Lampstand Nursing and Rehabilitation

Based on observation, interviews, and record reviews the facility failed to ensure the resident environment remained as free of accident hazards as is possible for one of three housekeeping carts (Housekeeping Cart #1) reviewed for hazards.The facility failed to ensure Housekeeping Cart #1, with chemicals inside the compartments, was locked when unsupervised. This failure could place residents at risk for injuries, illness, and hospitalization.Findings included:Observation on 04/08/2026 at 9:15 am revealed Housekeeping Cart #1 was located near 100 hall. The compartment where chemicals were stored was not locked. The compartment had glass cleaner, disinfectant cleaner, tub and tile cleaner, and bio waste degrader. Housekeeper G was not standing near the housekeeping cart, and no other staff was near the unlocked housekeeping cart. Housekeeper G was at the end of 100 hall. There were not any residents near the unlocked housekeeping cart.During an interview on 04/08/2026 at 9:25 a.m., Housekeeper G stated the housekeeping cart was expected to be locked anytime housekeeper walked away…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to ensure that a resident who is incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 ( Resident #16) of three residents reviewed for catheter care. The facility failed to have the appropriate size foley catheter ( a medical device used to drain urine from the bladder) in the facility when Resident #16 was complaining of pain from his catheter on 04/08/2026.This failure could place residents at risk for infection, sepsis( a serious condition in which the body responds improperly to an infection, causing organ damage) and hospitalization.Findings included:Review of Resident #16's face sheet, dated 04/09/2026, reflected Resident #16 was a [AGE] year-old-male admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus without complications ( a diagnosis of diabetes where high blood sugar exists but had not caused chronic damage to organ systems), benign…

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 appropriate treatment and services to prevent complications of enteral feeding for one (Resident #33) of two residents reviewed for enteral feeding (a tube is inserted directly through the abdomen to the stomach to provide nourishment). The facility failed to ensure RN D attended to a flow error alarm on a feeding pump for 45 minutes for Resident #33 on 04/08/2026. This failure could place residents at risk of malnutrition, pain, and/or significant changes in condition. Findings included: Record review of Resident #33's admission record, dated 04/08/2026, reflected a [AGE] year-old female admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses that included dysphagia following cerebral infarction (difficulty swallowing after blood flow to the brain was blocked causing damage to the brain), Gastrostomy status (a tube is inserted directly through the abdomen to the stomach to provide nourishment 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 ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 4 medication carts ( Medication Cart #1) reviewed for medication storage. The facility failed to ensure Medication Cart #1 was locked and medications were secure and not accessible to other staff, residents or visitors.This failure could place residents at risk of having unauthorized access to prescriptions, biologicals, and over-the-counter medications.Findings include:Observation on 04/09/2026 at 1:03 pm revealed medication cart #1 was unlocked against the wall by the common tv area. The back of the cart was against a half wall with the top open to the tv common area. The drawers of the medication cart were facing the area near the nurse's desk. The locking mechanism was protruding outward on the medication cart. The State Surveyor opened the drawers and captured photos. The med aide…

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 reviews, the facility failed to provide food that was prepared in a form designed to meet individual needs and by methods that conserve nutritive value and flavor for 4 residents who ate pureed diets from 1 of 1 kitchen reviewed for food and nutrition services.The facility failed to ensure that the lunch meal on 04/09/2026 was served at the correct temperature and was palatable. The facility failed to ensure [NAME] A refrained from adding an unmeasured amount of liquid to fish sticks, pureed meal during lunch service on 4/10/2026. This failure could affect residents at risk for diminished or altered nutritional status and potential weight loss.Email received from the Administrator on 04/09/2026 at 8:23 revealed 4 residents at the facility received a pureed diet. Observation and interview conducted on 04/10/2026 at 10:43 AM revealed [NAME] A placed an unmeasured amount of broth into the puree blender with the fish sticks. She did not measure the broth. [NAME] A proceeded to puree the fish sticks. She stated there were 4 residents on puree diets.…

