Viridian Wellness & Rehabilitation

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 any physical restraint imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms for 6 (Resident #70, Resident # 23, Resident # 39, Resident # 36, Resident #25, Resident #63) of 6 residents reviewed for restraints. The facility failed to ensure Resident #70, Resident #23, Resident #39, Resident #36, Resident #25 and Resident #63 were not inhibited from freedom of movement or activity in the secure unit when facility staff pushed two dining tables together and placed them in front of the single entrance to the dining area, to prevent the residents from leaving the area. This failure places the residents at risk of being restrained without medication indication.Findings Included: Record review of Resident #70's MDS, dated [DATE], revealed he admitted to the facility on [DATE]. Resident #70 had primary diagnoses of non-Alzheimer's dementia, and left side…

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 drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable and in accordance with State and Federal laws, the facility stored all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for two of four medication carts (300 hall nurses cart and 400 hall Medication Aides cart) reviewed for medication storage. 1. The facility failed to ensure Resident #64's unopened liquid Lorazepam 2mg /ml was stored in the refrigerator. 2. The facility failed to ensure an opened vial of insulin Lispro 100unit/1ml was properly labeled before storing in the 300-hall medication cart. 3. The facility failed to ensure a bottle of Assure Prism Control solutions (designed to check assure prism [NAME]…

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, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 facility kitchens reviewed for kitchen sanitation. The facility failed to ensure food items were properly stored in the facility's freezer. 2. The facility failed to ensure food and drink items were properly labeled. 3. The facility failed to ensure no outdated or spoiled foods were present. These failures could place residents at risk for food-borne illnesses. Findings Included: Observation of the facility's freezer on 09/14/24 at 9:12 AM revealed: - 2 bags of lettuce (each bag contained 6 heads of lettuce) visibly decomposed, brown discoloration, wilted and slimy, with liquid seepage. - 1 box lima beans were open and exposed to the air. - 2 gallon jugs of milk, were opened and were not labeled. - 1 container of instant mashed potatoes was not labeled. In an interview with the Dietary Manager on 9/14/2025, at 2:00 p.m., he stated when food deliveries arrived, staff were expected to inspect…

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 received services with reasonable accommodations for 2 of 5 residents (Resident #8, and Resident #14) reviewed for call light system access. The facility failed to ensure Resident #8 had access to their call light by allowing it to remain on the floor at the side of the bed, out of the resident's reach. The facility failed to ensure Resident #14 had access to their call light by allowing it to remain between the wall and mattress at the foot of the bed, out of the resident's reach. This failure could place residents at risk for delayed assistance and an inability to request help when needed. 1.) Record review of Resident #8's annual MDS dated [DATE], reflected the [AGE] year-old male resident was admitted to the facility with an original admission date of 09/20/2024 and had severely impaired cognitive function. Diagnoses included: cerebral palsy (a neurological disorder that affects body movement and muscle coordination).…

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 received the housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for two (Resident #20 & #49) of five residents reviewed for environment. The facility failed to maintain the wall air conditioning unit in Residents #20 and #49's room free of dust buildup. This failure could place residents at risk for a diminished quality of life due to the lack of a homelike environment. Findings included: 1.) Record review of Resident #49's annual MDS dated [DATE], reflected the [AGE] year-old male resident was admitted to the facility on [DATE] and had intact cognitive functioning, meaning they were alert, oriented, able to understand and process information, make decisions, and communicate their needs appropriately. Primary diagnoses included chronic congestive heart failure (a long-term condition where the heart is unable to pump enough blood to meet the body's needs for blood 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 interviews and record review, the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review for one (Resident #55) of five residents reviewed for PASRR services. The facility failed to ensure Resident #55 was properly screened for PASRR services. This failure could place residents at risk of not receiving specialized PASRR services which would enhance their highest level of functioning and could contribute to residents decline in physical, mental, and psychosocial well-being. Findings included: Record review of Resident #55's quarterly MDS Assessment, dated 06/13/25, revealed a [AGE] year-old-female admitted to the facility on [DATE] and had severe cognitive impairment. Diagnoses included Major Depressive Disorder, Recurrent, Moderate (severe, persistent sadness and loss of interest that interferes with daily life). Record review of Resident #55's Comprehensive…

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 develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care for the resident that met professional standards of care within 48 hours of the resident's admission for one (Resident #72) of five residents reviewed for baseline care plans. The facility failed to complete a baseline care plan for Resident #72. This failure could place newly admitted residents at risk of not receiving effective and person-centered care and services.Findings included: Review of Resident #72's Face Sheet, dated 09/16/25, reflected she was a [AGE] year-old female who originally admitted to the facility on [DATE], with diagnoses including schizoaffective disorder, bipolar type (a condition in which a person can experience several days of extreme highs as well as severe lows); chronic respiratory failure with hypoxia (a condition that occurs when the lungs cannot get enough oxygen into the blood or…

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

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 2 of 5 residents (Resident's #49 and #61) reviewed for ADL care. The facility failed to provide Residents #49, and #61 with showers based on their weekly shower/bathing schedule. This failure could place residents at risk of not receiving the care they require to maintain their highest practical well-being, and could result in low self-esteem, anxiety, embarrassment, and a decline in their quality of life. Findings include: 1) Record review of Resident #49's annual MDS dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #49 had intact cognitive functioning, meaning they were alert, oriented, able to understand and process information, make decisions, and communicate their needs appropriately. Resident #49's primary…

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 was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #17) of 5 residents reviewed for accidents and supervision. The facility failed to prevent Resident #17 from cleaning his fingernails with a rusted nail. This failure could place the resident at risk of injury or infection. Findings Include: Record review of Resident #17's MDS, dated [DATE], revealed a male resident who was admitted to the facility on [DATE]. Resident #17 had a BIMS score was 11, which indicated a moderate cognitive impairment. Resident #17's primary diagnosis which included acute and chronic respiratory failure with hypoxia (a sudden onset of severely low blood oxygen levels). Resident #17 had additional diagnoses which included chronic obstructive pulmonary disease (chronic inflammation and narrowing of airways making it difficult…

