Five Points at Lake Highlands Nursing and Rehab

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 residents (Resident #140 and Resident #190) of 5 residents observed for infection control. The facility failed to ensure:CNA C changed gloves and completed hand hygiene during incontinent care for Resident #140 on 3/29/26.CNA Q performed hand hygiene while providing incontinence care to Resident #190 on 03/29/26. CNA P and CNA Q wore proper PPE while performing incontinent care for Resident#190 ,who was in enhanced barrier precautions for indwelling medical devices on 03/29/26. These failures could place residents at risk for infection and cross contamination of pathogens and illness.Resident # 140Record review of the Quarterly MDS assessment dated [DATE] reflected Resident #140 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses included cerebral infarction (a condition caused by a blockage in blood…

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 immediately notify the resident representative and the resident's physician, when there was significant change in resident's physical, mental, or psychosocial status for one of eight (Resident #2) reviewed for resident rights. The facility failed to ensure LVN K notified the RP and the physician when Residents #2 was hit with the door. On 11/24/25 LVN K entered Resident #2's room hitting him with the door, she failed to complete an incident report, document assessments completed, and any required ongoing monitoring for delay in injury and failed to notify the resident's responsible representative of the resident's broken dentures. This failure could place residents at risk of not having their responsible party, physician and oncoming staff notified of changes, which could result in a delay in medical intervention and a decline in health. Findings included: Record review of Resident #2's Face Sheet dated 12/12/25 reflected an [AGE] year-old…

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 a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 1 of 7 residents (Resident #3). The facility failed to ensure Resident #3's room was free from hazards. This deficient practice could place residents at risk of living in an unsafe environment which could lead to falls and injuries.Findings include: Record review of Resident #3's Face Sheet, dated 12/09/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included muscle weakness and difficulty walking. Record review of Resident #3's Quarterly MDS assessment, dated 9/01/25, reflected a BIMS score of 15, an intact cognitive response. For ADL care, it reflected the resident required substantial assistance. Record review of Resident #3's Comprehensive Care Plan, dated 12/09/2025, reflected the resident was a risk for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure that 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 1 of 4 residents (Resident #5) reviewed for ADL care provided to dependent residents. The facility failed to ensure Resident #5 received any of her scheduled showers based on records reviewed for November and December 2025. This failure could place residents at risk of not receiving necessary services to maintain good personal hygiene, skin integrity, or decreased self- esteem.Findings Included: Record review of Resident #5's Face Sheet, dated 12/09/25, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included Cerebral Infarction impacting left dominant side (stroke) and reduced mobility. Record review of Resident #5's Quarterly MDS assessment, dated 9/16/25, reflected a BIMS score of 14, an intact cognitive response. For ADL…

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 election form, hospice plan care, and physician certification and recertification of the terminal illness specific to the patient and failed to designate a member of the facility's interdisciplinary team who was responsible for working with hospice representatives to coordinate care to the resident for one of three (Resident #2) residents reviewed for hospice services. The facility failed to coordinate care between the facility and Hospice Agency J for Resident #2 at the time of her Respite stay from 11/22/25 through 11/26/25 which resulted in her not receiving her Hospice aide services from 11/24/25 through 11/26/25. These failures could place residents on hospice at risk of not having services coordinated between service providers.Findings included:Record review of Resident #2's Face Sheet dated 12/12/25 reflected an [AGE] year-old female with an admission date of 11/22/25. Her diagnoses included Alzheimer's disease.…

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 resident had the right to be treated with respect and dignity for 1 of 4 residents (Resident #4) reviewed for dignity. The facility failed to ensure Resident #4 had a privacy curtain. This deficient practice could place the resident at risk of not feeling as if they were being treated with dignity and respect while being fed.Findings include:Record review of Resident #4's Face Sheet, dated 12/09/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included major depressive disorder and anxiety. Record review of Resident #4's Quarterly MDS assessment, dated 11/19/25, reflected a BIMS score of 8, a moderate impairment. For ADL care, it reflected the resident required supervision or touching assistance. Record review of Resident #4's Comprehensive Care Plan, dated 12/02/2025, reflected the resident had an impaired cognitive impairment and an intervention included providing the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 resident (Resident #3) of 6 residents reviewed for ADLs. The facility failed to ensure Resident #3 had his fingernails cleaned and trimmed on 11/06/25. 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. Record review of Resident #3's admission MDS assessment dated [DATE] reflected Resident #3 was an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included dehydration (occurs when the body loses more fluids than it takes in, leading to a depletion of water and electrolytes), coronary artery disease (a condition where the arteries that supply blood to the heart [coronary arteries] become narrowed or blocked), and benign prostatic hyperplasia (a non-cancerous…

