Corinth Rehabilitation Suites on the Parkway

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 1 (Medication Cart Hall 100) of 4 medication carts reviewed for pharmacy services.The facility failed to ensure Licensed Vocational Nurse A counted controlled drugs every change of shift and signed the medication sheet form after the count while she was responsible for the Medication Cart on Hall 100.The failure could place residents at risk of not having the medication available due to possible drug diversion.Findings Included:Record review of the Medication Cart on Hall 100's medication count sheet on 02/26/26 at 10:16 AM revealed missing signatures for shift change counts for Off duty and On duty for 02/03/26, 02/06/26, 02/08/26, and 02/12/26.Interview on 02/26/26 at 2:15 PM, Director of Nursing B stated the staff were trained by a nurse to perform counts at the beginning and end of their shift on the medication cart that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to administer medications according to physician's orders for 1 of 4 residents (Resident #1) reviewed for medications. The facility failed to follow Physician D's order by applying a second Lidocaine patch by accident to Resident #1. This failure could place residents at risk of harm by not receiving their medication as instructed by physician. Findings included: Review of the Care Plan dated 02/09/2026 for Resident #1 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included HIV (Human Immunodeficiency Virus is a virus that attacks the body's immune system which can lead to AIDS (Acquired Immunodeficiency Syndrome), Seizures, Hypokalemia (Low potassium levels), Cellulitis (Bacterial skin infection), Anxiety (Excessive worry or unease), Vitamin deficiency, Muscle Weakness, Neuralgia (Intense sudden and sever facial pain), Neuritis (Nerve or inflammation of the nervous system), Candidal balantis (Inflammation 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 provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident#1) of 9 residents reviewed for ADLs. The facility failed to ensure Resident #1 had facial hair on her chin removed on 01/07/2026. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life.Findings include: Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included non-Alzheimer's dementia (types of cognitive decline not caused by Alzheimer's disease), and hypertension (elevated blood pressure). Resident #1's BIMS score was a 13, which indicated Resident #1's cognition was intact. The MDS assessment indicated Resident #1 partial/moderate assistance with shower/bathe…

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 1 of 9 residents (Resident #2) reviewed for infection control. The facility failed to ensure CNA C changed gloves and performed hand hygiene while providing incontinence care to Resident #2. This failure could place residents at risk for infection and cross contamination.Findings include: A record review of Resident #2's Quarterly MDS assessment, dated 12/19/25, reflected Resident #2 was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hypertension (elevated blood pressure), fracture of part of neck of left femur, muscle wasting and atrophy, and Muscle weakness (generalized). Resident #2 had a BIMS score of 15 which indicated intact cognition. Resident #2 was frequently incontinent 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 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 (Resident #1 and Resident #2) of 6 residents reviewed for infection control. The facility failed to ensure: LPN A and CNA C wore appropriate PPE when transferring Resident #1 on EBP isolation from bed to wheelchair on 11/04/25. CNA B wore appropriate PPE, and performed proper hand hygiene between gloves change during incontinent care for Resident #2 on 11/04/25. This failure could place residents at risk of cross contamination which could result in infections or illness.1-Record review of Resident #1's Quarterly MDS assessment, dated 07/14/25, reflected Resident #1 was a [AGE] year-old female admitted [DATE], and readmitted [DATE]. Resident #1 had a BIMS score of 15, meaning her cognition was intact. She was completely…

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 response to allegations of abuse, neglect, exploitation, or mistreatment, all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. for 1 of 5 residents (Resident #1) reviewed for abuse/neglect. The facility failed to ensure they self-reported neglect for Resident #1. Resident #1 fell and had to call EMS to help him get off the floor on 08/10/25. This failure…