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 establish and 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 2 of 6 residents (Resident #6, Resident#64) reviewed for infection control. 1.The facility failed to ensure CMA C sanitized the blood pressure cuffs to prevent the spread of infections. 2.LVN B failed to don PPE prior to performing high contact resident care activities on Resident #6 who was on enhanced barrier precaution. These failures could place residents at risk for healthcare associated cross contamination and infections. Findings include: 1. Record review of Resident #6's Quarterly MDS Assessment, dated 08/6/25, reflected a [AGE] year-old female. Resident #6 had a BIMs score of 15, which indicated she had no cognitive issues. The resident had diagnoses which included Ulcerative Colitis, Crohn's disease (an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide activities based on the comprehensive assessment and care plan, designed to meet the interests of and support the physical, mental and psychosocial well-being of one resident (Resident #4) out of five who were reviewed for activities. The facility failed to consistently provide encouragement and assistance to participate in facility provided activities for Resident #4. This failure could place residents at risk for social isolation, depression, and a decline in psychosocial well-being.Findings included: Review of Resident #4's annual Minimum Data Set, dated [DATE] reflected the [AGE] year-old male resident was admitted to the facility on [DATE] with diagnoses which included cerebral palsy (a condition caused by damage to the developing brain that affects a person's ability to control their muscles, problems with movement, coordination) kidney failure (kidneys are no longer able to properly filter waste and extra fluid from the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to establish and 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 two (Resident #1 and Resident #2) of five residents, reviewed for infection control. 1. The facility failed to ensure CNA A performed hand hygiene during incontinence care for Resident #1 on 06/04/25.2. The facility failed to ensure CNA B and CNA D performed hand hygiene during incontinence care for Resident #2 on 06/04/25. This failure placed residents at risk for cross contamination and infections.Findings included: 1.Review of Resident #1's Annual MDS Assessment, dated 04/08/25, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His cognitive skills for daily decision making were severely impaired. The resident had a supra-pubic catheter (catheter inserted into the bladder…

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 coordinate assessments with the pre-admission screening and resident review (PASRR) program to the maximum extent practicable to avoid duplicative testing and effort, which included incorporating the recommendations from the Preadmission Screening and Resident Review level II determination and the Pre-admission Screening and Resident Review evaluation report into a resident's assessment, care planning and transitions of care for one (Resident #4) of five residents reviewed for Pre-admission Screening and Resident Review assessments. The facility failed to provide Habilitation Coordination, Independent Living Skills, Physical Therapy, Occupational Therapy, Speech Therapy. to Resident #4 as recommended and agreed upon by the Interdisciplinary Team (IDT) within the time frame set by PASRR. This failure could place residents with intellectual disabilities or mental illness at risk of not receiving services that would enhance their quality of life.Findings…

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 develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs and describes the services to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 of 5 (Resident #4) residents reviewed for care plans. The facility failed to implement Resident #4's comprehensive person-centered care planned interventions for speech and occupational therapies. Failure to implement the care plan as written could place residents at risk for unmet needs, avoidable decline, injury, or harm, as their individualized support measures are not being followed to ensure safety, health, and well-being.The findings included: Review of Resident #4's annual Minimum Data Set, dated [DATE] reflected the [AGE] year-old male resident was admitted to the facility on [DATE] with diagnoses which included cerebral palsy (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 (Resident #2) of 2 residents reviewed for catheter care. The facility failed to ensure Resident #2 received her Foley catheter change as ordered every month when RN E documented that he changed the Foley catheter on 05/13/25, but he only changed the bag and did not change the catheter. These failures could place residents at risk of cross-contamination and development of infections.Findings included: 1. Review of Resident #2's Annual MDS Assessment, dated 04/24/25, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her cognitive skills for daily decision making were severely impaired. The resident had a Foley catheter (tube to drain urine from the bladder) and was always incontinent of bowel movement. Her diagnoses included stroke, diabetes, non-Alzheimer's disease (form…

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 an effective pest control program so that the facility was free of pests and rodents for one, Resident #1, of five residents reviewed for environmental concerns. The facility failed to ensure Resident #1's room was free of gnats on 06/04/25 which were landing on a cloth near his tracheostomy collar. This failure could place residents at risk of having pests in their rooms and insect bites.Findings included: Review of Resident #1's Annual MDS Assessment, dated 04/08/25, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His cognitive skills for daily decision making were severely impaired. The resident had a supra-pubic catheter (catheter inserted into the bladder to drain urine) a colostomy (bag attached to the abdomen to collect bowel movement that excretes from the stoma), and a tracheostomy (a hole that surgeons make through the front of the neck and into the windpipe, also known as 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 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 Food and Nutrition Services. 1) The facility failed to ensure food items were properly labeled and dated with the product's name. 2) The facility failed to ensure food items were properly sealed when not in use. These failures could place residents at risk for food-borne illness and food contamination. Findings include: An observation on 5/21/2025 at 11:50 AM revealed in the dry food pantry one large plastic container of rice (was not labeled with the product type or dated); one opened bag of potato chips wrapped in plastic wrap (was undated and not properly stored according to the facility's policy); one opened bag of tortilla chips wrapped in plastic wrap (was undated and not properly stored according to the facility's policy). An observation on 5/21/2025 at 12:10 PM in the large refrigerator revealed two bags of opened bread (was not labeled, dated, nor properly…

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 ensure the resident had a safe, clean, comfortable, and homelike environment which included but not limited to receiving treatment and supports for daily living safely for 4 of 6 shower rooms (100, 300, 400 and 500 halls) reviewed for environment. 1. The facility failed to ensure the 100, 300, 400 and 500 hall shower rooms were clean and free of trash and soiled towels. 2. The facility failed to ensure the 100, 300, 400 and 500 hall shower rooms did not have broken and missing ceramic wall tiles. 3. The facility failed to ensure unnecessary items (one wheelchair, two hangers, two pillows, and two empty plastic storage bins) were not stored in the 300 hall shower room. These failures could place residents at risk of not having a safe, clean, sanitary, comfortable and homelike environment. Findings include: Observation on 05/21/2025 at 9:55 AM in the 100 Hall shower room revealed the following: - one 7.5 oz bottle of skin and hair cleanser left out opened on the sink; - unidentified debris observed on the floor…

