Brush Country Nursing and Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed, to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing activities program to support residents in their choice of activities, 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, encouraging both independence and interaction in the community for three of six residents ( Resident #10, Resident #17, and Resident #21) reviewed for activities. The facility failed to provide Resident # 3, Resident #10, Resident #17, and Resident #21 in room activities during July 2025 and August 1st thru August 22, 2025.This failure could place residents at risk for boredom, depression, and a diminished quality of life.Findings include:Record review of Resident #10's face sheet, dated 08/21/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, 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 as determined by considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment for 4 (Residents #17, #37, #3, and #73) of 20 residents reviewed for sufficient staffing. The facility failed to ensure that the facility had sufficient staffing to meet the needs of Residents #17, #37, #3, and #73. This failure could affect and diminish the resident's quality of life by potentially placing the residents at risk of not receiving timely care or receiving nursing interventions to meet the resident's needs, risk of injury, risk of safety, and/or it can make the resident feel neglected affecting their mental health and overall psychosocial well-being not being met by 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 observations, interviews, and record review, the facility failed to serve foods that were palatable and attractive and prepare food by methods that conserve nutritive value, flavor, and appearance for 1 of 1 kitchen observed. 1. The two test tray for lunch meal included foods that were bland, and unappealing. 2. The lunch meal trays being delivered to 300 hall residents were unappealing with small side portions. 3. The meal delivery cart doors left open during delivery of hallway meals and reducing the food temperatures. 4. Watery and mushy vegetables served to residents on 08/20/2025. These failures could place residents at risk of decreased food intake, hungry, unwanted weight loss, and diminished quality of life. Findings included: Observation on 08/19/2025 at 12:00 PM revealed unappealing meal trays with poor arrangement of food and small portions of okra being delivered to hallway 300.Food test tray #1 was received at 12:29 PM on 08/19/2025 and was well-presented and arrangement of food was appealing. The tray contained a large white serving plate with an adequate…

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 infection for 4 of 6 residents (Resident #29, #65, #70 and #86) reviewed for infection control. 1. The facility failed to ensure CNA C doffed gloves after giving care to Resident #65 and #86 disposed of PPE properly on 08/19/2025. 2. The facility failed to ensure staff wore PPE while providing high contact resident care (transfers and medication administration through a gastrostomy tube) to Residents #29 and #70 on 08/21/2025. These failures could place residents at risk for infection, hospitalization, or death.Findings included: 1. Record review of Resident #65's face sheet, dated on 08/21/2025, reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included local infection of the skin and…

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

Based on observations, interviews, and record review the facility failed to maintain essential kitchen equipment in safe operating conditions and according to manufacturers' specifications for the facility's one walk-in refrigerator and one walk-in freezer. 1. The facility failed to ensure that the walk-in freezer temperature was in safe operating conditions of 0 . 2. The facility failed to ensure the walk-in refrigerator's cooling fans were in safe operating conditions. These failures could place residents at risk for health complications, foodborne illnesses, and decreased quality of life. Findings include: Observation in the kitchen on 08/19/2025 at 4:37 PM revealed the walk-in freezer thermometer panel mount temperature was reading 3 . Observation in the kitchen on 08/20/2025 at 10:59 AM revealed the walk-in freezer thermometer panel mount temperature was reading 3 . Observation and interview in the kitchen on 08/20/2025 at 11:00 AM revealed a slow steady water leak from the bottom of the refrigerator cooling fans dripping into a large black plastic bin positioned directly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews the facility failed to develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles, for 2 of 3 (SW, and Marketing) staff reviewed for training in Care Plans and PASRR services in that:The facility failed to train the Social Worker in the assigned SW areas in the PASRR, and updating the Care Plans for advance directives. The facility failed to train the Marketing person about ensuring a PASRR was received at admission.This failure could place residents at risk for harm by not having a complete and accurate care plan or having a PASRR completed to support the residents needs and preferences. The finding included:Resident #7 Review of Resident #7's face sheet dated [DATE] revealed an [AGE] year-old male who was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infraction affecting right…

