Windsor Health And Rehabilitation

Based on interview and record review it was determined the facility failed to safely store narcotics for 1 of 1 sampled resident (#70) reviewed for safe medication storage. This placed residents at risk for misappropriation of their narcotic. Findings include:Resident 70 was admitted to the facility in 3/2026 with diagnoses including a fractured left femur (thigh bone) and a fractured left humerus (upper arm bone)On 7/10/26 at 10:15 AM Witness 5 (Complainant) stated two months ago Resident 70 was moved from the North Hall to the South Hall and there was a card of oxycodone (narcotic pain medication) missing. Witness 5 stated the card was located a few days later behind a picture frame in the North Hall.On 7/10/26 at 3:34 PM, Staff 4 (LPN) stated a couple of months ago she was counting medications with the night shift nurse and discovered Resident 70 was a card of oxycodone. Staff 4 stated the nurse manager was immediately notified.A 4/27/26 investigation indicated a card of Resident 70's oxycodone was missing on 4/25/26 and was found a few days later behind the back of a picture…

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 record review it was determined the facility failed to ensure a safe discharge for 1 of 2 sample residents (#60) reviewed for discharge planning. This placed residents at risk for unmet discharge needs and failed discharge. Findings include: Resident 60 admitted to the facility in 2/2026 with diagnoses including femur fracture.A 2/14/26 admission Skin/Wound Evaluation revealed Resident 60 had a stage 2 pressure wound to her/his right buttock.A 3/12/26 Face to Face/Discharge Orders revealed the facility requested orders for Resident 60 to have home health physical therapy and occupational therapy. Home health nursing services were not included in the orders.A review of the 3/2026 TAR revealed a 3/15/26 order to clean sacrum wound with wound cleanser, pat dry and apply medihoney to wound bed and cover with a bordered dressing daily and prn.A 3/16/26 Progress Note revealed Resident 60 discharged from the facility on 3/16/26.A 3/16/26 Discharge Summary/Plan of Care/Recapitulation of Stay evaluation revealed Resident 60 had a pressure injury to her/his buttock 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 interview and record review it was determined the facility failed to conduct a Significant Change MDS assessment within the required timeframe for 1 of 4 sampled residents (#51) reviewed for choices. This placed residents at risk for unassessed needs. Findings include: Resident 51 admitted to the facility in 2025 with diagnoses including dementia.A 6/19/26 Election of Hospice Benefit form revealed Resident 51 admitted to hospice services on 6/19/26.On 7/10/26 a Significant Change MDS assessment dated [DATE] was not yet completed, 22 days after Resident 51 admitted to hospice.On 7/10/26 at 2:08 PM Staff 38 (MDS Coordinator) confirmed Resident 51's Significant Change MDS was not yet completed. On 7/13/26 at 10:55 AM Staff 2 (DNS) stated a Significant Change MDS assessment was to be completed within 14 days of Resident 51's start on hospice services.

Based on interview and record review it was determined the facility failed to accurately complete a diabetic baseline care plan for 1 of 5 sampled residents (#2) reviewed for medications. This placed residents at risk for lack of diabetic care and monitoring. Findings include: Resident 2 admitted to the facility in 6/2026 with diagnoses including diabetes. The 6/18/26 admission MDS revealed Resident 8 received insulin. The 6/2026 and 7/2026 TAR revealed no monitoring for adverse reactions to insulin administration were in place. A 6/25/26 revised care plan revealed no diabetic focus or interventions for Resident 2. On 7/8/26 at 2:43 PM, Staff 18 (LPN) stated a Resident Care Manager was to verify orders for new residents and ensure all treatments, orders, and monitors were in place. Staff 18 stated she believed no treatments were missing for Resident 2. On 7/8/26 at 4:55 PM, Staff 25 (CNA) observed Resident 2's care plan and confirmed she was not able to identify Resident 2 was a diabetic which was important for the monitoring of hypoglycemia (low blood sugar levels). On 7/13/26 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.

