Arlington Residence And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews the facility failed to treat residents with respect and dignity for one of six residents (Resident #1) reviewed for resident rights. The facility failed to ensure RN A did not stand over Resident #1 while opening his brief and looking at his genitals with the door open and no curtain used, for anyone to see from the hallway on 08/29/25. This failure could affect residents who require assistance with ADLs of not wanting to get staff assistance if it were not done in private which could cause a decrease in the resident's self-esteem and psycho-social well-being resulting in embarrassment. Findings included: Observation on 08/29/25 at 2:40 PM, the door to Resident #1's room was open revealing RN A and CNA B in Resident #1's room. RN A had on gloves and was standing over Resident #1 with the resident's brief unfastened. RN A was looking at the resident's genital area, and the resident's legs was uncovered with his bedsheets at his ankles. When RN A saw 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, the facility failed to ensure when discharge is anticipated, a resident had a discharge summary that included, but not limited to a recapitulation of the resident's stay, that included but was not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology and consultant results and a final summery of the resident's status to include items, at the time of the discharge that was available to release to authorized persons and agencies, with the consent of the resident or resident's representative for 1 of 3 residents (Resident #1) reviewed for discharge summary. The facility failed to complete a discharge summary for Resident #1. This failure could place residents at risk of not having complete records after permanent discharge from the facility. Findings included: Record review of Resident #1's face sheet, dated 05/29/25, reflected the resident was a [AGE] year-old male, who was admitted to the facility on [DATE] and discharged to the hospital…

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 establish procedures to ensure that enough water was available in the facility in the event of a loss of normal water supply, for 1 of 1 facility. The facility's emergency water supply consisted of 0 gallons of water on hand for a census of 68 residents. This failure could place all residents in the facility at serious risk for complications from dehydration and sanitation. Findings included: Observation on 02/06/25 beginning at 12:50 PM of the facility revealed no emergency water in the facility. The kitchen was observed and the dietary manager was interviewed. No emergency was located. Two additional closets in the facility were observed and no emergency was located. Interview on 02/06/25 at 1:10 PM with the Dietary Manager revealed that the Dietary Manager was unaware of any placement of emergency water. The Dietary Manager stated that she had never ordered emergency water for the facility and had no knowledge of emergency water stored in the facility. The Dietary Manager said that she was unaware of any…

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, interview, and record review, the facility failed to ensure residents had a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 3 of 16 rooms (Rooms #118, #126, and #147) and 2 of 14 residents (Resident #37 and Resident #66) reviewed for clean, comfortable, and homelike environment and clean bed and bath linens that are in good condition. 1. The facility failed to replace stained ceiling tiles in room [ROOM NUMBER] 2. The facility failed to repair a ceiling HVAC vent in room [ROOM NUMBER]. 3. The facility failed to maintain a clean environment for Resident #37. 4. The facility failed to ensure there was an adequate supply of linens to meet resident needs. 5. The facility failed to repair the room door for Resident #66. This failure placed residents at risk of decreased feelings of self-worth and possible infections. Findings included: 1. Observation on 02/04/25 at 9:35 AM revealed the ceiling tiles…

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, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and of exploitation of residents and misappropriation of resident property for 1 of 8 employees (CNA D) reviewed for employment registry screenings. The facility failed to ensure a search of the EMR/NAR was completed for CNA D prior to employment and before providing direct patient care. This failure could place residents at risk for abuse, neglect, exploitation and misappropriation of property. Record review of CNA D's personnel file reflected a hire date of 07/07/23 and no EMR/NAR check was completed prior to this date. Interview on 02/06/22 at 12:12 PM with the HR Manager revealed she began working at the facility in March of 2024. The HR Manager stated that CNA D had no EMR/NAR checks completed prior to her employment and hire date of 07/07/2023 nor the annual EMR/NAR check. The HR Manager stated that she discovered this when she was asked by this surveyor for the documentation. The HR Manager said that it was her…

