Epic Nursing & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents had the right to be free from misappropriation of property and exploitation for 1 of 6 (Resident #5) reviewed for misappropriation and exploitation, in that: The facility failed to ensure Resident #5 was free from exploitation when the BOM took Resident #5's net spend credit card and used the card for personal use. The BOM used Resident #5's credit card and withdrew funds totaling $3700. This failure could place residents at risk of financial hardships and a decrease in resident's quality of life.Findings included: Record review of Resident #5's admission record dated 10/02/25 documented a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #5 had diagnoses included major depressive disorder (sadness), cognitive communication deficit (inability to communicate effective), and hypertension (high blood pressure). Record review of Resident #5's Quarterly MDS assessment, dated 09/23/25, revealed the resident had a BIMS…

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 conduct an initial comprehensive, accurate, standardized reproducible assessment of the resident's functional capacity within 14 days of admission for 1 (Resident #2) of 7 residents reviewed for Comprehensive Assessments being completed timely. The facility failed to complete a comprehensive assessment for Resident #2 within 14 days of admission. This failure placed newly admitted residents at risk of not having care and treatment needs assessed to ensure necessary care and services were provided to meet these needs.Findings included: Review of Resident #2's face sheet dated 9/26/2025 reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including Dementia (group of brain disorders that cause progressive cognitive decline), Parkinson's disease (progressive neurological disorder that affects movement, balance and coordination), hypotension (low blood pressure), anxiety disorder and Benign Prostatic Hyperplasia (BPH -…

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

Based on observation, interviews and record reviews, the facility failed to use services of a Registered Nurse for at least 8 consecutive hours, 7 days a week. The facility failed to have an RN at the facility on 8/11 to 8/15/2025, 8/18 to 8/22/2025, 8/25 to 8/28/2025, and 9/1/2025, 9/2/2025. This failure could place residents at risk of not receiving adequate care and services of an RN, and decreased quality of life. Findings included: An observation on 9/3/2025 at 11:22 am of the Daily Nurse Staffing Report posting reflected zero scheduled RN hours. Further observation on the 9/3/2025 at 11:22 am of the Daily Nurse Staffing Report reflected zero schedule RN hours. During an interview on 9/3/2025 at 12:15 pm, the DON stated she was not aware that her RN hours could not be used to fulfill the RN staffing hours requirement. She stated she was not familiar with the average daily census requirement and thought her RN hours in addition to the weekend RNs that worked would cover all the required RN hours. The DON stated she was responsible for nurse staffing hours but was not aware 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 provide pharmaceutical services which includes the accurate acquiring and administering of medications to meet the needs for 35 out of 72 residents reviewed for pharmacy services, in that:The facility failed to provide morning medications for 35 out of 72 residents on 8/31/2025 resulting in 305 medication errors. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, could result in worsening or exacerbation of chronic medical conditions, and hospitalization. Findings included: Resident #1 Review of Resident #1's face sheet dated 9/4/2025 reflected a [AGE] year-old female admitted on [DATE] with diagnoses that included: Cerebral Infarction (Stroke - brain attack), history of falling, Dementia (progressive cognitive disease), and Major Depressive Disorder (behavioral health disorder). Review of Resident #1's annual MDS dated [DATE] reflected a BIMS score of 14 suggesting no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 1 of 6 residents (Residents #4) reviewed for accident prevention. The facility failed to ensure that bleach was not attainable for Resident #4 on 08/26/2025. This failure could place residents at risk for accidents and hazards.Findings include: Record review of Resident #4's Face Sheet, dated 09/04/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. Resident #4 has the following diagnoses: anxiety disorder (feelings of worry or fear are so intense and constant that they don't go away), unspecified dementia (loss of normal brain function that makes it hard to remember, think, speak, and do other everyday tasks), schizophrenia (brain disorder where a person has trouble telling what's real from what's not, leading to a disconnect from reality), and cognitive communication deficit (difficulties with communication that stem from a problem…