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 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 6 residents (Resident #1, Resident #2) observed for infection control. The facility failed to ensure CMA A disinfected the blood pressure cuff in between blood pressure checks for Residents #1 and Resident #2 during a medication pass on 11/06/25. These failures could place residents at-risk of cross contamination which could result in infections or illness.Observations on 11/06/25 between 09:24 AM and 07:43AM revealed CMA A took a blood pressure cuff from the top of the medication cart, entered Resident #1's room, checked his blood pressure and put the blood pressure cuff back on the top of the medication carts without sanitizing it. CMA A gave Resident #1 his morning medications. CMA A moved the medication cart to the front of Resident #2's room. CMA A retrieved the blood pressure cuff from…

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 provide the necessary services to maintain good nutrition, grooming, and personal and oral hygiene to residents who are unable to carry out activities of daily living for one (Resident #1) of four residents reviewed for quality of life. The facility failed to assist Resident #2 with timely incontinence care . These failures could put residents at risk of poor personal hygiene, impaired skin integrity, and decreased feelings of self-worth and dignity. Findings included: A record review of Resident #2's Quarterly MDS assessment dated [DATE] revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #2 had history and diagnoses of Hemiplegia (complete paralysis of one side of the body) and Hemiparesis (involves weakness on one side of the body) following cerebral infarction (stroke) affecting right dominant side; Need for Assistance with Personal Care; Anxiety and MDD (a mood disorder that causes a persistent feeling 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.

Based on record review, observations and interviews, the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents, for one (medication cart #1) of two medication carts observed for medication storage. On 06/09/25 at 7:53 AM, MT Q failed to ensure medications were secured or attended to by authorized staff when MT Q did not lock the medication cart (#1) before she walked away. This failure placed residents at risk of a potential for more than minimal harm if a resident accessed and ingested medications or drug diversion. Findings included: During an observation on 06/09/25 at 7:53 AM revealed a medication cart (#1) unlocked, unattended and not under direct observation of authorized staff. The lock was in the out position, and anyone could open the drawers and left the medications accessible. Various multi-dose bottles of OTC medications were organized in the top drawer of the medication cart. Residents' routine and PRN medications and medication blister packs were organized in other drawers of the medication cart. One resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents in 1 of 5 rooms observed. The metal vent cover was missing from the air conditioning opening in the ceiling. The built-in dresser was missing 4 dresser drawers and 2 dresser doors. This facility failure could place Residents at risk for an unsafe environment. Findings include: Record review of Resident #2's face sheet dated 05/14/2025 revealed a [AGE] year-old admitted [DATE] with a readmission on [DATE]. Admitting diagnosis of Acute and Chronic Respiratory Failure with Hypercapnia (the inability to adequately remove carbon dioxide from the blood, leading to elevating levels of CO2 in the blood (hypercapnia) ; Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation (sudden worsening in airway function and respiratory symptoms in patients with COPD (a group of lung diseases that block airflow and make it difficult to breathe) ; Essential (Primary) Hypertension (high…

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 implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs in order attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #1) of five residents reviewed for care plans. The facility did not put a floor mat for Resident #1 as indicated in his care plan as an intervention in the resident's care plan who was a high fall risk while he was in his bed on 05/14/25. This failure can put residents at risk for falls to sustain injuries due to not following interventions for fall precautions in place. The findings included: Record review of Resident #1 admission record dated, 05/14/25, revealed a [AGE] year-old male readmitted to the facility on [DATE]. His diagnoses included Unspecified Parkinsonism (a progressive nervous system disorder, which affects the ability to move muscles and muscle spasms 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 to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 1 of 6 residents (Resident #10) reviewed for ADL care. The facility failed to ensure Resident #10 was provided showers as scheduled. This failure could place residents at risk of not receiving services and decreased quality of life. Findings included: Record review of Resident #10's admission record, dated 05/14/2025, revealed a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis that included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting right dominant side. Record review of Resident #10's quarterly MDS assessment, dated 04/29/2025, revealed a BIMS score of 14, indicating intact cognition. Further review of the MDS revealed Resident #10 required partial/moderate assistance in showering 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 observation, interview, and record review, the facility failed to ensure personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 4 (Emergency Response Cart 1) emergency crush carts reviewed for emergency preparedness. Facility failed to check inventory daily on an Emergency Response Cart 1 on C hallway from [DATE] to [DATE]. These failures could place residents at risk for delayed emergency response care. The findings included: Review of Emergency Response Cart 1's daily log inventory check off on [DATE] at 09:46 AM, revealed no check off was completed from [DATE] to [DATE] on Emergency Response Cart 1. Further review of the daily Emergency Response Cart 1 inventory log revealed it was also incomplete for [DATE] with the following items not checked off; Kling (a type of gauze bandage), blood pressure cuff, stethoscope, K-Y-…