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, interview, and record review, the facility failed to ensure residents unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 3 of 14 residents (Residents #29, #48, and #57) reviewed for ADLs. The facility failed to ensure Resident #29, #48, and #57 received showers as scheduled. These failures could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem. Findings included: Record review of Resident #29's Quarterly MDS Assessment, dated 01/23/25, reflected the resident was a [AGE] year-old female who was first admitted to the facility on [DATE], re-admitted on [DATE], and then re-admitted again on 11/20/24. Resident #29 had a BIMS score of 15, which indicated her cognition was intact. Her diagnosis included quadriplegia (paralysis of all four limbs), neurogenic bladder (urinary problems caused by nerve problems affecting bladder control), 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 observation, interview, and record review, the facility failed to provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being for 1 secure unit reviewed for activities. The facility failed to ensure there were organized activities provided to the residents in the secure unit . The failure placed residents at risk for a diminished quality of life, isolation, lack of stimulation. Findings included: Review of the facility's current February 2025 Activities Calendar for the secure unit reflected the following: 02/04/24 10:30 AM - Pretty Nails 2:00 PM - National Homemade Soup Day 3:00 PM - Table Games 02/05/24 10:00 AM - Exercise/Movie 10:30 AM - Arts and Crafts 2:00 PM - Resident Birthday Party 3:00 PM - Cookie and Apple Cider Social 02/06/24 10:00 AM - Exercise/Movie 2:00 PM Bingo 3:00 PM Senior Trivia Observation on 02/04/25 at 10:22 AM, of the secure unit revealed there were 7 residents in the dining room and the TV was on and there were no activities going on at the time. At 12:04 PM staff began to gather 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, the facility failed to ensure it received registry verification for 2 (CNA D and CNA E) of 5 employees reviewed for registry verification prior to allowing an applicant to serve as a nurse aide. The facility failed to ensure CNA D and CNA E had a current nurse aide certification while employed at the facility, while actively providing care for residents. This failure could result in residents being provided care by staff who have not provided documentation of training and competency in providing care. Findings included: Record review of CNA D's personnel file reflected a date of hire of [DATE]. The facility did not complete an EMR/NAR check upon hire or annually. Record review of CNA E's personnel file reflected a date of hire of [DATE]. The last Employability Stats Check Search that was completed on [DATE] reflected CNA E's NAR status would expire on [DATE]. Record review of the daily nursing staff schedule, for [DATE] reflected CNA D worked on [DATE] on shift 6:00 PM -…

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, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 7 residents (Residents #8) reviewed for pharmacy services. Facility failed to ensure Ranolazine 1000 mg ER (extended release) used for chest pain was administered on 02/03/25, 02/04/25 and 02/05/25 as ordered for Resident #8. This failure could place residents at risk of not receiving the therapeutic value of the ordered medications and leading to potential hospitalization. The findings were: Record review of Resident #8's entry MDS assessment, dated 11/27/24, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. The resident had diagnoses which included: chest pain. Resident #8 had moderate cognition with a BIMS(Brief Interview for Mental Status) score of 11. Record review of Resident #18's care plan 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.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure food items were kept away from potential airborne contaminants (dust and fuzz) on the ceiling vents. The facility failed to ensure stove backsplash was kept clean from buildup grease. This failure could place residents at risk for food contamination and food-borne illness. Findings included: Observation on 02/04/25 at 9:00 AM revealed three air conditioning vents over the food preparation area and two air conditioning vents by the dishwasher in the kitchen were observed to have built-up fuzz and dust stuck to them. Observed stove backsplash to have build-up grease stuck to it. Observation on 02/05/25 at 10:30 AM revealed three air conditioning vents over the food preparation area and two air conditioning vents by the dishwasher in the kitchen were observed to have built-up fuzz and dust stuck to them. Observed stove…

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 maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 2 washing machines (Washer A) reviewed for essential equipment. The facility failed to maintain a laundry washing machine (Washer A) in operating condition. This failure could place residents at risk of not having clean linen for their beds or personal clothing. Findings included: Observation and interview on 02/04/2025 at 11:00 AM with Resident #37 revealed Resident #37 had sheets on his bed with large brown stains on them. Resident #37 stated his sheets had been like that for about six days. Resident #37 also said he had asked two times in the past week to shower but was told by staff that there were no clean towels. Observation on 02/04/2025 at 2:45 PM of the facility laundry area revealed the facility had one commercial washing machine and one residential washing machine. The commercial washing machine appeared broken because parts were removed from it and lying on top of it. The only washing machine…