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 a safe, functional, sanitary, and comfortable environment for 1 of 5 halls reviewed for environment. The facility did not address moisture damage and discoloration in the ceiling on the hallway in the secure unit. This failure could place residents at risk of not living in a safe, functional, sanitary, and comfortable environment.The findings included: During on observation on 09/03/2025 at 11:37am, the ceiling in the hallway in the secure unit had water stains and a black substance in the ceiling. During an interview with LVN C on 09/03/2025 at 11:40am, LVN C stated that the ceiling has been like that for a while. LVN C stated the water stains and black substance were cause by an air condition leak in the ceiling. LVN C stated that black substance appeared to be mold to her. LVN C stated a negative outcome would be respiratory issues from the mold. During an interview with the Maintenance Director on 09/03/2025 at 11:45am, Maintenance Director stated that he was aware of the water stains in 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 interviews and record reviews, the facility failed to maintain the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 8 days of the 6-month review period, reviewed for RN coverage. The facility failed to ensure the facility maintained the required RN coverage for 8 days between April - June 2024. This failure could place residents at risk of not having their nursing and medical needs met and receiving improper care. Findings included: Review of CMS PBJ staffing reports reflected the facility triggered for no RN hours for FY Quarter 3 2024 (April 1 - June 30), revealed the facility did not have the required Registered Nurses coverage of at least 8 consecutive hours a day for the following dates: 04/07/24 no hours recorded. 05/04/24 no hours recorded. 05/05/24 no hours recorded. 05/18/24 no hours recorded. 05/19/24 no hours recorded. 06/01/24 no hours recorded. 06/15/24 no hours recorded. 06/16/24 no hours recorded. During an interview on 02/19/25, at 2:15 PM with the DON who stated when asked what does the facility do when there was…

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

Based on observation, interview, and record review the facility failed to store, prepare, distributed, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services. 1. The facility failed to ensure the ice machine in the tray-serving area was cleaned on 02/18/25. 2. The facility failed to ensure the opened packages of food in the dry goods pantry were sealed properly after opening on 02/18/25. 3. The facility failed to ensure the desert was covered until ready to serve on 02/19/25. 4. The facility failed to ensure the kitchen staff wore the appropriate hair covering while food was being prepared in the main kitchen on 02/19/25. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings include: Observations on 02/18/25 from 10:40 AM to 11:37 AM in the facility's main kitchen revealed: The ice machine had dried white drip stains on the door of the machine. There were brownish and white stains and build up above the door, where the front panel…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 6 (Resident #71) residents reviewed for Respiratory Care. 1. The facility failed to ensure Resident #71's handheld mouthpiece (device through which medication is inhaled) for his nebulizer (turns liquid medication into a mist) was properly stored when not in use on 02/19/2025. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings include: 1. Record review of Resident #71's Face Sheet, dated 02/19/2025, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #71 had diagnoses which included influenza (contagious respiratory infection) and acute (sudden onset) cough. Record review of Resident #71'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 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 two of eight residents (Resident #22 and Resident #38) reviewed for infection control. 1.The facility failed to ensure CNA B changed her gloves and performed hand hygiene while providing incontinent care to Resident #22 on 02/12/2025. 2.The facility failed to ensure LVN B changed her gloves and performed hand hygiene while providing wound care to Resident #38 on 02/20/2025. This failure could place residents at risk of cross-contamination and development of infections. The findings included: 1.Record review of Resident #22's Face Sheet, dated 02/12/2025, reflected the resident was an [AGE] year-old female who was admitted to the facility on 08/05/2020. Resident #22 had diagnoses which included dementia and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 6 residents reviewed for quality of care. The facility failed to document fluid intake for Residents #1 according to physician orders. This failure could place residents at risk of not receiving necessary medical care, and hospitalization. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including heart failure (occurs when the heart cannot pump enough blood and oxygen to the body), cognitive communication deficit (difficulty paying attention to a conversation, staying on topic, remembering information) essential primary hypertension (high blood pressure with no clear, identifiable cause), and Type 2 diabetes mellitus with diabetic neuropathy…

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, in response to allegations of abuse, neglect, exploitation, or mistreatment, have evidence that all alleged violations were thoroughly investigated and report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the allegation was verified appropriate corrective action was taken for one of three residents (Resident #1) reviewed for abuse and neglect . The facility failed to report, on 02/01/2025, the results of an investigation of an allegation of Abuse and Neglect involving Resident #1 when she had an unwitnessed fall on 01/27/2025. This failure could place residents at risk for continued abuse or neglect without appropriate corrective actions being taken. Findings included: Record review of Resident #1's face sheet, dated 02/07/2025, reflected an [AGE] year-old female who…