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 implement their written policies and procedures that prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of resident's property for one (Resident #1) of five residents reviewed for injuries of unknown origin. The facility staff failed to report an injury of unknown origin to the abuse and neglect coordinator when Resident #1 sustained a large bruise to her right and left eyes and laceration to her right eyebrow. This failure could place the residents at risk for further potential abuse due to unreported and uninvestigated allegations of abuse, neglect, and injuries of unknown origin. Findings included: Record review of Resident #1's Face Sheet dated 01/23/25 reflected Resident #1 was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #1's active diagnoses included Huntington's disease (a condition that leads to progressive degeneration of nerve cells in the brain that affects…

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 provide pharmaceutical services (including the procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of five residents reviewed for medications and pharmacy services. The facility failed to take Resident #1's blood pressure and administer her medication in accordance with the physician orders. Resident #1 was administered Propranolol (a beta blocker medication that relaxes blood vessels in the body is used to treat a variety of conditions including high blood pressure) three times a day from 12/01/24 through 01/18/25. The medication was only to be given if her blood pressure was over 110/60. However, there was no documented evidence to indicate her blood pressure was taken in her clinical record to validate the medication needed to be given and did not need to be held. This failure could place residents at risk for not receiving…

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 1 of 1 kitchen reviewed for kitchen safety. 1. The facility failed to ensure food in the facility's dry storage, refrigerator, and freezer areas were labeled and dated according to guidelines. 2. The facility failed to seal open items in plastic bags in the dry storage pantry, refrigerator, and freezer areas. 3. The facility failed to ensure that expired items in the dry storage pantry, refrigerator and freezer areas were removed. These deficient practices could affect residents who received meals and/or snacks from the main kitchen and place them at risk for cross contamination and other air-borne illnesses. Findings Included: Observation of the kitchen during the brief initial tour of the kitchen on 12/08/24 at 9:33 AM, revealed the following: Dry storage area *One box of twenty-five 4 fl. oz. of thickened unflavored water that expired on 11/27/24, *One box of thirty-eight 4 fl. oz. 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, interviews, 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 three (Resident #104, Resident #62, and Resident #89) of nine residents observed for infection control. 1. The facility failed to ensure CNA D performed hand hygiene while providing incontinence care to Resident #104. 2. The facility failed to implement enhanced barrier precautions for Resident #62 and Resident #89. These failures placed residents at risk for healthcare associated cross contamination and infections. Findings included: 1. Record Review of Resident #104's quarterly MDS assessment, dated 08/17/24, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's BIMs score was 5 indicating the resident's cognition was severely impaired. The resident was dependent…

