Community Health Center

Based on observation, record review, and interview, the facility failed to ensure:a. wounds with an infection were covered during meal time to prevent spread of infection for 1 (#5); andb. wound care was provided in a manner to prevent contamination for 1 (#10) of 3 sampled residents reviewed for wound care; andc. proper glove usage during colostomy care for 1 (#8) of 1 sampled resident for ostomy care.The administrator identified one resident with an ostomy and four residents with wounds resided in the facility. Findings: 1. On 04/07/26 at 7:22 a.m., Resident #5 was observed seated in the dining room with wounds on their legs uncovered. On 04/07/26 at 7:35 a.m., RN #1 was observed to don a gown and gloves and applied Silvercel (an anti-microbial wound medication) to Resident #5's right leg wound. RN #1 wrapped Resident 5's right leg with kerlix and Coban, then changed gloves. RN #1 applied Silvercel to Resident 5's left leg wound and wrapped with Kerlix and Coban (wound dressing wraps). RN #1 did not cleanse Resident #5's wounds before applying treatment. An undated Infection…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure accurate comprehensive assessments for 3 (#10, 18, and #21) of 12 sampled residents reviewed for accurate assessments.The administrator identified 32 residents resided in the facility. Findings: 1. On 04/06/26 at 11:21 a.m., Resident #18 was observed lying in bed with oxygen on at two liters. A physician's order dated 09/03/25, showed Resident #18 was to have oxygen at two liters per nasal cannula to keep oxygen levels greater than 89%. A significant change assessment, dated 03/23/26, showed Resident #18 was admitted to the facility on [DATE] with diagnoses which included malignant neoplasm of breast, Lewy bodies neurocognitive disorder, atrial fibrillation, and asthma. Resident #18's assessment did not show they used oxygen. 2. On 04/07/26 at 12:35 p.m., Resident #21 was observed seated in a geriatric chair participating in a music activity in which they were holding a drumstick. Resident #21 was observed having difficulty holding…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for 2 (#18 and #21) of 12 sampled residents reviewed for care plans. The administrator identified 32 residents resided in the facility. Findings: 1. On 04/06/26 at 11:21 a.m., Resident #18 was observed lying in bed with oxygen on at two liters. An undated Care Plan Policy, read in part, Community Health Centers' interdisciplinary team will conduct initially and periodically a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity .This care plan will include measurable objectives and timetables to meet a resident's medical, nursing, and psychosocial needs .Each resident will be assessed on a quarterly basis and necessary revisions of the care plan will take place with each quarterly review/assessment. A significant change assessment, dated 03/23/26, showed Resident #18 was admitted on [DATE] with diagnoses which included neurocognitive disorder with Lewy…