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 in accordance with accepted professional standards and practices that are completely and accurately documented for 1 (Resident #26) of 7 residents reviewed for medical records. The facility failed to maintain complete and accurate documentation of provided incontinent care for Resident #26. This deficient practice could place residents at risk for not receiving proper care due to incomplete and inaccurate records.The findings include: During an attempted interview with Resident #26 on 4/09/2026 at 2:15 p pm. to verify if he was changed or needed to be changed, he was unable to give comprehensive answer regarding his incontinent status. Record review of Resident #26's face sheet, dated 04/10/2026, reflected [AGE] year-old male originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included: unspecified convulsions (sudden, involuntary, and often violent contractions of muscles, characterized by…

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 for each resident, consistent with the resident rights, 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 4 (Resident #1) residents reviewed for measurable objectives and timeframes. The facility failed to enter dates into the Care Plan when Resident #1 sustained bruises, and no goal or interventions for the resident's diagnosis of schizophrenia (a mental health disorder). This failure could result in inadequate care due to incomplete and inaccurate care plans. The findings include: Record review of Resident #1's face sheet, dated 12/15/25, reflected a -[AGE] year-old male who was admitted to the facility on [DATE] and re-readmitted [DATE]. Resident #1 had diagnoses which included: TBI (traumatic brain injury), ID (intellectual disability,…

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 (Resident #1) of 5 residents observed for pharmacy services.The facility failed to assure Resident #1 was aware of the medications that he was administering.This failure could affect residents receiving medications by placing them at risk for medication errors. Findings included:Review of Resident #1's MDS assessment, dated 12/4/2025, reflected he was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses that included unspecified convulsions (A seizure occurs due to an electrical disturbance in the brain, while a convulsion describes the involuntary action of jerking and contraction), schizophrenia, unspecified (a serious mental health condition that affects how people think, feel and behave), weakness (the state…

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 the legal surrogate so designated may exercise the resident's rights to the extent provided by state law for 1 of 7 (Resident #1) residents reviewed for resident rights. The facility failed to ensure that LVN F did not care for Resident #1 on 10/08/2025 and 10/09/2025 after the RP told him to leave the room and not care for Resident #1 after 10/08/2025 at 7:32AM. This failure couple place residents whose rights are exercised through a legal representative at risk of not having their rights exercised.Findings Include: Record Review of Resident #1's Facesheet printed on 10/08/2025 revealed a 37 y/o male, admitted to the facility on [DATE]. Diagnoses included unspecified convulsions, schizophrenia, weakness, and personal history of traumatic brain injury (TBI). Record review of Resident #1's admission MDS, dated [DATE], reflected no BIMS score. Section GG -Functional Abilities - admission section reflected Resident #1 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, 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 Resident (Resident #1) of four residents reviewed for medication storage, in that: A bottle of Nystatin Topical Powder was found on 04/24/25 at 12:55 pm left unattended and unsecured at Resident #1's bedside. This deficient practice placed residents at risk for unauthorized access, drug diversion, or ingestion of medications leading to harm. Findings included: Review of Resident #1's face sheet dated 0414/25 reflected a [AGE] year-old female admitted to the facility on [DATE]. She had diagnoses of diabetes mellitus Type 2 (a chronic condition where the body either doesn't produce enough insulin, or the cells don't properly respond to the insulin produced, leading to elevated blood sugar levels), mild cognitive impairment, disorder of pituitary gland, and obesity. Review of Resident #1'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 interviews, observations, and record reviews, the facility failed to provide a notice of residents' rights to the residents during the residents' stay for three out of four halls. Information of residents' rights was posted only on Hallway 4 and not accessible for viewing by all facility residents. Resident rights were not included in residents' admission packets since November 2023. These failures placed residents at risk of a decreased quality of life, decreased awareness or their rights, and decreased execution of their resident rights. The findings were: Record review of facility's admission packet dated 10/19/22 reflected Health Care Center Policies, Information, and Required Notices: Acknowledgement of Receipt of Policies, Information, & Required Notices - Statement of Resident Rights Notice of rights and services (19.403)(B)(6). The Health Care Center must inform the resident, the resident's next of kin or guardian, both orally and in writing, a language that the resident understands. Of his rights and all rules and regulations governing resident conduct 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, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. 1. The facility failed to properly label food and dispose of store perishable foods in the dry storage pantry and walk in fridge. 2. The facility failed to ensure the ice machine was properly cleaned. These failures could place residents who were served from the kitchen at risk for consuming hazardous expired food and developing foodborne illnesses. Findings Included: Observation on 02/10/25 at 9:30 am revealed a 50-pound bag of yellow onions sitting in water on the floor in the dry storage room. Observation on 02/10/25 at 9:38 am revealed cold eggs sitting on the stove top in a pan with a spatula in the pan. Observation on 02/10/25 at 9:39 am revealed a pitcher of tea and a pan of cake sitting in the food warmer. The warmer was in the off position. Observation on 02/10/25 at 10:32 am revealed the inside of the ice machine had an unknown black slime by…

