Legacy Nursing and Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a baseline care plan that included instructions needed to provide effective and person-centered care of the residents, for 1 of 4 residents (Resident #1) reviewed for baseline care plans. The facility failed to ensure a baseline care plan was completed within 48 hours of admission that addressed the care needs of newly admitted Resident #1. This failure could place residents at risk of not receiving necessary care and services. The findings included: Record Review of Resident #1's face sheet dated 02/05/2026 reflected a [AGE] year-old female admitted on [DATE] with the following diagnoses frontal lobe and executive function deficit following cerebral infarction ( damage in the brain's frontal region, causing impairments with planning, organizing, initiating tasks, decision-making, emotional control, and behaviors), PSOAS- a long, ribbon-shaped muscle in your back- abscess ( a rare, severe collection of pus within the muscle…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure residents who were trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 resident (Resident #2) of 9 residents reviewed for trauma-informed care. The facility failed to ensure Resident #2 had a trauma screening that identified possible triggers when Resident #2 had a history of trauma. This failure could place residents at an increased risk for psychological distress due to re-traumatization and decreased quality of life. Findings included: Review of Resident # 2's Face sheet dated 02/05/2026 at 11:34 AM reflected an [AGE] year-old male, admitted on [DATE] with the following diagnoses: dementia and altered mental status (when a person exhibits symptoms like confusion or disorientation) Review of Resident #2's Quarterly 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 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 3 out of 5 residents reviewed for pharmacy services, in that: The facility failed to administer medications within the required timeframe for 3 residents (Resident #1, Resident #2 and Resident #3) of 5 residents resulting in late medication administration. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, could result in worsening or exacerbation of chronic medical conditions, and hospitalization.Findings included:Resident #1Review of Resident #1's face sheet dated 9/25/2025 reflected an [AGE] year-old male admitted on [DATE] with diagnoses that included: Parkinson's disease (chronic, progressive brain disorder that affects movement), Hemiplegia (paralysis on one side 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.

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 environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #5) out of 5 residents reviewed for infection control. The facility failed to clean up blood splatters on the floor of Resident #5's room after IV therapy.These failures placed residents at risk of transmission and/or spread of blood borne pathogens including infections or contagious diseases which could lead to infections and hospitalization.Findings included:Review of Resident #5's face sheet dated 9/25/2025 reflected resident was an [AGE] year-old female admitted on [DATE] with diagnoses: metabolic encephalopathy, hypertension (high blood pressure), atrial fibrillation (heart rhythm disorder), hypothyroidism (thyroid disorder), vitamin deficiency. Review of Resident #5's progress notes dated 9/22/2025 reflected .MD informed who ordered…

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 incorporate the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning and transitions of care for one of four residents (Resident #1)reviewed for PASRR services . The facility failed to submit a NFSS request form for PASRR Specialized Services within 20 business days after PASRR Comprehensive Service IDT Meeting on 12/23/2024. This failure could place residents at risk of not receiving needed individualized care, and specialized services to meet their needs. Findings include: Record review of Resident #1's face sheet, dated 06/11/2025, reflected a [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, and without mention of fluctuations (did not experience involuntary, erratic movements and there are no documented variations in the severity of their symptoms) 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 interview and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for two (Resident #1 and Resident #2) of four resident reviewed for catheters. 1. The facility failed to ensure Resident #1 had catheter care orders from 04/02/2025 to 05/07/2025. 2. The facility failed to ensure Resident #2 had catheter care orders from 05/09/2025 to 05/13/2025. These failures could place residents who required incontinent care at risk for development of new or worsening urinary tract infections or pain. Findings included: Review of Resident #1's face sheet dated 05/14/2025 revealed an [AGE] year-old man admitted on [DATE] with diagnoses of obstructive and reflux uropathy (blockage in urinary tract that prevents normal urine flow), dehydration, dysphagia (difficulty swallowing), and other acute osteomyelitis, right ankle and foot. Review of Resident #1's admission MDS dated [DATE] reflected a BIMS score of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 1 of 3 residents (Resident #48) reviewed for ADL's. The facility failed to ensure assistance was provided for repositioning and incontinent care every 2 hours for Resident #48 when he was observed to be left in his Geri-chair on 05/05/2025 from 7:00 AM until 4:00 PM. (9 hours). This failure could place residents at risk of not being provided care and assistance when needed. Findings Included: Review of Resident #48's face sheet dated 05/06/2025 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses intracranial injury (head injury), spastic hemiplegia affecting dominant side (Hemiplegia is a symptom that involves one-sided paralysis.), contracture of left hand (A permanent tightening of the muscles, tendons, skin, and surrounding tissues 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 observations, interviews, and record review the facility failed to ensure pain management was provided to residents who required such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 of 3 (Resident #150, and Residents #85) residents reviewed for pain management. A) The facility failed to ensure Resident #150 effective pain management by not evaluating effectiveness of current pain medications and not having her current pain medications available for administration. B) The facility failed to ensure that Resident #85 received at least daily assessments of pain for 34 of 49 days. This failure could place resident at risk for increased pain causing undo suffering. Findings included: A) Review of Resident #150 face sheet dated 05/06/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses chronic pain syndrome, and other specified disorder of bone density and structure,…