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, interviews, and record reviews, the facility failed to ensure each bed had ceiling suspended curtains, which extend around the bed to provide total visual privacy in combination with adjacent walls and curtains for 7 rooms (room [ROOM NUMBER], #117, #118, #120, #122, # 127, and #144) of 30 rooms reviewed for privacy. The facility failed to provide full privacy for residents of rooms #110, #117, #118, #120, #122, # 127, and #144 This failure could place residents at risk of no privacy. Findings included: Observations on 2/04/25 from 11:10 AM to 12:34 PM revealed room [ROOM NUMBER]-2 had no privacy curtain for the end of the bed; room [ROOM NUMBER]-2 had no privacy curtain for the end of the bed, curtain clips were present; room [ROOM NUMBER]-2 had no privacy curtain for the end of the bed; room [ROOM NUMBER]-2 had no privacy curtain for the end of the bed and had several missing slats in the window blinds; rooms # 122-2 and #127-2 had no privacy curtains at all; and room [ROOM NUMBER]-2 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 interview and record review, the facility failed to develop, implement, and maintain and effective training program for 8 of 11 staff (CNA A, CNA B, CNA, C, CNA D, CNA E, LVN G, LVN H,) reviewed for training. The facility failed to ensure CNA A, CNA B, CNA, C, CNA D, CNA E, LVN G, and LVN H were provided with training on dementia and abuse, neglect and exploitation. These failures could place residents at-risk for abuse and neglect due to lack of training. Findings included: 1. Record review of the facility's current, undated Staff Roster reflected CNA A was hired on 06/07/23. Record review of CNA A's training history revealed CNA A's training transcript did not indicate when last previous ANE training had been completed. 2. Record review of the facility's current, undated Staff Roster reflected CNA B was hired on 12/12/23. Record review of CNA B's training history revealed CNA B's training transcript did not indicate when last previous ANE training had been completed. 3. Record review of the facility's current, undated Staff Roster reflected CNA C was hired on 10/17/23.…

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, interview, and record review, the facility failed to ensure residents had the to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, for 1 of 4 residents (Resident #9) reviewed for restraints. The facility failed to care plan for Reisdent #9's half bedrails. This failure could place the resident at risk of entrapment or restraint. Findings included: Record review of Resident #9's undated admission Record reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included muscle weakness, personal care assistance, and diabetes. Record review of Resident #9's annual MDS reflected a BIMS score of 5 indicating she had severe cognitive impairment. Her Functional Status indicated she required assistance with all her ADLs. Record review of Resident #9's care plan dated 12/05/25 reflected she was at risk for falls and required assitance with transfers,…

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, the facility failed to maintain medical records on each resident that were complete and accurate in accordance with accepted professional standards and practices for 1 of 7 residents (Resident #1) whose clinical records were reviewed. The facility failed to ensure Resident #1's MAR was accurately and completely documented in their permanent clinical record on [DATE]. This failure could place all the residents, who resided in the facility, at risk for inaccurate or incomplete clinical records. Findings included: Record review of Resident #1's Face Sheet dated [DATE] reflected the resident was a [AGE] year-old female, who admitted to the facility on [DATE], with diagnoses which included acute combines systolic and diastolic heart failure (congestive heart failure), Type 2 diabetes (body does not produce insulin to maintain normal glucose levels), Stage 4 chronic kidney disease (advanced kidney damage requiring dialysis), and morbid (severe) obesity. The resident discharged…

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, the facility failed to notify the resident and/or the resident's representative and the Office of the State Long-Term Care Ombudsman representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood for one (Resident #1) of three residents reviewed for discharge rights. The facility failed to provide a copy of the written notice of immediate discharge to Resident #1 and the Ombudsman when the facility decided that Resident #1 needed to be immediately discharged on 10/02/24, due to non-compliance with the smoking policy. This failure placed residents at risk of not having access to available advocacy services, discharge options, and appeal processes. Findings included: Record review of Resident #1's Face Sheet, dated 11/07/24, reflected the resident was admitted to the facility on [DATE] and discharged on 10/03/24 with diagnoses which included: fibroblastic disorder (tumors that affect connective tissue), Type II…

