Golden Villa

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards in 1 of 1 kitchen reviewed for food service safety. 1. The facility failed to ensure all food items were labeled and dated in the walk-in cooler and the walk-in freezer. 2. The facility ensure that the Activity Director Assistant wore a hair net when entering the kitchen and 2 male staff members wore facial hair coverings while assisting with meal preparation. 3. The facility failed to the shelf above the stove top and parts of the oven were clean. These failures could place residents at risk of foodborne illness and food contamination. Findings include: Record review of an R. D. (Registered Dietician) Consultation Report dated 12/30/24 indicated, .Oven, microwave, range top need cleaning . Record review of a Summary Report of Meeting dated 03/31/25 indicated 9 dietary staff members were trained on Food Safety, Menus and Nutritional Adequacy, Infection Control Practices, and Employe Hygiene. The training indicated, .Uses hair…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide food that was palatable and attractive for 7 of 8 residents (Resident's #9, #11, #33, #42, #49, #57, and #84) reviewed for palatable food. The facility failed to provide food that was palatable and attractive to Resident #9, #11, #33, #42, #49, #57, and #84 who complained the food was bland, mushy, and overcooked, and the same foods were served over and over. These failures could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. The findings included: 1. Record review of a face sheet dated 06/04/25 revealed Resident #9 was an [AGE] year-old female and was admitted to the facility on [DATE] with diagnoses of dementia (memory loss), risk for protein-calorie malnutrition, and vitamin deficiency. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #9 was understood and understood others. The MDS revealed Resident #9 had a BIMS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure residents were free from abuse for 1 of 7 residents (Resident #17) reviewed for resident abuse. The facility failed to ensure Resident #17's was free from abuse when LVN J yanked Resident #17's left arm on 05/22/25. This failure could place residents at risk of physical harm, mental anguish, or emotional distress. The findings included: 1.Record review of Resident #17's face sheet dated 06/02/25 indicated Resident #17 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of parkinsonism, unspecified (a group of neurological conditions that share symptom similar to those of parkinson's disease), repeated falls, unspecified, dementia (a group of thinking and social symptoms that interferes with daily functioning), generalized osteoarthritis (a form of osteoarthritis where three or more joints are affected), myalgia (a medical term that refers to muscle pain) and fibromyalgia (a chronic condition that causes widespread…

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's environment remained free of accidents and hazards for 2 of 21 residents (Resident #38 and Resident #4) reviewed for accident hazards. 1. The facility failed to prevent Resident #38 from having antimicrobial antiseptic skin cleanser in her room. 2. The facility failed to ensure CNA B performed a safe mechanical lift transfer for Resident #4. This failure could place residents at risk for injury, harm, and impairment. Findings included: 1. Record review of Resident #38's Face Sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Dementia (a general term for the loss of mental abilities that affect daily life), Atrial Fibrillation (an irregular and often rapid heart rhythm that begins in the heart's upper chambers), Hyperlipidemia (a condition where there are high levels of lipids (fats) in the blood, including cholesterol and triglycerides). 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.