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

Based on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 of 1 walk-in freezer reviewed for environment. The facility failed to ensure the walk-in freezer was maintained to prevent the vent in the ceiling from dripping which caused a chunk of ice to form on the floor. This failure could affect all kitchen staff by placing them at risk for falls and slipping hazards inside the freezer. The findings include: Observation on 5/21/2025 at 12:30 PM, in the walk-in freezer revealed small pieces of ice and two large chunks of ice on the floor. There was one long icicle hanging from the vent in the ceiling of the freezer. In an interview on 5/21/2025 at 1:25 PM, the DM stated she had only worked at the facility for three days. The DM stated she had no idea how long the leak had been there. The DM stated she read in the Registered Dietician's notes, dated 9/30/24 (ice accumulation on floor); 12/13/24 (ice accumulation) and on 3/30/2025 ice all over the floor greater than…

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 interviews 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 for five (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) of five residents reviewed for pharmacy services. The facility failed to ensure that documentation of narcotic medications signed out on the narcotic count sheet were consistent with documentation of narcotic medications administered to Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5 as reflected on their MAR and nursing progress notes. These failures could place residents at risk for medication errors, potentially leading to overdose of narcotic pain medications, or diversion of narcotic pain medications. Findings included: 1) Record review of Resident #1's admission Record dated 4/23/25 reflected a [AGE] year-old female initially admitted to the facility om…

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, interviews and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 2 of 5 shower rooms (300 and 500 halls) reviewed for environment. The facility failed to ensure the 300 and 500 hall shower rooms were clean and free of trash and soiled towels. These failures could place residents at risk of not having a safe, clean, sanitary, comfortable, and homelike environment. Findings included: Observation on 04/19/2025 at 9:08 AM in the 500 Hall shower room revealed the following: *a soiled washcloth on a shower rack and two soiled towels (one wet and one dry) on the shower floor, *a gallon of liquid body soap in the shower area, and * a long black duffel bag on the floor located between the toilet and the trash bin. Observation on 04/19/2025 at 10:08 AM in the 300 Hall shower room revealed the following: *two used gloves, one inside out on the floor, in the corner to the right of the sink. *two used gloves and a hanger underneath the shower chair on the floor. In an interview on 04/19/25 at 10:15 AM, CNA C 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, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents on 3 of 5 Halls (200, 300 and 400 Halls) reviewed for environmental concerns. The facility failed to ensure residents overhead light fixtures illuminated in the resident's bedrooms on hall 200 (Rm# 206,212, and 222), hall 300 (Rm# 301, 303, and 310) and hall 400 (Rm#405, 406 and 419). This failure could place residents at risk of not having a safe and functional environment. Findings included: Interview and observation on 04/16/25 at 8:00 AM Resident#1 and Resident#2 who shared a room stated it was hard to see in their room. Right side of the room overhead fixtures did not work at all. Left side of the room overhead light fixture had one working light bulb. Interview on 04/16/25 at 9:30 AM MD stated that he had been employed at the facility for 3 months. The MD stated the old fixtures did not provide adequate light in residents rooms. The MD stated the light in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for one resident (Resident#1) of 5 residents reviewed for ADLs. -The facility failed to provide showers or bed baths for Resident #1 according to the facility's ADL schedule. This failure could place all residents who require assistance with ADL care at risk for poor personal hygiene, odors, and a decline in their quality of life. Findings included: Record review of Resident #1's Face Sheet, dated 03/18/25, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: osteomyelitis of vertebra, sacral and sacrococcygeal (inflammation caused by infection to tail bone), pressure ulcers, heart failure, hypertension (high blood pressure), type II diabetes, and paraplegia (loss of voluntary movement to lower parts of the body). Record review of Resident #1's care plan, dated 12/31/24,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for one of five residents (Resident #1) reviewed for accuracy of assessments. The facility failed to accurately reflect Resident #1's use of high risk medications in his most recent quarterly MDS assessment. The failure placed residents at risk for having inaccurate assessments. Findings included: Record review of Resident #1's face sheet, dated 03/05/25, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's DX included: Paranoid schizophrenia (Paranoia is a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly. Delusions and hallucinations are the two symptoms that can involve paranoia.), Acute bronchitis (is an inflammation of the bronchial tubes (airways) that leads to a persistent cough. It is typically caused by a viral infection, although it can also be caused by bacteria or other…

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 an effective pest control program, so the facility was free from pests and rodents for 2 of 2 residents (Resident #2 and Resident #3) reviewed for pest control. The facility failed to maintain an effective pest control program to ensure the facility was free of rodents and roaches in the facility kitchen and the rooms of Resident #2 and Resident #3. This failure could place residents at risk for an unsanitary environment in the kitchen and rooms of Residents #2 and Resident #3 and a decreased quality of life. Findings included: Record review of Resident #2's admission Record dated 02/27/24 reflected a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Record review of Resident #2's admission MDS assessment dated [DATE] reflected a BIMS score of 13 which indicated he was cognitively intact. His diagnoses included paraplegia (inability to move the lower part of the body);…

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 who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 1 (Residents #1) of 1 resident reviewed for tracheostomy care. The facility failed to ensure an extension cord was kept in Resident #1's room for use during a power outage in accordance with his Care Plan. This failure placed residents at risk of serious injury or hospitalization. Findings included: Record review of Resident #1's admission Record dated 2/26/25 reflected a [AGE] year-old male originally admitted to the facility on [DATE]. Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected he was rarely/never understood and had severely impaired cognitive skills. He had range of motion impairment in all extremities and was dependent on staff for all…

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

Based on observations, interviews, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for staff for 1 of 1 walk-in freezers reviewed for environment. The facility failed to ensure the kitchen walk-in freezer door was maintained to ensure the water did not drip from the vent onto the floor. This failure could affect all kitchen staff by placing them at risk for fall and slipping hazard inside the freezer. The findings included: Observation on 02/26/25 at 10:00 AM revealed a cardboard box filled with ice under the vent in the walk-in freezer. I was also on the floor around the box, and the ice covered the back corner of the floor and under one of the shelves. Interview with Kitchen Manager on 02/26/25 at 12:25 PM revealed Kitchen Manager stated the freezer had been leaking water from the vent inside the freezer for about six months. He stated he had verbally informed the previous maintenance director, and the administrator about the leakage. He stated the Administrator informed him last week that he had ordered the part to fix…