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, interview and record review, the facility failed to ensure each resident was treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for two (Residents #1 and #2) of four residents reviewed for dignity. 1. The Maintenance Director on 09/10/24 recorded Resident #1 with his personal cell phone while Resident #1 yelled and cursed at the facility staff. 2. CNA A took Resident #2's cell phone away when Resident #1 stated he was going to call 911 on 06/20/24. This failure could place residents at risk for a loss of dignity, decreased self-worth and decreased self-esteem. Findings included: Review of Resident #1's quarterly MDS assessment dated [DATE] reflected the resident was [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included stroke, hemiplegia (paralysis to one side of the body), history of traumatic brain injury, muscle weakness, abnormal gait 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, interview, and record review, the facility failed to ensure that menus were followed for 1 of 3 meals (lunch on 09/10/24) reviewed for meal accuracy. The facility failed to serve pureed bread during the lunch meal on 09/10/24 to all eight residents (Residents #5, #8, #9, #10, #11, #12, #13, and #14) who required a pureed diet. This failure could place residents at risk for poor intake and weight loss. Findings included: Review of Resident #5's admission record, dated 09/11/24, reflected the resident was a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #5's Quarterly MDS Assessment, dated 08/26/24, reflected he had a BIMS score of 99 indicating he was unable to complete the interview. His active diagnoses included non-alzheimer's dementia and malnutrition. Further review reflected Resident #5 received a therapeutic diet. Review of Resident #5's physician's orders reflected an order for pureed diet with a start date 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, interviews, and record review the facility failed to maintain an effective pest control program so that the facility was free of pests 1 of 5 (Resident #6) resident rooms, and 1 of 3 (Sunflower hallway) dining areas reviewed for environment. The facility failed to ensure Resident #6's room and Sunflower hallway were free of small brown bugs on 09/10/24 and 09/11/24. This failure could place residents at risk for insect borne illness, not having a home free of pests and a comfortable environment in which to live. Findings included: Interview on 09/10/24 at 3:15 PM with Resident #3 revealed he found cockroaches and bugs in his room every night. Resident #3 said the bugs crawled in his shoes, so he always had to check them before he put his feet in them. Interview on 09/10/24 at 3:50 PM with Resident #7 revealed she saw bugs in her room every day and all throughout the facility. Resident #7 said she told staff about the bugs, and they never did anything about them. Observation and interview…

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 store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of three staff (Cook C) and one of one kitchen reviewed for kitchen sanitation. Cook C failed to wear a beard restraint on 09/10/2024 while in the food preparation area and while serving the lunch meal service. This failure could place residents at risk for food contamination and foodborne illness. Findings included: Observation on 09/10/24 at 9:46 AM of the kitchen revealed [NAME] C had facial hair on his chin, and he was not wearing a beard restraint. [NAME] C was observed using the blender to make the pureed meat for the lunch service. Observation on 09/10/24 at 12:07 PM of the dining room revealed the facility's kitchen steamtables with the food being served to residents for the lunch meal service. [NAME] C had facial hair on his chin but was not wearing a beard restraint. [NAME] C began plating resident's meals. Interview on 09/10/24 at 1:23 PM with the DM revealed [NAME] C had facial hair…

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, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for one (Resident #1) of five residents reviewed for ADL care. The facility failed to remove Resident #1's facial hair. This failure could place residents at risk for social isolation, loss of dignity and self-worth. Findings included: Record review of Resident #1's face sheet, printed on 08/29/24, reflected the resident was an [AGE] year-old female who admitted to the facility on [DATE], with diagnoses of other specified myopathies (disease that affects the muscles that control voluntary movement), Type 2 diabetes mellitus with diabetic neuropathy (a serious complication of Type 2 diabetes that occurs when high blood sugar levels over time damage nerves in the body), mixed hyperlipidemia (a genetic condition that causes high levels of cholesterol and fat in the 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 interview and record review, the facility failed to permit a resident to return to the facility after being hospitalized or placed on therapeutic leave for 1 of 3 residents (Resident #1) reviewed for bed hold. The facility failed to re-admit Resident #1 after he was treated at a behavioral health hospital, when his discharge back to the facility was anticipated on 06/26/24. This failure could place residents at risk of not getting the care and services required. Findings included: Review of Resident #1's Face Sheet reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE] to the secure unit. Resident #1 had the following diagnosis: schizoaffective disorder (mental disorder with abnormal thought processes and unstable mood), heart failure, hyperlipidemia (high cholesterol), mild cognitive impairment (memory and thinking problems), and hypertension (high blood pressure). Record review of Resident #1's nursing home discharge MDS, dated [DATE], revealed Resident #1's BIMS,…