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

Based on record review and interview, the facility failed to ensure an as needed psychotropic medication was not used for more than 14 days for 1 (#4) of 3 sampled residents reviewed for unnecessary medications.The DON identified 27 residents utilized psychotropic medications. Findings: A physician's order, dated 01/12/26, showed Resident #4 was prescribed lorazepam (an anti-anxiety medication) oral concentrate 2 mg/ml. The directions for administration were to give 0.5 ml by mouth every four hours as needed for anxiety, restlessness, and/or agitation. There was no end date for this order. A medication administration record, dated 03/2026, showed Resident #4 was given lorazepam oral concentrate 2 mg/ml on 03/06/26, 03/08/26, and 03/14/26. An annual assessment, dated 03/19/26, showed Resident #4 was admitted to the facility with diagnoses which included depression and seizure disorder. On 04/08/26 at 11:59 a.m., certified medication aide #1 stated Resident #4 received lorazepam as needed for anxiety. On 04/08/26 at 12:06 p.m., the DON stated to ensure a resident was free from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, and interview, the facility failed to ensure a resident received the correct insulin dosage for 1 (#24) of 1 sampled resident reviewed for insulin administration.The administrator identified two residents in the facility received insulin. Findings: On 04/07/2026 at 8:50 a.m., RN #1 was observed to obtain Resident #24's finger stick blood sugar with a result of 190. RN #1 was observed to administer Fiasp FlexTouch Pen-injector 100 unit/ml (insulin) 9 units subcutaneously to Resident #24's right lower abdomen. An annual assessment, dated 01/14/26, showed Resident #24 had a diagnosis of diabetes mellitus. A physician's order, dated 01/31/26, showed Resident #24 was prescribed Fiasp FlexTouch Subcutaneous Solution Pen-injector 100 unit/ml, inject as per sliding scale: if 70 - 140 = 0; 141 - 180 = 3u; 181 - 220 = 6u; 221 - 260 = 9u; 261 - 300 = 12u; 301 - 340 = 15u; 341 - 500 = 18u. If greater than 341 give 18 units. On 04/07/26 at 8:57 a.m., RN #1 stated they did not know they administered 9 units of insulin instead of 6 units. They stated they would…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure informed consent was obtained for the use of an psychotropic medication for one (#29) of five sampled residents reviewed for unnecessary medications. The DON identified 27 residents were prescribed psychotropic medication. Findings: The facilty's Initiation of a Psychotropic Drug policy policy, dated 11/21/22, read in part, The family is to be notified .Explain our effects and inquire about their feeling toward the use if a psychotropic medication and explain the risk involved. Resident #29 was admitted on [DATE] with diagnoses which included major depressive disorder and dementia unspecified with other behavioral disturbances. A physician order, dated 12/26/23, documented Resident #29 was prescribed buspirone HCI oral tablet 15 mg .Give one tablet by mouth two times a day .Citalopram Hydrobromide Oral Tablet 10 mg. Give one tablet in the morning. A quarterly assessment, dated 4/9/24 documented Resident #29's cognition was significantly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, and interview, the facility failed to ensure a resident who was physically restrained has a physician order, was assessed, and monitored for one (#1) of one sampled resident reviewed for the use of physical restraints. The Administrator identified 35 residents resided in the facility. Findings: An undated facility policy titled Restraint Policy, read in part, All residents will have an assessment performed to determine the safety and protective needs of the resident prior to the application of the restraints. The policy also read, .restraints may be applied only on a physician's written order and shall identify the type and reason for the restraint .A restrained resident shall have their restraints released every two hours for at least ten minutes. Resident #1 had diagnoses which included cerebral palsy and dystonia. An annual resident assessment, dated 05/06/24, documented Resident #1 had severe cognitive impairment and required extensive assistance with ADL's. On 07/09/24 at 8:51 a.m., Resident #1 was observed in their wheelchair. There was 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, record review, and interview, the facility failed to ensure physical restraints were coded accurately on MDS assessments for one (#1) of one sampled resident reviewed for the use of physical restraints. The Administrator identified 35 residents resided in the facility. Findings: Resident #1 had diagnoses which included cerebral palsy and dystonia. An annual resident assessment, dated 05/06/24, did not document Resident #1's use of chair restraint. On 07/09/24 at 8:51 a.m., Resident #1 was observed in their wheelchair. There was a black belt around their waist with a quick release buckle. On 07/10/24 at 9:56 a.m., Resident #1 was observed their wheelchair in the common area. There was a black belt around their waist with a quick release buckle. On 07/10/24 at 10:06 a.m., the DON and Infection Preventionist instructed Resident #1 to undo the seat belt. Resident #1 was unresponsive to the instructions given. On 07/10/24 at 10:20 a.m., MDS Coordinator #1 stated it was considered a restraint if a resident is not able to undo their wheelchair seat belt. On 07/10/24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure oxygen tubing was labeled and dated, per the facility policy and professional standards of care, for one (#20) of one resident sampled for respiratory care. The DON identified one resident used supplemental oxygen. Findings: The facility's OXYGEN THERAPY policy, undated, read in part, Change device tubing every 30 days on the 15 th of the month on night shift and store the tubing in a bag when not in use. Tubing is to be dated. Resident #20 was admitted on [DATE] with diagnoses which included acute respiratory failure and major depressive disorder. A annual assessment, dated 04/01/24, documented Resident #20's cognition was intact. A physician order, dated 05/07/24, read in part, O2 via nasal cannula PRN to keep sats above 89% every shift. On 07/08/24 at 2:17 p.m., Resident #20 observed in bed wearing O2 with a nasal annual. There was no date observed on the O2 tubing or O2 saturator. On 07/10/24 at 1:39 p.m., CNA #1 went 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.

Based on record review and interview, the facility failed to ensure a medication regimen review gradual dose reduction was responded to timely for one (#35) of five sampled residents reviewed for unnecessary medications. The administrator identified 35 residents resided in the facility and received medication. Findings: The facility's Drug Regimen Review policy, dated 11/21/22, read in part, The consultant pharmacist documents potential or actual medication therapy problems, and communicates them to the primary physician and the Director of nursing. A written report is provided to the physician within seven working days. Resident #35 had diagnoses which included major depressive disorder and peripheral vascular disease. A physician order, dated 05/17/24, documented to administer tramadol 50 mg HCI oral tablet every 6 hours as needed for pain. A monthly medication review, dated 05/22/24, documented the pharmacist request to attempt a gradual dose reduction of the residents tramadol 50 mg every six hours as needed. The medication review was not documented as sent to the physician or…

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

The facility failed to ensure resident assessments accurately reflected the residents status for two (#5 and #6) of three sampled residents. The administrator stated the facility census was 35. Findings: 1. Resident #5 had diagnosis to include Alzheimer's disease. A physician order, dated 03/15/23, documented Resident #5 was to be provided a regular diet with a mechanical soft texture. A quarterly assessment, dated 01/14/24, documented Resident #5's proportion of total calories received through a parenteral or tube feeding was 25% or less; and the average fluid intake per day by tube feeding was 500 cc or less during seven days of the assessment. On 01/30/24 at 12:15 p.m., Resident #5 was observed in the dining room for the noon meal. Resident #5 had been served a mechanically soft diet and a family member was assisting with the meal intake. 2. Resident #6 had a diagnosis to include Barrett's esophagus and abnormal weight loss. A physician order, dated 05/12/22, documented Resident #6 was to be provided a regular diet with pureed texture and pudding thickened liquids. A quarterly…

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