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 in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility had evidence that all alleged violations were thoroughly investigated for 1 of 5 residents (Resident #1) reviewed for abuse/neglect. The facility failed to ensure they investigated an allegation of neglect for Resident #1. Resident #1 fell and had to call EMS to help him get off the floor on 08/10/25. This failure could place residents at risk for not having their allegations for neglect investigated which could lead to additional neglect. The findings included:Record review of Resident #1's admission MDS assessment, dated 08/07/25, revealed the resident was a [AGE] year-old male admitted on [DATE]. His BIMS score was 15 indicating his cognitive ability was intact. His diagnoses included non-Alzheimer's disease and unsteadiness on feet. The resident required maximum assistance to transfer between surfaces.Record 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accident hazards. The facility failed to provide adequate supervision for Resident #1. Resident #1 fell and had to call EMS to help him get off the floor on 08/10/25. This failure could place residents at risk for injury for not having adequate supervision. The findings included: Record review of Resident #1's admission MDS assessment, dated 08/07/25, revealed the resident was a [AGE] year-old male admitted on [DATE]. His BIMS score was 15 indicating his cognitive ability was intact. His diagnoses included non-Alzheimer's disease and unsteadiness on feet. The resident required maximum assistance to transfer between surfaces. Record review of Resident #1's Care Plan, dated 08/26/25, reflected: Resident is at risk for falling related immobility, muscle weakness, diabetes, and chronic pain.Facility…

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 the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 5 (Resident #20, Resident #59, Resident #51, Resident # , Resident #13 ) of 16 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #59 had her fingernails cleaned and trimmed on 5/28/25. 2- Resident #20 had her fingernails cleaned and trimmed on 5/28/25. 3- Resident #51 had his nails trimmed and cleaned on both hands on 05/28/25. 4- Resident #13 had her fingernails trimmed. 5- Staff provided consistent showers/baths for Resident #21. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: 1-Record review of Resident #59's Quarterly MDS assessment dated [DATE] reflected Resident #59 was a [AGE] year-old female admitted to the facility on [DATE] 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 a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one (Resident #31) of two residents reviewed for incontinence care. The facility failed to ensure CNA C provided timely and appropriate perineal care for Resident #31. This failure could place residents at risk for the development and/or worsening of urinary tract infections and skin breakdown. Findings include: Record review of Resident #31's Quarterly MDS assessment, dated 05/13/25, reflected a [AGE] year-old female with an admission date of 12/07/21 with diagnoses included down syndrome (a genetic disorder causing developmental and intellectual delays), dementia (a group of thinking and social symptoms that interferes with daily functioning), and cognitive communication deficit. Resident #31 had a BIMS score of 03 which indicated cognition was severely impaired. Resident #31 required moderate assistance…

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

Based on observation, interview, and record review, the facility failed to provide 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 2 (Hall 200 and 300) of 4 medication carts reviewed for pharmacy services. The facility failed to ensure: RN E responsible for Medication Cart Hall 200, counted controlled drugs every change of shift and singed the narcotic sheet form after the count. RN D responsible for Medication Cart Hall 300, counted controlled drugs every change of shift and singed the narcotic sheet form after the count. These failures could place residents at risk of not having the medication available due to possible drug diversion. Findings Included: Record review of the Medication Cart Hall 200 narcotic count sheet on 05/28/25 at 10:16 AM of , revealed missing signatures for Off duty and On duty for 05/09/25, 05/15/25, 05/21/25, and 05/22/25. Record review of the Medication Cart Hall 300 narcotic count sheet, on 05/28/25 at 10:30 AM…

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 review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. The facility failed to ensure food items in the facility reach in refrigerator were dated, labeled, and covered. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. Findings included: Observations on 5/28/25 at 9:30AM in the facility walk-in freezer revealed: Frozen French fries were not dated. Frozen southern style biscuit dough was left uncovered in a plastic bag, that was in an open cardboard box. Observation on 5/28/25 at 9:33 AM in the facility dry storage revealed: 3 hamburger buns wrapped in a plastic bag not dated or labeled. In an interview on 5/29/25 at 12:30 PM, the Dietary Manager revealed she expected all food items in the kitchen should be dated, labeled, and covered and everyone including cooks and herself were responsible for covering,…

