Fair Park Health & Rehabilitation Center

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 one of ten residents (Residents #47) reviewed for respiratory care. The facility failed to ensure Resident #47's breathing mask was properly stored when not in use on 07/08/2026. This failure could place residents at risk of respiratory infection and not having their respiratory needs met.Findings included: Record review of Resident #47's Face Sheet, dated 07/09/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with acute upper respiratory infection. Record review of Resident #47's Comprehensive MDS Assessment, dated 06/12/2026, reflected the resident had a moderate impairment in cognition with a BIMS score of 08. The Comprehensive MDS Assessment indicated the resident 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 observations, interviews, and record reviews, the facility failed to ensure the resident was free from abuse, neglect and corporal punishment of any type by anyone one of four residents (Resident #1) reviewed for abuse. PTA M reported and observed Resident #2 hitting Resident #1 while in the smoking area on 04/09/26. This failure could place residents at risk of sustaining serious harm and not being free from abuse.Findings included:Record review of Resident #1's Face Sheet, dated 05/06/26, reflected a [AGE] year-old female admitted [DATE]. Resident #1 had a diagnosis of COPD (obstructed airflow).Record review of Resident #1's Quarterly MDS Assessment, dated 03/20/26, reflected BIMS score of 12 indicating moderate cognitive impairment. The MDS assessment reflected the resident had active diagnoses of COPD and bi-polar.Record review of Resident #2's Face Sheet, dated 05/07/26, reflected a [AGE] year-old male admitted [DATE]. Resident #2 had a diagnosis of schizophrenia (severe brain disorder).Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systemically organized in accordance with accepted professional standards for 2 of 3 residents (Residents #1 and #2) reviewed for clinical records regarding wound care.1. The facility failed to ensure nursing staff documented that physician ordered wound care was provided to Resident #1 for a skin tear on her left buttocks on 03/06/26, 03/07/26, 03/08/26, 03/14/26, and 03/15/26 and for a post-surgical wound on her abdomen on 03/06/26, 03/07/26, 03/08/26, 03/14/26, 03/15/26, 03/20/26, 03/21/26, 03/28/26 and 03/30/26. 2. The facility failed to ensure nursing staff documented that physician ordered wound care was provided to Resident #2 on 03/10/26, 03/20/26, 03/27/26, 03/28/26, 03/29/26. This failure could place residents at risk for incomplete and inaccurately documented medical records that included their progress treatment,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 Residents (Resident #1, and Resident #2) observed for infection control. 1.The facility failed to ensure CNA D and RN A utilized Enhanced Barrier Precautions and performed hand hygiene during wound care for Resident #1 on 02/21/26. 2. The facility failed to ensure RN A handled Resident #1's wound care supplies appropriately to prevent cross contamination during wound care on 02/21/26. 3.The facility failed to ensure LVN B performed hand hygiene during wound care for Resident # 2 and failed to prevent cross contamination of wound care supplies on 02/21/26. These failures could place the residents at risk of cross-contamination and development of infection. Findings included: 1. Record Review of Resident #1's Face Sheet…

