Cedar Creek Nursing and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 1 (Resident #1) of 1 resident reviewed, in that: The facility failed to maintain the temperature of Resident #1's personal refrigerator was at or below 41 degrees F 12/1/25 to 12/4/25 and was documented 12/5/25 to 12/19/25. This failure could place residents at risk of foodborne illness due to consuming foods which might be spoiled. The findings included:Record review of Resident #1's admission record, dated 12/21/25, reflected resident was a [AGE] year-old female admitted [DATE] with diagnoses to include constipation, protein-calorie malnutrition, and nausea. Record review of Resident #1's quarterly MDS assessment, dated 12/02/25, reflected Resident #1 had a BIMS score of 12 out of 15, reflecting moderate cognitive impairment. Interview and record review on 12/20/25 at…

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

Based on observations, interviews, and record review, the facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for one of one kitchen. The facility failed to provide palatable food on the sampled foods on test tray: Green beans were cold Turkey was lukewarm Tater tots were overcooked, hard and had no soft potato inside This failure could place residents at risk of not being satisfied with their food or encouraged to increase their personal food intake with an outcome of weight loss and a diminished quality of life. The findings included: During the initial tour on 03/04/25 between 9:15 am and 11:30 am, Residents #11 and #24 complained about the food saying it was usually cold and lacked flavor. Resident #24 complained that the food was not restaurant quality. Confidential interviews during the Resident Meeting confirmed that the food was frequently cold and lacked taste. Several residents at this meeting noted that the meals were frequently late and often the trays sat on the hall in the carts for over 15 minutes before…

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 observation, the facility failed to ensure that residents had suitable, nourishing meals and snacks outside of scheduled meal service times. The facility failed to ensure residents were offered snacks at bedtimes. This failure could affect all residents who received meals served from the facility's only kitchen by placing residents at risk for, unplanned weight loss, and side effects from medication given without food, and diminished quality of life. Confidential interviews during the Resident Meeting on 03/05/25 revealed the facility did not offer snacks at bedtime unless the resident specifically asks for a certain snack. 3 of the 7 residents who attended the meeting and who were diabetic stated they did not receive any snacks with their names on them any time during the day to indicate they needed a snack due to diabetes. During an interview with the Dietary Supervisor (DS) on 03/06/25 at 12:59 pm, the DS stated they do provide snacks which are kept in the resident refrigerator located…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. 1. The facility dietary staff failed to wash their hands between tasks and before handling food. 2. The cook used his bare hands, which had not been washed prior to meal service, take rolls from the cooking sheet pan and put them on the plates as he served lunch. These failures could place residents at risk for food borne illness. The findings included: 1. The lunch meal service was observed on 03/06/25 beginning at 11:15 am. The cook was observed taking the food temperatures using a different thermometer for each item of food. Some of the items were below the required temperature so he had to place them back in the oven. While he was waiting for items to reheat, he was observed writing some notes on some of the tickets, flipping through pages of information from a folder, gathering serving utensils and washing the thermometers with water to be used to test the temperatures again. At no time during…

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 infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections for 3 of 12 residents (Residents #27, #4 and #24) reviewed for infection control. 1. The facility failed to ensure proper hand hygiene was performed and the blood pressure cuff and pulse oximeter were sanitized between resident use. 2. The facility failed to ensure proper hand hygiene was performed, going from a clean area to a dirty area, and the scissors used to provide wound care were sanitized prior to use. These deficient practices could place residents who received medications and wound care at-risk for infections. The findings included: 1. a. Record review of Resident #27's face sheet dated 3/7/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included diabetes with hyperglycemia (condition in which blood sugar…