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 control program designed to prevent the development and transmission of infection for 3 resident (Resident #1 and Resident #11, and Resident #44) of 10 residents observed for infection control. 1-The facility failed to ensure MA A disinfected the blood pressure cuff in between blood pressure checks for Resident #1 and Resident #11 on 05/28/25. 2- The facility failed to ensure CNA J and CNA K performed proper hand hygiene when changing gloves during morning care for Resident #44 05/29/25. 3- The facility failed to ensure CNA J and agency CNA K wore appropriate PPE when providing morning care for Resident #44 who supposed to be on EBP on 05/29/25. The failures could place residents at-risk of cross contamination which could result in infections or illness. Findings included: 1.Record review of Resident #1's Quarterly MDS assessment, dated 05/09/25, reflected Resident #1 was a [AGE] year-old female admitted to 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 record review and interviews, the facility failed to ensure completion of a discharge summary including a recapitulation of the resident's stay, and final status at discharge for two residents (Resident #69 and Resident #170) of five residents reviewed for discharge summary. The facility failed to complete a discharge summary for Resident #69 and Resident #170. This failure could place residents at risk of not having complete records after permanent discharge from the facility and disruption in the continuity of care. Findings included: Record review of Resident #69's face sheet dated 05/29/25, indicated a [AGE] year-old male who admitted to the facility on [DATE] and discharged from the facility on 3/15/25 with diagnoses which included dementia (memory loss), encephalopathy (disease affecting the brain leading to impaired brain function), cerebral ischemia (inadequate oxygen supply to the brain), bradycardia (lower than normal heart rate), Unspecified protein calorie malnutrition (inadequate intake or…

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 ensure residents receive treatment and care in accordance with professional standards of practice for one of twenty-four residents (Resident #45) reviewed for falls. The facility failed to follow the facility policy and did not promptly notify Resident #45's physician about a fall incident that occurred on 05/12/25 at 8:32 am. This failure could place residents at risk for a delay in treatment and diagnosis of new symptoms resulting in serious illness, hospitalization, and further decline in the resident's condition,. Findings included: Record review of Resident #45's quarterly MDS assessment dated [DATE] reflected Resident #45 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of unspecified open-angle glaucoma, muscle wasting and atrophy (the loss or thinning of muscle tissue), polyneuropathy (nervous system disorder), restless legs syndrome, functional dyspepsia (discomfort or pain in the upper abdomen), repeated falls,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 1 of 2 (Resident #221) residents reviewed for respiratory care, in that: The facility failed to ensure Resident #221's Oxygen humidification bottle and nasal cannula tubing was changed in a timely manner. This failure could place residents at risk for respiratory infection and not having their respiratory needs met. The findings were: Review of Resident # 221's admission MDS assessment dated [DATE] reflected a [AGE] year-old female re-admitted to the facility on [DATE]. Relevant diagnoses include Stroke ( blood supply to the brain interrupted ), Hypertension (high blood pressure), Pneumonia (infection of the lungs ), and Diabetes mellitus (high blood glucose). Resident #221 was on continuous Oxygen therapy on admission to the facility. Resident #221 had BIMS of 15 which indicated intact cognition. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the residents' right to privacy during administering medication for 1 of 2 residents (Residents #2) reviewed for privacy in that: The facility failed to ensure LVN A provided privacy by closing the door and privacy curtain for Resident #2 on 1/1/25. This failure could place residents at risk of diminished quality of life. The findings include: Record Review of Resident #2's MDS Quarterly assessment dated [DATE] revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident had BIMS score of 6 which indicated Resident #2 had severe cognitive deficit. Her diagnoses included nontraumatic brain dysfunction, hypertension (high blood pressure), Diabetes Mellitus (high blood glucose), Hyperlipidemia (high blood lipids), non-Alzheimer's dementia, Blindness right eye. Record Review of Resident #2's Physician orders dated 6/26/24 reflected, Lantus Solostar U-100 Insulin pen; 100 unit/ml (3mL), amount 15 units,…