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, easy to use, clean and comfortable environment for 4 of 10 resident rooms on the 100 - hall (Resident rooms #1, #2, #3, and #4). The facility failed to ensure Resident rooms #1, #2, #3, and #4, were thoroughly cleaned and sanitized. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.Findings include: An observation on 9/23/25 at 8:26 AM of resident room [ROOM NUMBER] reflected trash on the floor and white milk spilled on the floor, near the resident's bed. An observation on 9/23/25 at 8:27 AM of resident room [ROOM NUMBER] reflected large patches of brown and black stains on the floor, under the resident's bed. An observation on 9/23/25 at 8:28 AM of resident room [ROOM NUMBER] reflected large brownish stains on the floor, under the resident's bed. An observation on 9/23/25 at 8:28 AM of resident room [ROOM NUMBER] reflected…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure each resident is being watched and has assistance devices, when needed, to prevent accidents for six of nine residents (Resident #4, #5, #6, #7, #8, and #9) reviewed for accident hazards. The facility failed to ensure Resident #4, #5, #6, #7, #8, and #9 were properly supervised while smoking in the smoking area of the facility. This failure could place the residents at risk of harm and serious injuries. Findings include: 1 Record review of Resident #4's Face Sheet, dated 09/23/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included Asthma (inflamed airways) and COPD (lung disease). Record review of Resident #4's Quarterly MDS assessment, dated 8/22/25, reflected she had a BIMS score of 15 (intact cognitive response). For active diagnosis it reflected a stroke. Record review of Resident #4's Comprehensive Care Plan, dated 9/23/25, reflected the resident was a smoker and an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for one of three residents (Resident #2) reviewed for respiratory care. The facility failed to ensure Resident #2's nasal canula was properly stored in a bag when not in use on 09/23/25. This failure could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings include: Record review of Resident #2's Face Sheet, dated 09/23/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included Chronic Respiratory Failure (lack of oxygen) and Chronic Obstructive Pulmonary Disease (lung disease). Record review of Resident #2's Quarterly MDS assessment, dated 8/08/25, reflected he had a BIMS score…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the call system was accessible to residents while in their bed or other sleeping accommodations within the resident's room for two of five residents (Resident #1, and #3) reviewed for Reasonable Accommodation of Needs. The facility failed to ensure the call light system in Resident #1, and #3's room was in a position that was accessible to the residents on 09/23/25. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings include: 1. Record review of Resident #1's Face Sheet, dated 09/23/25, reflected he was an [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included stroke and lack of coordination. Record review of Resident #1's Quarterly MDS assessment, dated 9/05/25, reflected he had a BIMS score of 9 (moderate cognitive impairment). For ADL care, it reflected the resident required total assistance. Record 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 interview and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for two (Resident #1 and Resident #2) of two reviewed for abuse and neglect.The facility failed to ensure Resident #2 was free from abuse, on 6/27/25, when Resident #1 struck her in the forehead with a cane, which resulted in a laceration.This failure could place residents at risk of abuse and emotional stress. Findings include: 1. Record review of Resident #1's face sheet dated 02/26/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: dementia of unspecified severity without behavioral disturbance (a decline in memory or other cognitive function not accompanied by aggression), psychotic disturbance (delusions or hallucinations), delirium due to psychological condition (acute confusion linked to psychiatric causes), cognitive communication deficit (difficulty…

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 refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 (Resident #4) of 5W residents reviewed for PASARR. The facility failed to submit a complete and accurate request for nursing facility specialized services (NFSS) in the LTC Online Portal 02/20/2025 as required within 20 business days after the date of the Interdisciplinary Team meeting . The NFSS Request submittal by the NF was denied on 02/10/2025, and there was no evidence of facility follow up. to ensure the request was approved to provide specialized services for PASARR for the resident. These failures could place the resident at risk of not receiving necessary care and/or services. Findings Included: Record review of the NFSS submission for Resident #4 on 02/10/2025 revealed the submission was completed electronically, and not via SIMPLELTC web…

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 provide specialized rehabilitative services such as but not limited to physical therapy, speech -language pathology, occupational therapy, respiratory therapy, and rehabilitative services for mental illness and intellectual disability or services of a lesser intensity as required in the resident's comprehensive plan of care for 1 (Resident #4) of 5 residents reviewed for specialized rehabilitative services. The facility failed to ensure Resident #4 received physical therapy per the PASARR Comprehensive Service Plan January 2025 to April 2025 . This failure could place residents who require specialized rehabilitative services at risk of a decline in health status and a decreased quality of life. The findings included: Record review of Resident #4's admission Record, dated 06/10/2025, reflected a 39- year-old female. She was admitted to the facility on [DATE]. Record review of Resident #4's Medical Diagnosis list, dated 06/10/2025, reflected 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.

Based on observation, interview, and record review the facility failed to properly secure medications in a locked compartment for 1 of 2 medication carts (Unit 2) reviewed for drug storage. On 05/13/2025, LVN D left the Unit 2 medication cart unlocked and unattended for an unknown amount of time. These failures placed residents at risk for unauthorized access to the medication cart and consumption of harmful medications. Findings included: An observation and interview on 5/13/25 at 7:46 AM revealed an unlocked medication cart was situated in a hallway across from the Unit 2 nurses' station. There was no nurse or medication aide seen in the vicinity of the cart. RN C approached from around a corner and stated she did not know why the medication cart had been left unlocked and believed that MA E had the keys. RN C was observed locking the cart. During an observation and interview on 5/13/25 at 7:50 AM, MA E was passing medications on the 100 Hall and stated she did not have the keys to the 200 Hall at that time and believed the nurse had them. During an interview on 5/13/25 at 8:47…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen safety. 1. The facility failed to seal opened items in plastic bags in the dry storage pantry, refrigerator, and freezer areas on 05/12/25. 2. The facility failed to ensure an expired item in the dry storage pantry area was removed on 05/12/25. 3. The facility failed to ensure the dented cans in the dry storage area with the other canned food were removed from the shelf on 05/12/25. 4. The facility failed to clean the 6 A/C vents in the kitchen on 05/12/25. These deficient practices could affect residents who received meals and/or snacks from the facility's only kitchen by placing them at risk for cross contamination and other food-borne illnesses. Findings included: Observation of the facility's kitchen dry storage, refrigerator and freezer areas and the kitchen A/C vents on 05/12/25 at…

