Focused Care at Allenbrook

Based on observations, interviews, and record review, the facility failed to store, prepare and distribute food in accordance with professional standards for food safety in that -The facility failed to ensure that dented cans were not stored with undented cans.The facility failed to ensure that one of 2 refrigerators in the dining room was free from expired food products. These failures placed residents at risk of foodborne illness.Findings included:Kitchen observation with Dietary Manager on 03/10/26 at 8:30AM revealed there was one 28 oz can, of tomato soup that was dented stored together with un-dented can goods. The Dietary Manager removed the dented can from the shelf and said it was supposed to be in the office for return.Observation of Refrigerator #1 in the dining room revealed-2-5 lbs. of containers of cottage cheese -expired 02/16/266-one-quart half and half milk with expired date of 03/04/262-Gallons of milk with expired date of 03/01/262-Gallons of milk with expired date of 03/08/26 andone gallon of milk with expired date of 03/09/26.The dietary Manager took all expired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the status for one (Resident #10) of 18 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #10's annual MDS assessment accurately reflected her lack of natural teeth in her oral cavity.This failure could place residents at risk for receiving inadequate care and services due to inaccurate assessments.The findings included: Record review of Resident #10's face sheet dated 03/11/26 indicated she was admitted to the facility on [DATE] and was re-admitted on [DATE]. Her diagnoses included Chronic obstructive pulmonary disease (lung disease), dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems), behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, essential hypertension ( high blood pressure), generalized anxiety disorder, chronic pain syndrome, major depressive disorder, lack of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the medication error rates were not 5 percent or greater. During medication administration, a medication error rate of 7 percent was identified (2 errors out of 28 opportunities). These errors involved 2 of 9 residents (resident #20 and resident #52) and 1 of 2 MA (MA J) administering medications. 1. The facility failed to ensure that MA J did not attempt to administer divalproex sodium 500mg oral tablet to Resident #20 during the morning medication pass, when the physician's order indicated the medication was to be administered at bedtime. 2. The facility failed to ensure that MA J did not administer zinc sulfate oral tablet to Resident #52 when the physician's order specified zinc sulfate oral capsule resulting in administration of medication in a form inconsistent with the prescribed order. These failures placed residents at risk for medication errors and potential adverse outcomes.Findings include: Resident #20: Record…

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

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 1 of 1 kitchen reviewed for dietary services. -The facility failed to label, and date left over food items stored in the walk-in cooler. -The facility failed to ensure dented cans were not stored together with undented cans. These failures could place residents at risk for food contamination and foodborne illness due to cross contamination. The findings included: Initial kitchen observation on 12/09/24 at 8:40 AM revealed the following - (All food items were identified by the Dietary Manager) observation of the walk-in freezer in the kitchen revealed. -an open bag of chicken parties which was unlabeled and undated, -a half bag of chicken strips was un-labeled and undated. -3 full bags of chicken parties were unlabeled and undated. -chicken parties in a plastic bag were not sealed, were unlabeled and undated Observation of the dry goods storage revealed one 6 Ibs dented can of sliced apple and one…

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 conduct a comprehensive assessment of a resident in accordance with the timeframes, within 14 calendar days after admission, excluding readmission in which there is no significant change in the resident's physical or mental condition and not less than once every 12 months for 1 of 18 residents (Resident #47) reviewed for comprehensive annual assessments. The facility failed to ensure Resident #47's Annual MDS Assessment was completed within 14 days of the ARD. This failure could place residents at-risk of not having their assessments completed timely, which could result in denial of services and or payment for services. The findings include: Record review of Resident #47's admission Record, dated 12/11/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #47 had diagnoses which included fracture of right femur (broken thigh bone), dysphagia (difficulty swallowing), repeated falls, major…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the assessments accurately reflect the resident's status for 1 of 5 residents (Resident #24) reviewed for accurate assessments. The facility failed to ensure Resident #24's MDS accurately reflected the resident's falls. This failure could place residents at risk for not receiving needed services or receiving improper or incorrect care and services necessary for their physical, mental and psychosocial well-being. The findings include: Record review of Resident #24's face sheet reflected a [AGE] year-old male with an admission date of 8/15/2024. Resident #24 had diagnoses which included Displaced Intertrochanteric Fracture of Left Femur (Broken Hip), Unspecified Dementia (decline in mental abilities that affects daily life), Schizophrenia (chronic mental illness that affects how one thinks, feels, and behaves), Muscle Weakness, Difficulty in Walking, Unspecified Lack of Coordination, and Repeated Falls. Record review of Resident #24's Quarterly…