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 right to personal privacy and confidentiality of his or her personal and medical records for 1 of 5 residents (Resident # 31) reviewed for medical record confidentiality.The facility failed to ensure RN D kept Resident # 31's medical information confidential.This failure could place residents at risk of their medical information being provided to unauthorized personnel, other residents, or visitors.Findings include: Observation on 08/20/2025 from 9:08 AM until 9:12 AM revealed RN D was not at the medication cart. The computer screen was left open and facing the hallway which exposed Resident confidential medical information which included name and medications. Interview on 08/20/2025 at 9:14 AM, RN D stated resident name and monitoring were on the open screen; however, he could not remember if his diagnosis was on the screen. He stated he received in-service to always lock the computer screen when not standing at the medication cart. He stated he did not recall the date he received the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a new resident was not admitted with mental illness unless the state mental health authority determined, based on independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission for 1 of 12 residents (Resident #17) reviewed for PASRR services. The facility failed to ensure a PASRR screening was completed for Resident #17. This deficient practice could place residents at risk for not obtaining the services needed to treat their mental health diagnoses.The findings include: Record review of Resident #17's admission sheet, dated 08/19/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #17 had diagnoses which included cystitis without hematuria (inflammation of the bladder), somatization disorder (tendency to experience and express psychological distress as physical symptoms), fusion of the spine (surgical procedure that connect two…

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 the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for one of three residents (Resident # 29) reviewed for baseline care plans. The facility failed to complete a baseline care plan within 48 hours of admission for Resident #29. This failure could place residents at risk for not receiving care and services to meet their needs. Findings include: Record review of Resident #29's face sheet, dated 08/21/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #29 had diagnoses which included tracheostomy status ( a resident's condition of having a surgically created opening in their windpipe with a tube inserted to help them breathe), nontraumatic intracerebral hemorrhage, unspecified (bleeding within the brain tissue that is not caused by a physical injury 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 interview and record review the facility failed to ensure comprehensive care plans were developed within 7 days after completion of the comprehensive assessment for 2 of 7 residents (Resident #78 and Resident #37) reviewed for comprehensive assessments and timing. 1. The facility failed to ensure Resident #78's Comprehensive Care Plan was completed within seven days of the completion of the comprehensive assessment and no more than 21 days after admission. 2. The facility failed to ensure Resident #37's Comprehensive Care Plan was completed within seven days of the completion of the comprehensive assessment and no more than 21 days after admission. These failures could place residents at risk for not receiving necessary care and services or having important care needs identified and met.The findings include: 1. Record review of Resident #78's admission record, dated 08/21/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #78 had 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 observation, interview, and record review the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 12 residents (Resident #38) reviewed for Activities of Daily Living. The facility failed to ensure Resident #38 was provided her showers 3 times a week as scheduled. This failure could place residents at risk of not receiving services or care, diminished quality of life, and decreased self-esteem.Findings include: Record review of Resident #38's admission record, dated 08/21/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #38 had diagnoses which included hypertensive heart disease without heart failure (changes in the heart due to long term high blood pressure), hyperlipidemia (abnormally high level of fats in the blood), depression (a mood disorder with persistent feeling of sadness and loss…