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, and to help prevent the development and transmission of communicable diseases and infections, for two of two medication aides (MA A and MA B) observed for infection control practices during medication pass. A) MA A failed to sanitize the blood pressure cuff during medication pass after using it on Resident #46 then using it on Resident #45. B) MA B failed to sanitize the blood pressure cuff during medication pass after using it on Resident #133 then using it on Resident #28. This failure could place residents who require assistance with medication administration at risk for healthcare associated cross-contamination and infections. Findings included: A) Review of Resident #46's face sheet dated 02/11/2025 reflected she was admitted on [DATE] and readmitted on [DATE] with the following diagnoses anemia (Deficiency 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.

Based on observation, interview, and record review, the facility failed to maintain all mechanical and electrical equipment in safe operating condition in 1 of 1 kitchen, in that: The coffee brewing system was not heating. The left side of the double oven was not heating. One well on the steam table was not heating The mobile heated delivery cart was not maintaining a proper temperature. This deficient practice could place residents at risk of decreased resident's quality of life who receive meals from the kitchen and could result in foodborne illness for residents who received meals from the kitchen. Findings included: Observation in the kitchen on 02/10/2025 at 9:15 am revealed the heated delivery cart on with the temperature reading 75 degrees . Observation in the kitchen on 02/10/2025 at 9:15 am revealed the coffee pot had an error message stating, heating element malfunction. Observation in the kitchen on 02/10/2025 at 11:30 am revealed the left well of the steam table was not working. Observation in the kitchen on 02/10/2025 at 11:30 am revealed the left side compartment 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.

Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service in 1(DA B) of- 8 1 kitchen staff in that: DA B had not received training from facility management staff, mandatory online training, or obtained a food handlers certificate before working in the kitchen. This could leave the resident's at risk of consuming improperly handled food and a contracting a foodborne illness Findings included: Record Review on 02/12/25 at 2:30 PM of DA B's employee file revealed her application and background check, but nothing else. In an interview with DA B on 02/10/25 at 9:30 am, she stated that she had not been trained on how to use the dishwasher,. She stated she was not sure what temperature was appropriate for the dishwasher and what level the disinfectant was supposed to be at. In an interview with DA A on 02/10/25 at 9:35 am, she stated that DA B was hired on 02/04/25 and that she was trying to help her out, but was not able to teach her everything. She…