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 were provided an accurate Preadmission Screening and Resident Review (PASRR) Screening Based on interview and record review, the facility failed to refer a resident with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review for reviewed for 2 of 3 residents (Resident #47 and Resident #25) reviewed for resident assessments. The facility failed to update the PASRR Level 1 forms for Resident #47 and Resident #25 to indicate mental health illness. This failure could place residents at risk of not having their special needs assessed and met by the facility. Findings included: 1. Record review of Resident #47's admission Record, dated 12/11/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #47 had with diagnoses which included fracture of right femur (broken thigh bone), dysphagia (difficulty swallowing), repeated falls,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews the facility failed to ensure that resident received treatment and care in accordance with professional standards of practice for CR#1 reviewed for quality of care. The facility failed to monitor and ensured CR#1 received proper dressing changes on the Intra right jugular Vein (Central Line) on CR#1's neck. The facility failed monitor and ensured CR#1 received proper dressing changes on CR#1's Cholecystectomy tube. This deficient practice could affect residents by diminishing their quality of care. Findings Included: Record review of CR #1's undated Face Sheet reflected she was admitted to the facility on [DATE] and readmitted on [DATE]. She was a [AGE] year-old female with the following diagnoses: heart failure (heart fails to pump blood to give body a normal supply), hypertension (high blood pressure), peripheral vascular disease (poor circulation in blood vessels), gastroesophageal reflux disease (stomach acid repeatedly flows back up into the tube connecting the mouth…

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, and serve food under sanitary conditions in 1 of 1 kitchen: -The facility failed to ensure that the kitchen floors were clean and free of food particles. -The facility failed to ensure that food preparation equipment was clean and free of grease build up. -The facility failed to ensure food items in the refrigerator\freezer were dated, labeled, and appropriately sealed. These failures placed all residents who ate food served by the kitchen at risk of food-borne illness. Findings included: Observation on 10/31/23 from 9:15AM to 9:30AM, revealed the following: *the kitchen floor was dirty with food particles and grease around the cooking area and behind the stove. *One of two cooking stoves had grease built up inside and around outer part of the stove. * one of one commercial can opener in the kitchen revealed had grease and dark looking substance around the cutting blade and the blade holder. * freezer #1 revealed the floor of the freezer had food particles and the door had grease build up.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident maintained acceptable nutritional status, such as usual body weight or desirable body weight, unless the resident clinical condition demonstrated this was not possible, for 1 of 6 residents (Resident #62) reviewed for nutritional status, in that; Resident #62 who admitted to the facility with poor nutrition was not provided prompt intervention to prevent severe weight loss of -16.85 pounds in 6 months. This failure could affect all residents in the facility with weight loss at increased risk of weight loss. Findings included: Record review of Resident #62's admission sheet revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included muscle weakness, unspecified abnormalities of gait and mobility (a change to your walking pattern), depression, dementia (a group of thinking and social symptoms that interferes with daily functioning), and type 2 diabetes. Record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review the facility failed to revise the comprehensive care plan for 1 of 6 residents (Resident #62) reviewed for care plans in that: Facility failed to revise Resident #62's care plan to have assistance with feeding during each meal. This failure could place all residents at risk of not having their individually needs met and place them at risk of not receiving proper nutrition. Findings include: Record review of Resident #62's admission sheet revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included muscle weakness, unspecified abnormalities of gait and mobility (a change to your walking pattern), depression, dementia (a group of thinking and social symptoms that interferes with daily functioning), and type 2 diabetes. Record review of Resident #62's quarterly MDS assessment dated [DATE] revealed she had a BIMS score 06 out of 15 indicating severely impaired. Record review of Resident #62's Comprehensive Care Plan…

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 post-discharge plan of care was developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment and the post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services for 1 of 4 residents (CR # 1) reviewed for an effective discharge process. The facility failed to complete a discharge summary prior to and after CR#1's discharge. This failure could place residents at risk for incorrect, incomplete, or misleading information recorded regarding discharged residents and failures in the continuity of care for residents. Findings include: Record review of the undated admission sheet for CR # 1 revealed a [AGE] year-old female who was admitted to the facility on [DATE], readmitted on…

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