diskus (steroid and bronchodilator) 250-50…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility failed to ensure residents received assistive devices with meals. This affected one (#11) of three residents reviewed for assistive devices. The facility census was 78. Findings include: Review of the medical record for Resident #11 revealed an admission date of 05/31/13 with diagnoses of depression, insomnia, and paranoid schizophrenia. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #11 had impaired cognition and required limited assistance of one person for eating. Review of a physician order dated 04/06/23 revealed Resident #11 required a spouted cup with meals. Review of Resident #11's current care plan updated 07/29/23 revealed he had a nutritional problem due to receiving a mechanically altered diet. Interventions included a divided plate and spouted cup at every meal. Review of the meal ticket for Resident #11 for the noon meal on 09/05/23 revealed he should receive a spouted cup and divided…

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 staff accurately documented completed tasks in the medical record. This affected one (#30) of 14 records reviewed. The facility census was 78. Findings include: Review of Resident #30's medical record revealed an admission date of 06/27/17, with a diagnosis of dementia. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 had impaired cognition. Review of a physician order dated 11/17/22 revealed Resident #30 required staff to check the function of his wandering device on day and night shifts. Review of the Treatment Administration Record (TAR) for the evening shift on 09/02/23 revealed Licensed Practical Nurse (LPN) #252 checked the function on Resident #30's wandering device. Interview on 09/05/23 at 9:28 A.M., with LPN #252 revealed she had residents on her hall with a wandering device but could not identify them at that time. Follow-up interview and observation on 09/05/23 at 2:31 P.M., with…

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

Based on observation, medical record review, staff interview, and policy review, revealed facility staff failed to follow the infection control protocol when caring for residents. This affected one (#86) of one residents observed in isolation. The facility census was 78. Findings included: Review of Resident #86's medical record revealed an admission date of 09/06/23, with diagnoses including: colon cancer, liver cancer, prostate cancer, and lung cancer. The resident had a history of multi-drug resistant organism (MDRO). Review of Resident #86's medical record revealed a physician's order dated 09/05/23 for enhanced barrier precautions related to a history of MDRO when dressing, bathing, showering, transferring, personal hygiene, changing linens, toileting, and peri care. Providing care to resident with a history of colonized multi-drug resistant organism; klebsiella pneumoniae. Observation on 09/06/23 at 3:41 P.M., Resident #86's room door was closed with a sign posted which revealed the resident was on enhanced barrier precautions and any staff coming in contact with the resident…

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

Based on observation, resident and staff interview, and facility policy review, the facility failed to ensure food was stored and served in a safe and sanitary manner. This had the potential to affect all residents except eight (#13, #18, #25, #49, #57, #58, #60, and #61) residents the facility identified who did not receive food from the kitchen. The facility census was 72. Findings include: 1. Observation on 07/10/23 at 9:05 A.M. of the kitchen revealed a disposable cup in the sugar bin on top of the sugar. Observation of the stand-up refrigerator revealed a reusable container of what appeared to be chicken noodle soup approximately one-fifth full with no date or label. Observation of the walk-in refrigerator revealed a food delivery box on top which was sitting inside of another box. Upon lifting the top box up, it was discovered the bottom box had leaf lettuce inside with no barrier and the leaf lettuce was in contact with the bottom of the food delivery box that was sitting inside it. Interview on 07/10/23 at 9:10 A.M., with Dietary Manager #367 verified the cup inside 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 medical record review, observation, resident interview, resident representative interview, staff interview, and review of a facility policy, the facility failed to ensure dependent residents received assistance with bathing, personal hygiene, and transfers. This affected three (#62, #14, and #60) of five residents reviewed for activities of daily living. The facility census was 72. Findings include: 1. Review of Resident #62's medical record revealed an admission date of 02/28/23. Diagnoses included chronic obstructive pulmonary disease (COPD), type II diabetes, hypertension, cerebral infarction, difficulty walking, morbid obesity, and polyneuropathy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 was cognitively intact and required extensive assistance with dressing, toilet use, and personal hygiene. Additionally, Resident #62 had no refusals of care. Review of the plan of care initiated 02/28/23 revealed Resident #62 had an activities of daily living (ADL)…

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, and staff interview, the facility failed to provide timely repositioning regarding dependent resident assessed at risk for pressure ulcer development. This affected one (#14) two residents reviewed for repositioning and pressure-reducing interventions. The facility census was 72. Findings include: Review of Resident #14's medical record revealed admission to the facility on [DATE] with the diagnoses including cerebral infarction affecting right dominant side, Alzheimer's disease, dementia, hypertension, atrial fibrillation, type II diabetes mellitus, anemia, contracture left and right ankle. Review of the Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #14 with severe cognitive impairment, the resident was assessed to require two plus staff members for bed mobility and transfers, was dependent on staff for the completion of activities of daily living including toilet use and personal hygiene, and was assessed at risk for pressure ulcer development.…