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 interviews the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for one (Resident #98) of five residents reviewed for environment. The facility failed to ensure Resident #98's windowsill was repaired after it was broken leaving damaged wood and debris exposed to the room. This failure could place residents at risk for a diminished quality of life due to the lack of a homelike environment. Findings included: Record review of Resident #98's admission Record dated 12/8/24 reflected a [AGE] year-old female admitted to the facility on [DATE]. Record review of resident #98's Quarterly MDS assessment dated [DATE] reflected she was rarely or never understood and had severe cognitive impairment. Her diagnoses included kidney failure, pneumonia, aphasia (inability to speak), respiratory failure, stroke, seizure disorder, and anoxic brain damage (caused by lack of oxygen to the brain. She was fed 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 interviews and record review the facility failed to ensure all Pre-admission Screening and Resident Review (PASARR) level 1 residents with mental illness were provided with a PASARR level 2 evaluation for 7 of 10 residents (Resident #104, Resident #82, Resident #5, Resident #14, Resident #21, Resident #64's, and Resident #76), reviewed for resident assessment. Resident #104, Resident #21, Resident #64, and Resident #76 PASARR's level 1 screening form did not reflect mental illness and the residents did not have a PASARR level II evaluation. Resident #82 was not referred to the Local Mental Health Authority (LMHA) for PASARR Level 2 screening. Resident #5 and Resident #14 did not have a PASARR level 1 or 2 evaluation completed. These failures could place residents at risk of not receiving necessary specialized services to meet their individual needs. The findings were: Resident #104 Record review of Resident #104's quarterly MDS assessment, dated 08/17/24, reflected the resident was a [AGE] year-old…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to meet the resident's medical and nursing needs for one (Resident #57) of four reviewed care plans. The facility failed to develop a care plan to address Resident #57 smoking. This failure could place residents who smoke at harm due to not completing safe smoking assessment. Findings included: Review of Resident #57's quarterly MDS Resident Assessment, dated 10/03/24, revealed he was a [AGE] year-old male who admitted to the facility on [DATE]. His active diagnoses included Non-Alzheimer's Dementia, Malnutrition, Asthma, and Chronic Obstructive Pulmonary Disease. MDS revealed Resident #57's ADLs related to going from sitting to standing, transferring from chair to bed and back to chair, and walking 50 feet with 2 turns requiring Moderate Assistance helper does less than half the effort in lifting, and supporting resident's trunk. Review of Resident #57'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 unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one (Resident #104) of four residents reviewed for ADL care. 1. The facility failed to provide Resident #104 with thorough incontinence care on 12/08/24. This failure could place residents at risk for a skin breakdown and infection. Findings included: 1. Record Review of Resident #104's quarterly MDS assessment, dated 08/17/24, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's BIMs score was 5 indicating the resident's cognition was severely impaired. The resident was dependent on staff for all personal hygiene. The resident was always incontinent of bowel and bladder. Her diagnoses included non-Alzheimer's dementia, muscle weakness, and lack of coordination. Record review of Resident #104's Care Plans, revised…

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 ensure that a resident who was incontinent of bowel received appropriate treatment and services to restore as much normal bowel function as possibleto for 1 (Resident #104) of 4 residents reviewed for incontinence care. 1. CNA D failed to clean Resident #104's peri-area during incontinence care provided on 12/08/24. These deficient practices affect residents who depend on nursing care and could place residents at risk for infection and harm. The findings included: 1. Record Review of Resident #104's quarterly MDS assessment, dated 08/17/24, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's BIMs score was 5 indicating the resident's cognition was severely impaired. The resident was dependent on staff for all personal hygiene. The resident was always incontinent of bowel and bladder. Her diagnoses included non-Alzheimer's dementia, muscle weakness, and lack of coordination. 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.

Based on observation, interview, and record review it was determined the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable on one of five carts the medication cart. Medication cart contained an insulin pen of Humalog open with no open date. This failure could place residents receiving medications at risk for drug diversion, drug overdose, and accidental or intentional administration to the wrong resident which could lead to exacerbation of their disease process and deterioration in general health. Findings include: During observation/interview on 12/11//24 at 02:10 PM of the medication cart with LVN A, observation of top-drawer holding insulin, found an insulin pen of Humalog insulin with no open date. LVN A stated insulin expired 28 days after opening it and a negative outcome could be the medication loses potency and could be ineffective. During an interview on 12/10/24 at 03:29 PM with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident received food prepared in a from designed to meet individual needs for one (Resident #6) of 3 residents reviewed for nutrition services. The facility failed to ensure the lunch meal served to Resident #6 on 12/08/24 had the appropriate consistency for the meat serving for the mechanical soft diet. The deficient practice could affect residents who received mechanical soft meals from the kitchen by contributing to choking, poor intake, and/or weight loss. The findings included: 1. Record review of Resident #6's annual MDS assessment, dated 11/13/24, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His BIMS score was 13 which indicated his cognitive status was intact. The resident required supervision for eating. His diagnoses included difficulty swallowing and respiratory failure. The resident required a mechanically altered diet. Record review of Resident #6's care plans, dated 08/29/24,…

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 have housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for one (Hall 300) of three halls and five residents (Residents #2, #5, #6, #7 and #8) of 13 residents reviewed for safe clean environment. 1.The facility failed to ensure the housekeeping and nursing departments cleaned the Sit to stand mechanical lift on the 300 hall. 2. The facility failed to ensure Resident #2's bed frame, G-tube machine, wall, and light fixture was thoroughly cleaned and repaired a large hole in the wall next to the headboard of her bed. 3.The facility failed to ensure the housekeeping and nursing departments cleaned Residents #5, #6, #7, # 8's wheelchairs. 4. The facility failed to ensure Resident #8's room was cleaned properly and free from dust and debris particles. These failures could place residents at risk having a feeling of low self-esteem, respiratory and stomach issues and injury due inhaling…