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, record review and interviews, the facility failed to prepare food by methods that conserve nutritive value for 1 of 1 kitchen reviewed for food and nutrition services. 1. The facility failed to ensure Dietary [NAME] K refrained from adding an unmeasured amount of liquid from cooked carrots to puréed carrots during meal service on 5/6/2025. 2. The facility failed to ensure Dietary [NAME] K refrained from adding an unmeasured amount of pan juices to puréed roast during meal service on 5/6/2025. This failure had the potential to affect all residents who received puréed diets prepared in the facility's kitchen, placing those residents at risk for diminished or altered nutritional status and potential weight loss. Findings included: Observation on 5/6/2025 at 10:24 AM revealed Dietary [NAME] K placed cooked carrots into the puree blender. She began to add unmeasured liquid from the cooked carrots to the puree blender. Dietary [NAME] K added unmeasured liquid twice to the puree blender with cooked carrots. Dietary [NAME] K proceeded to prepare the puréed roast 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.

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen. 1. The facility failed to label and date all food items located in the walk-in refrigerator and in the dry food pantry area on 5/5/2025, 5/6/2025, and 5/7/2025. 2. The facility failed to discard expired food items located in the walk-in refrigerator and in the dry food pantry area. 3. The facility failed to clean and sanitize its cooking equipment, including the deep fryer and two ovens. 4. The facility failed to ensure that dietary staff wore hair restraints (e.g. beard restraints) to prevent hair from contacting food, per current Food Code. These failures could place residents who received meals from the kitchen at risk of foodborne illnesses. The findings included: Observation during the initial tour of the kitchen on 5/05/2024 beginning at 07:17 AM, the following was observed: Walk-in refrigerator: o Bag of coleslaw-not dated, not labeled, expiration date-4/25/2025. o Carton of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a baseline care plan that included instructions needed to provide effective and person-centered care of the resident, for one of four residents (Resident #150) reviewed for baseline care plans. The facility failed to ensure a baseline care plan was completed within 48 hours of admission that addressed the care needs of newly admitted Resident #150. This failure could place residents at risk of not receiving necessary care and services. The findings included: Review of Resident #150 face sheet dated 05/06/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses chronic pain syndrome, and other specified disorder of bone density and structure, multiple sites. Review of Resident #150 EMR reflected the only MDS completed was her entry MDS dated [DATE]. Review of her nursing admission assessment dated [DATE] completed by LVN E reflected she was assessed for pain on admission with the pain…