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 observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #2) of 6 residents observed for infection control. The facility failed to ensure Resident #2's urinary catheter was positioned safely off the floor. This failure could place the residents at risk of cross-contamination and the development of infection. Findings included: Review of Resident # 2 face sheet dated 06/03/2024 revealed she was a [AGE] year-old resident admitted to the facility 06/10/2023 from an acute care hospital. Relevant diagnoses included encephalopathy (changes in brain that lead to brain damage,) heart disease, hypertension (high blood pressure,) cerebrovascular disease (condition that affects blood flow and vessels in the brain,) hemiplegia (one sided paralysis) following cerebral infarction (brain…

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, interview, and record review, the facility failed to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 resident (Resident #1) of five residents reviewed for environment. The facility failed to ensure Resident #1 had a functional call light. This failure placed residents at risk of not being able to get staff assistance when they need it. Findings included: Review of Resident #1'S Face Sheet dated 06/03/2024 revealed she was a [AGE] year-old resident admitted to the facility on [DATE] from another skilled nursing home. Relevant diagnoses included fibroblastic disorder (connective tissue dysfunction,) diabetes type 2 (insulin resistance,) major depressive disorder (clinical depression where one feels sad, low, or worthless,) and insomnia (inability to sleep at night.) Review of Resident #1's admission MDS dated [DATE] revealed she was cognitively intact with a 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 interview and record review, the facility failed electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for 3 of 4 FY quarters reviewed (FY Quarter 1 2023 ([DATE]-[DATE]), FY Quarter 3 2023 (April 1-June 30), and FY Quarter 4 2023 (July 1-[DATE]) reviewed for administration. The facility failed to submit data to CMS for FY Quarter 1 2023 ([DATE]-[DATE]), FY Quarter 3 2023 (April 1-June 30), and FY Quarter 4 2023 (July 1-[DATE]). The facility's failures could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. Findings included: Review of the CMS PBJ report for CMS for FY Quarter 1 2023 (October 1- December 31) indicated the facility had failed to submit data…

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, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for five (01/01/23, 01/28/23, 01/29/23, 02/04/23, 02/05/23) of 90 days reviewed for nursing services. The facility failed to provide RN coverage for 8 consecutive hours daily for five (01/01/23, 01/28/23, 01/29/23, 02/04/23, 02/05/23) of 90 days. This deficient practice could place residents at risk of no receiving specific nursing services due to staff being left without supervisory coverage . Findings included: Record review of a timesheet for all nursing staff who worked on 01/01/23 reflected there was not an RN who worked that day. Record review of a timesheet for all nursing staff who worked on 01/28/23 reflected there was not an RN who worked that day. Record review of a timesheet for all nursing staff who worked on 01/29/23 reflected there was not an RN who worked that day. Record review of a timesheet for all nursing staff who worked on 02/04/23 reflected there was not an RN who worked that day. Record review of a timesheet…

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 provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident on two of four medication carts (back and front nurses' carts) and 3 of 3 staff (LVN R, RN NN, and LVN L) reviewed for pharmacy services. The facility failed to ensure the back and front nurses medication cart contained accurate narcotic logs for Residents #184, #62, and #43. LVN R, RN NN and LVN L failed to document the administration of narcotic medications in a correct and timely manner. This failure could place residents at risk for drug diversion and delay in medication administration. Findings included: Observation on 01/08/24 at 02:48 PM, of the nurses' medication cart and the narcotic administration record, with LVN R, revealed the following information: Resident #43's narcotic administration record sheet for Hydrocodone-Acetaminophen 5/325 mg was last signed off on 01/5/24 for a one-tablet dose given at 3:30…

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 provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 (front hall and back hall ) of four medication carts and one of one refrigerator reviewed for pharmacy services. 1. The facility failed to ensure expired medications in nurse medication carts for front hall and refrigerator were removed and destroyed. 2. The facility failed to ensure insulin were dated with opening dates. 3. The facility failed to ensure vaccines were stored at the right temperatures and refrigerator temperatures were being maintained within normal ranges. These failures placed residents at risk of receiving medications that were ineffective due to having expired medications on the cart, in the refrigerator, not putting opening date on insulin pens/vials and maintaining the refrigerator temperatures within ranges. Findings included: 1. Observation on 01/08/24 at 03:11 PM of the facility…

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, interview and record review, the facility failed to maintain infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 4 of 5 residents (Resident #184, Resident #59, Resident# 38, and Resident #2) reviewed for infection control. LVN B and MA D failed to perform hand hygiene between residents while administering medications to Residents #184, #59, #38 and #2. This failure could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Review of Resident# 184's entry MDS assessment, dated 01/05/24, revealed the resident was [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included elevated blood pressure, and atrial fibrillation (irregular heartbeat). Resident #184's BIMS score was not completed resident was newly admitted . Review of Resident #59's quarterly MDS…

