Park Terrace Rehabilitation Center

Based on medical record review, staff and resident interview, review of employee timecards, review of facility Self Reported Incident, review of facility investigations, and review of facility policy, the facility failed to thoroughly and accurately investigate alleged occurrences of abuse and misappropriation of medications. This affected two (#21 and #88) of four residents reviewed for abuse prohibition and one Self Reported Incident (#256925) in a facility census of 86. Findings include: 1.Review of a statement written on 09/22/25 (no time recorded) by Certified Nurse Aide (CNA) #605 documented he was told there was an issued with him and Resident #88. CNA #605 documented he was unaware what the resident was talking about. Review of a facility investigation on 09/23/25 at 12:00 P.M. revealed administration received a complaint from CNA #497 that Resident #88 was upset with CNA #605 and did not want him in his room. The Administrator advised the Director of Nursing and scheduler to keep CNA #605 out of the area. After further assessment the Administrator suspended CNA #605 that…

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

Based on medical record review and staff interview, the facility failed to ensure residents were suctioned per order. This affected one (#91) resident reviewed for respiratory therapy. The facility census was 86. Findings include: Review of the medical record for Resident #91 revealed an admission date of 06/18/25. Diagnoses included dementia, morbid obesity, end stage renal disease (ESRD), type two diabetes mellitus (DM2), obstructive sleep apnea (OSA), hypertension (HTN), metabolic encephalopathy, anemia, delirium, depression, anxiety, sepsis, dependence on renal dialysis, and convulsions.Review of the record revealed a physician order dated 11/15/25 at 2:00 P.M. for chest physiotherapy (PT) and oral suctioning every six hours for 48 hours per respiratory therapist for chest congestion for two days.Review of the medication administration record (MAR) revealed this order was completed on 11/15/25 at 2:00 P.M. Further review of the MAR for Resident #91 revealed this order was not completed on 11/15/25 at 8:00 P.M. and this administration time was documented with chart code 9. 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 medical record review and staff interview, the facility failed to obtain blood pressures to monitor the ordered parameters for administering medication for one (#91) of three residents reviewed for medication administration. The facility census was 86. Findings include: Review of the medical record revealed Resident #91 had an admission date of 06/18/25. Diagnoses included dementia, morbid obesity, end stage renal disease (ESRD), type two diabetes mellitus (DM2), obstructive sleep apnea (OSA), hypertension (HTN), metabolic encephalopathy, and dependence on renal dialysis. Review of the record revealed a physician order dated 08/16/25 for Midodrine 5 milligrams (mg) three times a day for hypotension, hold for a systolic blood pressure (SBP) greater than 90. Review of Resident #91's medication administration record (MAR) for September 2025 revealed no documentation of blood pressures being obtained prior to the administration of Midodrine to Resident #91 from 09/01/25 through 09/30/25. Review of Resident #91's MAR for October 2025 revealed no documentation of blood pressures…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure accurate and timely documentation in the medical record. This affected two (#87 and #91) of three residents reviewed for accurate documentation. The facility census was 86. Findings include: 1. Review of the medical record for Resident #87 revealed an admission date of [DATE] and a discharge date of [DATE]. Diagnoses included chronic respiratory failure with hypercapnia, severe protein-calorie malnutrition, chronic obstructive pulmonary disease (COPD), dementia, osteomyelitis of sacral and sacrococcygeal vertebra, heart failure, cerebral infarction, dependence on a respirator, heart disease, and atrial fibrillation. Review of the nursing progress note for Resident #87, dated [DATE] at 7:30 P.M., revealed it was created on [DATE] at 2:53 P.M. Review of the nursing progress note for Resident #87, dated [DATE] at 7:38 P.M., revealed it was created on [DATE] at 8:45 P.M. Review of the nursing progress note…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of a facility self-reported incident (SRI), review of a facility investigation, resident and staff interview, review of a facility policy, and review of facility corrective action documents, the facility failed to ensure a resident was free from verbal abuse. This affected one (#5) of three residents reviewed for abuse. The facility census was 86. Findings include: Review of Resident #5's medical record revealed an admission date of 12/27/21. Diagnoses included central cord syndrome at cervical vertebra 5 (C5), severe protein calorie malnutrition, stroke, epilepsy, quadriplegia, post-traumatic seizures, muscle weakness, cognitive communication deficit, peripheral vascular disease, and major depressive disorder. Review of Resident #5's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15…

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, review of hospital documentation, staff interview, and facility policy, the facility failed to ensure wound treatments and dressing applications were applied in accordance with physician orders. This affected one (#7) of three residents reviewed for wound care and treatment services in a facility census of 86. Findings include: Review of the medical record for Resident #7 revealed the resident admitted to the facility on [DATE] with the diagnoses including, type II diabetes mellitus with a foot ulcer, chronic kidney disease stage four (4), atrial fibrillation, anemia, heart failure, depression, absence the left leg above the knee, non-pressure chronic ulcer part of the right foot, absence the right toes, and hypertension. Review of the most current Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was assessed with intact cognition, was dependent on staff for the completion of activities of daily living, was incontinent of bowel and bladder, was at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and facility policy, the facility failed to provide timely interventions to prevent urinary incontinence. This affected one (#22) of three residents reviewed for incontinence care and services in a facility census of 86. Findings include: Review of Resident #22's medical record revealed the resident admitted to the facility on [DATE] with the diagnoses including, chronic obstructive pulmonary disease, type II diabetes mellitus, schizoaffective bipolar type, thyroid disorder, irritable bowel syndrome, coronary artery disease, and mild dementia with psychotic disturbance. Review of the most current Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #22 with severe cognitive impairment, no resistive behavior, utilized a walker for mobility, required supervision and touching assistance with ambulation and toileting, was always continent of bladder, and had no rated bowel continence. Review of a nursing plan of care dated 01/27/25 revealed it…

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, review of hospital documents, staff interview, and facility policy, the facility failed to ensure peripherally inserted central catheters (PICC) were maintained in accordance with physician orders and dressing changes were completed using appropriate appropriate technique. This affected two (#7 and #8) of two residents reviewed for PICC line care and treatment in a facility census of 86. Findings include: 1. Review of Resident #7's medical record revealed the resident admitted to the facility on [DATE] with the diagnoses including type II diabetes mellitus with a foot ulcer, chronic kidney disease stage four (4), atrial fibrillation, anemia, heart failure, depression, absence of the left leg above the knee, non-pressure chronic ulcer of part of the right foot, absence right toes, and hypertension. Review of the most current Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was assessed with intact cognition, was dependent on staff for the completion…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility incident and accident log, review of the Electronic Information Dissemination and Collection (EIDC - system used by facilities to report incidents to the State Survey Agency [SSA]) system, review of the facility Self-Reported Incidents (SRI), staff interview and review of the facility policy, the facility failed to report an incident of resident elopement to the SSA for Resident #3 and further failed to ensure allegations of abuse were thoroughly investigated for four (#26, #28, #30, and #31) residents reviewed for abuse. The facility census was 87. Findings include: 1. Review of the incident and accident log for the past three months revealed an incident of elopement for Resident #3 on 04/12/25. Review of the medical record for Resident #3 revealed an admission date of 03/28/25 with diagnoses of senile degeneration of the brain, anxiety, and diabetes mellitus type II. Review of the admission Minimum Data Set (MDS) assessment, dated 04/04/25, revealed Resident #3 was cognitively…

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

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure baseline care plans were completed. This affected one (#53) of one resident reviewed for baseline care plans. The facility census was 87. Findings include: Review of the medical record for Resident #53 revealed an admission date of 04/26/25 with diagnoses of acute respiratory failure, tracheostomy status, malignant neoplasm of the lung and supraglottis (upper part of the larynx), anxiety, and chronic obstructive pulmonary disease (COPD). Review of the admission assessment, dated 04/26/25, revealed Resident #53 was cognitively intact. Further review revealed a baseline care plan was not part of the admission assessment. Additional review of Resident #53's medical record revealed no evidence a baseline care plan was completed. Interview on 4/30/25 at 1:05 P.M. with the interim Director of Nursing (DON) verified a baseline care plan was not completed for Resident #53. Review of the facility policy titled Baseline Care Plan, undated, revealed the facility would develop and…