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 food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. The facility failed to ensure [NAME] C properly used proper hand hygiene during food preparation. This failure could place residents who ate food from the kitchen at risk for foodborne illness. Findings included: Observation on 01/16/2025 between 10:45 AM and 11:15 AM, [NAME] C was preparing residents' lunch meal. She was not wearing gloves when she was stirring food in pots on the stove. [NAME] C exited from the stove area and pushed a utility kitchen cart from the stove area located in front of the kitchen to the area back of the kitchen. [NAME] C touched her clothes and adjusted her hair net prior to picking up gloves from the container. [NAME] C did not wash or sanitize her hands prior to picking up the fourchettes ( a component of the glove where the fingers fit into the glove) on the gloves with her fingers on both hands. [NAME] C proceeded to put her…

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's right to a safe, clean, comfortable, and homelike environment for 1 (Resident #1) of 4 residents reviewed for environment. The facility failed to ensure Resident #1's room was free of odor and soiled sheets. This failure placed residents at risk of living in an uncomfortable environment leading to a diminished quality of life. Findings included: Record review of Resident #1's face sheet, dated, 01/17/2025, reflected an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included Parkinson's disease without dyskinesia, without mention of fluctuations (a progressive movement disorder of the nervous system. Dyskinesia (involuntary, erratic, writhing movements of the face, arms, legs, or trunk)), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a decline in mental ability…

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 did not ensure prompt efforts were made to document a resident grievance for one (Resident #2) of four residents reviewed for grievance resolutions. The facility failed to promptly document grievances regarding answering call lights and begin an investigation. This failure placed resident at risk of not having their grievances resolved. Findings included: Record review of Resident #2's face sheet, dated, 01/17/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had diagnoses which included chronic obstructive pulmonary disease, unspecified (a long- term lung disease that makes it hard to breathe), polyneuropathy, unspecified (a condition that occurs when nerves are damaged, causing problems with sensation, coordination, and other body functions), and morbid obesity with alveolar hypoventilation ( a severe form of obesity that can be life-threatening. Record review of Resident #2's admission MDS…

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 who was unable to carry out activities of daily living received the necessary services to maintain functional abilities for 1 (Resident #3) out of 7 residents reviewed for ADLs. The facility failed to ensure Resident #3 was placed in a safe and comfortable position while eating. This failure placed the resident at risk of discomfort and choking/aspiration. Findings included: Review of Resident #3's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of unspecified fracture of left femur, multiple sclerosis (a disease which causes nerve damage and disrupts communication between the brain and the body), dysphagia (difficulty swallowing), and cognitive communication deficit (communication impairment causing trouble reasoning and making decisions while communicating). Review of Resident #3's comprehensive MDS, dated [DATE], reflected a brief interview for mental status (BIMS) score…

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 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 one (Resident #3) out of five residents reviewed for infection control. 1. The facility failed to ensure staff wore PPE while providing care for Resident #3. 2. The facility failed to ensure staff followed the facility policy and tied back long hair to minimize cross contamination. These failures placed the residents at risk of cross contamination and infection. Findings included: Review of Resident #3's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of unspecified fracture of left femur, multiple sclerosis (a disease which causes nerve damage and disrupts communication between the brain and the body), dysphagia (difficulty swallowing), and cognitive communication deficit…

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 residents received services in the facility with reasonable accommodations of each resident's needs for 1 of 8 residents (Resident #1) reviewed for resident rights in that: The facility failed to ensure Resident #1's call light was within reach on 08/14/24. This failure could affect residents who needed assistance with activities of daily living and could result in needs not being met. Findings included: Record review of Resident #1's admission record dated 08/14/24 documented a 63year-old female admitted on [DATE]. Resident #1 had diagnoses which included: cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it) essential primary hypertension (abnormally high blood pressure that not caused by a medical condition), dysphagia (difficulty swallowing), and general anxiety disorder (mental health condition that causes people to feel constant, excessive, and unrealistic worry about…