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 in response to allegations of abuse, neglect, exploitation, or mistreatment that all alleged violations involving abuse, neglect, exploitation or mistreatment were reported immediately or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the State Survey Agency in accordance with state law through established procedures for one of two incidents (Resident #1) reviewed for abuse, neglect, and misappropriation. 1. The facility failed to report to the State Survey Agency when Resident #1 eloped from the facility on 12/31/24. This failure could place the residents in the facility at risk of continued abuse and neglect. Findings included: 1. Record review of Resident #1's Face sheet, dated 02/20/25, reflected the resident admitted on [DATE]. The resident's diagnoses included cerebral infarction (stroke), Bell's Palsy (condition that causes sudden weakness in the muscles…

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 ensure a resident who was incontinent of bladder received appropriate treatment and services for 1 of 3 residents (Resident #2) reviewed for catheter care. The facility failed to ensure LVN A followed relevant clinical guidelines and provided appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible. This failure could place the resident at risk of urethral tears or dislodging the catheter and urinary tract infections. Findings included: 1. Record review of Resident #1's annual MDS assessment, dated 12/17/24, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His BIMs score was 13 indicating his cognitive status was intact. His diagnoses included neurogenic bladder (a condition that affects the bladder's ability to function properly due to damage or dysfunction in the nerves that control it), paraplegia (a condition…

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 ensure they followed professional standards of practice in accordance with physician orders and facility policy for care of PICC lines for 1 of 2 (Resident #2) residents reviewed for parenteral and intravenous care. The facility failed to ensure Resident #2's PICC line dressing was intact. This failure placed the residents at risk of complications with their PICC line needed for infusion therapy. Findings included: Record review of Resident #2's annual MDS assessment, dated 12/17/24, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His BIMs score was 13 indicating his cognitive status was intact. His diagnoses included sepsis (sepsis is the body's extreme response to an infection), neurogenic bladder (a condition that affects the bladder's ability to function properly due to damage or dysfunction in the nerves that control it), paraplegia (a condition characterized by the loss of motor and sensory function in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances residents had and ensure that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued for two months (December 2024 and January 2025) of two months reviewed of resident council meetings and facility-received grievances. 1. The facility failed to document any attempts to resolve Resident #2's grievance when he expressed concern there was no hot or warm water available in his room. 2. The facility failed to document show evidence of attempts to resolve all grievances from 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 observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for two (Resident #2 and Resident #3) of five residents reviewed for ADLs. The facility failed to provide showers or bed baths consistently for Residents #2 and #3 per the facility bathing schedule in January 2025. This failure placed residents who were dependent on staff for bathing at risk for poor personal hygiene, odors, and a decline in their quality of life. Findings included: 1. Record review of Resident #2's Face Sheet reflected dated 01/30/25 reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Resident #2's active diagnoses included paraplegia (a condition that causes paralysis or loss of muscle function in both legs), neuromuscular dysfunction of bladder (impaired bladder control due to disrupted communication between the brain and the bladder muscles), Stage 4 pressure ulcer 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 interview and record review, the facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for one (Resident #1) of five residents reviewed for pressure ulcers. 1. The facility failed to ensure Resident #1 received all physician ordered wound care 10 out of 31 days in December 2024. 2. The facility failed to ensure Resident #1 received all physician ordered wound care 5 out of 30 days in January 2025. This facility failure could place residents at risk of developing infections or worsening of their wounds. Findings included: Record review of Resident #1's Face Sheet dated 01/30/25 reflected he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included paraplegia (a condition that causes paralysis or loss of muscle function in the lower half of the body, including both legs), pressure ulcer of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public for one hall (Hall 400) of six halls reviewed for physical environment. The facility failed to ensure the water heater supplying heat to three resident rooms on Hall 400 was in operating condition (including Residents #2, #3 and #4). The residents in the rooms did not have hot or warm water available as a result of the broken water heater. Findings included: Record review of Resident #2's Face Sheet reflected dated 01/30/25 reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Resident #2's active diagnoses included paraplegia (a condition that causes paralysis or loss of muscle function in both legs), neuromuscular dysfunction of bladder (impaired bladder control due to disrupted communication between the brain and the bladder muscles), Stage 4 pressure ulcer of right heel and Stage 4 pressure ulcer of right lower…

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 parenteral fluids were administered consistent with professional standards for 1 of 2 residents (Resident #1) reviewed for intravenous medications. 1. The facility failed to ensure the dressing on Resident #1's Midline catheter (used to deliver intravenous medications directly to the large central veins near heart) was changed timely. Resident #1 went without a dressing change for 15 days. 2. The facility failed to have orders for Midline catheter dressing changes. The failures could affect residents by placing them at risk for infections and cross-contamination. Findings included: Record review of Resident #1's admission Record dated 12/21/24 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #1's Quarterly MDS dated [DATE] reflected she was in a persistent vegetative state, she was dependent on staff for all ADLs and her diagnoses included hypertension (high blood pressure);…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on, observation, 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 for 1 (Resident #1) of 6 residents reviewed for pharmacy services in that: The facility failed to ensure Resident #1's Ketoconazole External Shampoo (used to treat hair loss and dandruff) was available and applied as ordered between 11/27/24 and 12/2/24. This failure placed the residents at risk of not receiving medications as ordered by the physician and a delay in treatment and worsening of their condition. Findings included: Record review of Resident #1's admission Record dated 12/21/24 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #1's Quarterly MDS dated [DATE] reflected she was in a persistent vegetative state, she was dependent on staff for all ADLs and her diagnoses included…