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 necessary services to maintain personal hygiene for two (Resident #1 and Resident #2) of five residents reviewed for bathing. The facility failed to provide showers to Resident #1 and Resident #2 in compliance with their shower schedules. This deficient practice could place residents at risk of a decline in their sense of well-being and level of satisfaction with life. Findings included: Review of Resident #1's admission MDS, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including heart failure, disorientation, Encephalopathy (a change in brain function causing confusion and agitation that may leave temporary or permanent brain damage), muscle wasting and atrophy, and cerebral infarction (when blood flow to a part of the brain is obstructed). Resident #1 had a BIMS score of 10, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews 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 residents' highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #1) reviewed for comprehensive care plans. The facility failed to ensure Resident #1's comprehensive care plan reflected Resident #1's physician's order dated 11/15/2024 diet was regular, puree, and nectar thick liquids. This deficient practice could place residents at risk for receiving improper care and services due to inaccurate care plans. Findings included: A record review of Resident #1's face sheet undated reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's diagnosis was Alzheimer's disease (type of dementia that affects memory, thinking, and behavior), and mild protein-calorie malnutrition (undernutrition characterized by poor growth). A record review of Resident #1's Initial 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 interview and record review, the facility failed to ensure residents were free from physical and verbal abuse for 1 of 6 residents (Resident #1) reviewed for abuse. The facility failed to prevent LVN A, on 07/28/24, from physically abusing Resident #1 when she hit Resident #1 in the right arm. These failures could place resident at risk for emotional distress, fear, decreased quality of life and further abuse. Findings included: Review of the face sheet for Resident #1 reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of: Spastic hemiplegia affecting right dominant side (type of paralysis that affects one side of the body), dysphagia (difficulty swallowing), urinary tract infection (an infection that affects part of the urinary tract, and muscle wasting and atrophy (when muscles waste away). Review of the Quarterly MDS Assessment for Resident #1 dated 05/21/24 reflected a BIMS score of 11 which indicated Resident #1 had moderate cognitive impairment. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents were free from misappropriation and exploitation of property for 1 of 6 residents reviewed for misappropriation of property. (Resident #2) The facility failed to protect Resident #2 from misappropriation/exploitation by allowing CNA C to take money from Resident #2 for CNA C's own well-being and personal expenses, exact date unknown. This failure could place residents who resided in this facility at risk of misappropriation of property. Findings included: Record review of a face sheet dated reflected Resident #2 was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included paraplegia (a chronic condition that affects the lower half of the body, causing loss of muscle function and sensory or motor impairment), idiopathic scoliosis (a spinal condition that causes the spine to curve abnormally to the side, sometimes in the shape of an S or C) urinary tract infection (an infection that affects part 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 an allegation of abuse was reported immediately but not later than 24 hours after the allegation was made for 1 of 6 residents (Resident #1) reviewed for reporting. The facility failed to ensure staff immediately reported an allegation to the abuse coordinator when CNAA reported on 07/29/24 to DON that LVN A had hit Resident #1 in the arm on 07/28/24. This failure could affect residents by placing them at risk of abuse if the reportable allegations are not reported timely after they are discovered. Findings included: Review of the face sheet for Resident #1 reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of: Spastic hemiplegia affecting right dominant side (type of paralysis that affects one side of the body), dysphagia (difficulty swallowing), urinary tract infection (an infection that affects part of the urinary tract, and muscle wasting and atrophy (when muscles waste away). 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 interviews and record review the facility failed to ensure assessments accurately reflected the resident's status for 1 of 6 residents (Residents #1) reviewed for resident assessments. The facility failed to ensure Resident #1's quarterly MDS dated [DATE] reflected that Resident #1 had an active diagnosis of dementia. This deficient practice could place residents at-risk for inadequate care due to inaccurate assessments. Findings included: A record review of Resident #1's face sheet dated 07/18/24 reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's diagnoses included malignant neoplasm of prostate (cancer cell form in the tissues of the prostate), lack of coordination (difficulties in controlling and organizing movements), type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema (advance stage where abnormal new blood vessels grow on the surface of the retina), Schizoaffective disorder (a mental health problem where you experience…