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 drugs and biologicals were stored in locked compartments, under proper temperature controls, and labeled in accordance with currently accepted professional principles for 1 of 1 medication storage room refrigerator and 1 of 3 (200 hall) medication carts reviewed for medication storage. 1. The facility failed to ensure the 200-hall medication cart was locked and medications were secured and not accessible to other staff, residents, or visitors. 2. The facility failed to ensure the refrigerator maintained the adequate temperature to store medications (35 - 40 degrees Fahrenheit) that required refrigeration prior to opening. These failures could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missed medications.Findings included: Observation on 08/20/2025 at 9:08 AM revealed an unlocked medication cart beside room [ROOM NUMBER]. The medication cart was between room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan 7 days after each comprehensive assessment and no more than 21 days after admission for 2 of 5 residents (Residents #1 and Resident #2) reviewed for care plan revision and timing. 1. The facility failed to updated Resident #1's care plan to reflect Resident #1's foley catheter was removed in 2023. 2. The facility failed to implement a comprehensive care plan for Resident #2. This failure placed residents at risk of not receiving the appropriate care and services to maintain the highest practical well-being. Findings include: Review of Resident #1 face sheet reflected an [AGE] year-old man admitted on [DATE] with diagnoses of unspecified dementia (group of symptoms affecting memory, thinking, and social abilities), depression (mood disorder that causes persistent feelings of sadness and loss of interest in activities), dysphagia (difficulty swallowing), and type 2 diabetes…

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 did not provide pharmaceutical services to meet the needs of each resident for seven (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) of 10 residents reviewed for pharmaceutical services. 1. The facility failed to ensure Resident #1 , Resident #2, Resident #3, Resident #4, Resident #5, Resident #6 and Resident #7 received their medications scheduled at 5:00 pm on 05/25/25. Findings included: 1. Review of Resident #1's face sheet dated 06/02/25 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including gastro-esophageal reflux disease, retention of urine, anxiety disorder, age-related physical debility, cognitive communication deficit, hypertensive heart disease and muscle weakness. Review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 15, indicating her cognition was intact. Review of Resident #1's care plan, dated 05/15/25…

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, observation, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 8 (1/1/25, 1/2/25, 1/3/25, 1/4/25, 1/5/25, 1/6/25, 1/7/25, and 1/8/25) of 9 days reviewed for RN coverage. The facility failed to ensure they had an RN charge nurse on duty for 8 days 01/01/2025 through 01/08/2025. This failure could place residents at risk of missed nursing assessments, interventions, care, and treatment. Findings included: Review of hand written nursing hours for December 31, 2024, to January 8, 2025, by the DON, reflected zero hours worked by an RN charge nurse on the following days: 01/02/2025, 01/06/2025, and 01/07/2025, And less than 8 hours worked by an RN charge nurse on the following days: 01/01/2025, 01/03/2025, 01/04/2025, 01/05/2025, and 01/08/2025. During an observation on 01/07/2025 at 11:35 AM and 01/08/2025 at 11:42 AM the staffing sign in sheet revealed 12-hour shifts for charge nurses. There were no RNs listed as charge nurses on the sign in sheet for 01/07/2025 and one nurse 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 provide pharmaceutical services, including timely administration of all drugs and biologicals to meet the needs for 2 (Resident #1 & #2) of 5 residents reviewed for pharmaceutical services. 1. The facility failed to ensure Resident #1's scheduled medications were administered in a timely manner in accordance with professional standards. Resident #1 was not given her carvedilol (a medication to lower blood pressure and regulate the heart rate) a total of 3 times, her hydralazine (a medication to lower blood pressure) a total of one time, isosorbide dinitrate (a medication to lower blood pressure) a total of one time and ciprofloxacin (an antibiotic) a total of one time. Resident #1 was given the following medications outside of the one hour before and one hour after window that meets professional standards: sodium bicarbonate (for acid indigestion) seven times, carvedilol (to lower blood pressure), Abilify (a mood stabilizer) eight times, sertraline (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 interview, observation, and record review, the facility failed to ensure the correct the resident and their family members had sufficient preparation and orientation to ensure safe and orderly discharge from the facility to home for 1 (Resident #1) of 3 resident's reviewed for discharge rights. The facility failed to ensure Resident #1 had the correct medications that were prescribed to her upon discharge on [DATE]. Resident #1 was discharged on 12/15/2024 with a blister card of Furosemide 40mg tablets, that were prescribed to Resident #3. Resident #1 was prescribed Furosemide 20mg tablets upon discharge. This failure could put the resident at risk for adverse reactions to a medication not prescribed to her including worsening kidney function, low blood pressure, and hospitalization. Findings included: Review of Resident #1's face sheet dated 1/8/2025, revealed an [AGE] year-old female admitted on [DATE] and discharged on 12/15/2024. Her Diagnoses include metabolic encephalopathy (a change in how 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 interviews and record review, the facility failed to ensure that medical records were accurately documented for three (Resident #1, Resident #2, and Resident #3) of five residents reviewed for accurate medical records. The facility failed to ensure Residents #1 and #2's facility self-reported incidents were documented in their EMRs and Resident #3's vitals were accurately documented. This deficient practice could result in errors in care and treatment. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including depression, anxiety disorder, epilepsy (seizures), and Alzheimer's disease (a chronic neurodegenerative disease that destroys brain cells). Review of Resident #1's quarterly MDS assessment, dated 11/11/24, reflected a BIMS score of 9, indicating she was moderately cognitively impaired. Review of Resident #1's quarterly care plan, revised 11/18/24, reflected she had impaired cognitive function…