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

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure person-centered care plans were completed. This affected one (#3) of four residents reviewed for care plans. The facility census was 87. Findings include: Review of the medical record for Resident #3 revealed an admission date of 03/28/25 with admitting diagnoses of senile degeneration of the brain, diabetes mellitus type II, and anxiety. Review of the admission Minimum Data Set (MDS) assessment dated , 04/04/25, revealed Resident #3 was cognitively impaired. Review of a nursing progress note dated 04/12/25 revealed Resident #3 was spotted in the parking lot, walking toward the street. Review of the physician orders revealed on 04/14/25, Resident #3 was admitted to the secure memory care unit. Review of Resident #3's plan of care revealed on 04/14/25, a focus area was initiated for the resident having a behavior problem as evidenced by elopement. Two interventions were implemented, medications as ordered and anticipate the resident's needs. Further review revealed no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility incident and accident log, staff interview, medical record review and review of the facility policy, the facility failed to provide adequate supervision to prevent resident elopement and further failed to timely implement interventions to ensure resident safety following an incident of elopement. This affected one (#3) of one resident reviewed for elopement. The facility census was 87. Findings include: Review of the incident and accident log for the past three months revealed an incident of elopement for Resident #3 on 04/12/25. Review of the medical record for Resident #3 revealed an admission date of 03/28/25 with diagnoses of senile degeneration of the brain, anxiety, and diabetes mellitus type II. Review of the admission Minimum Data Set (MDS) assessment, dated 04/04/25, revealed Resident #3 was cognitively impaired and had no behaviors of wandering. Review of the admission Wandering Risk Assessment, dated 03/28/25, revealed Resident #3 had no previous wandering, 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 medical record review, resident and staff interview, review of staff schedules, review of dialysis schedules, review of resident treatment tracker information, review of staff postings, review of shower schedules and shower sheets, review of the Facility Assessment, and policy review, the facility failed to ensure adequate staffing to meet the needs of the residents. This had the potential to affect all 89 residents in the facility. The facility census was 89. Findings include: 1. Review of the medical record for Resident #4 revealed an admission date of 11/11/24 with a readmission date of 01/23/25. Diagnoses included of end stage renal disease and dependence on renal dialysis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/14/25, revealed Resident #4 was rarely/never understood and received dialysis. Review of the current physician order dated 03/15/25 revealed Resident #4 received in-house hemodialysis on Mondays, Tuesdays, Wednesdays, and Fridays. Review of the medical record 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 of review of personnel records, review of staff training, and staff interview, the facility failed to ensure certified nurse aides (CNAs) received no less than 12 hours of annual in-service training. This affected five (#107, #115, #134, #130, and #107) of five CNAs reviewed and had the potential to affect all 89 residents. The facility census was 89. Findings include 1. Review of the personnel record for CNA #107 revealed a hire date of 10/20/22. Further review of personnel file revealed no documentation of the required 12 hours of annual inservice training. 2. Review of the personnel record for CNA #115 revealed a hire date of 11/23/22. Further review of personnel file revealed no documentation of the required 12 hours of annual inservice training. 3. Review of the personnel record for CNA #134 revealed a hire date of 01/19/23. Further review of personnel file revealed no documentation of the required 12 hours of annual inservice training. 4. Review of the personnel record for CNA #130 revealed a hire date of 05/31/23. Further review of personnel file revealed no…

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

Based on medical record review, review of a self-reported incident (SRI), review of hospital documentation, review of a fire and rescue report, review of dialysis resident tracking records, review of the Facility Assessment, review of daily posted staffing documentation, review of personnel job descriptions, and staff interview, the administration team failed to use its resources effectively and efficiently to maintain the highest practicable physical, mental, and psychosocial well-being of each resident when the facility failed to ensure measures were in place to prevent a medication overdose and investigation and put follow-up interventions in place to be prevent recurrence, failed to ensure allegations of staff-to-resident verbal abuse were thoroughly investigated, failed to ensure medical records were accurate, and failed to ensure adequate staffing to meeting resident needs for ventilators, bathing, and dialysis services. This deficient practice had the potential to affect all 89 residents residing in the facility. The facility census was 89. Findings include: 1. Review of the…

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

Based on review of a self-reported incident (SRI), review of staff timecards, review of staff employment status documentation, staff interview, and review of a facility policy, the facility failed to ensure an allegation of verbal abuse was thoroughly investigated. This affected one (#22) of three residents reviewed for allegations of abuse. The census was 89. Findings include: Review of an SRI created 03/06/25 at 6:25 P.M. revealed an allegation of verbal abuse by Resident #22 against Certified Nurse Aide (CNA) #365 was submitted to the State Survey Agency through the Enhanced Information Dissemination Collection (EIDC) system . Further review of the SRI revealed the Administrator suspended CNA #365 and was asked to leave the building immediately. The SRI further revealed another unnamed resident had similar concerns a few weeks earlier, and while the facility did not feel the actions were verbal abuse, CNA #365 was terminated from employment due to violating the resident care policy. There were no attachments to the SRI in the EIDC system. Interview on 04/07/25 at approximately…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, staff interview, and policy review, the facility failed to ensure a resident residing on a secured behavioral unit met the criteria for admission to the secured unit. This affected one (#90) of three residents reviewed for placement on the secured unit. The facility identified 22 residents as residing on the secured unit. The facility census was 89. Findings include: Review of the closed medical record for Resident #90 revealed an admission date of 12/10/24, a readmission date of 02/05/24, and a discharge date of 04/01/25. Diagnoses included subdural hemorrhage, intracranial injury, hypotension, generalized anxiety disorder, and difficulty walking. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #90 had impaired cognition. Review of the plan of care revised 03/18/25 revealed Resident #90 was at risk for elopement and wandering related to impaired safety awareness, traumatic brain injury, and impaired cognition. The resident resided…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, staff interview, resident representative review, and policy review, the facility failed to ensure a notice of transfer or discharge was provided to residents. This affected two (#90 and #9) of three residents reviewed for transfer and discharge notices. The facility census was 89. Findings include: 1. Review of the closed medical record for Resident #90 revealed an admission date of 12/10/24, a readmission date of 02/05/24, and a discharge date of 04/01/25. Diagnoses included subdural hemorrhage, intracranial injury, hypotension, generalized anxiety disorder, and difficulty walking. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #90 had impaired cognition. Review of a nurse's note dated 04/01/25 at 5:11 P.M. revealed Resident #90 exited the secured unit with staff remaining with the resident. The resident was transported to the hospital for evaluation. Further review of the nurses' notes from 04/01/25 through 04/07/25 revealed no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, staff interview, resident representative review, and policy review, the facility failed to ensure a bed hold notice was provided to residents. This affected two (#90 and #9) of three residents reviewed for bed hold notices. The facility census was 89. Findings include: 1. Review of the closed medical record for Resident #90 revealed an admission date of 12/10/24, a readmission date of 02/05/24, and a discharge date of 04/01/25. Diagnoses included subdural hemorrhage, intracranial injury, hypotension, generalized anxiety disorder, and difficulty walking. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #90 had impaired cognition. Review of a nurse's note dated 04/01/25 at 5:11 P.M. revealed Resident #90 exited the secured unit with staff remaining with the resident. The resident was transported to the hospital for evaluation. Further review of the nurses' notes from 04/01/25 through 04/07/25 revealed no documentation the resident 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 resident interview, medical record review, review of shower schedules, review of shower documents, staff interview, and review of the facility policy, the facility failed to ensure showers were provided to residents who required assistance with showers. This affected three (#9, #34, and #88) of three residents reviewed for showers. The facility census was 89. Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 04/26/24 with diagnoses of dependence on renal hemodialysis and tracheostomy status. Resident #9 discharged to an acute-care hospital on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/20/25, revealed Resident #9 had intact cognition and was dependent on staff for showers. Review of the shower schedule revealed Resident #9 was scheduled for showers on Wednesdays and Saturdays during second shift. Review of the shower sheets for March 2025 and April 2025 revealed Resident #9 received a shower on 03/05/25, a bath on 03/16/25,…

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

Based on medical record review, staff schedules, resident and staff interviews, and policy review, the facility failed to ensure residents on a mechanical ventilator received adequate care to decrease their need for ventilator dependence (wean from the ventilator). This affected one (#34) resident identified to require mechanical ventilation. The facility census was 89. Findings include: Review of the medical record for Resident #34 revealed an admission date of 03/07/25 with diagnoses of acute respiratory failure and tracheostomy status. Review of the modified comprehensive admission Minimum Data Set (MDS) assessment, dated 03/18/25, revealed Resident #34 had intact cognition, had a tracheostomy, and used an invasive mechanical ventilator. Review of the current physician order initiated 03/26/25 revealed Resident #34 should be weaned from the ventilator at night in two-hour increments with close supervision by respiratory therapy. Interview on 04/03/25 at 11:07 A.M. with Resident #34 revealed she was not aware whether she was making progress with weaning from the ventilator.…

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 and staff interview, the facility failed to ensure medications were ordered with instructions for the correct indication of use. This affected one (#83) of three residents reviewed for medications. The census was 89. Findings include: Review of the medical record for Resident #83 revealed an admission date of 10/12/23 with diagnoses of hypotension and dependence on renal dialysis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/15/25, revealed Resident #83 had intact cognition. Review of the current physician order, dated 03/30/24, revealed Resident #83 received Midodrine 10 milligrams (mg), one tablet by mouth three times daily for hypotension (low blood pressure) with instructions to hold for systolic blood pressure (SBP) less than 110 millimeters of mercury (mmHg). Interview on 04/07/25 at 10:04 A.M. with the Director of Nursing (DON) revealed Midodrine was used to treat low blood pressure. The DON further confirmed the physician order indicating the medication should be held for low SBP and did not reflect the way the medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, medical record review, staff interview, and policy review, the facility failed to ensure residents were screened for therapy services, and failed to ensure therapy staff pursued authorization to provide therapy services. This affected two (#9 and #68) of three residents reviewed for therapy services. The facility census was 89. Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 04/26/24 with diagnoses of dependence on renal hemodialysis and tracheostomy status. Resident #9 discharged to an acute-care hospital on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/20/25, revealed Resident #9 had intact cognition and was dependent on staff for showers and toileting. Review of the multidisciplinary care conference documentation, dated 07/30/24, revealed Resident #9 and Resident #9's son attended the care conference. Further review revealed Resident #9 would be referred for rehabilitation services for strengthening,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, staff and resident interview, and policy review, the facility failed to ensure accurate documentation was in the medical record and failed to ensure the medical record reflected care and services provided. This affected three (#21, #74, and #42) of nine residents reviewed for accuracy of the medical record. The facility census was 89. Findings include: 1. Review of the medical record for Resident #21 revealed an admission date of 08/15/23. Diagnoses included depression and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had intact cognition. Review of the physician orders for March 2025 revealed the resident had orders for supplemental vitamin D 2000 units at bedtime, lamotrigine 75 milligrams (mg) twice daily for seizures, and Miralax 17 grams twice a day for constipation. Review of Resident #21's medication administration record (MAR) for 03/30/25 revealed no documentation the resident was administered vitamin D,…

