Carrollton Health and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, 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 included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one of eight residents (Resident #8) reviewed for care plans. The facility failed to ensure that Resident #8 had a care plan for her oxygen use on 06/23/2026. This failure could place the residents at risk of not receiving the necessary care and services.Findings included: Record review of Resident #8's Face Sheet, dated 06/24/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #8's Comprehensive MDS Assessment, dated 03/24/2026, reflected…

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 that the residents' environment remained free of hazards as was possible for two of eight Residents (Resident #65 and #12) reviewed for accident hazard. The facility failed to ensure that Resident #65 did not have a container of germicidal wipes on her shelf on 06/23/2026. The facility failed to ensure that Resident #12 did not have scissors in his room on 06/23/26. These deficient practices placed the residents at risk for accidental injury, exposure to hazardous chemicals and misuse of sharp objects.Findings included: Record review of Resident #65's Face Sheet, dated 06/24/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with Dementia (A progressive loss of memory, reasoning, and communication skills) and need for assistance with personal care. Record review of Resident #65's Quarterly MDS Assessment, dated 05/06/26 did not reveal any BIMS score. The 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 observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infection for one of five residents (Resident #70) reviewed for incontinent care. The facility failed to ensure that CNA H did not place Resident #70's catheter bag on top of the resident, rendering the catheter bag and its tubing to above the bladder during transfer on 06/24/2026 This failure could place the residents at risk of urinary tract infection.Findings included: Record review of Resident #70's Face Sheet, dated 06/24/2026, reflected a 67-year- old female admitted to the facility on [DATE]. The resident was diagnosed with neuromuscular dysfunction of the bladder (the muscles and nerves that control the bladder do not work properly due to illness). Record review of Resident #70's Comprehensive MDS Assessment, dated 05/04/2026, reflected that the resident had moderate impairment in cognition with a BIMS score of 08. 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 ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two of ten residents (Resident #1 and Resident #14) reviewed for respiratory care. 1.The facility failed to ensure Resident #1's oxygen nasal canula was properly stored on 06/23/26. 2.The facility failed to ensure Resident #14's spirometer was properly stored when not in use on 06/23/2026. These failures could place residents at risk of respiratory infection, respiratory complications, and not having their respiratory needs met.Findings Include 1. Record review of Resident #1's face sheet, dated 06/23/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with the following: Chronic Obstructive Pulmonary Disease - COPD (a progressive, long-term lung disease that makes it…

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 effective pest control program so the facility was free of pests and rodents for one of 8 residents' rooms (Resident #69) reviewed for pest control. The facility failed to ensure Resident #69's room was free from gnats. This failure could place residents at risk for the potential spread of infection, cross-contamination, food-borne illness, and a diminished quality of life.Findings include: Record review of Resident #69's face sheet, dated 06/24/26, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with dementia (a condition characterized by loss of memory and ability to reason) and Type 2 Diabetes with hyperglycemia (adult-onset diabetes with consistently high blood sugar). Record review of Resident #69's Comprehensive MDS Assessment, dated 05/22/26, revealed the resident had a severe impairment with cognition with a BIMS score of 06. The resident was diagnosed with…

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 did not get ice from the ice cooler used for 1 of 1 (Resident #1) resident reviewed for infection control.Resident #1 got ice for her cup from an ice cooler, without the help of staff.This failure could result in contaminated ice that could transmit organisms to other residents, resulting in waterborne illnesses.Findings included:Record review of Resident #1's face sheet, dated 03/26/2026, revealed a [AGE] year-old woman admitted to the facility with a primary diagnosis of epilepsy (brain condition causing seizures). Other pertinent diagnoses included down syndrome, major depressive disorder, and mild intellectual disabilities (below-average intellectual functioning).Record review of Resident #1's MDS, dated [DATE], revealed she had a BIMs score of 07, indicating severe cognitive impairment.During an observation on 03/26/2026, the ADON had assisted Resident #1 with opening the lid on her cup. Resident #1 proceeded to walk…