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 develop and implement a comprehensive care plan that describes the services that are to be furnished to maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 18 residents (Resident #48), in that: The facility failed to ensure Resident #48's comprehensive care plan reflected a plan of care for his left hand and neck contractures (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen and a decrease in ROM). This failure could place residents at risk for not having care needs identified and a plan to address those needs developed. Findings included: Review of Resident #48's face sheet dated 05/06/2025 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses intracranial injury (head injury), spastic hemiplegia affecting dominant side (Hemiplegia is a symptom that involves one-sided…

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 review and update care plan for one of twelve residents (Resident #84) reviewed for care plans timing and revision. The facility failed to ensure that care plan was updated and revised with safety interventions appropriate to resident's cognitive status for Resident #84 after falls on 4/28/2025 and 5/3/2025. These failures could place residents at risk of not having their medical, nursing, and mental needs met, and of not having their safety needs addressed. Finding included: Review of clinical records for Resident #84 reflected an [AGE] year-old female admitted on [DATE], with diagnosis of Fracture to Left Humerus (left upper arm fracture), Multiple rib fractures, Dementia, Diabetes (a condition that affects the way the body processes blood sugar), and Hypertension (high blood pressure). Review of Resident #84's MDS dated [DATE] reflected a BIMS score of 3 (severe cognitive impairment ). Health conditions show one fall since admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure 1of 4 residents reviewed with limited range of motion (Resident 48), received appropriate treatment and services to prevent a decrease in range of motion. The facility failed to ensure Resident #48 had interventions in place for his right- hand contracture and neck 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) to prevent further decline of the range of motion in his right hand and neck. This deficient practice placed residents with contractures at risk for decrease in mobility, range of motion, and could contribute to worsening of contractures. Findings Include: Review of Resident #48's face sheet dated 05/06/2025 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses intracranial injury (head injury), spastic hemiplegia affecting dominant side (Hemiplegia is a symptom 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 observation, interview, and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one (Resident #84) of twelve residents reviewed for fall interventions. The facility failed to ensure adequate supervision and assistance devices to prevent accidents and develop effective interventions to prevent accidents for Resident #84 after falls on 2/8/2025, 4/28/2025, and 5/3/2025. These failures could place residents at risk of repeated falls with major injury and/or fracture. Findings include: Review of clinical records for Resident #84 reflected an [AGE] year-old female admitted on [DATE], with diagnosis of Fracture to Left Humerus (left upper arm fracture), Multiple rib fractures, Dementia, Diabetes (a condition that affects the way the body processes blood sugar), and Hypertension (high blood pressure). Review of Resident #84's MDS dated [DATE] reflected a BIMS score of 3 (severe cognitive impairment). Review of Resident #84'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 interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drug and biological) to meet the needs of each resident for 1of 5 residents (Resident #150) reviewed for medications and pharmacy services, in that: The facility failed to ensure Resident #150 physician ordered medication Fentanyl was available for administration. These deficient practices could place residents at risk of not receiving therapeutic dosage of medications and symptomatic changes in vital signs. Findings include: Review of Resident #150 face sheet dated 05/06/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses chronic pain syndrome, and other specified disorder of bone density and structure, multiple sites. Review of Resident #150 EMR reflected the only MDS completed was her entry MDS dated [DATE]. Review of her nursing admission assessment dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure it was free of a medication error rate of 5% or greater. There were four (4) medication errors in 35 opportunities for an error rate of 11.43% by 1 of 3 staff members observed (LVN C) administering medications to 1 of 7 residents. (Resident #35). Resident #35 was administered 325 mg Aspirin, crushed via PEG tube. Order stated 81 mg Chewable Aspirin, administered by mouth. Medication was administered with the incorrect dose and route of administration. Resident #35 failed to receive adequate physical assessment per the accepted standards and principles which apply to professionals, including vital signs for blood pressure and pulse, prior to receiving medications for lowering blood pressure. This failure could place residents at risk of not receiving medications as ordered and not receiving therapeutic benefits. Findings include: Review of Face sheet for Resident #35 reflected a [AGE] year-old male, admitted on [DATE], with 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.