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 staff interview and facility document review, the facility failed to ensure there was Registered Nurse (RN) coverage eight consecutive hours, seven days a week for 17 days during the timeframe from 02/01/25 through 03/13/25. This had the potential to affect all 91 residents. The census was 91. Findings included: Review of the Daily Timecard, for the timeframe from 02/01/25 through 03/13/25, revealed there was not consecutive eight hours of RN coverage on 02/01/25, 02/02/25, 02/07/25, 02/11/25, 02/15/25, 02/16/25, 02/19/25, 02/20/25, 02/21/25, 02/24/25, 02/25/25, 02/28/25, 03/01/25, 03/02/25,03/03/25, 03/05/25, and 03/07/25. Interview on 03/18/25 at 1:10 P.M., with Human Resources (HR) Coordinator #1 stated she had been working at the facility for three years, and for the previous three years she was responsible for scheduling prior to the Staffing and Scheduling Coordinator being hired. The HR Coordinator reviewed and confirmed there was no consecutive eight hours of RN coverage on the dates listed above. Interview on 03/18/25 at 2:23 P.M., with the Staffing and Scheduling…

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 personnel file review, staff interview, and policy review, the facility failed to provide dementia management and resident abuse prevention education for five Certified Nurse Aides (CNAs) (#9, #24, #27, #34, and #35 of five staff reviewed for training. This had the potential to affect all 91 residents in the facility. Findings included: Review of personnel files provided by the facility revealed the following: CNA #9's personnel file revealed a hire date of 08/16/2023. The personnel file contained no evidence of training or competency for abuse or dementia. CNA #24's personnel file revealed a hire date of 08/03/2022. The personnel file contained no evidence of training or competency for abuse or dementia. CNA #27's personnel file revealed a hire date of 05/29/2014. The personnel file contained no evidence of training or competency for abuse or dementia. CNA #34's personnel file revealed a hire date of 10/08/2017. The personnel file contained no evidence of training or competency for abuse or dementia. CNA #35's personnel file revealed a hire date of 03/08/2011. The…

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

Based on observation, medical record review, staff and resident interview, and facility policy review, the facility failed to ensure residents who were assessed by the facility to require supervision while smoking were supervised by staff when they went out to smoke, failed to ensure residents did not keep their smoking materials in their possession, failed to ensure residents smoked in the designated smoking area of the facility, and failed to ensure resident smoking evaluations were accurate. This affected four (#79, #70, #39, and #244) of six sampled residents reviewed for accidents in a facility census of 91. Findings included: 1. Review of a admission record revealed the facility admitted Resident #79 on 09/08/23. The resident had a medical history that included a diagnosis of chronic obstructive pulmonary disease. Review of a quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 02/13/25, revealed Resident #79 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Review of Resident #79's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and resident interview, and facility policy review, the facility failed to ensure a bed hold notice was issued for two (#61 and #78) of three sampled residents reviewed for hospitalization in a facility census of 91. Findings included: 1. Review of an admission record revealed the facility admitted Resident #61 on 01/30/25. The resident had a diagnosis of critical illness myopathy. Resident #61 was their own responsible party. Review of a quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 02/07/25, revealed Resident #61 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. Review of a discharge MDS assessment, with an ARD of 02/15/25, revealed Resident #61 discharged to a short-term general hospital on [DATE]. Review of Resident #61's progress notes dated 02/15/25 at 7:02 A.M. revealed the resident's family requested the resident be sent to the hospital as the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure the licensed nursing staff notified the physician of a resident's readmission to the facility and to obtain medication and/or treatment orders to direct staff how to care for one (#61) of 19 sampled residents in a facility census of 91. Findings included: Review of an admission record revealed the facility admitted Resident #61 on 01/30/25. The resident had a diagnosis of critical illness myopathy. Per the admission record, the resident was their own responsible party. Review of a quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 02/07/25, revealed Resident #61 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. Review of a discharge MDS assessment, with an ARD of 02/15/25, revealed Resident #61 discharged to a short-term general hospital on [DATE]. Review of Resident #61's progress notes dated 02/15/25 at 7:02 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.

Based on medical record review, staff interview, and review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) manual, the facility failed to ensure Minimum Data Set assessments were coded accurately for two (#38 and #65) of three residents reviewed for resident assessments in a facility census of 91. Findings included: 1. Review of an admission record revealed the facility admitted Resident #38 on 01/19/18. The resident had diagnoses of anxiety disorder, dementia, schizoaffective disorder, and major depressive disorder. Review of an annual Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 01/06/24, revealed Resident #38 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS assessment indicated the resident was not currently considered by the state level II Preadmission Screening and Resident Review (PASRR) process to have a serious mental illness and/or intellectual disability or a related condition. The MDS indicated the resident had active…

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

Based on observation, staff interview, medical record review, and facility policy review, the facility failed to ensure a resident received their tube feeding as ordered by the physician for one (#68) of three sampled residents reviewed for tube feeding in a facility census of 91. Findings included: Review of an admission record revealed the facility admitted Resident #68 on 10/25/23. The resident had diagnoses of cerebral infarction, chronic respiratory failure with hypoxia, tracheostomy status, dependence on respiratory (ventilator) status, protein-calorie malnutrition, and gastrostomy status. Review of a quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 03/11/25, revealed Resident #68 had a Staff Assessment for Mental Status (SAMS) that indicated the resident was severely impaired with cognitive skills for daily decision-making and had short-term and long-term memory problems. The MDS assessment indicated the resident had a feeding tube and received 51 percent (%) or more of their total calories through the feeding tube and 501 cubic…

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

Based on medical record review, resident and staff interview, and facility policy review, the facility failed to provide physician-ordered respiratory care and services for three (#4, #78, and #291) of four residents reviewed for respiratory care in a facility census of 91. Findings included: 1. Review of an admission record revealed the facility admitted Resident #4 on 04/26/24. The resident had a medical history that included diagnoses of chronic obstructive pulmonary disease (COPD), acute respiratory failure with hypoxia, obstructive sleep apnea, and tracheostomy status with dependence on respirator (ventilator). Review of an annual Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 12/18/24, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS assessment indicated the resident received oxygen therapy, suctioning, and tracheostomy care and used an invasive mechanical ventilator. Review of Resident #4's care plan included a focus area, initiated 05/17/24, that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, and policy review, the facility failed to provide coordination of treatment to ensure medications were administered as ordered for a dialysis resident. This affected one (#61) of two sampled residents reviewed for dialysis. The facility census was 91. Findings included: Review of the admission record indicated Resident #61 was admitted on [DATE]. According to the admission Record, the resident had a medical history that included a diagnosis of critical illness myopathy. Per the admission Record, the resident was their own responsible party. Review of Resident #61's Progress Notes, dated 03/06/25 at 5:29 P.M., revealed the resident arrived back in the facility from the hospital. Review of Resident #61's hospital Discharge summary dated [DATE], revealed Discharge Orders, that specified an order Cefazolin (an antibiotic used to treat many different kinds of bacterial infections) 2 grams (gm) intravenously piggyback every Monday and Wednesday after hemodialysis and 3 gm every…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, and policy review, the facility failed to ensure pharmacy recommendations were implemented timely for one (#65) of five sampled residents reviewed for unnecessary medications. The facility census was 91. Findings included: Review of the admission record indicated Resident #65 admitted on [DATE]. According to the admission record, the resident had a medical history that included diagnoses of paranoid personality disorder, schizoaffective disorder, adjustment disorder with mixed anxiety and depressed mood, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/12/25, revealed Resident #65 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated the resident took antipsychotic, antidepressant, hypoglycemic, and anticonvulsant medication during the seven-day look-back period. Review of Resident #65's Care Plan Report, included a focus…