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 the medical record contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress, including his/her response to treatments and/or services, and changes in his/her condition for 1of 4 residents (Resident #1) review for resident assessments. The facility failed to ensure Resident #1's face sheet dated 07/18/2024 reflected his current diagnosis of dementia. This deficient practice could place residents at risk for inadequate care due to inaccurate assessments. Findings included: A record review of Resident #1's face sheet dated 07-18-24 reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's diagnoses included malignant neoplasm of prostate (cancer cell form in the tissues of the prostate), lack of coordination (difficulties in controlling and organizing movements), type 2 diabetes mellitus with proliferative diabetic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for 3 of 6 residents (Residents #1, #2 and #3) reviewed for ADL care. The facility failed to ensure Resident #1 was cleaned, groomed, and free from the strong odor or urine; Resident #2 was cleaned, groomed, and free from the strong odor or urine; and, Resident #3 had adequate staff to help stand and ambulate to the bathroom to use the toilet. This failure placed residents at the facility at risk of diminished quality of life. Findings included: Record review or Resident #1's undated AR reflected a [AGE] year-old male, who was admitted to the facility on [DATE]. He was diagnosed with Diabetes Mellitus Type 2 (which was a condition of the body that disrupted how the body used sugar for fuel) and paraplegia, complete (which was symptom having affected the lower legs due to spinal cord injury 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 observations, interview, and record review, the facility failed to assess the care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that were present within that population when determining staffing requirements for 3 of 6 residents (Residents #1, #2, and #3) reviewed for staffing. The facility failed to schedule nursing staff for resident care based on an evaluation of pertinent information about the residents that may affect the services the facility must provide. This failure placed residents at the facility in risk of having their needs unmet. Findings included: Record review or Resident #1's undated AR reflected a [AGE] year-old male, who was admitted to the facility on [DATE]. He was diagnosed with Diabetes Mellitus Type 2 (which was a condition of the body that disrupted how the body used sugar for fuel) and paraplegia, complete (which was symptom having affected the lower legs due to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure each resident has a right to secure and confidential personal and medical records for two (2) (WS#1 and WS#2) of seven (7) stationary computer workstations reviewed for resident privacy. The facility failed to ensure Computer Workstation #1 (nurses station) and Workstation #2 (100 hall) were not left open, unattended, and visible to resident medical records. This deficient practice could place residents at-risk of exposure of their personal information to unauthorized individuals. Findings included: During an observation on 2/9/2024 at 10:52 am, workstation (WS) #1 at the nurses station was observed to be unattended with a resident face sheet visible. Further observation revealed a staff member came up to WS#1, put down her cup and walked away leaving screen remaining visible and unattended. At 10:56 am, the computer automatically locked the screen. There were two staff, one resident, one visitor, and two investigators in the vicinity of WS#1…

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 the right to reside and receive services in the facility 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 4 of 8 residents (Residents #12, #42, #45 and Resident #63) reviewed for accommodation of needs. 1. The facility failed to ensure Resident #12 and Resident #42's call light buttons were located within each residents reach. 2. The facility failed to ensure Resident #45 and Resident #63's call light pull strings, in their individual bathrooms, were free from entanglement and extended the maximum distance from the wall mount to the floor. This failure could place residents at risk of unmet physical needs and psychological anguish. Findings include: 1. Record review of Resident #12's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #12 had diagnoses which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 1 of 8 residents (Resident # 14) reviewed for MDS accuracy. The facility failed to ensure Resident #14's Annual MDS Assessment reflected the use of bed rails. This failure could place residents at risk of not receiving the care and services to meet their needs. Findings include: A record review of Resident #14's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #14's diagnosis which include other seizures (uncontrolled burst of electrical activity between brain cells that cause temporary abnormalities in muscle tone or movements), abnormal posture (rigid body movements and chronic abnormal position of the body), muscle weakness (lack of strength in muscles), parkinsonism (disorder that affects the nervous system and parts of the body controlled by the nerves), and dysphagia (swallowing difficulties). A record review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid to the maximum extent practicable to avoid duplicative and effort which includes referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon significant change in status assessment for 1 of 2 residents (Resident #53) reviewed for PASARR. The facility failed to ensure Resident #53 had an accurate PASRR Level 1 Screening which indicated a diagnosis of mental illness on 03/22/2022. This failure could place residents at risk of not receiving needed individualized care, and specialized services to meet their needs. Findings include: Record review of Resident #53's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia (impaired ability to remember,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that 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 2 of 7 residents (Resident #19 and Resident #72) reviewed for comprehensive care plans. The facility failed to ensure a comprehensive care plan was developed for Resident #19 which included measurable objectives and timetables to meet and implement the residents medical nursing mental and psychological needs . The facility failed to ensure a comprehensive care plan was developed for Resident #72 which included measurable objectives and timetables to meet and implement the residents medical nursing mental and psychological needs . This failure could place residents at risk of not having their preferences, choices, and goals met during their stay…