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 treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 of 2 resident units/halls (The Short Hall and Long Hall) reviewed for dignity. 1. The facility failed to ensure Resident #11 was provided privacy when she was administered insulin. 2. The facility failed to ensure Resident #27 was provided privacy when she was administered insulin. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth. The findings included: 1. Record review of Resident #11's face sheet dated 5/5/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted [DATE] and 1/1/25 with diagnoses that included type 2 diabetes with ketoacidosis (complication of diabetes that occurs when the body starts breaking down fat too quickly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 12 residents (Resident #4) reviewed for care plans: The facility failed to develop a person-centered care plan with interventions that addressed Resident #4's physician orders for the use of oxygen therapy. This failure could place residents at risk for not having their needs and preferences met. The findings included: Record review of Resident #4's face sheet dated 5/5/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dementia, heart failure, pneumonia, and shortness of breath. Record review of Resident #4's most recent significant change MDS assessment dated [DATE] revealed 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 the observation, interview, and record review the facility failed to ensure that the resident's environment remained free of accidents and hazards as was possible and each resident received adequate supervision to prevent accidents for 1 of 6 residents (Resident #4) reviewed for accidents. The facility failed to ensure Resident #4's fall mat was utilized per physician's orders. This failure could place residents at risk for accidents and injuries related to risk for falls. The findings included: Record review of Resident #4's face sheet dated 3/5/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dementia, abnormalities of gait and mobility, muscle wasting, muscle weakness and lack of coordination. Record review of Resident #4's most recent significant change MDS assessment dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making skills and was dependent on staff for bed mobility and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure 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 1 of 1 resident (Resident #4), reviewed for quality of care. Resident #4's oxygen nasal cannula was not covered or protected from the elements when not in use. This failure could place residents who received respiratory care at risk of developing respiratory complications and a decreased quality of care. The findings included: Record review of Resident #4's face sheet dated 3/5/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dementia, hypertension (high blood pressure), heart failure, and shortness of breath. Record review of Resident #4's most recent significant change MDS dated [DATE] revealed the resident was severely cognitively impaired for 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 all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 2 resident units/halls (The Long Hall), and 1 of 3 medication carts reviewed for storage of drugs and biologicals. 1. The facility failed to ensure Resident #22 did not have a jar of mentholated ointment (a topical analgesic and decongestant) at the bedside. 2. The facility failed to ensure the medication cart on The Long Hall was locked and secured. These deficient practices could place residents at risk of medication misuse or drug diversion. The findings included: 1. Record review of Resident #22's face sheet dated 3/6/25 revealed a [AGE] year old female admitted to the facility on [DATE] with diagnoses that included dementia, anxiety disorder (a mental health condition characterized by excessive fear, worry, or nervousness that is persistent and interferes with daily life), acute upper respiratory infection (sudden…

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 medical records on each resident that were complete and accurately documented for 1 of 1 (Residents #3) residents reviewed for medical records. The facility failed to ensure Resident #3's Letters of Guardianship were maintained current. This deficient practice could place residents at risk of improper care due to inaccurate medical records and lack of authority to provide consent for services. The findings were: Record review of Resident #3's admission Record dated 03/07/25 documented an [AGE] year-old male most recently admitted to facility on 10/31/23 with an original admission date of 05/18/18. Resident #3's diagnoses included unspecified dementia (a decline in cognitive function that does not meet the diagnostic criteria for a specific type of dementia), unspecified psychosis not due to a substance or known physiological condition (a mental state characterized by a loss of touch with reality and may involve hallucinations,…

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 reviews, the facility failed to maintain effective pest control for 1 of 1 kitchen reviewed for pests. The facility failed to have pest control effectively treat the kitchen for roaches. This deficient practice could place residents at risk of exposure to pests, diseases, infections, and diminished quality of life. The findings include: An observation and interview on 03/06/25 at 12:12 pm, revealed a live roach crawling on the wall near the oven which was next to the steam table. This observation was pointed out to the Dietary Supervisor who immediately caught the roach with a paper towel and removed it from the kitchen. The DS then went to tell the ADM to call the pest control company. The DS stated pest control had come out recently to treat for roaches and other insects. Record review of Pest Control log revealed that the pest control company had come out on 02/12/25 to treat for roaches and other pests and rodents. The Comments section of the report noted: Heavy German Cockroach activity found in kitchen. Highly recommend after hours…