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

Based on observation, staff interview, record review, and policy review, the facility failed to ensure there was a medication error rate of five percent (%) or less. There were 10 errors out of 26 opportunities observed, which yielded a medication error rate of 38.5%, This affected two (#68 and #57) of two residents observed for medication administration. Findings included: 1. Review of Resident #68's Physician Order Summary Report included the following orders: - an order dated 02/08/25, for docusate sodium oral liquid 50 milligrams (mg)/ 5 milliliters (ml), give 5 ml by way of gastrostomy tube in the morning for bowel regimen. - an order dated 02/08/25, for potassium chloride oral packet 20 milliequivalents, give one packet by way of gastrostomy tube in the morning for prevention of hypokalemia (low potassium). - an order dated 02/08/25, for sertraline hydrochloride (HCL) oral tablet 25 mg, give one tablet by way of gastrostomy tube in the morning for depression. - an order dated 02/08/25, for alprazolam oral tablet 0.25 mg, give one tablet by way of gastrostomy tube two times 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, record review, staff interview, and policy review, the facility failed to ensure staff donned recommended personal protective equipment (PPE) in a room labeled as requiring enhanced barrier precautions (EPB) for one (Resident #6) of five residents reviewed for transmission-based precautions or EBP. The facility further failed to ensure staff performed proper hand hygiene and glove changes during the provision of incontinence care for one (Resident #190) of two residents reviewed for bladder and bowel incontinence. The facility census was 91. Findings included: 1. Review of the admission record indicated Resident #6 admitted on [DATE]. According to the admission record, the resident had a medical history that included diagnoses of peripheral vascular disease, osteomyelitis (bone infection), and non-pressure chronic ulcer of other part of right foot with unspecified severity. Review of Resident #6's Physician Order Summary Report contained an active order dated 06/11/24 for EBP for a chronic…

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

Based on observation, staff interview, and review of facility policy, the facility failed to ensure soiled linen was contained to prevent cross contamination with clean linen. This had the potential to affect all 88 residents receiving laundry services. The facility census was 88. Findings include: Observation of the facility laundry on 01/14/25 at 6:40 A.M. with Housekeeper/Laundry Staff (HLS) #800 revealed the facility was equipped with two commercial washing machines and four commercial dryers. HLS #800 stated the facility was down to one operating washing machine and three commercial dryers. Located next to the dryers identified three wheeled laundry bins with soiled clothing and linens mixed together. The soiled laundry was mounted over the top of the bins and spilling to the floor. Two large piles of soiled laundry were located on the floor of the laundry room placed in front of the dryers. HLS #800 verified soiled linens were mixed with resident personal clothing and associated facility laundry. HLS #800 also stated the soiled laundry was piled on the floor in front of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interview, the facility failed to ensure wash clothes and towels were provided to residents. This had the potential to affect all 88 residents residing in the facility. Findings include: Observation on 01/14/25 at 6:04 A.M. with Certified Nurse Aide (CNA) #206 noted the main unit linen storage room supplied with seven washcloths and nine bath towels. Observation inside the house unit clean linen storage room discovered no clean washcloths or towels. Interview with CNA #206 stated frequently no washcloths or towels were available and staff cut linen (sheets and bath blankets) to cleanse residents. Observation on 01/14/25 at 6:09 A.M. with CNA #202 revealed the [NAME] unit clean linen storage room lacked any available clean washcloths or towels. CNA #202 stated staff will cut large size linens to cleanse residents. Observation on 01/14/25 at 6:40 A.M. with Housekeeping/Laundry staff (HLS) #800 during a tour of the facility laundry noted the facility utilizing one washing machine and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and resident and staff interview, the facility failed to ensure residents who were incontinent were provided with a supply of appropriately fitting incontinence garments and briefs. This affected 43 current residents (#2, #3, #5, #6, #7, #8, #10, #14, #15, #16, #17, #18, #20, #21, #22, #23, #24, #26, #28, #29, #30, #32, #33, #34, #35, #37, #39, #40, #41, #42, #43, #44, #45, #55, #69, #74, #76, #79, #81, #82, #86, #87, and #89) identified by the facility to require incontinence briefs. The facility census was 88. Findings include: Record review revealed Resident #2 admitted to the facility on [DATE]. Diagnoses included paraplegia and neurogenic bowel. According to the most current Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had intact cognition, dependent on staff for incontinence care, and was incontinent of bowel and bladder. Observation and interview on 01/14/25 at 5:55 A.M. of the facilities central supply storage with Licensed Practical Nurse (LPN)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, resident and staff interview, and review of facility policy, the facility failed to ensure residents who required assistance with activities of daily living (ADL) were assisted with bathing as scheduled. This affected four (#1, #2, #5, and #6) of six residents reviewed for ADL. The facility census was 88. Findings include: 1. Record review revealed Resident #1 admitted to the facility on [DATE]. Diagnoses included end stage renal disease, morbid obesity, congestive heart failure, and dependence on renal dialysis. According to the most current Minimum Data Set (MDS) assessment dated [DATE], Resident #1 had intact cognition and required supervision or touching assistance with ADL. On 12/30/24, a nursing plan of care was implemented to address Resident #1 has an ADL self-care performance deficit related to impaired balance. Intervention included shower days were Tuesday and Friday on day shift. Resident required supervision by one staff with personal hygiene. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, resident and staff interview, and facility staffing documentation, the facility failed to schedule sufficient nursing staff to ensure resident care and treatment was provided as indicated. This affected four residents (#1, #2, #5, and #6) and had the potential to additionally affect 32 residents (#3, #4, #7, #8, #9, #10, #11, #13, #14, #15, #16, #17, #18, #19, #22, #23, #70, #72, #73, #74, #75, #76, #77, #79, #81, #82, #83, #84, #85, #86, #87, and #88). The facility census was 88. Findings include: 1. There was an inadequate staffing issue to provide residents with routine bathing as scheduled. 1a. Resident #1's shower days were Tuesday and Friday on day shift and the resident required supervision by one staff with personal hygiene. Resident #1's shower/bath paper documentation between 12/24/24 and 01/13/25 revealed showers were administered on 12/26/24 and 01/13/25 with a bed bath on 01/09/25. 1b. Resident #2 required extensive assistance of one staff with showering…

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

Based on observation, staff interview, review of facility dietary spreadsheets and resident dietary order documentation, the facility failed to ensure dietary meal portions were provided as required. This affected 60 residents (#1, #2, #4, #6, #7, #8, #9, #10, #11, #12, #13, #14, #17, #18, #20, #21, #22, #25, #26, #29, #30, #33, #35, #37, #43, #44, #46, #48, #49, #51, #53, #54, #55, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #68, #69, #70, #71, #73, #74, #75, #76, #77, #78, #79, #80, #83, #84, #85, #87, and #88) of 86 residents who were on a regular diet and 15 of the residents who were on a no concentrated sweets diet (NCS). The facility census was 88. Findings include: Observation in the facilities kitchen on 01/14/25 at 11:45 A.M. with Dietary Director #1 revealed the lunch meal items were placed to the steam table which included meatloaf, gravy, mashed potatoes, french cut green beans, apple crisp. Dietary Director #1 confirmed dietary was utilizing a three-ounce slotted spoodle (cross between a serving spoon and a ladle) for french cut green beans and a four-ounce…

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, medical record review, and resident and staff interview the facility failed to ensure residents were provided with personal clothing and clothing was appropriately fitting. This affected one (#2) of six residents reviewed for clothing and personal affects in a facility census of 88. Findings include: Record review revealed Resident #2 admitted to the facility on [DATE]. Diagnoses included malignant neoplasm of bone, malignant neoplasm of thyroid gland, paraplegia, and neurogenic bowel. According to the most current Minimum Data Set (MDS) assessment dated [DATE], Resident #2 had intact cognition, no recorded behaviors, range of motion impairment bilateral lower extremities, utilized a wheelchair for mobility, dependent on staff for the provision of activities of daily living (ADL), and a weight of 254 pounds. Observation on 01/14/25 at 7:49 A.M. noted Certified Nurse Aide (CNA) #204 with CNA #205 providing Resident #2 with morning ADL care, including dressing. Resident #2 was placed in 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 medical record review and physician and staff interview, the facility failed to notify the physician regarding blood glucose monitoring following admission to the facility. This affected one (#1) of six residents reviewed for notification of physician in a facility census of 88. Findings include: Record review revealed Resident #1 admitted to the facility on [DATE]. Diagnoses included end stage renal disease, type II diabetes mellitus, nephrotic syndrome, and dependence on renal dialysis. According to the most current Minimum Data Set (MDS) assessment dated [DATE], Resident #1 had intact cognition, and received insulin injections. According to hospital community referral (HCR) documentation dated 12/24/24, Resident #1 was ordered to receive Humalog KwikPen Insulin 20 to 25 units three times daily with meals. Additional insulin administration included insulin glargine 40 units under the skin in the morning and 40 units before bedtime. The HCR noted short acting Humalog insulin dosage sliding scale blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, review of facility staffing schedules, and facility wound treatment policy, the facility failed to ensure wound treatments were provided as ordered by the physician. This affected one (#3) of six residents reviewed for the application of wound treatments in a facility census of 88. Findings include: Record review revealed Resident #3 admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure, dependence on ventilator and supplemental oxygen, tracheostomy, neuromuscular dysfunction of bladder, quadriplegia, and injury at cervical vertebra 2 of cervical spinal cord. According to the most current Minimum Data Set (MDS) assessment dated [DATE], Resident #3 had severe cognitive impairment, range of motion impairments to the bilateral upper and lower extremities, dependent on staff for the completion of activities of daily living, incontinent of bowel and bladder, at risk for pressure ulcer development, and admitted with 11 pressure…