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 resident rights for personal privacy for 5 of 5 residents (Resident #2, Resident #3, Resident #16, Resident #25, and Resident #54) residents reviewed for personal privacy. The facility failed to knock on Resident #2, Resident #3, Resident #16, Resident #25, and Resident #54's door when going into the residents' rooms. The deficient practice could affect all residents right to privacy in the facility and cause the resident to feel like their privacy is being invaded or the facility is not their home. Findings included: Review of Resident #2's Face Sheet dated 07/23/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2's diagnoses included atherosclerosis of native arteries of extremities (arteries are blocked), osteoporosis (weak and brittle bones), cognitive communication deficit (problems with communication), anxiety disorder, history of falling, contracture joint (permanently bent),…

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 the safe handling, humidification, cleaning, storage, and dispensing of oxygen for respiratory care services provided to 3 of 3 residents The facility failed to ensure Resident's oxygen tubing was dated to ensure it was changed weekly for 3 residents (Residents 9, 16, and 25. The facility failed to have a written policy to ensure the safe handling, humidification, cleaning, storage, and dispensing of oxygen on 7/23/24. The facility failed to ensure that the humidifier bottle had water for Resident 25. This failure placed the residents at risk of developing a respiratory infection from contamination of the tubing and humidifier water. Findings included: A review of Resident 9's face sheet dated 7/23/24 reflected she was a [AGE] year-old female with a diagnosis of chronic obstructive pulmonary disease which blocks air flow in the lungs. her other diagnoses were dysphagia (difficulty swallowing), anemia, cerebral infarction (stroke),…

