Focused Care at Summer Place

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 baseline care plan for each resident that included the instructions needed to provide effective and person-centered care for 1 of 6 residents (Resident #99) reviewed for baseline care plans. The facility failed to develop a baseline care plan that addressed Resident #99's use of a wound VAC (machine that promotes wound healing by applying negative pressure to the wound area by helping to draw the edges together and remove excess fluid) to her right thigh wound. This failure could place residents at risk of not receiving care and services to meet their needs.Findings included: Record review of a face sheet dated 08/28/2025 indicated Resident #99 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included non-pressure chronic ulcer of unspecified part of right lower leg with unspecified severity (wound of the right lower leg not caused by pressure). Record review of Resident #99'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, 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 2 of 24 residents (Resident #8 and Resident #9) reviewed for care plans. 1. The facility failed to ensure Resident #8's care plan included her fall on 04/03/25 and interventions.2. The facility failed to ensure Resident #9's care plan included the antianxiety medication prescribed for her anxiety. These failures could have placed residents at risk for not having their needs met. Findings included: 1.Record review of Resident #8's face sheet dated 09/03/25 indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with diagnoses history of falls, dementia (group of conditions that cause a decline in cognitive abilities), anxiety, and 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 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 24 residents (Residents #63) reviewed for ADL care.The facility failed to ensure Resident #63 was assisted with her personal hygiene to ensure she was free of body odor and had a clean gown on 08/25/2025. This failure could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem.Findings included: Record review of a face sheet dated 08/28/2025 indicated Resident #63 was a [AGE] year-old female initially admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following other cerebrovascular disease affecting right dominant side (weakness and paralysis to the right side of the body caused by a medical condition that affects the blood vessels and circulation of the brain)…

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 residents receive treatment and care in accordance with professional standards of practice for 1 of 4 (Resident #99) residents reviewed for quality of care. The facility failed to ensure Resident #99's wound treatment to her right posterior thigh was performed on 08/22/2025. This failure could place residents of risk for not receiving appropriate care and treatment, a decreased quality of life, and wound deterioration.Findings included: Record review of a face sheet dated 08/28/2025 indicated Resident #99 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included non-pressure chronic ulcer of unspecified part of right lower leg with unspecified severity (wound of the right lower leg not caused by pressure). Record review of Resident #99's Comprehensive MDS assessment dated [DATE] indicated she was usually understood by others and usually understood others. The MDS assessment indicated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 5 residents (Resident #67) reviewed for respiratory care. The facility failed to ensure Resident #67's oxygen was set at 3 liters per nasal cannula as ordered on 08/28/25. This failure could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care.Findings included: Record review of Resident #67's face sheet, dated 08/28/25, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease also known as COPD (a chronic lung disease that causes inflammation and narrowing of the airways, leading to airflow obstruction), anxiety (a feeling of fear, dread,…

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 dialysis services were provided consistently with professional standards of practice for 1 of 2 resident reviewed for dialysis services. (Resident #7) The facility did not provide ongoing assessments after Resident #7's dialysis treatments and did not keep ongoing communication with the dialysis facility. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs.Findings included: Record review of Resident #7's face sheet dated 08/28/25 indicated he was an [AGE] year-old male who re-admitted to the facility on [DATE] with the diagnoses of end stage renal disease (disease in which the kidneys lose ability to remove waste and balance fluids), dementia (a group of conditions that cause a decline in cognitive abilities, such as memory), high blood pressure, and heart failure. Record review of Resident #7's quarterly MDS dated [DATE] indicated he was usually…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 10 residents (Resident #91) and 1 of 2 medication rooms reviewed for pharmacy services. 1. The facility failed to reorder Resident #91's hydrocodone 7.5/325mg (pain medication) tablet timely resulting in Resident #91 having 3 days without medication. 2. The facility did not ensure the plastic bag of Lorazepam 2mg/ml (antianxiety medication) syringes in the station 2 refrigerator we reconciled. These failures could place the residents at risk of not having medications available for use, drug diversion, not receiving their medications as ordered, and exacerbation of their disease processes. Findings included: 1.Record review of Resident #91's face sheet dated 08/27/25 indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with the 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 observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 24 residents (Resident #23) and 1 of 10 medication carts (Station 1 Medication Cart) reviewed for drugs and biologicals. 1. The facility failed to ensure MA P secured the Station 1 Medication Cart, when it was not in use and unattended on 08/25/2025. 2. The facility failed to ensure Resident #23 did not have a container of zinc oxide, a package of hydrocortisone cream, and a 30-milliliter medicine cup filled with white cream in his room on the bedside table. These failures could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion.Findings included: 1. During an observation on 08/25/2025 starting at 1:18 PM, the Station 1 Medication Cart was unlocked an unattended on the hall. There were residents nearby the unlocked medication…