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 received their mail that is delivered on Saturdays. The facility failed to ensure resident's Saturday mail was delivered on the day it was received. This failure could affect 80 residents by placing them at risk of not receiving mail in a timely manner that could result in a decline in resident's psychosocial well-being and quality of life. Findings included: Record Review of Resident #45's Quarterly MDS dated [DATE], revealed Resident #45 was a [AGE] year-old who admitted to the facility on [DATE]. Resident #45's diagnoses included: Anemia, Hypertension, Seizure disorder, anxiety disorder, and Schizophrenia, Resident #1 had a BIMS (Brief Interview of Mental Status) score of 15, indicating an Intact or borderline cognition. Record Review of Resident #45's Care Plan most recently revised on 10/15/2024 revealed Resident #45 used anti-anxiety medications. Intervention/Tasks included need for staff to monitor/record occurrences of for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 2 of 2 residents, #41 and #45. The facility failed to ensure Resident's #45, #41 had information known to them on how to file a grievance or concern, who the grievance official was, how to file an anonymous grievance, and their right to obtain a written decision related to their grievance. These failures could affect the Resident's and their representatives' abilities to file a grievance in a timely manner and inhibit their right to request a written decision regarding the resolution of their grievance. Findings Included: 1. Record Review of Resident #45's Quarterly MDS dated [DATE], revealed Resident #45 was a [AGE] year-old who admitted to the facility on [DATE]. Resident #45's diagnoses included: Anemia, Hypertension, Seizure disorder, anxiety disorder, and Schizophrenia, Resident #1 had a BIMS (Brief Interview of…

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

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure food was properly stored in the facility's kitchen on 10/29/24. This failure could place residents at risk for food-borne illness. Findings Included: Observation of the facility's refrigerator on 10/29/24 beginning at 8:58 AM revealed: - 7 tomatoes with fuzzy white and black spots; -4 carrots with fuzzy white and black spots; - 1 bag of box of bacon open and exposed to air; and - 1 bag of ham open and exposed to air. Observation of the facility's freezer on 10/29/24 beginning at 9:06 AM revealed: -1 box of striped pangasius fillet open and exposed to air; and - 1 box of beef patties open and exposed to air. Observation of the facility's seasoning shelf on 10/29/24 beginning at 9:12 AM revealed: -2 containers of paprika open and exposed to air; -1 container of poultry seasoning open and exposed to air; -1 container of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, 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 (Resident #54 and Resident #56) of eight residents reviewed for resident rights. 1. The facility failed to assist Resident #54 to get out of bed. 2. The facility failed to provide Resident #56 clothing. This failure could place residents at risk for a loss of dignity, decreased self-worth and decreased self-esteem. Findings included: 1. Record review of Resident #54's admission MDS assessment, dated 08/22/24, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His BIMs score was 9 indicating his cognitive status was moderately impaired. His diagnoses included hip fracture and Stage III pressure ulcer. The resident had a foley catheter. The resident required maximum assistance to transfer to and from a bed to a chair.…

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 right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one(Resident #58) of six residents reviewed for reasonable accommodations. The facility failed to provide Resident #58 with a trapeze bar for repositioning self in bed. This failure could place residents at risk of not being able to have their needs met. Findings included: Record review of Resident #58's admission MDS Assessment, dated 08/21/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: anemia, hypertension, gastroesophageal reflux disease, neurogenic bladder, paraplegia, anxiety disorder, bipolar disorder, and asthma. His BIMS score was 15 out of 15, which revealed he was cognitively intact. Observation and interview on 10/30/24 at 1:30 PM revealed Resident #58 did not have a trapeze bar in his room. Resident #58 stated he was supposed 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 residents received the housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for two (Resident #56 & #135) of six residents reviewed for environment. 1. The facility failed to ensure Resident #56's walls in his room were in good repair. 2. The facility failed to ensure Resident #135's room was thoroughly cleaned. This failure could place residents at risk for a diminished quality of life due to the lack of a homelike environment. Findings included: 1. Record review of Resident #56's admission MDS assessment, dated 08/14/24, revealed he was a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included anemia, atrial fibrillation, heart failure, hypertension, gastroesophageal reflux disease, diabetes mellitus, depression, post traumatic stress disorder, asthma. His BIMS score was 11 of 15, which indicated he was moderately impaired. Observation and Interview on…

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 is 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 #54) of eight residents reviewed for resident rights. 1. The facility failed to assist Resident #54 to get out of bed. This failure could place residents at risk for a loss of dignity, decreased self-worth and decreased self-esteem. Findings included: Record review of Resident #54's admission MDS assessment, dated 08/22/24, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His BIMs score was 9 indicating his cognitive status was moderately impaired. His diagnoses included hip fracture and Stage III pressure ulcer. The resident had a foley catheter. The resident required maximum assistance to transfer to and from a bed to a chair. Record review of Resident #54's care plan, dated 10/14/24, reflected the resident did not have a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received appropriate supervision and assistance devices to prevent accidents for one (Resident #65) of six residents reviewed for incidents and accidents. 1. The facility failed to ensure Resident #65's smoking materials were kept at the nurses station on 10/29/24. 2. The facility failed to ensure hazardous items including razors and hand sanitizer was not stored in an area easily accessible to residents who resided within the secured unit. Hand sanitizer and disposable razors were observed in an unlocked area of the secured area. This failure could place residents at risk for accidents and injuries. Findings included: 1. Record review of Resident #65's MDS Assessment, dated 10/15/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: chronic obstructive pulmonary disease, diabetes mellitus, malnutrition, and anxiety disorder. His BIMS section was incomplete. His 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 have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 (Residents #73) out of 7 residents reviewed for sufficient staff. The facility failed to have adequate staff to prevent Resident #73 from wandering out of the secured unit and into the main area of the facility. An assigned Charge Nurse and CNA were both off the unit at the time Resident #73 left the unit. This failure could place residents at risk of not receiving the necessary care and services to maintain their highest practicable physical, mental, and psychosocial well-being. Findings included: Record review of Resident #73's admission Record dated 11/1/24 reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Record review of Resident #73's admission MDS assessment dated [DATE] reflected he had moderately…

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 who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 4 residents (Resident #55) reviewed for unnecessary medications. The facility failed to ensure Resident #55 did not receive duplicate medication therapy for Bupropion (anti-depressant medication). This failure could place residents at risk for adverse drug reactions (unintended, harmful events attributed to the duplicate use of these medications) and receiving unnecessary medications. Findings included: Record review of Resident #55's annual MDS assessment, dated 08/03/24, reflected Resident #55 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #55's BIMS score was 15 indicating her cognition was intact. Her diagnoses included anxiety disorder and depression. Record review of Resident #55's Care Plan dated 11/22/23,…