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 review and revise care plans for 1 (Resident #1) of 5 residents reviewed for care plan revision. The facility failed to complete a quarterly review and revision of Resident #1's care plan by 03/29/24. Resident #1's last care plan was reviewed, revised, and completed on 12/29/23. This failure could place residents at risk of not having their individual care needs met in a timely manner or a diminished quality of life. Findings included: Record review of Resident #1's admission record, dated 04/25/24, revealed he was a [AGE] year-old male who was admitted to the facility on [DATE], had an RP, and diagnoses including unspecified dementia (A group of thinking and social symptoms that interferes with daily functioning), unspecified recurrent major depressive disorder, unspecified mood [affective] disorder, cognitive communication deficit, unspecified chronic obstructive pulmonary disease (A group of lung diseases that block airflow and make it difficult…

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 under sanitary conditions in the facility's only kitchen reviewed for kitchen sanitation. The facility failed to discard of food products that were past the use by date or in accordance with facility policy. The facility failed to properly label left over food held in the walk-in refrigerator. The facility failed to ensure that their three-door refrigerator was operating at a temperature of 41 degrees Fahrenheit or less and that temperatures were properly logged. The facility failed to remove dented cans from the dry storage area to prevent service to residents. The facility failed to clean the industrial can opener. The facility failed to clean up a liquid spill in the kitchen. These failures could place the residents at risk of cross contamination, loss of nutritional value, weight loss, and foodborne illness. Findings included: Observation on 01/07/2024 at 9:09 AM revealed that the facility's three door refrigerator's exterior thermometer displayed 48 degrees…

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 enter baseline care plans for three of three Residents (Resident #136, Resident #138 and Resident #141) admitted within the last month and reviewed for new admissions to the facility. The facility failed to follow its policy which reflected residents must have a baseline care plan on admission and it must be presented to the resident. This failure put residents at risk for not being provided assistance as needed. Findings include: Resident #136 Review of the Face Sheet for Resident #136 reflected he was admitted on [DATE] with diagnoses of Sepsis, Acute Respiratory Failure, Fluid overload, Malignant Melanoma of skin, bacterial pneumonia, Depression, Atrial Fib, Cerebrospinal disease, COPD, Cellulitis of left lower limb, Pressure Ulcer of Sacrum. Review of MDS assessments for Resident #136 reflected no assessments had yet been completed. Review of Resident #136's assessment records reflected no baseline or other care plans were present for the 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 residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 3 of 22 residents (Resident #8, Resident #33, Resident #57 ) reviewed for ADL's. A) The facility failed to ensure assistance was provided for showering/bathing and personal hygiene for Resident #8. B) The facility failed to provide nail care for Resident #33. C) The facility failed to provide nail care for Resident #57. These failures could lead to a reduction in quality of life by creating isolating behaviors due to embarrassment, loss of self-esteem, and dignity and could contribute to health-related issues from lack of hygiene. Findings Included: A) Review of Resident #8's Face Sheet dated 01/08/2024 reflected a [AGE] year-old male admitted on [DATE] with the following diagnoses Autistic Disorder (A condition related to brain development that impacts how a person perceives 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 two of four residents reviewed with limited range of motion (Resident #33 and Resident #51), received appropriate treatment and services to prevent a decline in range of motion. A) The facility failed to ensure Resident #33 had interventions in place for her hand contractures to prevent further decline of her hand, associated pain and pressure areas. B) The facility failed to ensure Resident #51 had interventions in place for her left-hand contracture (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen and a decrease in ROM) and left knee contracture to prevent further decline of the range of motion in her left hand and left knee. This deficient practice placed residents with contractures at risk for decrease in mobility, range of motion, and contribute to worsening of contractures. Findings Include: A) Review of Resident #33's Face Sheet reflected a [AGE]…