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 respect the resident's right to personal privacy for four (Residents #1, #2, #3 and #4) of 13 residents reviewed for confidentiality of records. The facility failed to ensure LVN A did not leave Residents #1, #2, #3, #4's medication blister packs on top of an unattended Medication cart while she was in Resident #4's room with the door closed. This failure could place residents at risk of having their medical information exposed causing HIPAA violations with their personal information being known to other residents and visitors, resulting in embarrassment, frustration, and decreased psycho-social well-being. The findings included: Observation on 12/05/24 at 11:37 am to 11:46 am, Residents #1, #2, #3 and #4's medication blister cards were on top of and unattended medication cart. It was in front of Resident #4's room and the door was closed. Record review of Resident #1's December 2024 MAR Printed 12/05/24 revealed, Letrozole Oral Tablet…

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 #8) of 13 residents reviewed for infection control. The facility failed to ensure staff did not leave an unwrapped piston syringe (used to withdraw bodily fluids) to flush Resident #8's urinary catheter, was left on her dresser with her personal belonging around it. This failure could place residents at risk of getting sick with infections due to cross contamination which could result in a change in condition and decreased psycho-social well-being. Findings included: Observation on 12/05/24 at 12:14 pm revealed, Resident #8 was on EBP for a urinary catheter and wound on her sacral. There was a piston syringe and pack of gauze dressing on her dresser next to a basket of magazines and a toothbrush. There…

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 assist residents in obtaining routine and 24-hour emergency dental care for 4 out of 9 residents (Resident #3, Resident #4, Resident #7 and Resident #8) reviewed for dental services. The facility failed to provide timely dental services for Resident #3, Resident #4, Resident #7, and Resident #8 from December 2023 through May 17, 2024. This failure could place residents at risk of oral complications, dental pain, and diminished quality of life. Findings included: 1) Record review of Resident #3's face sheet showed a [AGE] year-old woman, who was admitted on [DATE]. Diagnoses included: Chronic Osteomyelitis (a bone infection that occurs when an infection does not clear up after treatment), Paraplegia (leg paralysis), Congestive Heart Failure (chronic condition in which the heart does not pump blood as well as it should), Cerebral Infarction (occurs as a result of disrupted blood flow to the brain due to problems with blood vessels 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 provide a safe, clean, comfortable, and homelike environment, for 5 of 9 residents (Residents #1, #2, #7, #8, #9) reviewed for environment. The facility failed to ensure Residents #1, #2, #7, #8, and #9 had hot water for washing and bathing in their rooms. This failure affected residents by placing them at risk for a diminished quality of life. Findings include: Record review of Resident's #1 Face Sheet dated 1-20-2024, showed a [AGE] year-old female who was re-admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of Multiple Sclerosis with unspecified protein-calorie malnutrition, calculus of kidney, muscle wasting and atrophy, and an unspecified disorder of the eyes. In an observation of Resident #1's bathroom on 1-20-2024 at 4:40PM, it was discovered that Resident #1 did not have hot water in her bathroom. Record review of Resident #2's Face Sheet dated 1-20-2024, showed a [AGE] year-old female with an admission date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide residents who were unable to carry out ADLs the necessary services to maintain good personal hygiene for 6 of 9 residents (Residents #1, #2, #5, #7, #8, #9) reviewed for showers. The facility failed to ensure Residents #1, #2, #5, #7, #8, and #9 received showers as scheduled. This failure affected residents by placing them at risk for discomfort, diminished self-esteem, and decreased quality of life. Findings include: Record review of Resident's #1 Face Sheet dated 1-20-2024, showed a [AGE] year-old female who was re-admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of Multiple Sclerosis with unspecified protein-calorie malnutrition, calculus of kidney, muscle wasting and atrophy, and an unspecified disorder of the eyes. Record Review of Resident #1's Social Service Quarterly Assessment, dated 1-18-2024 revealed a BIMS Score of 13 which indicated little to no cognitive impairment and required extensive…