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 store, prepare, distribute, and serve food in accordance with professional standards for foods safety for 1 of 1 kitchen reviewed for food safety and sanitation. The facility failed to ensure all food items were labeled and dated. The facility failed to ensure meat was properly thawed to the correct temperature. These failures placed residents at risk of foodborne illness. Findings included: An observation of the walk-in refrigerator on 07/21/2024 at 9:05 a.m. revealed approximately 25 fruit cups exposed to air and not labeled as to when prepped. A pan of ground meat that had been cooked without a label or date. A white bucket of boiled eggs was exposed to air and did not have a label or date as to when opened. Two trays of drinks exposed to air without a label and date on them. An observation of the walk-in freezer on 07/21/2024 at 9:08 a.m. revealed a plastic bag of chicken strips, hamburger patties, and English muffins that did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide the physician prescribed therapeutic diet to 1 of 4 residents (Resident #9) reviewed for therapeutic diets. Resident #9 did not receive a mechanical soft diet as ordered. This failure affected one resident and placed her at risk for choking and causing further health issues. The findings were: Record review of Resident #9's admissions record dated 07/23/2024 revealed that Resident #2 was admitted to the facility on [DATE]. Resident #9's diagnoses included cerebral infraction (long term effects of a stroke), lack of coordination, muscle weakness, dysphagia (difficulty swallowing), atrial fibrillation (abnormal heart rhythm), pressure ulcer of sacral region (wound on boney area on bottom), depression, cardiomyopathy (disease of the heart muscles), anemia (not enough healthy red blood cells), morbid obesity, hypertensive heart disease with heart failure (damage to heart and heart failure due to chronic 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 interview and record review, the facility failed to ensure all residents were discharged per facility requirements for one (Resident #1) of 8 residents reviewed for discharge requirements. The facility failed to complete and document in Resident #1's chart her discharge planning and summary upon her discharge on [DATE]. This failure placed residents at risk of improper discharges. Findings included: A record review of Resident #1's undated face sheet reflected a [AGE] year-old female admitted on [DATE] and discharged on 4/12/2024 with diagnoses of benign neoplasm of pituitary gland (abnormal noncancerous growth), gout (excessive uric acid), muscle weakness, hyperlipidemia (high cholesterol), depression, edema (fluid buildup), chronic kidney disease, unspecified convulsions, type 2 diabetes, spinal stenosis (narrowing of spinal column), hypothyroidism (underactive thyroid), morbid (severe) obesity and chronic pain syndrome. A record review of Resident #1's quarterly MDS assessment dated [DATE] reflected…

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 provide appropriate timing of notice before transfer for one (Resident #1) of 8 residents reviewed for discharge notices. The facility failed to provide notice at least 30 days before Resident #1 was discharged on 4/12/2024. This failure placed residents at risk of being improperly discharged . Findings included: A record review of Resident #1's undated face sheet reflected a [AGE] year-old female admitted on [DATE] and discharged on 4/12/2024 with diagnoses of benign neoplasm of pituitary gland (abnormal noncancerous growth), gout (excessive uric acid), muscle weakness, hyperlipidemia (high cholesterol), depression, edema (fluid buildup), chronic kidney disease, unspecified convulsions, type 2 diabetes, spinal stenosis (narrowing of spinal column), hypothyroidism (underactive thyroid), morbid (severe) obesity and chronic pain syndrome. A record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 12, which 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 provide a copy of the records or any portions thereof (including in an electronic form or format when such records are maintained electronically) upon request and 2 working days advance notice to the facility to one (Resident#1) of 5 residents reviewed for planning care. As on 03/05/24, the facility failed to provide a copy of the results of the care plan meeting conducted on 01/25/24, as requested by Resident #1 and her representative initially on 02/04/24 and reminded again on 02/16/24. This failure could place the resident at risk for not being a part of the decision making related to their care resulting in decreased quality of care, loss of independence, and decreased psychosocial well-being. Findings include: Review of Resident # 1' s Face Sheet on 03/05/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of Gastro-esophageal Reflux Disease (stomach acid repeatedly flows back into the tube connecting 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide comfortable and safe temperature levels at a range of 71 to 81 degrees Fahrenheit for two (Resident #1 and Resident #2) of eight residents reviewed for homelike environment. The facility failed to ensure Resident #1 and Resident #2's room was maintained less than 81 degrees Fahrenheit in that the room reached 88.9 degrees Fahrenheit. This failure could place residents at a major risk of heat exhaustion, dehydration, hospitalization, and death. Findings included: Resident #1 A record review of Resident #1's face sheet dated 9/26/2023 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of hemiplegia (paralysis of one side of the body) affecting left nondominant side, cerebral infarction (stroke), visuospatial deficit (conditions affecting the ability to perceive, analyze, synthesize, manipulate and transform visual patterns and images), hypertensive heart disease (type of heart disease caused by 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 ensure residents had a right to a safe, clean, comfortable and homelike environment which included but was not limited to receiving treatment and supports for daily living safely for three of eight rooms (Room # 305, #310, and #508) reviewed for environment. The facility failed to ensure resident rooms were cleaned and sanitized daily, and in accordance with the facility's Housekeeping Workers' Checklist. This failure could place residents at risk of the spread of disease-causing organisms in the residents' living areas and on resident care equipment. Findings include: Observations on 06/13/23 at 10:35 AM and 06/14/23 at 2:00 PM of room [ROOM NUMBER], which was occupied by two residents that could not be interviewed, revealed the center area of the room floor had black dirt spots and the corner of the floors had thick black dirt patches. The residents' bathroom bottom wall had some drywall work done but it was dirty and the wood looked as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide food was prepared by methods that conserve nutritive value, flavor and appearance and food and drink was palatable, attractive, and at a safe and appetizing temperature for 1 of 8 residents (Residents #72 ) that were reviewed for meal presentation and taste. 1. The facility failed to ensure [NAME] A prepared regular, mechanical, and puree stir fry chicken and vegetables with taste and not overcooked during meal service on 06/14/23. Resident meals were observed mushy and watery for the puree, and the vegetables overcooked. 2. The DM failed to serve juice that was not watered down. The apple and cranberry juice contained more water than juice. 3. The DM failed to have orange juice available to resident's during the machine outage from 6/10/23 to 06/14/23. The failures could place resident's at risk of a loss of appetite, altered nutritional status and weight loss. Findings include: Observation on 06/14/23 at 12:45 PM revealed [NAME] 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 store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for kitchen sanitation for 84 residents that received meals from the kitchen. The facility kitchen staff failed to label and date food stored in the dry storage, preparing areas and the kitchen. These failures could place residents at risk for food-born illness and food contamination. The findings include: During an initial tour of the facility kitchen on 06/13/23 at 9:00 AM revealed the following: 1- thickener observed in a clear plastic 4 oz. cup, therefore being exposed to environment and contaminants that affect the food quality. 1-28 oz. container of black pepper dated 4/18/21 indicating it had expired. 1-28 oz. container of cayenne pepper dated 1/5/21 indicating it had expired. 1 box of [NAME] noodles was undated 1 package of crackers revealed the date had rubbed off on the plastic unable…