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, review of facility staffing schedules, and facility wound treatment policy, the facility failed to ensure pressure ulcer wound treatments were provided as ordered by the physician. This affected one (#3) of six residents reviewed for the application of wound treatments in a facility census of 88. Findings include: Record review revealed Resident #3 admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure, dependence on ventilator and supplemental oxygen, tracheostomy, neuromuscular dysfunction of bladder, quadriplegia, and injury at cervical vertebra 2 of cervical spinal cord. According to the most current Minimum Data Set (MDS) assessment dated [DATE], Resident #3 had severe cognitive impairment, range of motion impairments to the bilateral upper and lower extremities, dependent on staff for the completion of activities of daily living, incontinent of bowel and bladder, at risk for pressure ulcer development, and admitted…

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, medical record review, resident and staff interview, and review of facility incontinence policy, the facility failed to provide residents with timely incontinence care and application of related and appropriate incontinence products. This affected one (#2) of three residents reviewed for incontinence care in a facility census of 88. Findings include: Record review revealed Resident #2 admitted to the facility on [DATE]. Diagnoses included malignant neoplasm of bone, malignant neoplasm of thyroid gland, paraplegia, and neurogenic bowel. According to the most current Minimum Data Set (MDS) assessment dated [DATE], Resident #2 had intact cognition, no recorded behaviors, dependent on staff for the provision of activities of daily living (ADL), incontinent of bowel and bladder, and was at risk for pressure ulcer development with no skin breakdown. On 03/01/23, a nursing plan of care was implemented to address Resident #2's ADL self-care performance deficit related to disease process. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, physician and staff interview, and review of policy, the facility failed to ensure medications were administered as ordered by the physician. This affected two (#1 and #4) of four residents reviewed for medication administration. The facility census was 88. Findings include: 1. Record review revealed Resident #1 admitted to the facility on [DATE]. Diagnoses included end stage renal disease and type II diabetes mellitus. According to the most current Minimum Data Set (MDS) assessment dated [DATE], Resident #1 had intact cognition and received insulin injections. According to hospital community referral form (CRF) documentation dated 12/24/24, Resident #1 was ordered to receive Humalog KwikPen Insulin 20 to 25 units three times daily with meals. The CRF noted short acting Humalog insulin dosage sliding scale blood glucose monitoring obtained before meals and at bedtime. Physician follow-up appointment instructions noted Physician #001 listed for follow-up regarding…

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 facility policy review, the facility failed to ensure medications were administered according to the physician orders to the residents without any significant medication errors. This affected one (#4) of four residents reviewed for medication administration. The facility census was 88. Findings include: Review of Resident #4's medical record revealed Resident #4 admitted to the facility on [DATE] with the diagnoses including type II diabetes mellitus, end stage renal disease (ESRD), and dependence on renal dialysis. According to the most current Minimum Data Set (MDS) assessment dated [DATE], Resident #4 had intact cognition and received renal (Hemo) dialysis. Review of the physician orders dated 08/27/24 revealed an order for Sevelamer Carbonate oral tablet (used to lower phosphorous levels in the blood if you have ESRD with dialysis) 800 milligrams (mg) give four tablets by mouth with meals (morning, afternoon, evening) related to end stage…

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 resident and staff interview, the facility failed to ensure residents were provided with a bed of appropriate size and comfortable, intact mattress. This affected one (#1) of six residents observed for the provision of furniture and room furnishings. The facility census was 88. Findings include: Record review revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included morbid obesity. According to the most current Minimum Data Set (MDS) assessment dated [DATE], Resident #1 had intact cognition. Resident #1's height was six foot two inches and weight of 282 pounds. There was no documentation indicating Resident #1's bed was assessed for proper size or if the mattress was examined for designed pressure relieving properties. Observation on 01/14/25 at 6:13 A.M. revealed Resident #1 was lying in bed resting on his back with both feet pressed against the foot board and his head at top of mattress. On 01/15/25 at 5:55 A.M., Resident #1 was observed in…

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, and staff interview, the facility failed to maintain an odor free and clean environment in the secured behavior unit. This had the potential to affect all 26 residents on the secured behavior unit (#19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, and #44). Additionally, the facility failed to maintain a clean, sanitary environment. This affected one resident (#19) resident in the secured behavior unit. The facility census was 87. Findings include: 1. Observation on 05/08/24 at approximately 7:55 A.M. upon entrance to the secured behavior unit revealed a strong odor of urine. Approximately five residents were lined up in the hallway to enter the dining room and State Tested Nurse Aide (STNA) #205 was standing at the entrance to the unit. Interview on 05/08/24 at 8:08 A.M. with STNA #205 confirmed the hallway smelled strongly of urine at the time the surveyor entered the unit on 05/08/24. Observations…

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, medical record review, staff interviews, review of the facility's perineal care protocol and urinary incontinence clinical protocol, the facility failed to ensure timely incontinence care was provided and included the appropriate technique while providing care to a resident who was incontinent. This affected one (Resident #12) of three residents reviewed for incontinence care in a facility census of 87. Findings include: Review of Resident #12's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure, end stage renal disease, dependence on renal dialysis, chronic obstructive pulmonary disease, congestive heart failure, type II diabetes mellitus, morbid obesity, and irritable bowel syndrome. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had intact cognition, ability to make needs known, required supervision or touching assistance with activities of daily living, continent of bowel 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 policy review, the facility failed to administer medications as ordered and within scheduled time frames resulting in a medication error rate greater than five (5) percent (%). A total of three (3) medication errors were observed out of 25 opportunities for a medication error rate of 12%. This affected one (#12) of 10 residents observed during medication administration. The facility census was 88. Findings include: Review of Resident #12's medical record revealed an admission date of 07/10/23. Diagnoses included diabetes mellitus type two, dysphagia, coronary artery disease, and transient ischemic attack. Review of Resident #12's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed with intact cognition. Review of Resident #12's medical record revealed a physician order dated 08/27/23 for the blood pressure medication carvedilol 12.5 milligrams to be given twice daily. Review of Resident #12's medical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure medications were administered as ordered and within prescribed time frames resulting in a significant medication error. This affected one (#12) of 10 residents observed during medication administration. The facility census was 88. Findings include: Review of Resident #12's medical record revealed an admission date of 07/10/23. Diagnoses included diabetes mellitus type two, dysphagia, coronary artery disease, and transient ischemic attack. Review of Resident #12's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed with intact cognition and received insulin and injections during the assessment seven day look back period. Review of Resident #12's most recent care plan revealed the resident had diabetes mellitus. Interventions included administering diabetes medication as ordered by the doctor. Review of Resident #12's medical record revealed a physician order dated…

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

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure residents were provided with timely incontinence care. This affected one (Resident #3) of three residents sampled for incontinence care. The facility census was 93. Findings include: Review of the medical record for Resident #3 revealed an admission date of 06/06/23 with diagnoses including central cord syndrome, bilateral lower extremity contracture, peripheral vascular disease, quadriplegia, chronic obstructive pulmonary disease, major depression, severe protein calorie malnutrition, hypertension, and absence of kidney. Review of the Minimum Data Set (MDS) assessment for Resident #3 dated 12/21/23 revealed the resident was cognitively intact and dependent on staff for the completion of activities of daily living (ADLs) and was coded as always incontinent of bowel and bladder. Review of the care plan for Resident #3 dated 09/23/23 revealed the resident was incontinent of bowel and bladder related to a spinal injury. Intervention included the following:…

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

Based on medical record review, observation, staff interview, review of the facility policy, and review of the manufacturer instructions, the facility failed to ensure blood sugar monitoring and associated insulin administration were implemented in accordance with physician orders. This affected one (Resident #4) of eight residents reviewed for medication administration. The facility census was 93. Findings include: Review of the medical record for Resident #4 medical record revealed a physician's order dated 01/09/24 for insulin Lispro inject subcutaneously before meals for diabetes mellitus type II according to blood sugar sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units. Insulin administration was schedule for 6:00 A.M., 11:00 A.M. and 4:00 P.M. Observation on 01/17/24 at 1:29 P.M. revealed Registered Nurse (RN) #401 checked Resident #4's blood sugar and the result was 247. RN #401 returned to the medication cart and obtained an insulin Lispro pen and turned the dose knob to four units. The nurse did not…