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 an owner's manual for an air mattress, the facility failed to ensure medical equipment was utilized in a safe manner. This affected one (#4) of four residents reviewed for accidents and hazards. The facility census was 72. Findings include: Review of Resident #4's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure, dependence on respirator, tracheostomy, chronic obstructive pulmonary disease, hypertension, polyneuropathy, low back pain, type II diabetes mellitus, peripheral vascular disease, left knee contracture, anxiety disorder, and major depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was assessed with intact cognition, required extensive assistance of one staff for bed mobility, and required physical assistance of one person for locomotion using a wheelchair with no history of sustaining falls.…

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, and staff interview, the facility failed to ensure timely incontinence care was provided. This affected one (#14) of one residents reviewed for the provision of incontinence care. The facility census was 72. Findings include: Review of the medical record revealed Resident #14 admitted to the facility on [DATE] with the diagnoses including cerebral infarction affecting the right dominant side, Alzheimer's disease, dementia, hypertension, atrial fibrillation, type II diabetes mellitus, anemia, and contracture of the left and right ankle. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #14 was assessed with severe cognitive impairment, required two plus staff members for bed mobility and transfers, was dependent on staff for the completion of activities of daily living including toilet use and personal hygiene, and was incontinent of bowel and bladder. Review of Resident #14's medical record noted a nursing plan of care revised on 10/18/22 which…

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 maintain a peripherally inserted central catheter (PICC) line per physician orders. This affected one (#65) of one residents reviewed for peripheral vascular access. The facility identified five residents with peripheral vascular access lines. The facility census was 72. Findings include: Review of Resident #65's medical record revealed an admission date of 06/09/23. Diagnoses included gastrointestinal stromal tumor of the large intestine, pneumonia, chronic obstructive pulmonary disease (COPD), type II diabetes, emphysema, neoplasm of unspecified behavior of the digestive system, hypertension, depression, anxiety disorder, and malignant neoplasm of lower lobe, right bronchus, or lung. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 was cognitively intact, received antibiotics, and received intravenous (IV) medications. Review of the plan of care, initiated 06/12/23, revealed Resident #65 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and resident and staff interview, the facility failed to ensure medications were available for administration. This affected one (#36) of one residents reviewed for availability of medications. The facility census was 72. Findings include: Review of the medical record revealed Resident #36 was admitted on [DATE]. Diagnoses included peripheral vascular disease, anemia, unspecified atrial fibrillation, major depressive disorder edema, muscle weakness, chronic venous hypertension with ulcer of right lower extremity, and essential hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was cognitively intact. Review of Resident #36's physician orders revealed an order dated 03/14/23 for the eye medication Systane Ultra Preservative Free (PF) Ophthalmic Solution 0.4-0.3% with instructions to instill two drops in both eyes three times a day for dry eyes. Review of the July 2023 medication administration record (MAR) revealed Resident #36's Systane…

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 maintain a peripherally inserted central catheter (PICC) line which resulted in the delay of administering an intravenous (IV) antibiotic medication as ordered. This affected one (#65) of five residents reviewed for medications. The facility census was 72. Findings include: Review of Resident #65's medical record revealed an admission date of 06/09/23. Diagnoses included gastrointestinal stromal tumor of the large intestine, pneumonia, chronic obstructive pulmonary disease (COPD), type II diabetes, emphysema, neoplasm of unspecified behavior of the digestive system, hypertension, depression, anxiety disorder, and malignant neoplasm of lower lobe, right bronchus, or lung. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 was cognitively intact, received antibiotics, and received intravenous (IV) medications. Review of the plan of care, initiated 06/12/23, revealed Resident #65 had an IV access.…

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 not left at the bedside. This affected two (#59 and #70) of four residents observed for medication storage. The facility census was 72. Findings include: 1. Review of Resident #59's medical record revealed an admission date of 02/16/23. Diagnosis included a stage four pressure ulcer to bilateral hips, chronic obstructive pulmonary disease, chronic kidney disease, congestive heart failure, and contractures of the bilateral ankles. Observation on 07/10/23 at 10:31 A.M. revealed Resident #59 had a medication cup on her bedside table which contained her morning medication. Interview with Resident #59 on 07/10/23 at 10:31 A.M. stated the nurse left the medication cup on the table for her to take at her leisure. Interview with Licensed Practical Nurse (LPN) #356 on 07/10/23 at 10:33 A.M. verified the morning nurse left the medication unattended in Resident #59's room. 2. Review…

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 interview, the facility failed to ensure resident equipment was maintained in a clean and sanitary manner. This affected two (#40 and #58) of five residents reviewed for a clean and sanitary environment. The facility census was 72. Findings include: 1. Observation on 07/10/23 at 10:10 A.M., revealed Resident #40's electric wheelchair leg rest and foot area was covered with a thick layer of dirt and debris. An unknown brown thick substance was dripped on the leg area approximately three to five inches. Interview with Resident #40 during the observation voiced his wheelchair had never been cleaned. Interview on 07/10/23 at 5:05 P.M., with State Tested Nurse Aide (STNA) #381 verified Resident #40's wheelchair was very dirty and needed cleaned. STNA #381 stated third shift staff clean resident wheelchairs. Observation on 07/11/23 at 11:11 A.M., revealed Resident #40's wheelchair continued to remain dirty and in need of cleaning. Observation on 07/12/23 at 10:08 A.M., revealed Resident #40's wheelchair continued to remain dirty and in need 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.