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, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #39) of 18 residents reviewed for care plans. The facility failed to develop a care plan with measurable objectives and timeframes to address Resident #39's diagnosis of bullous pemphigoid (rare skin condition causing large, fluid-filled blisters). This failure could place residents at risk of receiving inadequate interventions not individualized to their care needs. Findings included: Review of Resident #39's MDS, dated [DATE], revealed the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's disease, CVA (stroke), non-Alzheimer's dementia, malnutrition, bullous…

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, interview, and record review, the facility failed to ensure a residents who were unable to carry out activities of daily living received necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one (Resident #39) of 18 reviewed for ADLs. The facility failed to ensure Resident #39's contractured hands were kept clean and free of odor. This failure had the potential to affectcould place residents by placing them at risk for poor personal hygiene, odors and a decline in their quality of life. Findings included: Review of Resident #39's MDS, dated [DATE], revealed the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's disease, CVA, non-Alzheimer's dementia, malnutrition, bullous pemphigoid, and muscle wasting. The MDS further reflected the resident was not able to completed a BIMS due to her cognition being severely impaired. Review of Resident #39's care plan, revised on 11/19/23, 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 observation, interview, and record review, the facility failed to ensure that residents receive proper treatment and care to maintain good foot mobility and good foot health for 1 (Resident #72) of 18 residents reviewed for foot care. The facility did not ensure Resident #72 received toenail care. This failure could place residents at risk for not receiving foot care which is consistent with professional standards of practice. Findings included: Review of Resident #72's MDS dated [DATE], revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. Resident #72 had diagnoses which included end stage renal disease, aphasia (loss of ability to understand or express speech), CVA (stoke), and nontraumatic intracerebral hemorrhage . The MDS further reflected Resident #72 had long and short- term memory impairment. Review of Resident #72's care plan, revised on 10/09/23, revealed the resident had ADL self-care performance deficit related to nontraumatic intracerebral hemorrhage.…

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, interview, and record review, the facility failed to ensure a resident who was fed by enteral means received appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding which included but not limited to aspiration, pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and nasal-pharyngeal ulcers for one of four residents (Resident #73) reviewed for feeding tubes. The facility failed to follow physician's orders of providing Resident #73 with his 20 hours of feeding intake. This failure could place residents at risk for a decline in health or adverse effects due to inappropriate management of g-tube care. Finding included: Record review of Resident #73's face sheet, dated 01/10/24, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included aphasia (a comprehension and communication (reading, speaking, or writing) disorder resulting from damage or injury to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for one of 3 residents (Resident #184) reviewed for oxygen therapy. The facility failed to acquire oxygen orders for Resident #184. This facility failure could place residents at risk of missing or receiving inadequate treatment. Findings included: Record review of Resident #184's face sheet, dated 01/10/24, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included atrial fibrillation (an irregular heart rhythm that begins in your heart's upper chambers), dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease…

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, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Resident #53) reviewed for dialysis. The facility failed to ensure post-dialysis assessments were completed for Resident #53 after return from dialysis treatment. This failure could place residents at risk of inadequate post dialysis care. Findings included: Record review of Resident #53's, undated, face sheet reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #53 had diagnoses which included acute kidney failure (when kidneys suddenly become unable to filter waste products from blood) and chronic kidney disease stage 3 (mild to moderate damage to kidneys, and they are less able to filter waste and fluid out of the blood). Record review of Resident #1's quarterly MDS…