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

Based on medical record review, staff interview and review of facility policy, the facility failed to administer medications within physician ordered parameters. This affected one (#6) of four residents reviewed for medication administration. The facility census was 92. Findings include: Review of Resident #6's medical record revealed an admission date of 09/29/23. Diagnoses included hypertension, high cholesterol, chronic obstructive pulmonary disease (COPD), cirrhosis, seizures, peripheral vascular disease, atrial fibrillation, paraplegia, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/12/23, revealed Resident #6 was cognitively intact. Review of the plan of care, dated 11/08/23, revealed Resident #6 had an altered cardiovascular status, peripheral vascular disease, and a pacemaker related to atrial fibrillation. Goals identified for Resident #6 included to remain free from complications of cardiac problems and peripheral vascular disease, maintain a heart rate within acceptable limits and to remain free of signs and symptoms 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 medical record review, observation, staff interview, and policy review, the facility failed to administer medications as ordered by the physician. In total, two medication errors were observed out of 31 opportunities for a medication error rate of 6.45 percent (%). This affected one (#1) of four residents observed for medication administration. The facility census was 95. Findings include: Review of the medical record for Resident #1 revealed an admission date of 07/26/23. Diagnoses included schizophrenia, hypertension, anxiety, depressive disorder, cerebral palsy, type two diabetes mellitus, and heart failure. Review of a physician order dated 07/27/23 revealed Resident #1 was ordered the anti-diabetic medication Riomet oral solution 500 milligrams (mg) per five milliliters (mL) with instructions to give five mL by mouth one time a day. The medication was scheduled to be administered at 8:00 A.M. daily. Review of a physician order dated 07/27/23 revealed Resident #1 was ordered the cholesterol lowering medication Lipitor 40 mg by mouth once daily. The medication 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 medical record review, review of a facility investigation, staff interviews, review of facility self-reported incidents, and policy review, the facility failed to report an allegation of neglect to the State Survey Agency when a resident with cognitive impairment eloped from the facility secured memory care unit without staff knowledge. This affected one (#96) of three residents reviewed for wandering and elopement. The facility census was 95. Findings include: Review of the medical record revealed Resident #96 had an admission date of 06/02/23. The resident was discharged from the facility on 07/31/23. Diagnoses included dementia, Alzheimer's disease with late onset, cognitive communication deficit, and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #96 had moderate cognitive impairment. The resident required the limited assistance of one staff for bed mobility, transfers, walking, locomotion on the unit, toileting, 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 review of hospital discharge orders, review of physician orders, review of medication administration records, staff interview, and policy review, the facility failed to ensure medication orders were correctly entered and administered per physician orders. This affected one (#97) of three residents reviewed for medication administration. The facility census was 95. Findings include: Review of the medical record for Resident #97 revealed an admission date of 07/25/23 and a discharge date of 08/08/23. Diagnoses included infection and inflammatory reaction due to internal right knee prosthesis, chronic migraine, generalized anxiety disorder, fibromyalgia, primary insomnia, morbid obesity, and muscle weakness. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #97 had intact cognition. The resident required supervision for bed mobility; extensive assistance of one staff for locomotion on and off the unit, and toileting assistance, and limited assistance of one staff 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 medical record review, staff interview, and policy review, the facility failed to ensure a resident was timely screened for therapy services. This affected one (#95) of three residents reviewed for therapy services. The facility census was 95. Findings include: Review of the medical record revealed Resident #95 had an admission date of 07/26/23. Diagnoses included schizophrenia, hypertension, anxiety, depressive disorder, cerebral palsy, chronic obstructive pulmonary disease, type two diabetes mellitus, and heart failure. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident required supervision with bed mobility, transfers, walking, locomotion on the unit, dressing, eating, toileting, and personal hygiene. Review of a physician after visit summary dated 08/01/23 at 2:00 P.M. revealed the physician made referrals for Resident #95 for physical and occupational therapy due to lumbosacral radiculopathy (narrowing of the space where…

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

Based on observation, staff interview, and policy review, the facility failed to store foods and maintain the kitchen in a safe and sanitary manner. This affected all 75 residents residing in the facility. The facility census was 75. Findings include: Observation of the kitchen on 01/12/23 between 8:00 A.M. and 9:00 A.M. revealed unidentified debris and a few dead insects stuck to the wall above the clean cooking pots on the storage rack near the three compartment sink. Observation of the floor throughout the kitchen had black substance on the floor tile along the wall edges with dirt and debris on the floor in the corners. There was standing water on the floor under the three compartment sink and the spraying device used to clean food items off dirty dishes with a soaking wet rag laying in the water on the floor. There was missing floor tile observed under the dishwasher with standing water and grease observed in this location. There was a heavy black substance observed under the dishwasher and food debris observed on top of the dishwasher. Observation of the walk-in freezer…

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, personnel file review, staff interview, policy review, and review of the tuberculosis control plan, the facility failed to complete two step tuberculosis testing on staff upon hire and failed to ensure the first step testing results were negative prior to direct resident contact and failed to ensure annual tuberculosis screening for all employees. This has the potential to affect all residents. Additionally, the facility failed to ensure body excretions were cleaned up timely. This affected one resident (#16) out of 23 residents who resided on the secured unit. In addition, the facility failed to ensure clean linens were transported in a sanitary manner. This affected nine residents (#02, #03, #04, #07, #16, #41, #54, #59 and #67) out of 23 residents residing on the secured behavior unit. The facility census was 75. Findings include: 1. Review of the personnel file for State Tested Nursing Assistant #321 revealed a hire date of 03/23/22 and had no evidence for tuberculosis testing. Review of the personnel file for State Tested Nursing Assistant #308 revealed a…

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

Based on observation, resident and staff interview and policy review, the facility failed to ensure a clean, sanitary and homelike environment. This affected 23 residents (#02, #03, #04, #07, #09, #11, #13, #16, #22, #26, #31, #32, #37, #40, #41, #42, #48, #53, #54, #59, #64, #67 and #69) residing on the secured behavior unit, 15 residents (#01, #10, #24, #27, #30, #35, #38, #39, #46, #52, #55, #66, #70, #77, and #81) residing on the secured memory care unit, and residents (#14 and #19) out of 75 residents who reside in the facility. The facility census was 75. Findings include: 1. Observation on 01/09/23 at 10:16 A.M. of Resident #16's room revealed several brown colored spots, approximately quarter sized, on the floor near the foot of the bed. Interview with Resident #16 at the time of the observation revealed the resident's room was not cleaned very often. Observation on 01/09/23 at 12:10 P.M. of Resident #16's room revealed the brown spots remained on the floor. Observation on 01/09/23 at 3:19 P.M. of Resident #16's room revealed the brown colored spots remained on the floor.…

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, pharmacy interview and policy review, the facility failed to ensure administration of pneumococcal vaccines. In addition, the facility failed to thoroughly document the administration of influenza vaccinations per facility policy. This affected four residents (#04, #13, #15 and #31) out of five residents reviewed for vaccination status. The facility census was 75. Findings include: 1. Review of Resident #04's medical record revealed an admission date of 10/11/19 and a readmission date of 03/06/20. Diagnoses included Parkinson's disease, peripheral vascular diseases, chronic kidney disease, major depressive disorder, dementia, dysphagia, chronic obstructive pulmonary disease (COPD) and schizophrenia. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #04 was moderately cognitively impaired, had not received the pneumococcal vaccination and the pneumococcal vaccination was not offered. Review of a vaccination consent…

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

Based on observation, staff interview, resident representative interview, and medical record review, the facility failed to maintain resident dignity by not trimming facial hair on a female resident. This affected one resident (#52) out of one resident reviewed for dignity. The facility census was 75. Findings include: Review of Resident #52's medical record revealed an admission date of 11/10/22. Diagnoses included dementia with behavioral disturbance, diabetes mellitus type II, essential hypertension, spinal stenosis, cognitive communication deficit, and dysphagia. Review of the Minimum Data Set (MDS) assessment completed 12/23/22 revealed Resident #52 was assessed with severely impaired cognitive skills for daily decision making, required extensive assistance with personal hygiene, and was assessed with no rejection of care during the assessment look back period. Review of an activities of daily living (ADLs) self-care deficit care plan revealed an intervention that Resident #27 required limited assistance from one staff member for hygiene and grooming. Observation on 01/09/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and durable power of attorney interview, and policy review, the facility failed to ensure resident care conference were held with resident representatives as required. This affected one resident (#27) out of one resident reviewed for care planning. The facility census was 75. Findings include: Review of Resident #27's medical record revealed an admission date of 05/30/19. Diagnoses included dementia with other behavioral disturbance, pseudobulbar affect, cognitive communication deficit, anxiety, and essential hypertension. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #27 was assessed with severely impaired cognitive skills for daily decision making. Review of Resident #27's face sheet dated 05/30/19 revealed Resident #27 had a durable power of attorney (DPOA) who was listed as her first emergency contact. Review of Resident #27's medical record revealed the last documented care conference was held on 04/12/21 at 11:00 A.M., and Resident #27's DPOA 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 medical record review, observation, staff interview and policy review, the facility failed to ensure residents that required assistance with bathing were provided adequate care and services. This affected one resident (#19) out of three residents reviewed for activities of daily living. The facility identified 14 residents who required staff assistance with bathing. The facility census was 75. Findings include: Review of Resident #19's medical record revealed an admission date of 12/31/21. Diagnoses included cerebral atherosclerosis, vascular dementia, hypertension, asthma, major depressive disorder. Review of the comprehensive Minimum Data Set (MDS) dated [DATE] revealed Resident #19 was assessed with impaired cognitive skills for daily decision making and required one-person physical dependence with bed mobility, transfer, dressing, grooming, and incontinent care. The activities of daily living (ADLs) Care Area Assessment (CAA) as part of the annual MDS assessment revealed Resident #19 required total…