Based on observation and interview the facility failed to ensure expired and/or discontinued medications were removed from use for one of two medication storage rooms in the facility. The facility failed to ensure expired and/or discontinued medications were removed from use for one medication storage room. This failure could place residents at risk of not receiving the intended therapeutic benefits of their medications. Findings include: Observation and interview on 05/07/2025 at 11:25 AM of medication storage review for Medication Storage closet on Hall 100 revealed six bottles of Multivitamins with an expiration date of 01/2024 and one box of Nicotine Patches with an expiration date of 04/2024. The ADON present at the time of the review observed and removed the expired packages from the room. The ADON stated that medications would be disposed of per facility policy. Interview on 5/8/2025 at 1:52 PM with DON stated that her expectation is that the supply person monitor the expiration dates when supplies are restocked. She stated a Unit Manager/ADON will be assigned to review this…

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 and follow accepted national standards for two of three residents reviewed for infection control practices. (Resident #5 and Resident #35). The facility failed to ensure that LVN C, LVN E, and Hospice RN P followed Enhanced Barrier Precautions when providing care and use of invasive lines for Resident #5 with medication administration through a PEG tube and for Resident #35 during urinary catheter bag change. These failures could place the residents at risk for developing infection. Findings included: Review of Face sheet for Resident #35 reflected a [AGE] year-old male, admitted on [DATE], with diagnoses including Cerebral Infarction (interruption of blood flow to the brain), Dysphagia (difficulty swallowing),…

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 in 1 of 1 kitchen reviewed for kitchen and food sanitation. 1. The facility failed to label and date all food items located in the refrigerators and freezer. 2. The facility failed to ensure damaged or dented canned food items were kept in a separate designated area and not used. 3. The facility failed to ensure kitchen staff practiced proper hand hygiene and glove use when preparing food. 4. The facility failed to ensure kitchen staff cleaned and sanitized the blender in between pureed food items. 5. The facility failed to ensure staff used proper hygienic practice when handling food and feeding a resident. 6. The facility failed to ensure kitchen staff were knowledgeable about food holding temperatures, and the appropriate device used to measure internal temperature . These failures could place residents at risk for food contamination and foodborne illness. Findings included: During the initial tour 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations listed in the findings, the facility failed to ensure all Pre-admission Screening and Resident Review (PASARR) Level I Screening for residents diagnosed with mental illness were accurate and residents were provided with a PASARR Level II Screening for 2 of 2 resident's (Resident #42 and Resident #55) reviewed for PASARR coordination. The facility failed to ensure Resident #42-Level 1 screening dated 10/05/2020 - listed no and Resident #55 PASARR-Level 1 screening dated 11/01/2022 - listed no PASARR Level 2 evaluation. This failure could place residents at risk for not receiving necessary mental health services, causing a decline in mental health. Findings included: Record review of Resident #42's face sheet dated 03/29/2024 revealed a [AGE] year-old woman admitted on [DATE]. Resident #42 had diagnoses which included spinal stenosis-lumbar region without neurogenic claudication (an abnormal narrowing of the spinal canal or neural foramen that results in pressure on the spinal cord or nerve…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews , and record review the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive and at a safe and appetizing temperature for residents who consumed foods orally from the only kitchen in the facility in that: 1. The kitchen test tray of the lunch meal foods was burnt, inedible, and unappealing. 2. The facility failed to provide palatable food that was attractive or appetizing to residents' who complained the food did not look or taste good. This failure could place residents at risk of decreased food intake, hunger, unwanted weight loss, and diminished quality of life. The findings included: 1. An observation at 03/29/2024 at 12:40 PM a lunch test tray was sampled. The test tray consisted of country fried steak with cream gravy, mac and cheese, green beans, and corn bread. On the side there was a small bowl of fruit cobbler, a glass of water, and a glass of sweet tea. Initial observation of the meal the food looked…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to assess each resident quarterly using the Minimum Data Set form specified by the state and approved by CMS for 1 of 3 residents (Resident #57) reviewed for quarterly assessments, in that: The facility failed to ensure a quarterly MDS assessment was completed within 92 days of the previous quarterly assessment for Resident #55. The quarterly MDS Assessment was required to be completed, signed and transmitted by the due date of 02/28/2024. It was signed and completed on 03/29/2024. This failure could place residents at risk for not having their needs met in a timely manner. The findings included: Record review of Resident #57's face sheet reflected a [AGE] year-old resident with an original admission date of 10/11/2019 with the following diagnoses type 2 Diabetes Mellitus without complications (a disease that occurs when a person's body does not use insulin effectively), Venous Insufficiency (Chronic) (Peripheral) ((CVI) happens when your leg veins become…