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 establish a system of disposition of controlled drugs to enable an accurate reconciliation and failed to maintain account of controlled drugs for 1 of 5 residents reviewed for pharmacy services.MA A was unaware of how to dispose controlled medication. MA B failed to update count sheet for Resident #1 after administering controlled medication to the resident, causing discrepancy between medication card and count sheet. These failures could lead to suspected drug diversion and medication error. Findings included:An observation on 3/5/2026 at 8:30am revealed MA A was passing medication to residents in hall 400.In an interview on 3/5/2026 at 8:30am, MA A stated she had not had a refusal of narcotics or controlled medication from residents before. MA stated if the resident refused controlled medication, she would waste the medication in the sharp bin on her medication cart. She stated she could do it with or without a witness. She stated she did not think a witness was needed to waste controlled medication. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 3 of 6 residents (Resident #5, #6, and #7) reviewed for accident prevention.The facility failed to ensure Resident #5 did not have a can of Lysol spray in his room on 01/30/2026.The facility failed to ensure Resident #6 did not have a can of aerosol air freshener spray in her room on 01/30/2026. The facility failed to ensure Resident #7's cell phone charging cord was plugged correctly into the outlet in her room on 01/30/2026.These failures could prevent the residents from having an environment that was free from hazards. Findings included:Record review of Resident #5's Face Sheet, dated 01/30/26, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #5 had diagnoses of Dementia (memory decline) and depressionRecord review of Resident #5's Quarterly MDS Assessment, dated 12/21/25, reflected Resident #5 had severe…

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 that residents, who needed respiratory care, were provided care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for four of six residents (Resident #1, #2, #3 and #4) reviewed for respiratory care.The facility failed to ensure Resident #1 and #2's breathing treatment mask was properly stored in a bag when not in use on 01/30/26. The facility failed to ensure Resident #3 and #4's nasal canula was properly stored in a bag when not in use on 01/30/26. These failures could place residents at risk for respiratory infection and not having their respiratory needs met.Findings included: Record review of Resident #1's Face Sheet, dated 01/30/26, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had a diagnosis of COPD (obstructed airflow).Record review of Resident #1's Quarterly MDS Assessment, dated 12/21/25,…

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 were adequately equipped to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from three of six residents (Resident #7, #8, and #9) reviewed for Resident Call System. The facility failed to ensure the call light system in Resident #7, #8, and #9's rooms were in a position that was accessible to the residents on 01/30/26.This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings included: Record review of Resident #7's Face Sheet, dated 01/30/26, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #7 had diagnoses of lack of coordination and history of falling.Record review of Resident #7's Quarterly MDS Assessment, dated 12/12/25, reflected Resident #7 had severe cognitive impairment. The Quarterly MDS Assessment…

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, record review and interview the facility failed to ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #1) of five residents reviewed for pressure ulcers. The facility failed to provide appropriate treatment to Resident #1's skin issues. This failure placed residents at risk for the decline in quality of life and the wounds being infected or deteriorating.Review of Resident #1's face sheet dated 10/06/25 revealed he was a [AGE] year-old male, he was originally admitted on [DATE] and readmitted on [DATE]. Admitting diagnoses included, hypertension, anxiety, major depression, dementia,…

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 residents' right to be treated with respect and dignity during wound care for 1 of 4 residents (Resident #2) reviewed for respect and dignity in that: The facility failed to ensure RN B provided privacy by leaving the door open and not pulling privacy curtain, exposing Resident #2's abdomen when providing Resident #2 while changing gastroenterology tube (feeding tube) supplies. This failure could place residents at risk of emotional distress and low self-esteem.Findings included: Record review of Resident #2's quarterly MDS assessment, dated 06/06/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: Cerebral Vascular Disease (stroke), aphasia (unable to speak), dysphagia (unable to swallow), and hypertension (high blood pressure). Resident #2's cognition was severely impaired, and were unable to make decisions and required assistance from one staff 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, interview, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as is possible and ensured each resident received adequate supervision for one (Resident #1) of four residents reviewed for accidents and hazards. The facility failed to ensure Resident #1 was free of injury from accident hazards when CNA D failed to follow policy and procedure and report to the nurse in charge, when CNA D found Resident #1 was on the floor in her room. CNA D picked the resident up from the floor and placed her in wheelchair taking the resident to the dining room for breakfast. The LVN did not assess Resident #1 before she was moved by CNA D. These failures could place residents at risk for harm, pain, and injury.Findings included: Record review of Resident #1's significant change MDS assessment, dated 10/27/2025, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. The resident had diagnoses which included:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles in locked compartments and permit only authorized personnel to have access to the keys for 1 (Resident #2) of 4 reviewed for storage of drugs, in that: The facility failed to ensure Resident #2's calmoseptine ointment (ointment applied to the bottom to treat and prevent redness) was secured. This failure could place residents at risk of medication misuse and diversion.The findings were: Record review of Resident #2's quarterly MDS assessment, dated 06/06/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: Cerebral Vascular Disease (stroke), aphasia (unable to speak), dysphagia (unable to swallow), and hypertension (high blood pressure). Resident #2's cognition was severely impaired, he was unable to make decisions and required assistance from one staff 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, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 (CNA A and RN B) staff members and 2 of 2 residents (Residents #3, and #2) reviewed for infection control procedures. CNA A failed to change their soiled gloves and perform hand hygiene during incontinent care on Residents #3. RN B failed to change her soiled gloves and perform hand hygiene during replacement of gastroenterology tube (feeding Tube) supplies for Residents #2. These failures could place residents at risk for cross contamination and infectionsFindings included: Record review of Resident #3's quarterly MDS Assessment, dated 09/01/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: Hypertension (increased blood pressure),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure all assistive devices, wheelchairs were maintained and free of hazards for three (Residents #4, #40, and #55) of 6 residents reviewed for essential equipment. The facility failed to properly maintain wheelchairs for Residents #4, #40, and #55. The failure could place residents at risk for equipment that is in unsafe operating condition, that could cause injury. Findings included: Review of Resident #40's quarterly MDS assessment, dated 03/07/2025, reflected she was an [AGE] year-old male admitted to the facility on [DATE], with diagnoses of Dementia (confusion), cerebral vascular accident (stroke), and instability on feet. Review of the Resident #40's plan of care dated 04/17/2025 with updates reflected goals and approaches to include wheelchair mobility. Observation on 05/04/2025 at 12:00 p.m. revealed Resident #40 confused, was sitting in her wheelchair in the dining room and had no skin problems. The wheelchair's right armrest…