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, interview and record review, the facility failed to provide special eating equipment and utensils for one (Resident #5) of two residents reviewed for meal service. The facility failed to provide Resident #5 a divided plate at lunch on 01/08/24 to assist her with eating independently. This failure could place residents at risk for loss of self-worth and empowerment for independent eating, which could lead to unplanned weight loss. Findings included: Review of Resident #5's face sheet, dated 01/10/24, reflected the resident was a [AGE] year-old female who originally admitted to the facility on [DATE], and readmitted on [DATE]. Her diagnoses included cerebral palsy (a group of disorders that affect movement, muscle tone, balance, and posture), dysphagia (a condition with difficulty in swallowing food or liquid. This may interfere in a person's ability to eat and drink), and cognitive communication deficit. Review of Resident #5's quarterly MDS assessment, dated 12/28/23, reflected she had 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, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 (Cook H) of 3 staff reviewed for kitchen sanitation. Cook H failed to properly wear a hair restraint while in the food preparation area. This failure could place residents at risk for food contamination and foodborne illness. Findings included: Observation on 01/07/24 at 12:05 PM, [NAME] H walked in to the kitchen without wearing a hair restraint. Observation on 01/07/24 at 12:08 PM, [NAME] H walked in the kitchen again without wearing a hair restraint. Interview on 01/07/24 at 12:10 PM, [NAME] H revealed she knew she was supposed to be wearing a hair restraint while in the kitchen and should have put one on before entering. [NAME] H said she forgot about that requirement because today was her first day back from being on maternity leave. [NAME] H said the purpose of wearing a hair restraint was to keep hair out of the food. Interview on 01/08/24 at 1:30 PM, the Dietary Manager revealed all staff…

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, the facility failed to ensure residents have the right to be free from abuse for 1 (Resident #1) of 5 residents reviewed for abuse. The facility failed to ensure Resident #1 did not physically abuse Resident #2 during their interactions on 08/29/23. This failure could place residents at risk of being abused. Findings included: Review of Resident #1's MDS dated [DATE] reflected the resident was an [AGE] year-old male admitted to the facility on [DATE]. The resident had severe cognitive impairment with a BIMS score of 4. The resident's diagnoses included stroke, non-Alzheimer's dementia, anxiety disorder, depression, and psychotic disorder. Review of Resident #1's care plan revised on 10/02/23 revealed Resident #1 was on psychotropic medications related to depressive disorders, delusional disorders, anxiety disorders. Interventions included monitor/record occurrence of target behavior symptoms (specify: pacing, wandering, disrobing, inappropriate response to verbal…

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, the facility failed to implement their written policies and procedures to prohibit abuse, neglect, exploitation or misappropriation of resident property for 1 (Resident #1 ) of 5 residents reviewed for abuse. The facility failed to implement their policies and procedures related to reporting allegations of abuse when Resident #1 and Resident #2 were in a physical altercation on 8/29/23. This failure could place residents at risk of not being protected from abuse, neglect, and/or misappropriation. Findings included: Review of the facility's policy titled Abuse and Neglect , review date 09/06/22, reflected the following: Policy Statement It is the policy of the facility to administer care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. .All allegations and/or suspicions of abuse must be reported to the Administrator immediately All allegations of abuse will be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse and neglect, including injuries of unknown source, were reported immediately, but not later than two hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials including to the State Survey Agency in accordance with State law through established procedures for 1 (Resident #1 ) of 5 residents reviewed for abuse and neglect. RN A failed to report to the Administrator when Residents #1 and #2 got into a physical altercation on 08/29/23. This failure could place residents at risk of incidents of abuse, neglect, and/or exploitation not being reported timely and thoroughly investigated. Findings included: Review of Resident #1's MDS assessment dated [DATE] reflected the resident was an [AGE] year-old male admitted to the facility on [DATE]. The resident had severe cognitive…