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 a comprehensive care plan for one resident (Resident #94) of eight reviewed, in that: A) The facility failed to ensure Resident #94's Comprehensive Care Plan reflected a revision for his isolation precautions related to MRSA (Methicillin Resistant staphylococcus aureus) and his current skin condition. B) The facility failed to ensure Resident #46's Comprehensive Care Plan reflected his use of a indwelling urinary catheter. This failure could place a resident at risk for errors in provider care, poor wound healing/worsening wound condition, and the potential spread of infection. Findings included: A) Review of Resident #94's Face sheet dated 03/28/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses Huntington's Disease (is a rare, inherited disease that causes the progressive breakdown (degeneration) of nerve cells in the brain.), Cerebral Infarction (the pathologic process 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 observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for two of six residents reviewed for catheter care (Resident #4 and Resident #46). A) The facility failed to ensure Resident #4's had a plan of care for her catheter, that it was secured to her body with a catheter secure device and failed to monitor her catheter care per the facility policy. B) The facility failed to ensure Resident #46's catheter was ordered by a physician, had a plan of care and was secured to his body with a catheter secure device per the facility policy. This failure to secure catheters placed residents with urinary catheters at risk for traumatic removal and catheter acquired infections. Findings included: A) Review of Resident #4's Face sheet dated 02/02/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses Diabetes Mellitus Type 2 (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 the safe handling, humidification, cleaning, storage, and dispensing of oxygen for respiratory care services provided to 3 of 3 residents (Resident 35, 53, and 56) reviewed for respiratory care. The facility failed to ensure Residents oxygen tubing was dated to ensure it was changed weekly for 3 residents (Resident 35, 53, and 56) as ordered by the physician and as verbally reported to be the facility policy by DON. The facility failed to have a written policy to ensure the safe handling, humidification, cleaning, storage, and dispensing of oxygen on 03/29/2024 at 10:10 a.m. A policy is required per guidelines. The facility failed to ensure that the Oxygen setting matched the physicians order for 1 of the 3 residents. Oxygen set at 4 Liters per minute instead of the 3 Liters per minute ordered. This failure placed the residents at risk of developing a respiratory infection from contamination of the tubing and humidifier water.…

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 of transmission of communicable diseases and infections for 3 of 3 resident reviewed (Resident #24, #52, and #5) for infection control. The facility failed to ensure MA-F performed proper hand hygiene and failed to ensure MA sanitized equipment for infection control during 03/28/2024 medication pass for Residents #24, #52 and #5. This failure placed residents at risk for development of communicable diseases and infections. Findings included: Review of 03/28/2204 face sheet for Resident 24 reflected he was a [AGE] year-old male admitted [DATE] with diagnoses of Cerebrovascular Disease, Diabetes Type 2, Cerebral Infarction (stroke) with right side paralysis, Congestive Heart Failure and Depression. Review of March 2024 Medication Administration Record for Resident 24 reflects…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury for 1 of 3 residents (Resident # 1) reviewed for abuse and neglect. The facility failed to ensure allegations of abuse of CNA A slapped Resident #1 on 10/18/2023 was reported to the state survey agency within two hours after the administrator was informed of the alleged abused. This failure could place residents at risk of emotional, physical and mental abuse and neglect. Findings included: Record review of Resident #1's facility face sheet, dated 12/07/2023 , reflected Resident #1 was an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with primary 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.