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 have evidence that all alleged violations were thoroughly investigated and measures were taken to prevent further potential abuse, neglect, exploitation or mistreatment in accordance with State law, including to the State Survey Agency, and report the results within 5 working days of the incident, and if the alleged violation is verified appropriate, corrective action must have been taken for 1 of 5 residents (Resident #1) reviewed for neglect. The facility failed to report findings to the state agency within five days for an allegation of neglect made on 1/2/25. This failure placed residents at risk of not having their allegations investigated or reviewed timely by the state survey agency. Findings included: Record Review of Resident #1's MDS Quarterly assessment dated [DATE] revealed she was a [AGE] year-old female admitted to the facility on [DATE] and discharged on 1/6/2025. Resident had BIMS of 9 which indicated Resident #1 had moderate cognitive…

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 based on the comprehensive assessment of a resident, the residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of three residents reviewed for quality of care. LVN A failed to complete fall assessment after Resident #1 had a witnessed fall in the facility on 1/1/25. This failure could place residents at risk for injuries related to falls. The noncompliance was identified as Past Noncompliance (PNC). The noncompliance began on 01/1/25 at 8:13 PM and ended on 01/02/25. The facility had corrected the noncompliance before the Incident investigation began. Findings include: Record Review of Resident #1's MDS Quarterly assessment dated [DATE] revealed she was a [AGE] year-old female admitted to the facility on [DATE] and discharged on 1/6/2025. Resident had BIMS of 9 which indicated Resident #1 had…

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 (Residents #1 and Resident #2) of three residents reviewed for infection control. 1.LVN A failed to perform hand hygiene and changed gloves while administering medications to Resident #1 and Resident #2 on 1/1/2025. This failure could affect residents by placing them at risk for spread of infection through cross-contamination of pathogens and illness. Findings include: Record Review of Resident #1's MDS Quarterly assessment dated [DATE] revealed she was a [AGE] year-old female admitted to the facility on [DATE] and discharged on 1/6/2025. Resident had BIMS of 9 which indicated Resident #1 had moderate cognitive impairment. Her diagnoses included nontraumatic brain dysfunction, hypertension (high blood pressure), Diabetes…

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 that the residents' right to review survey results were readily accessible to residents, family members and legal representatives of residents reviewed for resident rights. The facility failed to ensure survey results were located and placed in a readily accessible location where individuals wishing to examine survey results without having to ask to review them. The facility failed to ensure residents were informed of their right to view survey results. This failure could affect residents who reside in the facility and could result in a lack of awareness for visitors, family, and residents regarding the survey results and the plan of correction submitted by the facility. The findings were: The confidential group meeting at 11:00 a.m. on 4/17/24, revealed residents were not aware of the location of the results of Federal or State surveys nor were they aware of their right to review the results of these surveys. In an interview at 2:07 p.m. on 04/17/24, the Activities Director said he thought the results…

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 Resident #270 Based on interview and record review, the facility failed to ensure all alleged violation of abuse and neglect were thoroughly investigated for 2 (Resident #370 and Resident # 270) of 17 residents reviewed for abuse, neglect, and misappropriation of property, in that; 1- The facility failed to conduct investigation following self-report of neglect allegation for unwitnessed fall for Resident #370. 2- The facility failed to conduct investigation following self-report of neglect allegation report to the administrator attention by Resident #270's family member. This failure could affect residents by placing them at risk for neglect by not having their incidents investigated. The findings were: 1- Resident #370 Review of Resident #370's Quarterly MDS assessment dated [DATE] reflected Resident #370 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Diabetes (high blood glucose), cancer ( abnormal increase in number of cells), end stage renal disease, and dysphagia…