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 was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 3 of 8 residents (Resident #10, Resident #26 and Resident #83) reviewed for respiratory care and services. 1. The facility failed to cover the nasal cannula tubing with a bag on an oxygen concentrator machine that was not in use for Resident #10 and Resident #83. 2. The facility failed to cover the face mask with a bag on nebulizer machine that was not in use for Resident #26. This failure could place residents at risk for developing respiratory complications. Findings included: 1. Record review of Resident #10's face sheet, dated 06/04/25, indicated reflected he was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included flail chest (a traumatic disorder that happens when three or more ribs located next 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 observations, interviews, 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 1 of 22 residents (Residents #4) reviewed for infection control practices. The facility failed to ensure CNA B did not contaminate Resident #4, Resident #4's clothing, clean brief, clean incontinent pad, bedding, and bed remote after CNA B had performed incontinent care. These failures could place residents at risk for cross contamination, at an increased risk of infection, and the spread of infection. Findings included: Record review of Resident #4's face sheet dated 6/03/25 indicated he was [AGE] years old and admitted to the facility on [DATE]. Resident #4 had diagnoses which included dementia (forgetfulness), heart disease, diabetes (high blood sugar), hemiplegia (complete or severe loss of motor function 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 maintain an effective pest control program so the facility was free from pests and rodents for 2 of 2 residents (Resident #1 and Resident #2) reviewed for pest control. The facility failed to maintain an effective pest control program to ensure the facility was free of roaches. This failure could place residents at risk for an unsanitary environment and a decreased quality of life. Findings included: 1.Record review of a face sheet dated 11/26/2024 indicated Resident #1 was [AGE] year-old female, admitted to the facility on [DATE], with diagnoses including transient cerebral ischemic attack (brief blockage of blood flow to the brain), pain, dementia (degenerative brain disease - loss of memory, language) and urinary tract infection. Record review of the comprehensive MDS dated [DATE] indicated Resident #1 had a BIMS of 06 and was severely cognitively impairment. Resident #1 required supervision for eating, maximal assistance for toileting,…

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 an accurate MDS assessment was completed for 4 of 19 residents reviewed for MDS accuracy. (#61, #51, #12, and #13) 1.The facility failed to code the MDS with an accurate weight for Resident #61. 2.The facility failed to code the wound and wound treatment for Resident #61. 3.The facility failed to code the diagnoses of anxiety and depression for Resident #51. 4. The facility failed to ensure Resident #12 use of an antidepressant (are prescription medicines to treat depression), Duloxetine, was reflected on her MDS. 5. The facility failed to ensure Resident #13 diagnoses of anxiety (is a feeling of fear, dread, and uneasiness) and major depressive disorder (is a mood disorder that causes a persistent feeling of sadness and loss of interest) were listed on the primary active diagnoses of Psychiatric/Mood Disorder on the MDS. These failures could place residents at risk for not receiving needed care and services. Findings included: 1.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 4 of 19 residents (Resident #61, Resident #77, Resident #30 and Resident #12) reviewed for comprehensive person-centered care plans. 1.The facility failed to implement a nutritional care plan with interventions for Resident #61's weight loss and implement a wound care plan with interventions for Resident #61's open lesion to his left lower extremity. 2.The facility failed to implement a nutritional care plan with interventions for Resident #77's weight loss. 3.The facility failed to ensure Resident #12 use of an antidepressant (are prescription medicines to treat depression) and diuretic (water pills, help your kidneys put extra salt and water…

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 food that is palatable, attractive, and at a safe and appetizing temperature for 7 (Residents #30, #33, #36, #44, #45, #63, and #82) of 89 residents reviewed for palatable food. 1.The facility did not provide meals services in a manner to ensure palatable food served was appetizing to residents. 2.The facility failed to provide palatable food served at an appetizing temperature or taste to Residents #30, #33, #36, #44, #45, #63 and #82, who complained the food served did not taste good. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. Findings included: During an interview on 04/29/2024 at 10:54 AM, Resident #45 said she does not eat the food at the facility, because it tasted horrible. She said she had to buy her own food and made sandwiches. She said on one occasion she tried to eat chicken from the facility, and it was raw and bleeding, when she bit into the chicken. During an interview on 04/29/2024…