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 and record review, the facility failed to accommodate the needs and preferences for two of twenty residents (Residents #33 and #74) reviewed for accommodation of needs, in that: The facility failed to ensure that Residents #33 and #74 had their call lights in reach. This deficient practice could place residents at risk for not receiving timely care and nursing interventions. Findings included: Resident #33 Review of Resident #33's Face Sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnosis cerebral palsy, severe intellectual, paralytic syndrome (loss of weakness or movement). Review of Resident #33's Quarterly MDS assessment dated [DATE] reflected Resident #33 was assessed to have a BIMS score of five (5) indicating severe cognitive impairment. Resident #33 required extensive assist with all ADLs. Further review reflected Resident #33 had impairment in range of motion (ROM) to the upper (shoulder, elbow, wrist, hand) and lower extremity (hip,…

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 recognize the residents right to formulate an advance directive for one of three residents (Resident #138) reviewed for DNR status. The facility failed to enter a life code status for Residents #138 in his chart until pointed out by the surveyor on second day of survey. This failure could place residents at risk of not having their end of life wishes met. Findings include: Review of the Face Sheet for Resident #138 reflected he was admitted on [DATE] with diagnoses of Fluid Overload and Pyuria. On 1/09/24 an admission MDS assessment had not been completed for Resident #138. Review of the Care Plan for Resident #138 dated 1/06/24 reflected interventions were in place for: risk of pressure ulcer development, fall risk, Foley Catheter, Diuretic therapy, ADL deficits, and Fluid Overload. A DNR intervention was added to the Care Plan on 1/08/24 after surveyor intervention. Review of Resident #138's out of hospital Do Not Resuscitate Order (DNR) dated 1/05/24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 1 resident (Resident #74) reviewed for physical environment, in that: The facility failed to maintain a clean commode free from feces. These failures could affect resident by placing him at risk for diminished quality of life due to the lack of a well-kept environment, infection, and illness. Findings included: Review of Resident #74's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] readmission date 11/21/2023 with the following diagnosis acute cerebrovascular, schizophrenia, bipolar disorder, and unspecified dementia, unspecified severity, without behavioral 11/21/2023 secondary disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #74's Quarterly Minimum Data Set (MDS) dated [DATE] reflected Resident #74 was assessed to have a Brief Interview for Mental Status (BIMS) score of three (3) indicating…

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 received care, consistent with professional standards of care to prevent development or worsening of diabetic ulcers for one of five (Resident #1) residents reviewed for diabetic ulcers. The facility failed to ensure Resident #1 received her physician ordered diabetic ulcer preventative measures routinely. This failure could place residents at risk for worsening pressure ulcers leading to discomfort, pain, and potential infections. Findings included: Review of Resident #1's Face sheet dated 01/08/2024 revealed a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses Chronic Kidney Disease Stage 4 (It is the last stage before kidney failure. It is likely someone with stage 4 will need dialysis or a kidney transplant in the near future.), Myocardial Infarction (Damage to the heart muscle caused by a loss of blood supply due to blocks in the arteries.), and Type 2 Diabetes Mellitus (A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that residents received care, consistent with professional standards of care to prevent development or worsening of pressure ulcers for one of one (Resident #32) reviewed for pressure ulcers. The facility failed to ensure Resident #32 received her physician ordered pressure ulcer preventative measures routinely. This failure could place residents at risk for worsening pressure ulcers leading to discomfort, pain, and potential infections. Findings included: Review of Resident #32's Face Sheet dated 01/09/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, type 2 diabetes and morbid (severe) obesity. Record review of Resident #32's comprehensive MDS dated [DATE] reflected Resident #32's functional status required extensive assistance of two-person physical assist for…