Based on interview and record review it was determined the facility failed to provide ROM for 1 of 1 sampled resident (#16) reviewed for decreased ROM. This placed residents at risk for contractures. Findings include:Resident 16 was admitted to the facility in 2017 with diagnoses including flaccid hemiplegia (complete lack of movement) of the right side following a cardiovascular accident (stroke).On 7/6/26 at 10:00 AM Resident 16 stated she/he was unable to move her/his right side and Resident 16 stated staff did not assist her/him with ROM exercises.A 5/12/25 revised Care Plan indicated Resident 16 was to receive ROM in the morning and evening.A review of Resident 16's chart revealed no documentation of ROM exercises being completed.On 7/10/26 at 10:04 AM Staff 27 (CMA) stated she never saw ROM exercises being completed with Resident 16.On 7/10/26 at 10:21 AM, Staff 29 (CNA) stated there was no time to complete ROM exercises with residents.On 7/10/26 at 11:19 AM, Staff 21 (CNA) stated Resident 16's extremities were moved when they got her/him dressed but ROM exercises were 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 interview and record review it was determined the facility failed to ensure residents received appropriate supervision during meals for 1 of 3 sampled residents (#58) reviewed for accidents. This placed residents at risk for choking and aspiration. Findings include:Resident 58 was admitted to the facility in 5/2024 with diagnoses including lung cancer and dysphagia (difficulty swallowing). A 1/17/26 SLP progress note indicated Resident 58 needed distant supervision while eating. A review of Resident 58's current care plan indicated no information related to the provision of distant supervision while eating. A 5/4/26 facility investigation indicated Resident 58 was eating without supervision and the 1/17/26 recommendation for distant supervision while eating was never put in place for Resident 58. On 7/10/26 at 11:13 AM, Staff 37 (RN) stated Resident 58 had difficulty swallowing. Staff 58 stated distant supervision meant staff needed to keep the residents within line of sight while the residents were eating. On 7/10/26 at 11:16 AM, Staff 21 (CNA) stated Resident 58 had…

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

Based on observation, interview and record review it was determined the facility failed to ensure physician orders for respiratory care, an individualized respiratory care plan, and ongoing respiratory monitoring and assessment were in place for 1 of 2 sampled residents (#4) reviewed for respiratory care. This placed residents at risk for breathing difficulty. Findings include:Resident 4 was admitted to the facility in 1/2026 with diagnoses including COPD (chronic obstructive pulmonary disease- a lung disease that restricts airflow and makes breathing difficult) and respiratory failure. Physician Orders dated 1/30/26 indicated Resident 4 used a CPAP (Continuous Positive Airway Pressure- a device that blows a steady stream of pressurized air into your airway through a mask) machine while sleeping, but if she/he removed the CPAP, or refused to wear it, then the facility was to implement supplemental oxygen. The order further indicated the resident was to be on room air (natural breathing with no supplemental oxygen) when awake. The 2/11/26 Care Plan reiterated the same information as…

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 record review it was determined the facility failed to ensure dialysis (a procedure which removes waste products and excess fluid from the blood when the kidneys are no longer functioning properly) services were in place including communication with the dialysis provider for 1 of 1 sampled resident (#46) reviewed for dialysis. This placed residents at risk for dialysis complications and delayed treatment. Findings include: Resident 46 admitted to the facility in 6/2026 with diagnoses including end stage renal disease.A 6/26/26 Care Plan revealed resident 46 had dialysis on Mondays, Wednesdays, and Fridays.A review of Resident 46's Pre Dialysis Evaluation and Post Dialysis Evaluations from 6/24/26 and 7/8/26 revealed the following days when the facility did not have a Pre Dialysis or Post Dialysis Evaluation:-6/26: no Pre Dialysis Evaluation was completed;-7/1: no Pre Dialysis Evaluation was completed;-7/6: no Pre Dialysis Evaluation or Post Dialysis Evaluation was completed;-7/8: no Pre Dialysis Evaluation was completed.A 7/3/26 Progress Note indicated 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 interview and record review it was determined the facility failed to ensure the call light was accessible for 1 of 3 sampled residents (#10) reviewed for accommodation of needs. This placed residents at risk for the inability to call for assistance. Findings include:Resident 10 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (chronic condition where the heart is unable to pump blood effectively, leading to fluid buildup in the lungs and other body parts) and weakness.A review of Resident 10's 2/27/26 admission MDS revealed she/he was cognitively intact.A 2/26/26 Facility Reported Incident (FRI) reported Resident 10 received a bed bathe on 2/23/26 on the evening and the call light was not accessible to the resident until the next morning. Resident 10 reported no one checked in on her/him throughout the night and the resident needed to use the toilet.On 3/17/26 at 10:08 AM Staff 6 (CNA) stated she checked on Resident 10 on 2/24/26 at approximately 7:40 AM 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 interview and record review it was determined the facility failed to provide pain medication as ordered for 1 of 3 sampled residents (#7) reviewed for pain management. This placed residents at risk for worsening discomfort. Findings include:Resident 7 admitted to the facility in 10/2025 with diagnoses including right tibia and fibula fracture with an external fixator (device to stabilize fracture from the outside using pins, clamps and rods) and diabetes.The 10/23/25 physician order indicated Resident 7 was to receive oxycodone 5 MG every four hours as needed for pain.On 10/27/25 a public complaint was received by the State Agency which alleged the facility ran out of Resident 7's pain medication on 10/25/25 and Resident 7 had requested pain medication prior to a physical therapy session on 10/27/25.The 10/29/25 admission MDS Pain CAA revealed to administer pain interventions per provider orders.A review of the 10/2025 TAR revealed Resident 7 reported a pain level of nine on 10/27/25 at 6:00 AM.A 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to protect the resident's right to be free from neglect by staff for 1 of 3 sampled residents (#103) reviewed for abuse and neglect. This placed residents at risk for abuse. Findings include:Resident 103 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD) with acute exacerbation and respiratory failure. The resident was on hospice services.Resident 103's Physician Order dated 11/4/25 included to administer morphine sulfate 0.25 ml by mouth every hour as needed for shortness of breath and/or moderate to severe pain.On 11/5/25 at 4:57 AM, Resident 103's Progress Note indicated the resident had a period of COPD exacerbation, was groaning, had difficulty breathing and was complaining of being thirsty.On 11/5/25 at 6:29 PM, Resident 103's Progress Note indicated the resident was having difficulty swallowing and all tablet medication would be held. The resident was distressed, had rapid…