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 4 residents reviewed for foley catheter care (Resident #31 and #47) and 1 of 2 residents reviewed for incontinent care (Resident #13) infection control practices. 1.The treatment nurse did not change her gloves when going from dirty to clean when providing catheter care to Resident #31. The treatment nurse did not sanitize or wash her hands after performing catheter care when she changed her gloves. 2. The facility failed to ensure CNA F changed her gloves and performed hand hygiene appropriately while providing incontinent care to Resident #13. 3. CNA D did not change her gloves or sanitize her hands after removing Resident #47's foley catheter stabilizer device. CNA D put the dirty towel back into 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 observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 19 residents reviewed for environment. (Resident #4) The facility failed to replace missing slats from Resident #4's window blinds. These failures could place residents at risk of an unsafe or uncomfortable environment and a decrease in quality of life and self-worth. Findings included: Record review of a face sheet revealed Resident #4 was [AGE] years old and was admitted on [DATE] with diagnoses including Transient Cerebral Ischemic Attack (A brief stroke-like attack that, despite resolving within minutes to hours, still requires immediate medical attention to distinguish from an actual stroke), Hyperlipidemia (An elevated level of lipids - like cholesterol and triglycerides - in your blood), Overactive bladder (A problem with bladder function that causes the sudden need to urinate.) Record review of a quarterly MDS assessment dated [DATE] indicated Resident #4 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 interview and record review, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 2 of 19 residents (Residents #12 and Resident #13), reviewed for care plans. The facility failed to revise and update Resident #12's comprehensive care plan for the type of blood thinner she was prescribed. Resident #12's care plan indicated she was prescribed Eliquis (is an anticoagulant drug (blood thinner) that helps prevent blood clots) instead of Aspirin (help prevent another heart attack or clot-related stroke). The facility failed to revise and update Resident #13's comprehensive care plan to reflect she was no longer prescribed Eliquis, discontinued on 04/08/24. These deficient practices could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings included: 1. Record review of a face sheet printed on 04/29/24 indicated Resident #12 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 ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #43) and 2 of 4 staff (CNA F and LVN H) reviewed for transfer. The facility failed to ensure CNA F and LVN H performed a safe 2 person transfer for Resident #43. This failure could place residents at risk of injury from accidents. Findings included: Record review of a face sheet printed 05/01/24 indicated Resident #43 was an [AGE] year-old, female and was admitted on [DATE] and 01/04/23 with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning) and age-related osteoporosis (is a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes). Record review of a quarterly MDS assessment dated [DATE] 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure each residents' drug regimen was free from unnecessary psychotropic drugs (without adequate behavior monitoring) for 1 (Resident # 12) of 5 residents whose medications were reviewed in that: 1.The facility failed to ensure Resident #12 had behavior monitoring (monitor activities and mood) for her prescribed Duloxetine (antidepressant; is used to treat depression and anxiety). 2. The facility failed to ensure Resident #12 had behavior monitoring for her prescribed Lorazepam (antianxiety; is a prescription medication that's used for anxiety, insomnia, and seizures) 3. The facility failed to ensure Resident #12 had side effects monitoring (are defined as unintended responses to approved pharmaceuticals (is any kind of drug used for medicinal purposes) given in appropriate dosages) for her prescribed Duloxetine. 4. The facility failed to ensure Resident #12 had side effects monitoring for her prescribed Lorazepam. These deficient practices could…

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 of 2 Residents (Resident #2) reviewed for PRN (as needed) pain medication administration. The facility failed to ensure the documentation of Resident #2's prn (as needed) pain medications were documented in the MAR. This failure could place residents at risk of delayed pain medication administration, or over medication. Findings included: Record review of the face sheet for Resident #2 dated 2/16/24 indicated she was [AGE] years old, re-admitted to the facility on [DATE] with diagnoses including dementia, breast cancer, heart failure, type 2 diabetes, and pain. Record review of the MDS assessment dated [DATE] indicated Resident #2 made herself understood and understood others. The MDS indicated she had severe cognitive impairment (BIMS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for residents who were unable to carry out activities of daily living for 1 of 5 resident reviewed for ADLs. (Resident #1) The facility failed to provide Resident #1 with her scheduled showers and hair washing. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health. Findings included: Record review of Resident #1's face sheet dated 10/26/23 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning), type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose)), blindness one eye, and history of traumatic…