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 comprehensive person-centered care plans for each resident 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 (Resident #370) of 4 residents reviewed for comprehensive care plans. The facility failed to develop a comprehensive person-centered care plan to address Resident #370 keeping food in her room in unsanitary conditions. This failure placed residents at risk of not receiving individualized care and services to meet their needs. Findings include: Review of Resident #370's Quarterly MDS assessment dated [DATE] reflected Resident #370 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Diabetes (high blood glucose), cancer ( abnormal proliferation of cells), end stage renal disease (complete loss of kidney function), 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 observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #59) of 8 residents reviewed for ADLs. The facility failed to ensure Resident #59 had his fingernails cleaned and trimmed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: Record review of Resident #59's Comprehensive MDS assessment dated [DATE] reflected Resident #59 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including dementia, muscle wasting and atrophy, and cognitive communication deficit. Resident #59's BIMS score of 99 indicated Resident #59 was unable to complete the interview. The MDS assessment indicated Resident #59 required maximal assistance with toileting and personal hygiene. Record review of Resident #59's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, 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 one (Resident #59) of two residents reviewed for incontinence care. The facility failed to ensure CNA A provided appropriate perineal (genital and rectal areas) care for Resident #59 after an incontinent episode when she failed to clean from front to back. This failure could place residents at risk for the development and/or worsening of urinary tract infections and skin breakdown. Findings included: Record review of Resident #59's Comprehensive MDS assessment dated [DATE] reflected Resident #59 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including dementia, muscle wasting and atrophy, and cognitive communication deficit. Resident #59's BIMS score of 99 indicated Resident #59 was unable to complete the interview. The MDS assessment indicated Resident #59 required maximal…

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

Based on observation, interview, and record review, the facility failed to provide 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 (Med Aide Cart hall 200) of 3 carts reviewed for pharmacy services. The facility failed to ensure MA C, responsible for Med Aide cart hall 200, removed medications in unsecure containers from the Med Aide Cart. This failure could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication. Findings Included: Record review and observation on 04/17/24 at 12:00 PM of Med Aide Cart Hall 200, with MA C revealed the blister pack for Resident #61's Hydroco/APAP 7.5 - 325 mg tablet (controlled medication used for pain) had 1 blister seal broken and the pill still inside the broken blister and taped over. Interview on 04/17/24 at 12:05 PM, MA C stated she was unaware when the blister pack seal was broken,…

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 control program designed to prevent the development and transmission of infection for 2 resident (Resident #59 and Resident #46) of 8 residents observed for infection control. The facility failed to ensure: 1- CNA A performed hand hygiene and changed gloves during incontinent care for Resident #59. 2- LVN B performed hand hygiene after performing FSBS (finger stick blood sugar) checks on Resident #46 and cleaning the glucometer, before re-entering the medication cart and drawing the Resident's Insulin. These failures could place residents at risk for infection and cross contamination of pathogens and illness. Findings include: 1- Record review of Resident #59's Comprehensive MDS assessment dated [DATE] reflected Resident #59 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including dementia, muscle wasting and atrophy, and cognitive communication deficit. Resident #59's BIMS score of 99…

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 a safe, functional, sanitary, and comfortable environment for residents, staff and the public for two of thirteen residents (Resident #1 and Resident #2) reviewed for environment. 1. The facility failed to ensure Resident #1's room had a toilet that flushed and repaired walls. 2. The facility failed to ensure Resident#2's room had a closet door that was functional and repaired flooring. These failures could place residents at risk for living in an unsafe, unsanitary, and uncomfortable environments. Findings include: 1. Record review of Resident #1's face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), anxiety disorder (persistent and excessive worry that interferes with daily activities), and high blood pressure. Record review of the…

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

Based on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for facility's one dumpster and used grease disposal container for garbage disposal, in that: 1. Facility failed to ensure used grease disposal container was disposed of by contract company. 2. Facility failed to ensure dumpster did not have items of recliner, wheelchairs, mattress and used PPE gloves on the ground behind dumpster. This deficient practice could place residents at risk for exposure to germs and diseases carried by vermin and rodents. Findings included: Observations on 02/28/23 at 9:50 AM and 03/01/23 at 12:54 PM revealed grease disposal trash container to the side of the facility's dumpster revealed it was closed but full to the top with pieces of fries on top. Observation on 02/28/23 at 9:50 AM of behind exterior dumpster revealed a recliner, four wheelchairs and mattress behind it with used gloves and trash debris on ground. There was a sticky substance on ground behind dumpster. Dumpster was open. Observation on 03/01/23 at 12:57 PM of behind exterior…