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 accurate acquitting, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 4 (Resident #56) for medication pass 1. RN D failed to follow physician orders to administer Resident #56's ASA (aspirin) capsule 81 mg per G-tube (feeding tube), and instead administered chewable ASA 81 mg per G-tube. RN D failed to check the medication room and to inquire of the other nursing staff if the staff had the appropriate ASA on their medication carts. 2. RN D failed to follow physician order to administer Resident #56's Calcium D (vitamin supplement) oral tables 600-400 mg and administered Over the counter Calcium D. RN D did not mix the Calcium D completely prior to administering the medication per G-tube. 3. RN D failed to administer Resident #56's Maalox (anti-acid) (aluminum/magnesium) Suspension, Suspension 200-200-20 5 ml 30 cc per G-tube. RN D administered Geritol 5 ml instead.…

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 five percent (5%) or greater for 3 of 30 opportunities during medication pass resulting in a 10 percent (10%) error rate for one (Residents #13) of 4 residents observed for medication pass. 1. RN D failed to administer Resident #56's ASA (aspirin) capsule 81 mg per G-tube (feeding tube), and instead administered chewable ASA 81 mg, as RN D had no ASA capsules 81 mg on her medication cart. 2. RN D failed to administer Resident #56's Calcium D (vitamin supplement) oral tables 600-400 mg correctly. RN D crushed the incorrect Calcium D (that was not supposed to be crushed) and delivered by G-tube. 3. RN D failed to administer Resident #56's Maalox (anti-acid) (aluminum/magnesium) Suspension, Suspension 200-200-20 5 ml 30 cc per G-tube. RN D administered Geritol 5 ml instead. These failures could place residents at risk for not receiving therapeutic dosages of their medications as ordered by 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 interview and record review, the facility failed to provide or obtain radiology and other diagnostic services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services. Promptly obtain the Chest X-ray per the ordering physician's orders for one (Resident #39) of five residents reviewed for radiology services. The facility failed to obtain the chest X-ray and the results for Resident #39's chest in a timely manner, resulting in a delay to diagnosis Resident #39. The routine X-ray should be completed on the same day as ordered. This failure could place residents at risk of injury, pain and a delay in treatment. Findings included: Record review of Resident #39's electronic admission record revealed a [AGE] year-old female who admitted on [DATE] with a diagnoses that included Coronary Artery Disease (blocked arteries), Hypertension (high blood pressure), and Pneumonia (infection of the lungs). Record review of Resident #39's Quarterly MDS assessment,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 (RN D) staff members and 1 of 5 residents (Residents #56) reviewed for infection control procedures. RN D failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #56 and was observed using blood pressure cuffs on two other unknown residents. RN D failed to cleanse her hands following stoma care and prior to administering G-tube medications for Resident #56. The failures could place residents at risk for cross contamination and infections. Findings included: Record review of Resident #56's quarterly MDS assessment, dated 02/05/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #56 had diagnoses which included: Cerebrovascular Accident…