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 an accurate MDS was completed for 6 of 24 reviewed for MDS accuracy. (#55, #35, #33, #66, and #69 ) The facility failed to accurately document Resident #55's anticoagulant usage The facility failed to accurately document Resident #35's opioid usage. The facility failed to accurately document Resident #33's opioid usage. The facility failed to accurately document Resident # 66's fall with injury, antibiotic usage, and diagnosis of UTI. The facility failed to accurately document Resident # 69's falls and rejection of care behaviors. These failures could place residents at risk for not receiving needed care and services. Findings included: 1. Record review of an undated face sheet revealed Resident #55 was a 64- year-old- female, admitted on [DATE] with the diagnoses of dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), COPD (a group of lung…

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, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 4 of 24 residents (Resident #55, Resident #66, Resident #35, and Resident #33) reviewed for comprehensive person-centered care plans. The facility failed to implement a nutritional care plan with interventions for Resident #55. The facility failed to develop a care plan and implement care plan interventions for Resident #66's falls. The facility failed to develop a care plan for Resident #35's fractured wrist and opioid use. The facility failed to develop a care plan and implement interventions for Resident #33's triggered care area of dehydration/fluid maintenance and heart failure. These failures could place residents at risk of not having their…

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 for 1 of 1 kitchen reviewed for kitchen sanitation in that: 1. The facility failed to ensure CNA A was not filling cups with ice using an ice scoop and directing the ice from the scoop into her hand and then into the drinking glass 2. CNA was handling cups by the rim while serving residents. These deficient practices could place residents who received meals from the main kitchen at risk for food borne illness. The findings were: During an observation on 02/27/23 at 11:36 a.m., CNA A was observed in the dining room while assisting in serving lunch holding cups (approximately 4) by the rim. CNA A was observed filling cups with ice (approximately 20) using an ice scoop and directing the ice from the scoop into her hand and then into the drinking glass. CNA A was observed serving these cups (approximately 4) to residents. During an interview on 03/02/2023 at 10:35 a.m., the Dietary Manager stated that it…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and providing written rationale, by the provider, when an antibiotic was used despite criteria, to determine the appropriate the use of an antibiotic for 5 of 8 residents reviewed antibiotic use. (Resident #7, Resident #60, Resident #62, Resident #66, Resident #110) 1. The facility failed to ensure the appropriate use of antibiotics to treat infections for Residents #66 and #7. 2. The facility failed to add a diagnosis to support use for prescribed antibiotics for Resident #60, #62, #66, and #110. 3. The facility failed to follow their policy to use the Suspected UTI SBAR form to communicate concerns with the physician. These failures could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections. Findings included: 1. Record review of the face sheet dated 03/03/23 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of his or her individuality for 1 of 30 residents reviewed for dignity. (Resident #86) The facility failed to provide privacy for Resident #86 during feeding tube administration. This failure placed residents at risk for diminished quality of life, loss of dignity and self-worth. Findings included: Record review of the face sheet dated 03/03/23 revealed Resident #86 was [AGE] year-old female admitted on [DATE] with diagnoses including dysphagia (difficulty swallowing foods or liquids) and gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food) status-placed 11/11/2022. Record review of Resident #86's consolidated physician order dated 02/14/23-03/15/23 revealed Enteral (is a medical device used to provide nutrition to people who cannot…

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 make prompt efforts to resolve grievances for 1 of 24 residents (Resident #29) reviewed for grievances. The facility failed to file a grievance report and investigate when Resident #29's Representative reported to the SW that CNA BB cut Resident #29's hair without the Resident Representative's permission. This deficient practice of not resolving grievances promptly could place residents at risk for abuse, neglect, and not having their needs met. Findings included: Record review of Resident #29's face sheet dated 4/08/22 revealed Resident #29 was an [AGE] year-old female, and she was admitted to the facility on [DATE]. She had diagnoses including history of urinary tract infection, panic disorder (sudden episode of intense fear or anxiety and physical symptoms, based on a perceived threat rather than imminent danger), delusional disorder (belief or altered reality that is persistently held despite evidence or agreement to the contrary,…