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 treat each resident with respect, dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 5 (Resident #1) observed for resident rights. The facility failed to ensure Resident #1 was treated with dignity and respect while being fed by a staff member. This failure can damage resident's self-esteem and self-worth causing negative psychosocial outcomes affecting their health. Findings include: Record review of Resident's #1 Face Sheet dated 1-20-2024, showed a [AGE] year-old female who was re-admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of Multiple Sclerosis with unspecified protein-calorie malnutrition, calculus of kidney (hard deposits made of minerals and salts that form inside your kidneys), muscle wasting and atrophy, and an unspecified disorder of the eyes. 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 observation, interview, and record review the facility failed to ensure that the Resident's environment remained as free of accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 9 residents reviewed for accidents. The facility failed to ensure Resident #1 had an environment free of accident hazards by not keeping her bed at a safe angle while being fed thereby preventing a choking hazard. This failure affected residents by placing them at risk for choking and aspiration. Findings include: Record review of Resident's #1 Face Sheet dated 1-20-2024, showed a [AGE] year-old female who was re-admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of Multiple Sclerosis with unspecified protein-calorie malnutrition, calculus of kidney, muscle wasting and atrophy, and an unspecified disorder of the eyes. Record Review of Resident #1's Social Service Quarterly Assessment, dated 1-18-2024 revealed 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 observations, interviews and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 2 (Resident #11 and Resident #81) of 2 residents reviewed for accidents, hazards, and supervision. 1. The facility failed to ensure safe smoking for Resident #11 when he had a lighter and a pack of cigarette in his possession. 2. The facility failed to ensure safe smoking for Resident #81 when he had a lighter and a pack of cigarettes in his possession. This failure could place residents at risk for injury, burns and an unsafe smoking environment. Findings include: 1. Record review of Resident #81's face sheet dated 11/07/23 indicated Resident #81 was a [AGE] year-old male, with an original admission to the facility on [DATE] and readmitted on [DATE]. Resident #81 had diagnoses which included dementia (group of symptoms affecting memory, thinking and social abilities) alcohol dependence, tobacco use, major depression, and difficulty in walking. 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 observation, interview and record review, the facility failed to establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas and smoking safety that also took into account nonsmoking residents for 2 of 2 residents (Resident #11, Resident #81) reviewed for safe smoking. The facility failed to develop a policy to address residents signing in and out on a Release of Responsibility for Leave of Absence form to smoke, which included Resident #11 and Resident #81. This failure could place residents at risk for injury, burns and an unsafe smoking environment. Findings include: 1. Record review of Resident #81's face sheet dated 11/07/23 indicated Resident #81 was a [AGE] year-old male, with an original admission to the facility on [DATE] and readmitted on [DATE]. Resident #81 had diagnoses which included dementia (group of symptoms affecting memory, thinking and social abilities) alcohol dependence, tobacco use, major depression, 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 observation, interview and record review the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal pharyngeal ulcers for one of 3 residents (Resident #7) reviewed for enteral nutrition. LVN D failed to check for residual volume prior to medication administration. This failures could place residents at risk for metabolic abnormalities, medical complications, or a decline in health. Findings included: Record review of Resident #7's face sheet, dated 07/07/23, reflected a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included Gastrostomy status (an opening in the stomach at the abdominal wall made surgically to introduce food), dysphasia (speech disorder) and cerebral palsy…

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 11%, based on three out of 27 opportunities, which involved 2 of 5 residents (Resident #7 and Resident #75) reviewed for medication errors. 1. LVN D failed to administer medications as ordered to Resident #7 by administering Vitamin B-12 1000 mcg instead of Vitamin B-12 500 mg and administered Folic acid 800 mcg instead of 1mg. 2. LVN D failed to administer medication as ordered to Resident #75 by administering Levemir 18 units instead of Lantus 18 units. These failures could place residents at risk of not receiving the desired therapeutic effect of their medications and uncontrolled pain. Findings include: 1. Record review of Resident #75's face sheet, dated 07/07/23, reflected a 71-years old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #75 had diagnoses which included:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to 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 one of five residents (Resident #152) reviewed for infection control. 1. CNA A failed to complete hand hygiene while providing incontinent care to Resident #152. 2. The facility failed to ensure linens and trash were not on the floor in Resident #152's room and bathroom. These failures could place residents at risk for contamination and infection and foul smell in the rooms. The findings include: 1. Observation on 11/05/23 at 09:35 AM revealed there were linens on the floor and trash on the floor in room [ROOM NUMBER] and there was foul smell in the room. Observation on 11/05/23 at 12:50 PM revealed there were linens and a used brief on the floor in the bathroom. CNA A was in the bathroom collecting the linens.…

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.