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 reviews 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 1 of 6 residents (Resident #234) reviewed for Activities of Daily Living care provided to dependent residents. The facility failed to ensure Resident #234 received baths or showers since being admitted to the facility on [DATE]. This failure could place residents at risk of not receiving necessary services to maintain good personal hygiene. Findings include: Record review of Resident #234's face sheet, dated 06/15/23, revealed a 66 -year-old male who was admitted to the facility on [DATE]. Resident #234's relevant diagnoses included Quadriplegia (Paralysis) and Neuromuscular Dysfunction of Bladder (Bladder control). Record review of Resident #234's Baseline Care Plan, dated 06/07/23, revealed for personal hygiene, the resident required a One-person, and for transfer support,…

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 and interview the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable and the facility failed to ensure, in accordance with State and Federal laws, all drugs were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 2 of 4 medication carts (#1 and #2) reviewed for medication storage. 1. The facility failed to ensure the medication carts #1 and #2 were secured and unable to be accessed by unauthorized personnel and residents. These failures could place residents at risk for not receiving drugs and biologicals as needed and a drug diversion. Findings include: An observation on 06/14/23 at 12:15 PM revealed a medication cart #1 was parked at the nurse's station and was unlocked. There were no staff observed at or near the medication cart or nurse's station. There were no residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based observation, interview and record review the facility failed to 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 of three residents (Resident #10 and Resident #24) reviewed for infection control. The facility failed to ensure MA S sanitized the blood pressure device and cuff between use with Resident #10 and Resident #24. This failure could place residents at risk of cross-contamination and infections. Findings include: Record review of Resident #10's face sheet, dated 06/15/23, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #10's relevant diagnoses included breast cancer, difficulty swallowing, difficulty walking, anxiety and dementia. Record review of Resident #24's face sheet, dated 06/15/23, revealed a [AGE] year-old female who was re-admitted to the facility on [DATE]. 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.