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 were secure during transportation to prevent accidents for 1 of 3 residents reviewed for accidents. (Resident # 93) The facility did not ensure a wheelchair was secured while transporting Resident # 93. Resident # 93 was struck by an unsecure wheelchair during transport. This failure could place residents who travel in the facility van at risk of an accidents. Findings included: A Face sheet dated 11/30/17 indicated Resident # 93 was [AGE] years old and admitted on [DATE]. Shows that Resident #93 Unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety disorder, dizziness and giddiness, primary osteoarthritis An MDS dated [DATE] revealed Resident #93's BIMs (Brief Interview for Mental Status) score was a 08 indicating Resident # 93's cognition was moderately impaired. Shows that Resident # 93 supervision while transferring, walking in her room, walking in a hallway, dressing, toilet use,…

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 had a urinary catheter, received appropriate treatment and services to prevent urinary tract infections to the extent possible for 1 of 2 residents reviewed for catheter care. (Resident #66). Resident #66 was not provided with a secure anchored in place indwelling urinary catheter and Resident #66's urine collection bag was placed on the floor. These failures could place residents at risk for urinary tract infections, pain, confusion, and sepsis (infections that spread to the blood). Findings included: Record review of an undated face sheet revealed Resident #66 was an [AGE] year-old-female admitted to the facility on [DATE] with the diagnoses of obstructive uropathy (is blockage of urinary flow, which can affect one or both kidneys depending on the level of obstruction), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily…

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 appropriate treatment and services to prevent complications was provided for 1 of 2 resident reviewed for feeding tube management. (Resident #86) 1. The facility failed to flush Resident #86's gastrostomy tube with water before administering enteral feeding. 2. The facility failed to prevent air from entering Resident #86's gastrostomy tubing during enteral feeding and flushes. These failures placed residents at risk for clogged tubing, trapped air, vomiting, and aspiration. Findings included: Record review of the face sheet dated 03/03/23 revealed Resident #86 was [AGE] year-old female admitted on [DATE] with diagnoses including dysphagia (difficulty swallowing foods or liquids) and gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food) status-placed 11/11/2022. Record review of the quarterly MDS, dated [DATE], revealed Resident #86 was understood and understood others.…

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 medication error rates were not 5 percent or greater. There were 4 errors out of 25 opportunities, which resulted in a 16 percent medication error rate which involved 1 of 5 residents (Resident #55) reviewed for medication administration. 1. The facility failed to ensure Resident #55 received her Pro-stat (indicated for increased protein needs in low volume related) at 8:00 p.m. instead of 10:00 a.m. 2. The facility failed to ensure Resident #55 received her Alprazolam (used to treat anxiety and panic disorders) on time. 3. The facility failed to ensure Resident #55 had hold parameters for her Metoprolol (a beta-blocker that affects the heart and circulation (blood flow through arteries and veins) which was held with no order or notification to the MD. 4. The facility failed to ensure Resident #55 received her Prednisone (a corticosteroid medicine used to decrease inflammation and keep your immune system in check, if it is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 24 residents (Resident #98) reviewed for clinical records. The facility failed to ensure LVN U did not document a nursing progress note on Resident #98 on 3/2/23, when Resident #98 was not in the facility. This failure could place residents at risk for inaccurate assessments and monitoring. Findings included: Record review of Resident #98's physician orders indicated he was [AGE] years old and admitted to the facility on [DATE] with diagnoses including displaced spiral fracture of shaft of the right femur (fracture of the right thigh bone), dependance on renal dialysis, Hypertensive urgency (marked elevation in blood pressure without evidence of target organ damage), anemia, type II diabetes, chronic respiratory failure (slow developing respiratory failure that happens when the airways that carry air to your…

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.