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 maintain a medication administration error rate below 5 percent. There were 5 errors out of 32 opportunities which resulted in a 15 percent error rate for three (Resident #8, #58, and #45) of three residents reviewed for medication errors. 1) LVN A failed to administer to Resident #8 his famotidine dose via J-tube (tube inserted into the small intestine to deliver food or medications) during the medication administration observation. 2) MA B failed to administer to Resident #58 his Baclofen tablet and pregabalin tablets and failed to administer the correct dose and type of Colace during the medication administration observation. 3) MA B failed to administer to Resident #45 her Flonase during the medication administration observation. This failure could place residents at risk of not receiving the intended therapeutics effects of medications. Findings included: 1) Record review of Resident #8's admission Record dated 11/1/24 reflected he…

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 establish and 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 three (Resident #54, Resident #33, and Resident #24) of eight residents observed for infection control. 1. The facility failed to ensure Residents #54 and #33 were placed on enhanced barrier precautions. 2. LVN G failed to change her gloves and perform hand hygiene during incontinence care for Resident #24. These failures place residents at risk for healthcare associated cross contamination and infections. Findings included: 1. Record review of Resident #54's admission MDS assessment, dated 08/22/24, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His BIMs score was 9 indicating his cognitive status was moderately impaired. His diagnoses included hip fracture and Stage III pressure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #54) of 3 residents reviewed for catheter care. 1. The facility failed to ensure Resident #54 had a catheter stabilization device. These failures could place residents at risk of urinary tract infections and urethral damage. Findings included: Record review of Resident #54's admission MDS assessment, dated 08/22/24, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His BIMs score was 9 indicating his cognitive status was moderately impaired. His diagnoses included hip fracture and Stage III pressure ulcer. The resident had a foley catheter. Record review of Resident #54's Face Sheet, dated 10/30/24, reflected he had a diagnosis of obstructive and reflux uropathy (a condition in which the flow of urine is blocked.) Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, 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 3 of 5 residents (Residents #1, #2, and #3) reviewed for respiratory care. The facility failed to change and date Residents #1, #2 and #3's oxygen and nasal cannula tubing and humidifier bottle every week. This failure could place residents at risk for respiratory infections . Findings Include: 1. Record review of Resident #1's face sheet, dated 10/15/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included: metabolic encephalopathy (neurological disorder), morbid obesity (excessive body fat), heart disease, cholelithiasis (gallstones) and type II diabetes (the body's inability to regulate…

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, based on the comprehensive assessment and care plan, both facility-sponsored group and individual activities and independent activities designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident for 4 (Residents #1, #2, #3 and #4) of 4 residents reviewed for activities. The facility failed to provide individualized and group activities for Residents #1, #2, #3 and #4 on the secure unit. The facility failed to ensure Residents #1, #2, #3 and #4 had an individualized activity care plan. These failures could place residents at risk for decline in quality of life, social and mental psychosocial wellbeing. Findings included: 1. Record review of Resident #1's face sheet dated 09/26/24 reflected she was a [AGE] year old female who admitted to the facility on [DATE]. Resident #1's active diagnoses included dementia with mood disturbance (a chronic condition that causes a gradual decline…

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 baseline care plans were completed within 48 hours of the resident's admission for 3 out of 5 residents (Resident #6, Resident #7, Resident #8) whose care was reviewed for baseline care plans. The facility failed to ensure that baseline care plans were completed within 48 hours for Resident #6, Resident #7, and Resident #8. This failure could place the resident at risk for not having continuity of care among nursing home staff to safeguard against adverse events that are most likely to occur right after admission. The findings included: Record Review of Resident #6's admission MDS assessment dated [DATE] reflected she was an [AGE] year-old female, admitted to the facility on [DATE]. She had a BIMS scoring of 14/15 indicating no cognitive impairment. Her diagnoses included: Muscle weakness, chronic respiratory failure with hypoxia (Condition where your body is not getting enough oxygen to your blood) and cognitive communication deficit…

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 both facility-sponsored group activities individual activities that are designed to meet the residents' interests, and support the physical, mental, and psychosocial well-being of 4 out of 6 residents (Resident #2, Resident #3, Resident #4, and Resident #5) whose care was reviewed in the facility's secured unit. 1. The facility failed to post a designated activity calendar outlining the monthly activities for residents in the facility's secured unit and in each of the residents' designated rooms within the facility's secured unit. 2. The facility failed to ensure that a designated activity program was created and implemented in the facility's secured unit. The facility failed to ensure that the residents in the secured unit had direct access to engaging activity items such as books, newspapers, music items, arts/craft items or any items designated in the residents MDS assessment or comprehensive plan of care related to activities.…

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 determine and outline in the facility's, facility assessment, the necessary amount of emergency food and water necessary for their facility population during an emergency for 1 of 1 facility. 1.The facility failed to outline in their facility assessment, the amount of food and water necessary to maintain their resident population. These failures placed residents at risk of not having emergency water and food. Findings Included: Record Review of the facility's, facility assessment, no date indicated on the assessment, revealed the following sections: Facility Profile Resident Population Care & Competency requirements Resident Acuity Workforce Training Evaluation Physical Plant Services Ethnic, Cultural, Religious Needs Resources Contracts Natural Hazards Technological Hazards Human Hazards Hazardous Materials Record review of the facility's, undated facility assessment section titled, facility profile revealed a current census of 71 and total capacity of 204. Record review of the facility's, undated 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.