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 ensure each resident received and the facility provides food that accommodates residents' food preferences for 1 of 24 residents (Resident #6) reviewed for food preferences and the accommodation of resident's meal choices. The facility did not honor Resident #6's preference for fruit punch on 08/25/25 and 08/26/25. This failure could result in a decrease in resident choices, diminished interest in meals, and weight loss. Findings included: Record review of Resident #6's face sheet, dated 08/28/25, reflected Resident #6 was a [AGE] year-old female, readmitted to the facility on [DATE] with a diagnosis which included cerebral palsy (group of conditions that affect movement and posture). Record review of Resident #6's significant change in status MDS assessment, dated 06/20/25, reflected Resident #6 usually made herself understood, and usually understood others. Resident #6's BIMS score was 15, which indicated her cognition was intact.…

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 liquids consistent with the resident's needs for 1 of 23 (Resident #83) residents reviewed for liquid inconsistency. The facility did not ensure that staff served Resident #83 her 8-ounce water during her lunch meal on 08/26/25. This failure could place residents at risk for dehydration and loss of interest in eating. Findings included: Record review of Resident #65's face sheet, dated 08/28/25, indicated she was an [AGE] year-old female, admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses which included Diabetes mellitus (a group of diseases that affect how the body uses blood sugar).COPD, or chronic obstructive pulmonary disease (a condition caused by damage to the airways or other parts of the lung), and Heart failure (occurs when the heart muscle doesn't pump blood as well as it should). Record review of the order summary report dated 08/28/25 indicated Resident #83 had the following orders: *Carb…

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

Based on observation, interviews, and record reviews, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to maintain proper kitchen sanitation when [NAME] D went outside the kitchen and returned without proper hand hygiene protocols. This deficient practice could place residents who were served from the kitchen at risk for health complications and foodborne illnesses.Findings included: During an observation on 08/27/25 at 11:30 a.m., [NAME] D had some keys on the kitchen counter. [NAME] D removed her keys from the kitchen counter to a container that contained individualized packages of sugar, salt, and pepper. [NAME] D then picked up her keys and went outside the kitchen, and returned without hand hygiene. [NAME] D went over to the counter where another staff member was preparing drinks for the residents, and put her hands near the glasses, and was about to help the other staff member when stopped by the state surveyor. During an interview on 08/27/25 at 11:45…

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 collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 2 of 5 residents (Residents #'s 4 and 12) reviewed for hospice services. 1. The facility failed to obtain Resident #4's most recent updated hospice plan of care. 2. The facility failed to ensure Resident #12's hospice records were a part of their records in the facility. These deficient practices could place residents at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs.Findings included: 1. Record review of Resident #4's face sheet, dated 08/27/25, indicated a [AGE] year-old female who readmitted to the facility on [DATE] with diagnoses which…

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 properly store, prepare, distribute, and serve food in accordance with the professional standards for food service safety 1 of 1 kitchen reviewed for safety requirements.1. The facility failed to ensure spoiled strawberries were not stored in the walk-in cooler. 2. The facility failed to ensure raw meat was not stored on top of ready to eat green apples in the walk-in cooler. 3. The facility failed to ensure food items in the freezer #1, #2 and dry pantry were labeled, dated and sealed. These failures could place residents, who received food and beverages from the kitchen, at risk for health complications, foodborne illnesses, and decreased quality of life.Findings included:During observation and interview in the kitchen on 07/22/25 with the DM at 10:20 a.m. of the walk-in cooler indicated there were:on the first shelf were four unopened, clear 30-ounce containers, each containing strawberries that had a gray hairy like coating. The DM said she did not know when the strawberries arrived, and it looked like…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents had the right to retain and use personal possessions for 1 of 5 residents (Resident #2) reviewed for personal property. LVN B took Resident #2's personal cell phone away from her on 11/9/2024 and it was out of Resident #2's possession until the next shift arrived. This failure could place residents at risk of being deprived of their ability to use personal cell phone. Findings included: Record review of the undated face sheet indicated Resident #2 was an [AGE] year-old female that admitted [DATE] with diagnoses that including: Metabolic encephalopathy (problems with a patient's metabolism causes brain dysfunction with causes ranging from low blood sugar to excess fluid in the brain. Symptoms may cause confusion or coma.), Dementia (conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), and Generalized Anxiety Disorder (excessive and uncontrollable worry about events or activities that…