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

Based on interviews and record reviews, the facility failed to provide a resident environment that was free of pests and rodents for 1 of 1 facility reviewed for effective pest control in that: The facility failed to provide a resident environment that was free of pests This deficient practice could place residents at risk of remaining in an environment that was not free of pests and rodents. The findings included: Record review of grievance log for the past year revealed no grievances about pest control. Record review of pest control log for the past 6 months revealed no mention of cockroaches. Interview on 02/10/25 at 01:33 PM, Complainant C revealed she was at the facility this week, exact date unknown, and there were German cockroaches. She revealed she was aware of what German cockroaches looked like because she has experienced an infestation before and stated if you see one then that means there were more. She revealed their dropping can cause respiratory issues and nasal infections. Interview on 02/10/24 at 01:44 PM, CNA A and CNA B revealed they have a lot of roaches in 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 reviews the facility failed to ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the event caused serious bodily injury for 1 of 11 residents (Resident #3) whose records were reviewed for abuse and neglect: Confidential Staff Members A, B, and H failed to report to the administrator about an allegation of neglect of Resident #3 by RN J. These deficient practices could affect residents by contributing to further abuse and neglect. The findings included: Record review of Resident #3's admission record reflected a male initially admitted [DATE] with diagnoses to include unsteadiness on feet, muscle wasting and atrophy, lack of coordination, weakness, age-related physical debility, cognitive communication deficit, and abnormalities in gait and mobility. Record review of Resident #3's quarterly MDS assessment, dated 10/30/24, reflected the resident had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure A resident who is unable to carry out activities of daily living receives the necessary services to maintain grooming, and personal for 3 of 3 (#1, #4, #5) residents reviewed for ADL care, in that: The showers were not completed due to 1 CNA on the 2-10pm shift on Monday (2/10/2025). 1. Resident #1 did take a shower, after continuous asking of staff. 2. Resident # 4 did not take a shower for the month of January 2025 according to the POC task for CNA's. 3. Resident # 5 did not take a shower for the month of January 2025 according to the POC task for CNA's. This failure could affect residents and result in residents not receiving assistance when needed for daily care. The Findings were: Record review of the shower schedule for Resident #1, #4 and #5 was Monday, Wednesday and Friday in the evening shift (2-10 PM shift). 1.Record review of Resident's #1's admission Record dated 2/12/2025 documented he was admitted on [DATE], re-admitted on [DATE]…

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 ensure Privacy and Confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records and a right to secure and confidential personal and medical records for 3 of 9 (room [ROOM NUMBER], #47 and resident #76) reviewed for privacy and confidentiality, in that: 1. LVN J did not knock on rooms #55 and #47 before entering rooms. 2. LVN Z left her computer open in the hallway, with people passing by, with resident #76's personal information. This could affect and result in resident privacy being violated. The Findings were: 1. a. Observation on 1/26/2025 at 10:33 AM LVN J went into room [ROOM NUMBER] and did not knock on the door before entering room. b. Observation on 1/26/25 at 10:00 AM LVN J went into room [ROOM NUMBER] and did not knock on the door before entering room. Interview on 1/26/25 at 10:38 AM with LVN J confirmed she did not knock on the 2 doors, and she should have knocked…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews the facility failed to ensure comprehensive person-centered care plans were developed and implemented for each resident to meet medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment as required for 1 of 1 (Resident #1) resident reviewed for care plans in that: Resident #1's care plan did not have interventions for his left hand contracture to maintain or improve mobility on hand. This could affect all resident with contractures and could result in a decrease in mobility. The Finding were: Record review of Resident's #1's admission Record dated 2/12/2025 was documented he was admitted on [DATE], re-admitted on [DATE] with applied income. Record review of Resident #1 had diagnoses of cerebral infarction, epilepsy, pain, anxiety, restlessness and agitation, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and abnormal gait and mobility.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable for 1 of 1 (Resident #1) residents in that: Resident #1 had a left sided hand contracture with no devices to maintain or improve mobility on hand. This could affect resident with contractures and could result in a decrease in mobility. The Finding were: Record review of Resident's #1's admission Record dated 2/12/2025 was documented he was admitted on [DATE], re-admitted on [DATE] with applied income. Record review of Resident #1 had diagnoses of cerebral infarction, epilepsy, pain, anxiety, restlessness and agitation, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and abnormal gait and mobility. Record review of Resident #1's admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (Residents #1) reviewed for comprehensive care plans in that: The facility failed to develop a plan of care to address Resident #1's multiple wounds. This failure could place residents at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs. The findings included: Record review of Resident #1's face sheet dated 2/5/25 revealed an admission date of 1/2/25 and discharge date of 1/29/25 (transfer to hospital on 1/28/25) with admission diagnoses that included: sepsis (infection in the blood), type 2 diabetes with neuropathy (nerve damage), and peripheral vascular…