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 interviews and record review it was determined the facility failed to ensure the resident was free from involuntary seclusion by staff for 1 of 3 sampled residents (# 104) reviewed for involuntary seclusion. This placed residents at risk for mistreatment. Findings include:Resident 104 was admitted to the facility in 2025 with diagnoses including hip fracture and dementia. Resident 104's 12/2025 Care Plan did not include interventions to keep the resident at the nurse's station all night to prevent falling. On 12/12/25, the State Survey Agency received a call from Witness 1 (Former Staff). Witness 1 stated on 12/6/25 she was notified that Staff 6 (LPN) forced Resident 104 to stay up in her/his wheelchair most of the night on 12/5/25. The resident was kept at the nurse's station up until around 2:00-2:30 AM when staff provided the resident with incontinence care. Staff refused to get the resident back out of bed because Resident 104 made multiple requests to go to bed and the resident did not usually stay up at night. Staff 6 got Resident 104 back up and took 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 interview and record review it was determined the facility failed to ensure allegations of abuse or neglect were reported timely for 2 of 3 sampled residents (#s 103 and 104) reviewed for abuse reporting. This placed residents at risk for continued abuse and neglect. Findings include:1. Resident 103 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD) with acute exacerbation and respiratory failure.Resident 103's Physician Order dated 11/4/25 included to administer morphine sulfate 0.25 ml dose by mouth every hour as needed for shortness of breath and/or moderate to severe pain.On 12/12/25, the State Survey Agency received a public complaint by Witness 1 (Former Staff), which reported on 11/6/25 Staff 7 (LPN) was assigned to Resident 103's care and had refused to administer the resident's ordered pain medication even when staff members were reporting the resident was exhibiting screaming, shortness of breath, and very anxious behaviors. Witness 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to thoroughly investigate allegations of potential abuse and neglect for 2 of 3 sampled residents (#103 and 104) reviewed for abuse investigations. This placed residents at risk for continued abuse and neglect. Findings include:1. Resident 103 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD) with acute exacerbation and respiratory failure.On 12/12/25, the State Survey Agency received a public complaint by Witness 1 (Former Staff), which reported on 11/6/25 Staff 7 (LPN) was assigned to Resident 103's care and had refused to administer the resident's ordered pain medication even when staff members were reporting the resident was exhibiting screaming, shortness of breath, and very anxious behaviors. Witness 1 stated she was not told about the incident when it occurred, so she was not able to investigate the incident. Witness 1 stated Staff 1 (Administrator) was aware 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 interview and record review it was determined the facility failed to follow physician orders for 2 of 3 sampled residents (#s 10 and 11) reviewed for physician orders. This placed residents at risk for a delay in treatment and adverse medication side effects. Findings include: 1. Resident 10 admitted to the facility in 2/2017, with diagnoses including peripheral vascular disease. Resident 10's 9/10/24 Physician Order revealed an order for a right hand x-ray. Resident 10's 10/8/24 Physician Assistant Encounter Note indicated her/his 9/10/24 x-ray was negative for a fracture. Resident 10 continued to have pain and limited range of motion. Repeat x-rays were ordered on 9/18/24 and 9/24/24, but were not completed. Resident 10's 10/10/24 Hospital Records revealed a right wrist fracture. On 7/2/25 at 9:50 AM, Staff 1 (Resident Care Manager) acknowledged the facility did not obtain Resident 10's right hand x-ray per physician orders on 9/8/24 and 9/24/24. 2. Resident 11 admitted to the facility in 9/2024, with diagnoses including kidney failure. Resident 11's 9/29/24 Physician…