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 report an incident of possible injury of unknown origin or neglect immediately, but no later 2 hours after the allegation is made if the events that caused the allegation involve abuse or result in serious bodily injury, or no later than 24 hours if the events that cause the allegation do not involve abuse to the State Agency in accordance with State law for 1 of 5 residents (Resident #1) reviewed for incidents. The facility failed to report to State Agency when Resident #1 was located in the visitor bathroom, deceased and a possible head injury, on [DATE]. This failure to report could place the residents at risk for unreported allegations of neglect and injuries of unknow origin not being investigated due to not reporting. Findings included: Record review of Resident #1's physician's orders dated [DATE] indicated Resident #1 was admitted on [DATE], was an [AGE] year-old female, and had diagnoses of cerebral infarction (a condition where part of the…

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

Based on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food prepared by methods that conserve nutritive value, flavor, and appearance and were palatable, attractive, and at a safe and appetizing temperature for 1 of 1 kitchen. The facility did not ensure the oatmeal and bread served for breakfast on 07/30/24 was palatable and the oatmeal recipe was followed. The facility did not ensure the Spanish rice served at the noon meal on 7/30/24 was palatable and the recipe was followed. These failures could place the residents at risk of a decline in their satisfaction and weight loss. Findings included: During confidential interviews on initial rounds on 7/29/24 from 8:30 a.m. to 11:15 a.m., the residents complained about the food being bland and not having flavor. A family member complained that the pureed food was too thick, and they had to add soup to thin it for the resident to be able to eat it. 1.During an observation and interview on 07/30/24 at 8:53 a.m., the pureed test tray contained bread, oatmeal 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 observation, interview and record review, the facility failed to provide food prepared in a form designed to meet individual needs of each resident for 1 of 1 kitchen. The facility did not ensure the pureed oatmeal and bread served for breakfast on 07/30/24 was in the correct food form. This failure could place the residents at risk of choking. Findings included: During a confidential interview on initial rounds on 7/29/24 at 10:03 a.m., a family member complained that the pureed food was too thick, and they had to add soup to thin it for the resident to be able to eat it. During an observation and interview on 07/30/24 at 8:53 a.m., revealed the pureed test tray contained bread, oatmeal and scrambled eggs. The pureed oatmeal was thick, had large lumps, stuck to the spoon when the spoon was lifted out of the oatmeal and was bland. The bread was thick, dry, stuck to the palate upon tasting and was bland. The DM said the oatmeal and the bread were too thick, the oatmeal had lumps, and the food items were bland. She said the possible negative outcome of the pureed food 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 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 3 of 19 residents (Residents #47, #51, & #70) reviewed for incontinent care. CNA E and CNA F did not sanitize/wash their hands between glove changes before, during, and after incontinent care for Residents #47 & #51. CNA H did not change gloves, sanitize/wash her hands between glove changes, touched clean items with dirty gloves, and did not completely clean Resident #70 when providing incontinent care. These failures could place residents at risk of exposure to communicable diseases and infections. Findings included: 1. Record review of a face sheet dated 07/30/24 indicated Resident #47 was an [AGE] year-old female admitted on [DATE]. Her diagnoses included dementia (the loss of cognitive functioning-thinking,…