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 ensure the resident environment remains free of accident hazards as possible. The facility failed to ensure a needle was disposed of safely when a blood draw needle was found in a Resident #48's room with blood in tubing. This failure put residents in danger of accidental injury and exposure to blood borne illness. Findings include: Observation on 1/07/24 at 9:07 am of Resident #48's room revealed a used needle (butterfly type) with blood visible in tubing was on the extra bed in the room. In an interview at the time Resident #48 stated she had a lab test some days earlier but she stated she rarely touched the extra bed. Review of the Face Sheet for Resident #48 reflected she was admitted on [DATE] with a diagnoses of: Hypo-osmolality and Hyponatremia, Restless legs syndrome, Anxiety disorder, Bipolar disorder, Chronic pain syndrome and congenital spinal deformity. Review of the MDS assessment for Resident #48 dated 12/15/23 reflected a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents who are incontinent of bladder receive appropriate treatment and services to prevent urinary tract infections for two of four residents reviewed for catheters (Resident #22, and Resident #138). A) The facility failed to ensure Resident #22's received care to prevent urinary tract infections when they stored his catheter bag on the floor. B) The facility failed to ensure Resident #138 received care to prevent urinary tract infections when they stored his catheter bag on the floor. These failures could place residents with foley catheters at risk for urinary tract infections and change of condition. Findings included: A) Review of Resident #22's Face sheet dated 01/08/2024 reflected a [AGE] year old male admitted on [DATE] with the following diagnosies Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), Chronic Diastolic (Congestive) Heart failure (A condition where the heart can't…

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 respiratory care was provided consistent with professional standards of practice for 2 of 6 Residents (Resident #22 and #59) reviewed for respiratory care. A) The facility failed to ensure Resident 22's oxygen tubing was changed weekly and his oxygen concentrator filter was clean and in place. B)The facility failed to ensure Resident #59's oxygen tubing and nasal canula were dated and changed. The facility further failed to ensure Resident #59 was comfortable by receiving humidified air to prevent dried nasal passages. This failure could place residents who use respiratory equipment at risk for respiratory infections. Findings included: A) Review of Resident #22's Face sheet dated 01/08/2024 reflected a [AGE] year old male admitted on [DATE] with the following diagnoses Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), Chronic Diastolic (Congestive) Heart failure (A condition where the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews the facility failure to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles. The facility failed to ensure safe medication administration when an observation during medication pass on [DATE] revealed five loose pills were found within the medication cart's drawers and greatly increased the chances for accident administration to the wrong resident. This failure put residents at risk for accidental ingestion of medication that was not prescribed to them and subsequent side effects. Findings include: Observation of the Medication Cart for hall 100 on [DATE] at 11:00 AM revealed medication was loose in the cart with Med Aide M. Observation revealed OTC meds were not marked for opening dates. Med Aide Sterling stated the facility policy indicated they no longer had to mark opening dates on OTC medications. Observation revealed 5 loose pills were found in the medication drawer, one clear oblong, two white oblong, 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 observation, interview and record review, the facility failed to provide reasonable accommodation of one of one (Resident #31) resident reviewed with needs and preferences to assist the resident in maintaining and/or achieving independent functioning, dignity, and well-being to the extent possible in accordance with the resident's own needs and preferences. The staff did not accommodate Resident #31's dietary preferences. This failure could affect residents who have told the facility their food preferences and rely on the facility to not serve them food that they have told them they dislike to the detriment to their dignity and quality of life . Findings include: Review of Resident #31's Face Sheet dated 01/07/2023 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of major depressive disorder, cognitive communication, mood [affective] disorder, vascular dementia, and hemiplegia and hemiparesis following cerebral infarction 04/09/2022 secondary affecting left dominant…

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 a safe functional environment for room [ROOM NUMBER], 200 hall, Resident #22, staff, and the public. A large crack in the floor was observed from the outside wall in room [ROOM NUMBER](Resident #22's room) which extended all the way through the room and across 200 hallway. Ants were noted building a mound from the crack under Resident #22's bed. This failure could place residents at risk for an unsafe environment. Findings included: Review of Resident #22's Face sheet dated 01/08/2024 reflected a [AGE] year old male admitted on [DATE] with the following diagnoses Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), Chronic Diastolic (Congestive) Heart failure (A condition where the heart can't fill up with blood properly due to stiffening of the left ventricle.) and retention of urine (A condition where your bladder doesn't empty all the way or at all when you urinate.). Review of 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.