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

Based on observation, interview and record review it was determined the facility failed to ensure kitchen staff wore appropriate hair restraints during meal preparation for 1 of 1 facility kitchen reviewed for sanitation. This placed residents at risk for unsanitary foods. Findings include Review of the US FDA Food Code 2022 revealed: -food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food. On 3/12/25 at 11:43 AM Staff 18 (Cook) was observed plating meals without wearing a hair restraint. Staff 4 (Dietary Manager) was asked what the expectation was for hair restraints during tray line meal service and she stated Staff 18's hair was less than a half inch so there was no requirement to wear a hair restraint. The facility policy for hair restraints was requested. On 3/12/25 at 1:41 PM Staff 4 stated she reviewed food code and confirmed staff with hair of any length were to have a hair restraint in place.

Based on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 2 of 5 sampled CNA staff (#s 9 and 12) reviewed for sufficient and competent nurse staffing. This placed residents at risk for a lack of competent staff. Findings include: A review of personnel records on 3/14/25 indicated the following employees had not received their annual performance evaluations: -Staff 9 (CNA), hired dated was 12/5/22 and the last performance review was completed on 1/10/24. -Staff 12 (CNA), hired date was 5/26/16 and the last performance review was completed on 6/8/23. On 3/14/25 at 10:23 AM PM Staff 2 (Director of Nursing) confirmed annual performance reviews were not completed for Staff 9 and Staff 12.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to include residents in the developient of the comprehensive care plan for 3 of 4 sampled residents (#s 15, 32, and 42) reviewed for care planning. This placed resident at risk for lack of a comprehensive care plan. Findings include: 1. Resident 15 was admitted to the facility on [DATE] with diagnoses including diabetes. A review of Resident 15's medical record revealed there was a care conference completed with Resident 15 on 1/31/25. On 3/10/25 at 9:48 AM Resident 15 stated no one discussed medication or treatment changes with her/him and she/he did not have a care planning meeting. On 3/12/25 at 10:10 AM Staff 16 (Interim Social Services) stated she completed a 72 hour care meeting with residents on admission, but the facility did not do a care planning meeting with residents after the initial comprehensive MDS was completed. On 3/14/25 at 9:25 AM Staff 17 (Interim MDS Coordinator) stated she assisted in development 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 observation, interview and record review it was determined the facility failed to ensure residents were assessed for removal of the a catheter for 1 of 1 sampled resident (#42) reviewed for urinary catheter. This placed residents at risk for increased infections. Findings include: Resident 42 admitted to the facility in 2/2025 with diagnoses including hip fracture. A 2/6/25 Hospital Discharge Order for Resident 42 revealed she/he had a urinary catheter in place and included orders for the facility to attempt removal of the catheter one week from the date of discharge from the hospital. A 2/7/25 Progress Note from Resident 42's provider revealed she/he had an indwelling foley catheter in place, a trial of voiding was to be attempted when the acute symptoms improved, and the facility was to refer Resident 42 to an outpatient urologist for further evaluation and recommendations. A review of the medical record revealed no documentation a urology referral was made or attempted and no documentation of an attempt to remove Resident 42's catheter. On 3/10/25 at 2:11 PM Resident 42…

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

Based on observation, interview, and record review the facility failed to complete IV dressing changes for 1 of 1 resident (#39) reviewed for antibiotics. This placed residents at risk for IV site infections. Findings include: Resident 39 was admitted to the facility in 1/2025 with diagnoses including an abscess (a pocket of pus that forms when the body is fighting off an infection) of the abdominal wall. A review of Resident 39's Physician Orders revealed a 3/6/25 order for zoxyn (an IV antibiotic) every 6 hours. A review of Resident 39's Physician Orders revealed an unscheduled order for PICC line (a central IV line inserted peripherally) care per protocol and next change was due 1/27/25. On 3/14/25 at 9:28 AM Staff 13 (LPN) stated she did not change Resident 39's PICC dressing, as it did not come up on the MAR to change the dressing. Staff 13 stated she did not know how often PICC dressings were to be changed. On 3/14/25 at 10:51 AM Staff 3 (LPN Resident Care Manager) stated PICC dressing changes were to be done weekly and as needed. Staff 3 stated she could not find when…