Based on observation, interview and record review the facility failed to ensure that survey results were posted and, in a place, readily accessible to residents and visitors at the facility. The facility failed to ensure that survey results were posted and accessible for review on 07/15/24. This failure could impact the residents and visitors' ability to freely review the facility's outcome of regulatory compliance surveys without asking staff for survey results. Findings Included: Observation on 07/15/24 at 12:05 PM during rounds revealed no survey results binder or sign indicating location of results was posted anywhere in the facility. Observation on 07/15/24 at 1:34 PM during rounds revealed no survey results binder or sign indicating location of results was posted anywhere in the facility. An interview with the Administrator on 07/15/24 at 3:37 PM revealed that she was responsible for ensuring that the survey results sign and binder was posted in a clear and accessible spot within the facility per facility policy. The Administrator said that she had the survey results and sign…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to coordinate the assessment with the pre-admission screening and resident review (PASRR) program for one (Resident #10) of five resident assessments reviewed for PASRR evaluations. The facility did not correctly identify Resident #10 as having a mental illness diagnosis, failed to correct his PASARR Level One screen accurately to reflect the information, and failed to appropriately complete Form 1012, Mental Illness/Dementia Resident Review, in a timely manner to be signed by the attending physician for Resident #10. This failure could place residents with psychiatric diagnoses with Dementia as their primary diagnosis at risk for missed assessments, interventions and services. The findings were: Review of Resident #10's Annual MDS assessment dated [DATE] reflected he was a [AGE] year-old male, re-admitted to the facility on [DATE]. He had a BIMS score of 15/15 indicating no cognitive impairment. The MDS revealed that Resident #10 had an active diagnoses…

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 develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames that met the residents clinical and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #10) out of 6 residents reviewed for care plans. The facility failed to ensure that Resident #10's comprehensive care plan included his diagnosis of bipolar disorder. This failure could place residents at risk of having received inadequate interventions not individualized to their care needs. Findings Included: Record Review of Resident #10's demographic sheet, dated 07/18/24, reflected he was a [AGE] year-old male, admitted to the facility originally on 5/4/07 and then re-admitted to the facility recently on 8/9/23. Resident #32's diagnoses included: Bipolar disorder (a serious mental illness characterized by extreme mood swings), Alzheimer's disease (brain disorder that causes problems with memory,…

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 the facility residents received proper treatment and care to maintain mobility and good foot health for 2 (Resident #11 and Resident #12) of 5 residents reviewed for foot care services. 1. The facility failed to provide podiatry services to Residents #11 and #12. This failure could lead to increased potential negative outcomes related to foot health. Findings Included: Record Review of Resident #11's demographic sheet, dated 07/18/24, revealed he was a [AGE] year-old male with an initial admission date to the facility of 11/1/2023. Resident #11's active diagnoses included: Type 2 diabetes mellitus with hyperglycemia (person with a condition of diabetes that has high blood sugar levels), muscle weakness (generalized), peripheral vascular disease, unspecified (condition where the arteries narrow, causing reduced blood flow to the arms or legs). He had a BIMS score of 14/15 revealing no cognitive impairment. Record Review of…

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

Based on observation, interview and record review, the facility failed to ensure that the daily staffing was posted and readily accessible for review for 1 of 1 facilities. The facility failed to post the daily nursing staffing information on 07/15/24. This failure could affect residents, facility visitors, vendors and emergency personnel by placing them at risk of not having access to information regarding daily nursing staffing in a timely manner. Findings Included: Observation on 07/15/24 at 11:05 AM during rounds revealed no posted nursing staffing information was anywhere in the facility. Observation on 07/15/24 at 1:34 PM during rounds revealed no posted nursing staffing information was anywhere in the facility. An interview on 07/15/24 at 2:45 PM with the ADON revealed that the DON was responsible for the scheduling and posting of the daily nursing staff information. An interview on 07/15/24 at 2:50 PM with the DON revealed that he was responsible for the daily nursing posting and forgot to do so on 07/15/24. The DON said the daily nursing staffing was supposed to be posted…

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, in that: The facility failed to ensure that food in the kitchen was labeled with the product name, dated with a opened date or use by date and sealed. The facility failed to ensure that kitchen equipment was clean and free of debris. These deficient practices could affect 69 residents who received meals and/or snacks from the main kitchen and place them at risk for food borne illness. Findings Included: Observation of the kitchen on 7/16/2024 at 2:30 PM, revealed that inside the refrigerator included: an open container of whipped topping that was on the shelf and it was not dated with an open date or use by date. The container of whipped topping had what appeared to be a white flaky substance on the lid. Inside the refrigerator was a container of strawberry topping and it was not labeled with the product name and dated with an open or use by date. The container of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that take into account nonsmoking residents for one (Resident #15) of three residents reviewed for smoking. The facility failed to ensure Resident #15 had a smoking evaluation. This failure could place residents at risk for injury, burns, and an unsafe smoking environment. Findings Include: 1. Review of Resident #15's admission MDS assessment, dated 06/28/24, reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Her cognition was intact. Her diagnoses included high blood pressure, diabetes, and paraplegia (inability to voluntarily move the lower parts of the body). The resident did not use tobacco. Review of Resident #15's Care Plan for July 2024, reflected the resident did not have a care plan for smoking. Review of Resident #15's Safe Smoking Evaluation…

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 all alleged violations which involved abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation result 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 (Residents #1) of 1 resident reviewed for injuries of unknown origin. The facility failed to report to the State Survey Agency on 05/10/24 when Resident #1's x-ray results reflected a fractured right knee, and the cause of the injury was unknown. This failure could place residents at risk of not having incidents of possible abuse and neglect investigated in a timely manner by the State Survey Agency placing residents at risk of continued and/or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and help prevent the development and transmission of infection for 5 (Residents #2, #3, #4, #5, and #6) of 12 residents reviewed for infection control. 1. On 04/30/24 MA A, CNA B, and CNA C brought Residents #2, #3, #4, #5, and #6 to the locked unit dining room and fed them and did not wash their hands nor the hands of the residents. 2. On 04/30/24 CNA B assisted Residents #2, #3, and #4 with their noon meals, he cut up their food and fed them and did not sanitize his hands. 3. On 04/30/24 CNA C touched the hand of Resident #5 and assisted him to his seat then touched his eating utensil without sanitizing her hands. 4. On 04/30/24 during the noon meal on the locked unit a visitor brought cookies to the residents, this visitor used her ungloved hands and gave each resident present (#2, #3, #4, #5, #6) a cookie…