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 follow up on recommendations for wound care. This affected one resident (#16) out of two residents reviewed for non-pressure related skin conditions. The facility identified seven residents with non-pressure related skin conditions. The facility census was 75. Findings include: Review of Resident #16's medical record revealed an admission date of 10/26/22 and a readmission date of 12/24/22. Diagnoses included cutaneous abscess of abdominal wall, schizoaffective disorder, cutaneous abscess of limb, trochanteric bursitis, paranoid schizophrenia, iron deficiency, open wound of abdominal wall, hidradenitis suppurativa, colostomy status, major depressive disorder, and generalized anxiety disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was moderately cognitively impaired, required extensive assistance with bed mobility, dressing, toilet use and personal hygiene and had no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident and staff interviews, and policy review, the facility failed to ensure pressure ulcer treatment was implemented. This affected two residents (#19 and #33) out of two residents reviewed for pressure ulcers. The facility census was 75. Findings include: 1. Review of Resident #19's medical record revealed an admission date of 12/31/21. Diagnoses included cerebral atherosclerosis, vascular dementia, hypertension, asthma, major depressive disorder. A facility acquired pressure ulcer acquired to the right lateral ankle on 07/11/22 related to decreased mobility. Review of the comprehensive Minimum Data Set (MDS) dated [DATE] revealed Resident #19 was assessed with impaired cognitive skills for daily decision making and required one-person physical dependence with bed mobility, transfer, dressing, grooming, and incontinent care. The activities of daily living (ADLs) Care Area Assessment (CAA) as part of the annual MDS assessment revealed Resident #19 required total…

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 and resident interview, medical record review, and policy review, the facility failed to ensure fall interventions were in place as ordered or care planned. This affected two residents (#16 and #46) out of three residents reviewed for falls. The facility identified 18 residents assessed at high risk for falls. In addition, the facility failed to ensure medications were secured. This affected one (#31) of one residents reviewed for self-administration of medications on the secured behavior unit. The facility identified 23 residents on the secured behavior unit who were assessed to be unsafe with self-administration of medications. The census was 75. Findings include: 1. Review of Resident #46's medical record revealed an admission date of 10/24/19. Diagnoses included dementia with other behavioral disturbance, tinea unguium, other specified peripheral vascular disease, chronic kidney disease, paranoid schizophrenia, chronic obstructive pulmonary disease, and liver disease. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and staff interview the facility failed to ensure physician orders were in place for catheter care. This affected one resident (#16) out of one residents reviewed for catheter care. The facility identified two residents with indwelling catheters. The facility census was 75. Findings include: Review of Resident #16's medical record revealed an admission date of 10/26/22. Diagnoses included cutaneous abscess of abdominal wall, schizoaffective disorder, cutaneous abscess of limb, hemorrhage of anus and rectum, trochanteric bursitis, paranoid schizophrenia, iron deficiency, open wound of abdominal wall, hidradenitis suppurativa, colostomy status, major depressive disorder, and generalized anxiety disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was moderately cognitively impaired and required extensive assistance with bed mobility, dressing, toilet use and personal hygiene. Additionally, Resident #16 had an indwelling…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and staff interview, the facility failed to ensure physician orders were in place for colostomy care. This affected one resident (#16) out of one residents reviewed for colostomy care. The facility identified five residents with colostomies. The facility census was 75. Findings include: Review of Resident #16's medical record revealed an admission date of 10/26/22. Diagnoses included cutaneous abscess of abdominal wall, schizoaffective disorder, cutaneous abscess of limb, hemorrhage of anus and rectum, trochanteric bursitis, paranoid schizophrenia, iron deficiency, open wound of abdominal wall, hidradenitis suppurativa, colostomy status, major depressive disorder, and generalized anxiety disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was moderately cognitively impaired and required extensive assistance with bed mobility, dressing, toilet use and personal hygiene. Review of a plan of care focus area initiated…

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, staff interview, and review of the facility assessment, the facility failed to ensure enough staff were available to provide activities of daily living care for dependent residents. This affected one resident (#19) out of three residents reviewed for activities of daily living. The facility census was 75. Findings include: Review of Resident #19's medical record revealed an admission date of 12/31/21. Diagnoses included cerebral atherosclerosis, vascular dementia, hypertension, asthma, major depressive disorder. Review of the comprehensive Minimum Data Set (MDS) dated [DATE] revealed Resident #19 was assessed with impaired cognitive skills for daily decision making and required one-person physical dependence with bed mobility, transfer, dressing, grooming, and incontinent care. The activities of daily living (ADLs) Care Area Assessment (CAA) as part of the annual MDS assessment revealed Resident #19 required total assistance with ADLs and the facility will proceed to…

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

Based on observation, staff interview, medical record review, review of drug manufacturer's instructions, and policy review, the facility failed to ensure insulin medication was administered as ordered and without significant error. This affected one resident (#08) out of five residents observed during medication administration. The facility census was 75. Findings include: Review of Resident #08's record revealed an admission date of 03/29/19. Diagnoses included hypertension, anemia, chronic kidney disease, peripheral vascular disease and type II diabetes mellitus. Review of a physician order dated 05/07/20 revealed Resident #08 was ordered Insulin Lispro Solution Pen-Injector 100 units per milliliter per a sliding scale, if blood sugar was 150 milligrams per deciliter (mg/dL) to 200 mg/dL give one unit, 201 mg/dL to 250 mg/dL, give two units, 251 mg/dL to 300 mg/dL, give three units, 301 mg/dL to 350 mg/dL, give four units, and 351 mg/dL to 400 mg/dL, give five units and if the blood sugar 401 mg/dL to 450 mg/dL, give six units. Observation on 01/11/23 at 7:06 A.M. revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure residents had laboratory values obtained as ordered. This affected one resident (#27) out of five residents reviewed for unnecessary medication. The facility census was 75. Findings include: Review of Resident #27's medical record revealed an admission date of 05/30/19. Diagnoses included dementia with other behavioral disturbance, pseudobulbar affect, cognitive communication deficit, anxiety, and essential hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 was assessed with severely impaired cognitive skills for daily decision making. Review of a physician order dated 12/16/19 revealed Resident #27 was ordered a liver profile every three months for medication use. The order was still active in Resident #27's physician orders as of 01/12/23. Review of Resident #27's electronic medical record and paper medical record revealed no documentation of liver profile laboratory…

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 interviews, the facility failed to ensure meals were served to all residents. This affected one resident (#33) out of three residents reviewed for food. The facility census was 75. Findings include: Review of Resident #33's medical record revealed an admission date of 02/09/22. Diagnoses included type II, diabetes mellitus, peripheral vascular disease, hypothyroidism, atherosclerosis, end stage renal disease with dependency on renal dialysis, morbid obesity, major depressive disorder, anxiety disorders, hypertension, heart failure. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #33 was cognitively intact for daily decision making and required supervision for bed mobility, transfers, locomotion, eating, personal hygiene and was independent with dressing and one-person physical assist for physical help in part of bathing. Review of the physician orders for Resident #33 revealed a diet order dated 12/28/22 for a renal diet.…

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 and staff interview, and policy review, the facility failed to ensure accurate and complete medical records. This affected two residents (#16 and #33) out of two resident records reviewed for complete and accurate medical records. The facility census was 75. Findings include: 1. Review of Resident #33's medical record revealed an admission date of 02/09/22. Diagnoses included type II, diabetes mellitus, peripheral vascular disease, hypothyroidism, atherosclerosis, end stage renal disease with dependency on renal dialysis, morbid obesity, major depressive disorder, anxiety disorders, hypertension, heart failure. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #33 was cognitively intact for daily decision making and required supervision for bed mobility, transfers, locomotion, eating, personal hygiene and was independent with dressing with limited assistance for toilet use. one person physical assist for physical help in part 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 observation, staff interview, and review of facility policy, the facility failed to store food in a safe and sanitary manner. This had the potential to affect 83 residents who received food from the kitchen. The facility identified one Resident (#5) received no food by mouth and no food from the kitchen. The facility census was 84. Findings include: Observation on 02/03/20 at 8:54 A.M. of the kitchen dry storage area revealed a gallon jug of maple syrup, 3/4 used, with visible black fuzzy growth on the inside of the jug. The jug was labeled by the manufacturer, Refrigerate After Opening. Interview on 02/03/20 at 8:58 A.M. with Dietary Manager #200 verified the black fuzzy growth appeared to be mold, and the jug of maple syrup was to be refrigerated after opening, however was being stored on stored on a shelf in the un-refrigerated dry storage room. Observation on 02/03/20 at 9:01 A.M. of the walk in refrigerator revealed five oranges in a box for use which were soft, partially broken down, and had a white and green fuzzy substance on them. There were 12 green peppers 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.