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 nutrition, grooming, and personal and oral hygiene for two (Residents #64, and #65,) of ten residents reviewed for ADL care. The facility failed to ensure staff provided consistent showers/baths and shaving to Residents #64 and #65 This failure could place residents at risk of not receiving needed hygiene care which could cause skin breakdown, a loss of dignity and self-worth. Findings included: 1. Record review of Resident #64's Quarterly MDS assessment, dated 0/27/23, reflected a [AGE] year-old male admitted to the facility on [DATE]. He had a BIMS score of 14 which indicated he was cognitively intact. His active diagnoses included quadriplegia (paralysis of all four limbs). He was totally dependent for bathing and required extensive two-person assistance of personal hygiene, dressing, toilet use and transfers. He…

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, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards in one of one kitchen reviewed for kitchen sanitation. 1. Facility failed to ensure fryer was cleaned after use and grease was changed. 2. Dietary [NAME] Z failed to wash hands during lunch meal preparation on 02/28/23. These failures could place residents at risk for food contamination and food-borne illness. Findings included: 1. Observation in facility's kitchen on 02/28/23 at 9:43 AM revealed grease in fryer was dark brown with couple fries floating on top of grease with food particles and crumbs on fryer. Interview on 02/28/23 at 9:45 AM revealed Dietary Manager stated the fryer was last used for dinner yesterday evening. She stated she expected the fryer should have been cleaned off after use. Dietary Manager stated the grease in the fryer had not been changed due to grease container was full. She stated the company had not come out to dispose of the used grease in 4 months. She stated she had called them several times.…

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 one (Resident #31) of five residents observed for infection control. CNA B and NA C failed to perform hand hygiene during incontinent care for Resident #31 and CNA B failed to perform hand hygiene before leaving Resident #31's room. Theses failure could place residents at risk for infection and cross contamination. Findings included: Review of Resident #31's Quarterly MDS assessment dated [DATE], reflected a [AGE] year-old female with an admission date of 04/29/16. Resident #31 was severely cognitively impaired and unable to complete the interview for mental status. She was totally dependent of one-to-two-person assistance with all ADLs and was always incontinent of bowel and bladder. Her diagnoses included aphasia (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 the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for two (Residents #31 and Resident # 52) of eighteen residents reviewed for comprehensive care plans. 1. The facility failed to care plan Resident #31's contractures to her right and left shoulders with interventions required to prevent further decline. 2. The facility failed to care plan Resident #52's contractures to his right hand with interventions required to prevent further decline. These failures could place residents at risk for possible adverse side effects, adverse consequences, and decreased quality of life and care and worsening of contractures. Findings include: 1. Record review of Resident #31's Quarterly MDS assessment dated [DATE], reflected a [AGE] year-old female with an admission date of 04/29/16. Resident #31 was severely cognitively…

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 and to restore continence to the extent possible for one (Resident #31) of two residents reviewed for incontinence care. The facility failed to ensure NA C provided appropriate perineal care for Resident #31 after an incontinent episode when she failed to separate the residents' labia and clean down the middle. This failure placed residents at risk for the development and/or worsening of urinary tract infections and skin breakdown. Findings include: Review of Resident #31's Quarterly MDS assessment dated [DATE], reflected a [AGE] year-old female with an admission date of 04/29/16. Resident #31 was severely cognitively impaired and unable to complete the interview for mental status. She was totally dependent of one-to-two-person assistance with all ADLs and was always incontinent of bowel and bladder. 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 interview and record review the facility failed to obtain from hospice the hospice plan of care, hospice election form and the physician certification of the terminal illness for two (Resident #21 and #4) of two residents reviewed for hospice records. 1.The facility failed to obtain the hospice election form and a physician certification of terminal illness for Resident #21. 2.The facility failed to obtain the hospice a physician certification of terminal illness for Resident #4. These failures could place residents at risk for services and treatments not being coordinated. Findings included: 1. Record review of Resident #21's electronic face sheet revealed an [AGE] year-old female admitted to the facility on [DATE]. Resident #21 had diagnoses which included Rhabdomyolysis, pain, psychosis, cirrhosis of liver. Record review of Resident #21's March 2023 electronic physician's orders reflected on 10/25/22 she was admitted to hospice. Record review of Resident #21's electronic clinical record and hospice…

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.