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 complete a discharge summary that included but was not limited to, (i) A recapitulation of the resident's stay that includes, but was not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results; (ii) A final summary of the resident's status; (iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter) for one of (Resident #43) of two residents reviewed for discharge planning. 1. The facility failed to complete a discharge summary and a reconciliation of medications for Resident #43 when he planned discharge home on [DATE]. This failure could place residents at risk of a recapitulation of the stay being unavailable to help ensure continuity of care once they went back home and/or discharged from the facility. Findings included: 1. Record Review of Resident #43's admission face sheet dated 03/08/2025 reflected that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living, received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 6 residents (Residents #22) reviewed for ADL care. CNA G failed to ensure Resident #22 was provided her shower as scheduled on the 2:00 PM to 10:00 PM shift on 5/12/25. This failure could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem. Findings included: Record review of Resident #22's admission Record dated 5/12/25 reflected a [AGE] year-old female originally admitted to the facility on [DATE]. Record review of Resident #22's Quarterly MDS assessment dated [DATE] reflected she had a BIMS score of 9 indicating moderately impaired cognition. Her diagnoses included hypertension (high blood pressure); stroke; hemiparesis (muscle weakness or partial paralysis on one side of the body often caused by a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 one of five (Resident #22) residents reviewed for pharmacy services. The Facility failed to ensure nursing staff ordered medications in a timely manner for Resident #22 resulting in her missing a scheduled morning dose of Robaxin used to control her muscle spasms on 5/13/25. This failure placed the residents at risk of not receiving medications as ordered by the physician and a delay in treatment and worsening of their condition. Findings included: Record review of Resident #22's admission Record dated 5/12/25 reflected a [AGE] year-old female originally admitted to the facility on [DATE]. Record review of Resident #22's Quarterly MDS assessment dated [DATE] reflected she had a BIMS score of 9 indicating moderately impaired cognition. Her diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided care consistent with professional standards of practice for 2 (Resident #1 and #4) of 4 residents reviewed for Respiratory Care. 1. The facility failed to ensure that Resident #1's nasal cannula, for the oxygen concentrator, was placed in a sanitary container when not in use. 2. The facility failed to ensure that Resident #4's oxygen tubing (flexible tube used to deliver oxygen to the nose through two prongs) was changed. These failures could place residents at risk for respiratory infection and not having their respiratory needs met. Findings included: Record review of Resident #1's Face Sheet, dated 10/23/2024, reflected she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included COPD, and history of pneumonia. Record review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected, he had a Brief Interview for Mental Status…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 1 (Resident #2) of 3 residents reviewed for accident prevention. The facility failed to ensure Resident #2's bed was placed in the lowest position to assist in fall prevention. This failure could prevent residents from having an environment that was free and clear of accidents and hazards. Findings included: Record review of Resident #2's Face Sheet, dated 10/23/2024, reflected he was an [AGE] year-old male admitted on [DATE]. Relevant diagnoses included muscle spasms, lack of coordination, and muscle weakness. Record review of Resident #2's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected, he had a Brief Interview for Mental Status (BIMS) score of 5 (severe cognitive impairment) and for ADL care it reflected assistance for transfers, toileting, and bathing and the resident was totally dependent for assistance. Record 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 that all drugs and biologicals were accurately dispensed and administered to meet the needs of each resident when 1 (Resident #3) of 6 residents were reviewed for pharmaceutical services. The facility failed to ensure that Resident #3 did not miss doses of medication that was to be administered at bedtime. This failure could place residents at risk of not receiving their medications as ordered by their physician. Findings included: Review of Resident #3's Face Sheet, dated 10/23/24, reflected that Resident #3 was a [AGE] year-old female admitted [DATE] with cerebral infarction (stroke: blood flow to the brain is blocked) affecting left non-dominant side, left elbow contracture (permanent tightening of the muscle), and unspecified pain. Review of Resident #3's Quarterly MDS (Minimum Data Set: screening tool to assess health status) Comprehensive Assessment, dated 10/02/24, reflected that Resident #3 had moderate cognitive impairment with 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.