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 maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that was not possible or the resident preferences indicated otherwise for 1 of 8 residents (Resident #4) reviewed for nutrition status maintenance. The facility failed to measure and record Resident #4's body weight, as ordered by the resident's physician, for two consecutive months (November 2023 and December 2023.) This failure could place residents at risk of weight loss, weight gain, nutritional deficit, and adverse health consequences. Findings include: Record review of Resident #4's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses which included other Sequelae of Cerebrovascular Disease (which was a diagnosed medical classification influenced by a disease of how…

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, which include tracheostomy care and tracheal suctioning, was provided, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 7 residents (Resident #13) reviewed for respiratory care. The facility failed to ensure Resident #13's nebulizer masks and tubing were covered. This failure could place residents at risk for respiratory infections. Findings include: Record review of Resident #13's Care plan, dated 11/13/23, reflected Resident #13 was care planned for potential complication related to diagnosis of Chronic Obstructive Pulmonary Disease with an approach to administer Nebulizer treatments and / or inhalers as ordered. Monitor for effectiveness, side effects. Record review of Resident #13's Quarterly MDS, dated [DATE] , reflected Resident #13 had a BIMS score of 05, which indicated severe 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 provide pharmaceutical services which included procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of resident for 1 of 4 residents (Resident #28) reviewed for pharmacy services. The facility failed to order Resident #28's Coreg (carvedilol) 3.125 mg, (for hypertension), in a timely manner. The failure could place residents at risk of medicinal adverse effects, decreased health status and being hospitalized . Findings include: Record review of Resident #28's face sheet reflected a [AGE] year-old female who was admitted on [DATE]. Her diagnoses included acute on chronic systolic congestive heart failure (a condition that occurs when the heart muscle doesn't pump blood as well as it should); other psychoactive substance use; dehydration; hypertension (high blood pressure); and COPD (trouble breathing). Record review of Resident #28's Active Physicians Orders,…

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 the medication error rate was not five percent or greater. The facility had a medication error rate of 6.45%, based on 2 errors out of 31 opportunities, which involved 2 of 4 residents (Residents #28 and Resident #47) observed during medication administration for medication errors. The facility failed to ensure Resident #28 received Coreg (carvedilol) 3.125 mg, (for hypertension) as ordered by the physician. The facility failed to ensure Resident #47 received Tramadol/Acetaminophen 37.5-325, 2 tablets (for chronic pain) as ordered by the physician. These failures could place residents at risk of inadequate therapeutic outcomes. Findings include: Record review of Resident #28's face sheet reflected a [AGE] year-old female who was admitted on [DATE]. Her diagnoses included acute on chronic systolic congestive heart failure (a condition that occurs when the heart muscle doesn't pump blood as well as it should); other psychoactive…

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 Tag: 880 S/S= F Based on observations, interview and record review, the facility failed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 4 halls located within the facility. The facility failed to slow the spread of covid 19 by staff not wearing mask when in the facility while current covid 19 outbreak was occurring. The facility failed to ensure dirty soiled linens were properly discarded to the laundry. These failures could place residents at risk for covid 19 infection and communicable diseases. Findings included: A) In an observation on 8/12/23 at10:08 AM upon entry to the facility there were no postings on the front door or notification that the facility was having a covid 19 outbreak. No mask was available at the front door. No staff was observed wearing mask when entering the facility. Staff answered the door with no mask in place. Three nurses were sitting at nurses' station with no mask in…

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.