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 record review it was determined the facility failed to ensure psychotropic medications were decreased as ordered 1 of 5 sampled residents (#2) reviewed for medications. This placed residents at risk for unnecessary psychotropic medications. Findings include: Resident 2 admitted to the facility in 7/2024 with diagnoses including diabetes. A review of Resident 2's physician orders revealed a 9/26/24 order to for Trazodone 150 mg; this order was discontinued on 12/31/24. A 10/21/24 Note to Attending Physician/Prescriber recommended the facility reduce Resident 2's Trazodone 150 mg dose to Trazodone 100 mg. The provider responded on 11/5/24 with an order to reduce Resident 2's Trazodone to 100 mg. A review of the physician orders revealed the facility failed to implement the order for Resident 2 until 1/1/25. On 3/12/25 at 4:00 PM Staff 2 (DNS) reviewed the 10/21/24 Note to Attending Physician/Prescriber and confirmed the order to reduce Resident 2's Trazodone to 100 mg was not implemented until 1/1/25.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility failed to ensure medication rooms were free of expired biologicals for 1 of 2 sampled medication rooms reviewed for medication storage. This placed residents at risk for diminished treatment efficacy. Findings include: On 3/14/25 at 9:09 AM two medications were observed to be expired in medication storage room [ROOM NUMBER]. The expired medications included healthy eyes(Leutin), and terbinafine (antifungal medication). On 03/14/25 at 9:09 AM Staff 13 (LPN) confirmed Terbinafine x 3 and Healthy eyes w/ Luten were expired and should not be given to residents. On 3/14/25 at 9:38 AM Staff 2 (DNS) confirmed the medication was expired and was not to be given to residents.

Based on observation, interview and record review it was determined the facility failed to follow infection control practices for wound care for 1 of 2 sampled residents (#6) reviewed for pressure ulcers. This placed residents at risk for wound infections. Findings include: Resident 6 was admitted to the facility in 2/2017 with diagnoses including diabetes. A review of Resident 6's Physician Orders revealed a 3/5/25 order for wound care to Resident 6's buttocks. On 3/11/25 at 11:00 AM Resident 6's dressing change to her/his buttocks wound was observed with Staff 14 (LPN). Staff 14 completed hand hygiene, donned gloves, cleaned the wound, removed contaminated gloves, applyed new gloves without completing hand hygiene first, applyed medihoney (an ointment for wound healing), applyed a clean dressing, removed gloves, and then completed hand hygiene. On 3/11/25 at 11:09 AM Staff 14 acknowledged she did not complete hand hygiene when she changed her gloves during wound care. Staff 14 stated she completed hand hygiene at the beginning and end of a dressing change. On 3/11/25 at 11:20 AM…

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 record review it was determined the facility failed to ensure residents were offered pneumonia vaccines for 1 of 5 sampled residents (#10) reviewed for vaccinations. This placed residents at increased risk for pneumonia. Findings include: Resident 10 admitted to the facility in 12/2024 with diagnoses including hypertension. A review of Resident 10's medical record revealed she/he was eligible for, but was not offered, a pneumonia vaccine. On 3/13/25 at 11:11 AM Staff 2 (DNS) was asked to review Resident 10's pneumonia vaccine. Staff 2 reviewed the medical record and stated there was no indication the pneumonia vaccine was administered prior to admission or offered after admission to the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility failed to follow infection control standards for 1 of 2 halls reviewed for transmission-based precautions and medication administration. This placed residents at risk for cross-contamination and spread of infection. Findings include: 1. Resident 4 readmitted to the facility in 10/2023 with diagnoses including end stage renal disease. The 11/13/23 progress note indicated Resident 4 tested positive for COVID. On 11/16/23 at 8:00 AM Staff 3 (CNA) was observed standing in the hallway behind Resident 4. Resident 4 was in her/his wheelchair in front of her/his door. Resident 4 was observed wearing an N95 mask. Staff 3 was observed wearing a surgical mask and was not wearing an N95 mask, a face shield, a gown, or gloves. The sign on Resident 4's door indicated staff were to wear an N95 mask, a face shield, a gown and gloves for resident care. Resident 4 entered her/his room independently and Staff 3 put on PPE prior to going into her/his room. Staff 3…

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.