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 each resident to remain in the facility, and not transfer or discharge the resident from the facility for 1 of 8 (Resident #2) residents reviewed for transfer and discharged rights. The facility failed to ensure Resident #2 was given a safe discharge on [DATE]. This deficient practice could place residents at risk of improper discharge or transfer. The findings were: Record review Resident #2's Face sheet dated was admitted to the facility on [DATE]. Resident #2 was diagnosed with acute embolism and thrombosis of left femoral vein (both conditions that disrupt blood flow), anxiety disorders (A type of mental health condition-may respond to things with fear), chronic pain syndrome (A condition that causes pain beyond the normal healing process) and morbid obesity (Chronic disease in which a person has a body mass index of 35 or higher). Record review of Resident #2's MDS assessment dated [DATE] revealed, he had a BIMS score of 13 indicated…

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 employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity, and diagnoses of the facility's resident population. The facility failed to ensure a qualified dietitian or other clinically qualified nutrition professional was employed either full-time, part-time, or on a consultant basis. This failure could place residents at risk of not having their nutritional needs met, weight loss, and an increased risk for wounds. Findings include: Interview on 02/15/24 at 3:42 p.m. the facility's former RD stated she stopped providing consulting services to the facility in December 2023 due to not being paid for over 5 months. She stated she was concerned for residents as the facility currently had no RD. Interview on 02/15/24 at 3:55 p.m. the Administrator stated the facility had no dietician or other clinically qualified nutrition professional either contracted or on…

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 that residents who needed respiratory care were provided with such care, consistent with professional standards of practice for 3 (Resident #5, #14, and #62) of 7 residents reviewed for respiratory care, in that: The facility failed to: A.) Label and date the oxygen tubing and concentrator water bottle for Resident #5 and Resident #62. B) Label and date Resident # 14 oxygen tubing These deficient practices could place residents that receive oxygen therapy at risk for inadequate care and respiratory infection. Findings Included: Resident #5 Record review of Resident #5 face sheet dated 1/24/24 reflected a [AGE] year-old female admitted on [DATE], diagnosis include Chronic Respiratory failure with Hypoxia (low oxygen). Record review of Resident #5's MDS dated [DATE], reflected a BIMS score of 14 indicating she was cognitively in tack. Functional level impaired on both sides and needs staff supervision for mobility, incontinent,…

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 a safe, functional, sanitary comfortable, environment for residents staff and the public for one (room [ROOM NUMBER]) of nine resident rooms reviewed for environment. The facility failed to ensure the AC/heating unit located in room [ROOM NUMBER] was clean. This failure could place residents at risk for diminished quality of life due to a lack of a well-kept environment and reduced air quality in the room. Findings included: An observation on 1/17/24 at 9:20 AM, revealed Resident #1 was in room [ROOM NUMBER]B, sitting on the side of his bed facing the window. His knees were directly in front of an AC/heating unit located beneath a window. The resident was cognitively impaired and unable to be interviewed. The AC/heating unit was on and blowing warm air. Front cover appeared loose. A moist black substance was observed along the edges of the louvers from where the air was blowing. The top portion of the cover surrounding the louvers…

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 develop and implement an effective discharge planning process that focused on the resident's discharge goals the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions for 1 (Resident #1) of 4 residents reviewed for discharge planning. The facility failed to develop a discharge plan for Resident #1 after he expressed his desire to return home on [DATE]. Resident #1 made his own arrangements and left the faciity on [DATE] with no documented discharge plan in place. This failure could place residents at risk of not receiving care and services to meet their needs upon discharge. Findings included: Record review of Resident #1's Face Sheet dated 12/13/23 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including lack of coordination, muscle weakness, altered mental status, repeated falls,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents fed by enteral feeding received the appropriate treatment and services to prevent complications of enteral feedings for 2 of 2 residents (Resident #1 and Resident #2) reviewed for gastrostomy tube management. The facility did not ensure Resident #1's and Resident #2's enteral feeding was infused as ordered by the physician. This failure could place 2 residents who had G-tube feedings at risk for dehydration, weight loss, and/or metabolic abnormalities. Findings included: Record review of Resident #1's Face Sheet, dated 10/16/23, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: unspecified sever protein-calorie malnutrition (It may occur due to a lack of nutrients in the diet or a problem with nutrient absorption), obstructive and reflux uropathy(conditions that affect the urinary tract due to blockage or backward flow of urine), encounter for attention 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 interview and record review, the facility failed to implement its written policies and procedures that prohibit and prevent abuse and neglect for one (Resident #39) of one resident reviewed for abuse. The facility failed to immediately report an incident of abuse to the State Survey Agency when on 07/11/23, Resident #39 made an allegation of CNA K spitting in his food. This failure could place residents in CNA K's care at risk for abuse. Findings included: Review of the facility's Abuse Prevention policy dated 2001 (Revised December 2016) reflected the following: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms . 6. Identify and assess all possible incidents of abuse. 7. Investigate and report any allegations of abuse…

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 all alleged violations involving mistreatment, neglect, abuse, or misappropriation of resident property were reported immediately, but not later than 2 hours after the allegation was made, to the administrator of the facility and to other officials (including to the State Agency) for 1 (Resident #39) of 1 resident reviewed for Abuse and Neglect in that: LVN J, CNA K and LVN L failed to report possible abuse to the Administrator when Resident #39 alleged CNA K spit in his food. Because the Administrator was not informed, the abuse allegation was not reported to the State Agency within two hours. This failure could place the residents at risk of abuse, neglect, exploitation and misappropriation of resident property. Findings included: Review of Resident #39's MDS (Minimum Data Set) Form dated 07/15/23 reflected Resident #39 was a [AGE] year-old male with a BIM's (Brief Interview for Mental Status) score of 15 indicating Resident # 39 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that included measurable objectives and timeframes to meet resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 (Resident #34 and #16) of 8 residents reviewed for care plans. 1. The facility failed to ensure Resident #34 had a care plan for suctioning. 2. The facility failed to ensure Resident #16 had a care plan for oxygen use. 3. The facility failed to ensure Residents #34 and #16, who were using oxygen, had a comprehensive care plan identifying reasons for the oxygen and interventions to ensure the residents received the oxygen therapy they needed in case of a power outage. These failures could place residents at risk for not being provided necessary care and services. Findings included: 1. Review of Resident #34's MDS, dated [DATE], reflected he was a [AGE] year-old male admitted on…

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.