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 ensure its medication error rates were not 5% or greater. The facility had a medication error rate of 8%, based on 2 errors out of 25 opportunities which involved 1 of 6 residents (Resident #21) observed during medication administration reviewed for medication errors . 1. LVN C failed to administer Resident #21's losartan and fluticasone nasal spray at the prescribed times. These deficient practices could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings included: A record review of Resident #21's admission record, dated 02/06/2024, revealed an admission date of 09/08/2023 with diagnoses which included chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems). A record review of Resident #21's admission MDS assessment, dated 11/22/2023, revealed Resident #21 was a [AGE] year-old female admitted to 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 reviews the facility failed to ensure residents were free of any significant medication errors, for 1 of 7 residents (Residents #6) reviewed for significant medication errors. 1. The facility failed to administer to Resident #6, lisinopril (a medication which lowers blood pressure) according to the physician's orders. Resident #6 was administered lisinopril while Resident #6 had low blood pressure. 2. The facility failed to administer to Resident #6, hydrochlorothiazide (a medication which lowers blood pressure) according to the physician's orders. Resident #6 was administered lisinopril while Resident #6 had low blood pressure. These failures could place residents at risk for not receiving the therapeutic effects of the medications prescribed. The findings included: A record review of Resident #6's admission record, dated 02/04/2024, revealed an admission date of 12/02/2021 with diagnoses which included hypertension (high blood pressure). A record review of Resident #6's…

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

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. 1. Cut onions, cut lettuce, and parmesan cheese were in zip lock bags and did not have a used by date, in the refrigerator. 2. The dish machine temperature/chemical log for February 2024 was missing. 3. The DM did not write on the substitute log the meal for Saturday, 2/3/2024. 4. The facility prepared and stored 9 peanut butter and jelly sandwiches in the resident's snack pantry refrigerator without any indicators to identify when the sandwiches were prepared or when the sandwiches were to be thrown out for food safety. This could affect residents and could result in residents not getting fresh foods, dishes that are not sanitized and cause harm. The Findings were: 1. In an observation on 2/04/2024 at 9:40 AM in the kitchen with [NAME] F in Refrigerator #2, there were cut onions in a zip lock bag that had an open date of 1/31/2024 and no use by date. There was also cut lettuce in…

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

Based on observations, interviews, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen. In the kitchen 1 (left side) of the 2 ovens on the range were not fully functional. This could affect all residents that eat meals from the kitchen and could result in residents not getting warm food cooked in the oven. The findings were: In an observation and interview on 2/04/2024 at 09:40 AM [NAME] F stated, the oven worked off and on and sometimes would not fully cook the meal. [NAME] F stated she was not sure how long. In an interview with Resident #14 stated she had a peanut butter and jelly sandwich, chips, and dessert on Saturday (2/3/2024). She stated she was told the oven did not work by the staff. In an interview on 2/04/2024 at 4:46 PM the Dietary Manager (DM) stated, the left oven was not working well and would go off and on. The DM stated Friday it was working well and then on Saturday it did not work well. She stated the menu was substituted and she had asked the warranty company 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 interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 8 residents (Residents #27) reviewed for care plans. 1. The facility failed to support Resident #27's needs for post-traumatic stress disorder (PTSD). These failures could have placed residents at risk for not having their needs met. The findings included: A record review of Resident #27's admission record, dated 02/05/2024, revealed an admission date of 09/15/2023 with diagnoses which included PTSD. A record review of Resident #27's entry MDS assessment dated [DATE] revealed Resident #27 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 10 out of 15 which indicated moderate cognitive impairment. Further review of Resident #27's MDS 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 interviews and record review the facility's interdisciplinary team failed to review and revise the care plan after each assessment, including both the comprehensive and quarterly review assessments for 1 of 8 (Resident #12) residents reviewed for revised care plans. The facility failed to revise Resident #12's care plan to remove conflicting plans for Resident #12's diet texture needs. This failure could place residents at risk for harm with conflicting care plans. The findings included: A record review of Resident #12's admission record, dated 02/05/2024, revealed an admission date of 08/19/2023 with diagnoses which included dysphagia following cerebral infarction (difficulty swallowing after a stroke). A record review of Resident #12's quarterly MDS assessment dated [DATE] revealed Resident #12 was a [AGE] year-old female admitted for long term care and could not participate in a BIMS score assessment. A record review of Resident #12's physician's orders summary dated 02/06/2024 revealed on 11/29/2023…