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 assessments accurately reflected the status for 1 of 19 residents reviewed for assessments. (Resident #70). The facility failed to complete an accurate resident assessment for Resident #70. Resident #70's resident assessment did not reflect that she received an antidepressant medication. This failure could place residents at risk of not having individual needs met and a decreased quality of life. Findings included: Record review of a face sheet dated 07/30/24 indicated Resident #70 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included anxiety disorder (persistent and excessive worry that interferes with daily activities) and depression (mental illness that negatively affects how you feel, the way you think and how you act). Record review of the July 2024 physician orders indicated Resident #70 had an order dated 03/13/24 for Paroxetine (antidepressant) 20 mg daily for anxiety . Record review of MDS dated [DATE] indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 2 of 19 residents reviewed for care plans. (Residents #59 and #70) The facility did not have a care plan to address Resident #59's nausea and vomiting. The facility did not have a care plan to address Resident #70's incontinence of bowel and bladder. This failureThe failures could place residents at risk of not having individual needs met and not receiving needed services. Findings included: 1. Record review of the face sheet dated 07/31/24 indicated Resident #59 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included malignant neoplasm of the bone (bone cancer). Record review of an MDS assessment dated [DATE] indicated Resident #59 had a BIMS of 11 indicating she had moderately impaired cognition. Record review of physician's orders for July 2024 indicated Resident #59 had an order…

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 residents who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents reviewed for respiratory care and services. (Resident #292) The facility failed to administer BIPAP (a machine that can help people breathe when they have trouble breathing due to health issues) therapy as ordered by the physician for Resident #292. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: Record review of physician orders dated July 2024 indicated Resident #292, admitted [DATE], was a [AGE] year-old female with a diagnosis of acute respiratory failure (a condition that occurs when the lungs cannot release enough oxygen into the blood to remove carbon dioxide {a waste product that your body…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a physician, physician assistant, nurse practitioner, or clinical nurse specialist provided orders for the resident's immediate care and needs for 1 of 19 residents reviewed for physician services. (Resident #59) LVN D notified the on-call NP of Resident #59 having nausea and vomiting and the on-call NP did not provide an order for the resident's need. This failure could place residents at risk of not having individual immediate needs met and a decreased quality of life. Findings included: Record review of the face sheet dated 07/31/24 indicated Resident #59 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included malignant neoplasm of the bone (bone cancer). Record review of an MDS assessment dated [DATE] indicated Resident #59 had a BIMS of 11 indicating she had moderately impaired cognition. Record review of physician's orders for July 2024 indicated Resident #59 had an order dated 02/05/24 for outpatient…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 8 residents reviewed for medication administration. (Resident #59) LVN D did not administer prn nausea medication ordered for Resident #59 when she requested the medication. This failure could place residents at risk for not receiving the desired therapeutic effects of medications and decreased quality of life. Findings included: Record review of the face sheet dated 07/31/24 indicated Resident #59 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included malignant neoplasm of the bone (bone cancer). Record review of an MDS assessment dated [DATE] indicated Resident #59 had a BIMS of 11 indicating she had moderately impaired cognition. Record review of physician's orders for July 2024 indicated Resident #59 had an order…

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 all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access, for 3 of 3 medications reviewed for security. The facility did not ensure Plavix (antiplatelet), Lasix (medication used to remove fluid from the body), and Lexapro (antidepressant) were stored securely when the medications were left unattended at the nursing station. This failure could place residents at risk of harm by misappropriation of property and drug diversion. Findings included: During an observation on 07/30/24 at 04:57 a.m., medications received from the pharmacy in a pharmacy bag was left at the 100/200 Halls nurses' station unattended and no staff was in eyesight. The medication was accessible to staff, residents or visitors. During an observation on 07/30/24 at 05:03 a.m., LVN D returned to the nurses' station and did not address the medications on the desk. During an observation on 07/30/24 at 05:05 a.m., LVN D left the nurses' station to answer a call…

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 electronically transmit encoded, accurate, and complete MDS data to the CMS System within 14 days after the facility completed the resident's assessment for 1 of 3 residents reviewed for MDS assessments. (Resident #70) The facility failed to transmit to the CMS system Resident #70's discharge MDS assessment dated [DATE]. This failure could place the residents at risk for not having the MDS assessment transmitted as required. Findings included: During an interview and record review on 05/24/23 at 04:15 PM an admission MDS dated [DATE] indicated Resident #70 admitted on [DATE]. The discharge MDS indicated she was discharged on 02/02/23. The discharge MDS in Resident 70's EMR indicated the status was Exported. The MDS Nurse and the Corporate MDS Nurse said a completed and transmitted MDS would have Accepted under the status. They said since she was discharged it was not looked at again by them. They said it was their responsibility to ensure the MDSs were…

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.