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. 1. The facility failed to ensure refrigerator items were dated and labeled. 2. The facility failed to ensure ice scoop was left outside of ice bin. 3. The facility failed to ensure [NAME] A performed hand hygiene during lunch meal service on 4/4/24. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed, and food contamination. Findings included: Observation in the kitchen on 04/03/24 at 9:43 AM revealed a box of celery in the walk-in refrigerator that was not dated and labeled. Observation in the kitchen on 04/03/24 at 9:50 AM revealed a box of tomatoes in reach-in refrigerator that was not dated and labeled. Observation on 04/03/24 at 09:52 AM revealed that ice scoop was left inside the ice bin touching the ice cubes within the ice machine. Observation of lunch meal…

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 2 (Resident #19, Resident #22) of 8 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #19 had her fingernails cleaned and trimmed. 2- Resident #22 had his fingernails cleaned and trimmed. 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 #19's Quarterly MDS assessment dated [DATE] reflected Resident #19 was a [AGE] year-old female readmitted to the facility on [DATE] with diagnoses included hemiplegia (paralysis of one side of the body) affecting left side, lack of coordination, and contracture of the left elbow. Resident #19 had a BIMS score of 9, which indicated her cognition was moderately impaired. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide treatment and services to prevent complications of enteral feeding for one (Residents #25) of one resident reviewed for feeding tubes in that: LVN B failed to check placement of Resident #25's G-Tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach) by checking for gastric residual (quantity remaining) prior to administering the resident medications. This failure could affect residents by placing them at risk of obstruction of the G-tube, nausea, vomiting and potential for aspiration and discomfort. Findings included: Record review of Resident #25's Quarterly MDS assessment, dated 04/03/24, reflected he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including dysphagia (swallowing difficulties), cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), and 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.

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 #23) reviewed for respiratory care, in that: The facility failed to ensure Resident #23 Oxygen humidity bottle were labeled or dated. These failures could place the resident at risk for respiratory infection and not having their respiratory needs met. The findings were: Review of Resident # 23s Quarterly MDS assessment dated [DATE] reflected a [AGE] year-old female re-admitted to the facility on [DATE]. Relevant diagnoses include Chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing- related problems), Congestive heart failure (compromised blood supply from heart to meet body's needs), Hyperlipidemia (high blood lipid level), Schizophrenia {severe mental disorder) and was on oxygen therapy in the facility. Review of Resident #23's care plan dated…

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 1 resident (Resident #10) of 8 observed for infection control. The facility failed to ensure RN C performed hand hygiene and changed gloves during wound care for Resident #10. This failure could place residents at risk for infection and cross contamination. Findings include: Record review of resident #10's Quarterly MDS assessment, dated 03/20/24, reflected a [AGE] year-old male with an admission date of 08/15/23 with diagnoses included peripheral vascular disease, chronic ulcer of unspecified part of left lower leg, and non-pressure chronic ulcer of other part of unspecified foot. Resident #10 had a BIMS of 12 which indicated Resident #10's cognition was moderately impaired. Resident#10 required moderate assistance of one-person physical assistance with dressing, and toileting hygiene. The resident was occasionally 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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #1) of 3 residents reviewed for infection. The facility failed to ensure CNA A performed hand hygiene during incontinence care for Resident #1. This failure placed residents at risk for infection. Findings included: Review of Resident #1's Face Sheet dated 02/21/24, reflected he was an [AGE] year-old male admitted on [DATE]. His diagnosis included Alzheimer's disease. An observation and interview on 02/21/23 at 11:15 AM with CNA B and CNA A revealed they were preparing to provide Resident #1 with incontinence care. The resident was lying in bed, with his brief already removed. CNA A washed her hands and put on gloves. CNA A cleansed the resident's penis and scrotal area. Resident #1 was assisted 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, interview, and record review revealed the facility failed to make prompt efforts to resolve grievances for 1 of 5 residents (Resident #1) whose records were reviewed for grievances. The facility failed to document, investigate, and respond to Resident#1's family member/visitor's complaint communicated to the Administrator. This deficient practice could contribute to the resident's frustration and feelings of hopelessness. The findings were: A review of Resident #1's electronic sheet face dated undated revealed a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included Dysphagia (swallowing difficulties), Vascular parkinsonism (symmetrical lower-body parkinsonism with gait unsteadiness and absence of tremors), and encephalopathy (damage or disease that affects the brain). Resident #1 had a guardian listed. A review of Resident #1's Minimum data set (MDS) dated [DATE] revealed a brief interview of mental status (BIMS) of 02, indicating…

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