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 that the resident environment remains as free of accident hazards as was possible for 1 (Resident #14) of 6 smokers. Resident #14 had a personal lighter that was in her purse. This could affect all residents and could result in a fire. The findings were: Record review of Resident #14's admission record dated 2/7/2024 revealed she was admitted on [DATE], re-admitted on [DATE], and she was her own responsible party. Record review of Resident #14's admission record revealed her diagnoses were dementia without behaviors, major depressive disorder, anxiety, protein calorie malnutrition, chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and pain. Record review of Resident #14's Quarterly MDS assessment dated [DATE] revealed her BIMS score was 11/15 (moderately impaired), she had no behaviors, she used a wheelchair to mobilize, she was independent for hygiene,…

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

Based on observations, interviews, and record review the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access, for 1 of 1 medication cart, reviewed for security. The facility failed to attend and secure the short-hall medication cart. This failure could place residents at risk for harm by misappropriation of property and not receiving the therapeutic effects of their medications. The findings included: During an observation on 02/04/2024 at 08:56 AM, revealed the facility's short-hall medication cart was stationed by the nurse station at the beginning of the facility's 2 halls, the short-hall and the long-hall. Further observation revealed the medication cart unattended, and unlocked. The medication cart was observed to have the lock button unengaged and unlocked. Observations from 02/04/2024 from 08:56 to 09:09 AM revealed LVN B was attending residents at the end of the long-hall and residents were ambulating nearby the unattended unsecured medication cart. RN A and LVN H…

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 and implement written policies and procedures that: Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, and Establish policies and procedures to investigate any such allegations, for 1 of 30 residents (Resident #1) reviewed for investigating injuries of unknown origin, in that. Resident #1 was discovered on 6/16/2023 by LVN A with an injury of unknown origin and did not report the injury to the Administrator or the DON. This deficiency could have placed resident at risk for harm by abuse, neglect, and or mistreatment. The findings included: A record review of Resident #1's admission record dated 11/07/2023, revealed an admission date of 04/18/2022, a discharge date of 06/19/2023, with diagnoses which included downs syndrome and osteoporosis. A record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was a [AGE] year-old mentally disabled female admitted…

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 ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures for 1 of 30 residents (Resident #1) reviewed for reporting injuries of unknown origin, in that. Resident #1 was discovered on 6/16/2023 by LVN A with an injury of unknown origin and did not report the injury to the Administrator or the DON. This deficiency could have placed resident at risk for harm by abuse, neglect, and or mistreatment. The findings included: A record review of Resident #1's admission record dated 11/07/2023,…

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 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 professional standards for food service safety, in that: The facility failed to keep personal items and keys out of the food preparation areas. This failure could place residents at risk for food borne illness. The findings included: During an observation and interview on 11/8/2023 at 11:00 AM of the kitchen revealed a food preparation table with 2 pills, one oval blue capsule and 1 oval white pill, in a small clear zip top bag, next to a half full clear 500ml water bottle, which was next to a similar sized multicolored drink tumbler. Further observation revealed a set of keys on a nylon fob atop of another food preparation table. The facility's [NAME] stated the counter where the pills were and the drinks were had a food puree machine, a bread toaster, a blender, and a coffee dispenser. The cook stated the pills and drinks were hers. The [NAME] stated the keys on the other food prep…

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.