Based on observation, resident and staff interview, medical record review, and facility policy review, the facility failed to ensure a resident's call light was in reach, failed to ensure the water from a resident's bathroom sink was able to be utilized and failed to provide furnishings to meet the residents' needs and preferences. This affected five (#72, #75, #134, #135 and #182) of nine residents reviewed with environmental concerns. The facility census was 84. Findings include: 1. Review of Resident #72's medical record revealed an admission date of 09/23/19. Diagnoses included schizoaffective disorder bipolar type, anxiety, unspecified dementia without behavioral disturbances and aplastic anemia. Review of the Minimum Data Set (MDS) assessment, dated 01/09/20, revealed Resident #72 had severely impaired cognition, was a limited assist with bed mobility and supervision with transfers, toileting, and personal hygiene. Observation on 02/04/20 at 10:03 A.M. revealed the faucet to the sink in Resident #72's bathroom was missing its handle. A small, approximately one inch, metal…

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 interview and observation, the facility failed to provide a comfortable and homelike environment. This affected six resident rooms (Resident #21, #23, #27, #49, #50 and #52) reviewed for environmental concerns. The facility census was 84. Findings include: Observation on 02/03/20 between 9:30 A.M. and 11:33 A.M. during the initial tour of the facility revealed the following environmental concerns: • There were no closet doors for resident personal belongings in Resident #27, #50 and #52's rooms. • The right side of the sliding closet door in Resident #49's room was put on backward, rendering the handle to the right side of the closet inaccessible. • There were no toilet paper holders in the bathrooms of Resident #21 and #23's rooms. Toilet paper was seen sitting on the ledge of the handicap rails in both rooms. Observation on 02/04/20 between 1:50 P.M. and 2:25 P.M. revealed the above environmental findings remained in place. Interview with Maintenance Assistant (MA) #110 during the observation verified all findings. MA #110 stated he was was new employee and was unaware of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident and staff interview, self-reported incident review and facility policy review, the facility failed to implement their abuse policy by not reporting to the State Survey Agency and completing thorough investigations regarding four allegations of physical abuse. This affected two residents (#24 and #79) and had the potential to affect 21 residents residing on the locked unit of Serenity Cove. The facility census was 84. Findings include: 1. Review of the medical record for Resident #24 revealed the resident was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder, bipolar type, major depression and anxiety. Review of the admission Minimum Data Set (MDS) assessment, dated 11/13/19, revealed Resident #24 was cognitively intact with no cognitive impairment. Resident #24 was noted with delusions and was positive for behavioral symptoms of putting himself at significant risk for physical illness or injury, putting others at risk for physical…

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 2. Review of Resident #79's medical record revealed an admission date of 04/09/19. Diagnoses included dementia with behavioral disturbances, type II diabetes, hypertension, chronic obstructive pulmonary disease, heart disease, anxiety disorder, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment, dated 01/15/20, revealed Resident #79 was rarely or never understood. The resident had short and long term memory problems. Resident #79 was aware of the location of his room, staff names and faces as well as he was in a nursing home. Resident #79 was not able to recall the season. Resident #79 had disorganized thinking and displayed inattention during the review period. Resident #70 required extensive assistance with bed mobility, and dressing. Review of the nursing progress notes revealed there two notes regarding Resident #79 being hit by Resident #24 and there were no SRI's submitted. On 11/28/19, Resident #79 was making some gestures (Resident #79 had impaired hearing and knew sign…

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, staff and resident interview, self-reported incident review and facility policy review, the facility failed to thoroughly investigate four allegations of resident-to-resident abuse. This affected two residents (#24 and #79) and had the potential to affect 21 residents residing on the locked unit of Serenity Cove. The facility census was 84. Findings include: 1. Review of the medical record for Resident #24 revealed the resident was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder, bipolar type, major depression and anxiety. Review of the admission Minimum Data Set (MDS) assessment, dated 11/13/19, revealed Resident #24 was cognitively intact with no cognitive impairment. Resident #24 was noted with delusions and was positive for behavioral symptoms of putting himself at significant risk for physical illness or injury, putting others at risk for physical injury and significantly intruding on the privacy or activity of others. Resident #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 medical record review, observation, staff interview and review of the facility's policy, the facility failed to review and revise the plan of care for Resident #24. This affected one (Resident #24) of 24 residents reviewed for care planning. The facility census was 84. Findings include: Review of the medical record for Resident #24 revealed the resident was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder, bipolar type, major depression, anxiety, epilepsy, hypothyroidism and gastro-esophageal reflux disease. Review of the admission Minimum Data Set (MDS) assessment, dated 11/13/19, revealed Resident #24 was cognitively intact with no cognitive impairment. Review of Resident #24's physician orders revealed one-on-one for safety was ordered on 12/09/19. Review of Resident #24's plan of care (POC) revealed a focus of aggressive behaviors related to his diagnosis of schizoaffective bipolar disorder. Interventions included Resident #24 was to have one-on-one supervision 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, and review of the facility policy, the facility failed to provide scheduled showers to a resident (#73) who required assistance with bathing. The facility further failed to to provide assistance to a resident (#10) who was dependent on staff for eating. This affected two residents (#73 and #10 of three reviewed for Activities of Daily Living (ADLs). The facility census was 84. Findings include: 1. Review of Resident #73's medical record revealed an admission date of 03/07/19. Diagnoses included end stage renal disease, hypertension, atrial fibrillation, cardiomegaly, type II diabetes mellitus, and hyperlipidemia. Review of the annual Minimum Data Set (MDS) assessment, dated 01/09/20, revealed Resident #73 had no cognitive impairment, and required a physical assist of one person when bathing. Review of the care plan, dated 01/30/20, revealed the resident required extensive assistance from staff when showering. Review of the ADL documentation 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 review of the facility's policy, the facility failed to provide activities to meet the interests and psychosocial needs of the residents. This affected one (Resident #77) of two residents reviewed for activities. The facility census was 84. Findings include: Review of Resident #77's medical record revealed an admission date of 06/29/17. Diagnoses included hemiplegia and hemiparesis, dysphagia, type II diabetes, hypertension, aphasia, atrial fibrillation, peripheral vascular disease, dementia, major depressive disorder, and gastrostomy status. Review of the Minimum Data Set (MDS) assessment, dated 01/14/20, revealed a Brief Interview for Mental Status (BIMS) score of zero indicating Resident #77 was rarely or never understood. Resident #77 required extensive assistance with bed mobility, transfer, locomotion, dressing, toilet use and personal hygiene. Resident #77 was totally dependent on staff for eating. Resident #77 displayed no behaviors during the review period. Review of the care plan, last revised 01/05/20,…

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 and staff interview and facility policy review, the facility failed to provide the care and services necessary for wound care for Residents #1 and #134. This affected two (#1 and #134) of two residents reviewed for non-pressure wounds. The facility census was 84. Findings include: 1. Review of the medical record for Resident #1 revealed she was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder, depression, Crohn's disease, anemia, morbid obesity, anxiety and hypertension. Review of the annual Minimum Data Set (MDS) assessment, dated 01/06/20, revealed Resident #1 was positive for one surgical wound. Review of the physician orders, dated 12/30/19, revealed an order for the coccyx wound to cleanse with normal saline, apply Dakin's half strength moistened gauze to wound bed, cover with a dressing and Hypafix tape to secure. Change every day and as needed. Review of the treatment administration record (TAR) for January and February…

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 policies, the facility failed to ensure one Resident's (#8) smoking materials were kept secured. The facility also failed to ensure fall interventions were in place for one Resident (#10). This affected two residents of six reviewed for accidents and supervision. The facility census was 84. Findings include: 1. Review of Resident #8's medical record revealed an admission date of 09/20/19. Diagnoses included diabetes, schizoaffective disorder, major depressive disorder, and bipolar disorder. Review of Resident #8's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of Resident #8's smoking assessment dated [DATE] revealed Resident #8 required supervision during smoking, and the facility was to store Resident #8's smoking materials. Review of Resident #8's care plan revised 01/22/20 revealed the resident was noncompliant with smoking. Resident #8 was to be instructed on smoking…

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

Based on medical record review, staff interview, and review of facility policy, the facility failed to administer medication as ordered. This affected one Resident (#65) of five reviewed for medications. The facility census was 84. Findings include: Review of the medical record for Resident #65 revealed and admission date of 01/11/17. Diagnoses included diabetes mellitus, schizophrenia, depression, anxiety, chronic obstructive pulmonary disease (COPD), and Parkinson's disease. Review of the nurse progress note dated 12/11/19 revealed Resident #65 did not receive medications as scheduled during the 6:00 A.M. to 6:00 P.M. shift on 12/07/19 and 12/08/19. Per administration record, no medications were signed off for either day during the stated shift by the floor nurse. Resident #65's physician was notified of the missed medications. Review of the physician orders for Resident #65 revealed the following ordered medication from 12/06/19 to 12/31/19: Amlodipine (blood pressure) 5 milligrams (mg) once daily, Aspirin 81 mg once daily, Claritin (allergy) 10 mg once daily, Clonazepam…

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 address pharmacy recommendations for one Resident (#38). The facility further failed to provide a rationale for the use of an antianxiety medication beyond 14 days for one Resident (#76). This affected two Residents (#38 and #76) of five reviewed for unnecessary medications. The facility census was 84. Findings include: 1. Review of the medical record for Resident #38 revealed she was admitted to the facility on [DATE] with diagnoses of bipolar disorder; depression, epilepsy, diabetes, anxiety, and schizoaffective disorder. Review of the pharmacy recommendations for Resident #38 dated 06/26/19 revealed she had been taking the medication Buspar (anxiety) 30 milligrams (mg) twice daily since 01/2019. Please evaluate the current dose and consider a dose reduction. Resident #38 had been taking the medication Lamictal (seizure/bipolar) 125 mg twice daily since 01/2019. Please evaluate the current dose and consider a dose reduction. 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.