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, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible for 1 (Residents #3) of 3 residents reviewed for accidents and supervision. The facility failed to ensure Resident #3 did not have cigarettes and a lighter in his possession and failed to supervise the resident while smoking. These failures could place the residents at risk of injury and harm. Findings included: Review of Resident #3's MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident had moderately impaired cognition with a BIMS score of 12. The resident's diagnoses included non-Alzheimer's dementia, anxiety disorder, and depression. The MDS further reflected the resident usually understood others and was usually understood. Resident #3 ambulated independently and was also independent with ADLs. Review of Resident #3's care plan revised on 10/08/23 reflected Resident #3 smoked 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, interviews and record reviews, the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 6 residents (Residents #1, #2, and #3) reviewed for Activities of Daily Living (ADLs) care provided to dependent residents. The facility failed to ensure Residents #1, #2, and #3 received adequate activities of daily living care with baths or showering, nail care, or dressing. This failure placed residents at risk of not receiving necessary services to maintain good personal hygiene, skin integrity, or decreased self- esteem. Findings included: Record review of Resident #1's Face Sheet, dated 09/25/23, revealed the resident was a 65 -year-old female admitted on [DATE] readmitted [DATE] with diagnoses that included Dementia, Down Syndrome, Lack of Coordination, Muscle Weakness, Schizoaffective Disorder (mental disorder, abnormal thought processes 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 observation, interview, and record review, the facility failed to provide comfortable and safe temperature levels between a range of 71 to 81 degrees Fahrenheit for one (Secure Unit) of three halls reviewed for environment. The facility failed to ensure temperatures on the secure unit did not rise above 81 degrees Fahrenheit. These failures increased the risk of residents experiencing decreased comfort and could affect the wellbeing of residents. Findings included: Observation on 09/07/23 at 10:08 AM revealed the secure unit thermostat temperature was 81 degrees Fahrenheit. The thermostat was set at 74 degrees Fahrenheit. Interview on 09/07/23 at 10:10 AM with Housekeeper C revealed she had been employed for about a week. She stated today 09/07/23 was the first time she was assigned to the secure unit. She stated she had noticed that the secure unit was warmer than the other halls. Housekeeper B stated she believed the Maintenance Director was aware of the issue. Observation and interview on 09/07/23 at 10:57 AM revealed Resident #2 lying on her bed. Resident #2 stated she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to equip each room to assure full visual privacy for each resident for 4 (Rooms 124 A bed, 117 A bed, 130 A and B bed, and 133 A bed) of 10 rooms reviewed for privacy. The facility failed to provide curtains to ensure residents privacy in 4 dual occupancy rooms throughout the facility. This failure could place residents at risk of decreased self-worth by being exposed during resident care. Findings included: Observation and interview on 9/07/23 at 9:51 AM of Resident #1's room revealed she was in her wheelchair. Further observation revealed there was not a privacy curtain available to surround Resident #1's bed. Resident #1 was in A bed (nearest to the door) and had a roommate. Resident #1 said she wished she had a privacy curtain in her room so she could have privacy when she wanted it. Resident #1 said she had been at the facility for a while and had never had a privacy curtain for her A bed . Observation on 09/07/23 from 9:57 AM-10:30 AM of room [ROOM…

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, interview, and record review the facility failed to coordinate an assessment with the Preadmission Screening and Resident Review program (PASRR) under Medicaid to the maximum extent practicable to avoid duplicative testing and effort for two (Residents #11 and #12) of three residents reviewed for PASRR services. 1. The facility failed to submit Resident #11's PASRR Comprehensive Service Plan (PCSP) form in the LTC Online Portal for Resident #11 by the specific deadline. 2. The facility failed to submit Resident #12's PASRR Comprehensive Service Plan (PCSP) form in the LTC Online Portal for Resident #12 by the specific deadline. These failures could place residents with a positive PASRR evaluation at risk of not receiving specialized PASRR services which could contribute to a decline in physical, mental, psychosocial well-being and quality of life. Findings included: 1. Review of Resident #11's face sheet, dated 09/07/23, reflected she originally admitted to the facility on [DATE] 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 inform the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in mental or physical condition of a resident who has mental illness or intellectual disability for one (Resident #10) of one resident reviewed. The facility failed to notify Resident #10's state mental health agency or intellectual disability agency of a significant change for Resident #10 when he expired on [DATE]. This failure could affect residents in the facility that are PASRR positive for their mental health agency or state intellectual disability agency not being notified of a significant change for residents. Findings included: Review of Residents #10's face sheet, dated [DATE], reflected the resident admitted to the facility on [DATE] and discharged from the facility on [DATE]. His diagnoses included cerebral palsy, seizures, and cognitive communication deficit. Review of Resident #10'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 observation, interview, and record review the facility failed to ensure residents were free from neglect for 1 of 4 residents (Resident #1) reviewed for neglect. Resident #1 was left lying in a brief of feces and urine for over two hours. This failure could place residents at risk of being neglected. Findings included: Record review of Resident #1's MDS assessment dated [DATE] reflected she was a [AGE] year-old woman with an admission date of 06/10/23. Her cognition was moderately impaired. Her diagnoses included stroke and pain. She was always incontinent of urine and bowel. She was totally dependent on 2 staff for toileting. Record review of Resident #1's care plan, not dated, reflected the resident was totally dependent on staff for toilet use. An observation and interview on 08/23/23 at 1:05 PM with Resident #1 revealed she was awake, alert, oriented, and upset. She said her brief had not been changed for the 6:00 AM - 2:00 PM shift. She said her brief was last changed by the 10:00 PM - 6:00 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.