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 parenteral fluids administered consistent with professional standards of practice and in accordance with physician orders for 2 of 4 resident (Resident #52 and Resident #3) reviewed for peripheral intravenous care. The facility did not ensure Residents #52's and #3's PICC line dressings were changed per the physician's order. This failure placed residents at risk of developing an infection. Findings included: Review of Resident #52's face sheet, dated 04/11/24, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included aftercare following joint replacement surgery, infection and inflammatory reaction due to internal right knee prosthesis, hypokalemia (low potassium), and essential hypertension (high blood pressure). Review of Resident #52's admission MDS assessment, dated 03/05/24, reflected a BIMS score of 15 indicating no cognitive impairment. The 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 observation, interview, and record review, the facility failed to provide residents with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for one (Resident #45) of five residents reviewed for call lights. The facility failed to ensure Resident #45's call light was accessible. This failure could place the residents at risk of falling, further injury, and unnecessary pain from not being able to call for help. Findings included: Review of Resident #45's face sheet, dated 04/11/24, reflected the resident was a [AGE] year-old female who was originally admitted on [DATE] and readmitted on [DATE]. Her diagnoses included metabolic encephalopathy (a brain disorder caused by various diseases or toxins that affect the body's chemistry and disrupt the brain's function), acute kidney failure (a sudden condition where the kidneys lose their ability to filter waste products from the blood), and adjustment disorder…

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 had a safe, clean, comfortable, and homelike environment for 1 of 2 residents (Resident #46) reviewed for physical environment. The facility failed to ensure Resident #46's gastronomy tube (a tube placed through the abdominal wall with the aid of an endoscope into the stomach used for feeding patients unable to swallow food) pole and floor was clean. These failures could place the residents at risk for the spread of infection and disease, a diminished quality of life and a diminished clean, homelike environment. Findings included: Review of Resident #46's face sheet, dated 04/11/24, revealed the resident was a [AGE] year-old-female who admitted to the facility on [DATE] and readmitted on [DATE]. The resident's diagnoses included gastrostomy status (surgical procedure for inserting a tube through the abdomen wall and into the stomach, used for feeding), epilepsy (seizure disorder) and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure assessments accurately reflected the resident status for 1 of 5 residents (Resident #63) reviewed for MDS assessment accuracy in that: Resident #63's quarterly MDS assessment dated [DATE] was coded incorrectly in that it indicated she had a wound infection when she did not. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: Review of Resident #63's face sheet, dated 04/11/24, reflected the resident was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included unspecified dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and cognitive communication deficit (problems with communication that have an underlying cause in a cognitive deficit rather than a primary language or speech deficit). Review of Resident #63's quarterly MDS assessment, dated 01/10/24, reflected no 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 interview and record review, the facility failed to ensure any drug regimen irregularities reported by the Pharmacist Consultant were acted upon, for 1 of 1 resident (Resident #49) reviewed for unnecessary medications, and medication regimen review. The facility's Pharmacist Consultant recommended Residents #49's Lidocaine External Patch 4 % (Lidocaine) required to be updated to read wear 12 hours and then off 12 hours. This failure could place residents on lidocaine patch at risk for possible adverse side effects, adverse consequences, and decreased quality of life. Findings included: Record review of Resident #49's face sheet dated 04/11/24 revealed the resident was a [AGE] year-old female who originally admitted to the facility 05/18/21. The diagnoses included disorder of muscles and multiple sclerosis (disorder in which the body's immune system attacks the protective covering of the nerve cells in the brain, optic nerve, and spinal cord, called the myelin sheath). Record review of Resident #49'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 ensure residents are free of any significant medication errors for 1 of 3 residents (Resident #45) reviewed for medication administration. The facility failed to prevent Resident #45 from being provided Losartan Potassium, a medication designed to lower a person's blood pressure, while Resident #45 was assessed with blood pressure lower than the physician recommended parameters for providing the medication. This failure could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. Findings included: Review of Resident #45's face sheet, dated 04/11/24, reflected the resident was a [AGE] year-old female with an initial admission date of 07/25/23 and admission date of 09/22/23. Her diagnoses included unspecified dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and essential hypertension (a form of high blood pressure. Review of Resident #45's quarterly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure in accordance with State and Federal laws, they stored all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for 1 of 4 residents (Residents #36) reviewed for pharmacy services. The facility failed to ensure Resident #36 took her medications when they were administered, which resulted in the resident saving the medication in her room. This failure could place residents at risk of not receiving the therapy needed. Findings included: Review of Resident #36's face sheet, dated 04/11/24, revealed the resident was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included essential hypertension (high blood pressure) and depression (mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident #36's MDS assessment, dated 04/02/24, revealed a BIMS score of 0 which indicated…

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