Golden Acres Living and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure each resident bedside was adequately equipped to allow all residents to call for staff assistance through a communication system that would relay the call directly to a staff member or a centralized staff work area for 1 of 7 residents (Resident# 67) reviewed for residents' call system. The facility failed on 01/20/2026 to ensure the call light system was working and available to Resident #67 These failures could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they needed support for daily living.Record review of Resident #67's MDS assessment dated [DATE] reflected he was a [AGE] year old male with an admission date of 12/05/2024. His diagnoses included Alzheimer's disease with early onset (a brain disorder that destroys memory, thinking, and reasoning skills), spinal stenosis (narrowing of the spinal canal which causes pain), thrombocytopenia (low number of platelets 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 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 4 (Resident #17, Resident #28, Resident #91, and Resident #255) of 16 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #17 had his fingernails cleaned and trimmed. 2- Resident #91 had his fingernails trimmed. 3- Resident #28 had his fingernails cleaned and trimmed. 4- Resident #255 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 included: 1- Resident #17 Review of Resident #17's Quarterly MDS assessment dated [DATE] reflected Resident #17 was an [AGE] year-old male with initial admission date to the facility on [DATE]. His diagnoses included cerebral infarction (a loss of blood flow to part of the brain,…

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 a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 3 of 5 Residents (Resident #27, Resident #133, Resident #41) reviewed for respiratory care. 1-The facility failed to ensure Oxygen (O2 ) in use signage was on Resident #133's doorway. 2-The facility failed to ensure Resident #27's nasal cannula tubing was changed in a timely manner. 3-The facility failed to ensure Resident #41 nasal cannula tubing was labeled or dated. This failure could place residents at risk of not receiving appropriate respiratory care. The findings were: 1- Resident #133 Record Review of Resident#133's Quarterly MDS assessment dated [DATE] reflected, Resident #133 was an [AGE] year-old-male admitted to the facility on [DATE]. His relevant diagnoses included: anemia (low red blood cell count), heart failure…

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

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 food items in the facility walk-in freezer were labeled and dated. 2. [NAME] A failed to ensure to use appropriate hand hygiene during meal prep. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. Findings included: Observation on 10/28/24 at 10:21 AM in the facility's walk-in freezer revealed 3 big bags of unidentified food items that did not have a date or label on it. Interview on 10/28/24 at 10:22 AM with the Dietary Manager revealed the unidentified food items were frozen popcorn shrimp. Observation on 10/28/24 at 10:26 AM along with the Dietary Manager, revealed [NAME] A was prepping for chicken salad sandwiches in the facility kitchen prep room. [NAME] A had donned gloves while mixing the chicken salad…

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 control program designed to prevent the development and transmission of infection for 3 residents (Resident #35, Resident #44, and Resident#45) of 8 residents observed for infection control. The facility failed to ensure: 1- CNA I performed hand hygiene between change of gloves during incontinent care for Resident #44. 2- CMA F disinfected the blood pressure cuff in between blood pressure checks for the Resident #35 and Resident #45 These failures could place residents at risk for infection and cross contamination of pathogens and illness. Findings included: 1-Record review of Resident #44's Quarterly MDS assessment dated [DATE] reflected Resident #44 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included reduced mobility, muscle weakness, and cognitive communication deficit. Resident #44 had a BIMS score of 09, which indicated Resident #44's cognition was moderately impaired.…

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 the resident has the right to reside and receive services in the facility with accommodation of resident needs and preferences for 1 of 30 residents (Resident #255) reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system was within reach of the Resident #255 lying in bed. This failure could place residents in the facility at risk of being unable to have a means of directly contacting caregivers. Findings included: A record review of Resident #255's MDS assessment dated [DATE] reflected Resident #255 was a [AGE] year-old male with a BIMS score 03 of 15, indicating severe cognitive impairment. Resident #255 was admitted to the facility on [DATE] with the diagnoses of Dementia (a progressive loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), seizures disorder, 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.

Based on observations, interviews, and record review the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 (Resident #104) of 2 residents reviewed for catheter care. The facility failed to ensure CNA B kept Resident #104's urine catheter bag below the level of the bladder during incontinent care. This failure could place residents at risk for urinary tract infections. Findings included: Record review of Resident #104's Quarterly MDS assessment, dated 10/09/24, reflected an admission date of 09/25/22. Resident #104 had a BIMS score of 09, meaning her cognition was moderately impaired. She required maximal assist with ADLs. Resident #104's active diagnoses included reflux uropathy (condition where urine flows backward from the bladder into the ureters and sometimes the kidneys), diabetes mellitus, and Alzheimer's disease. Record review of Resident #104's care plan, dated 06/22/23, reflected . [Resident#104] has indwelling catheter . Goal: will show no sign/symptoms of urinary…

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 ensure residents toileting facilities were adequately equipped to allow residents to call for assistance for 7 Residents (Resident#10, Resident#13, Resident#30, Resident#64, Resident#75, Resident#96, and Resident#134) of 30 residents reviewed for residents' call systems. The facility failed to ensure the call light system was accessible to a resident, lying on the floor in the residents' toilets, located between two adjacent rooms in all female secured unit: . Resident#30 . Resident#75 . Resident#96 . Resident#134 . Resident#64 . Resident#13 . Resident#10 This failure could place residents in the facility at risk of being unable to have a means of directly contacting caregivers. Findings included: Resident#30 -Observation on 10/28/24 at 09:55 AM resident toilet call light pull string was hanging over the toilet paper dispenser. The dispenser was fixed to the wall six feet from the floor. Resident#75/Resident#96 -Observation on 10/28/24 at 09:56 AM Residents shared toilet in the two adjacent rooms call light…

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 alleged violations involving abuse and neglect were reported immediately, but not later than 2 hours after the allegations were made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for one (Resident #1) of nine residents reviewed for abuse and neglect. The Abuse Coordinator failed to report an allegation of sexual abuse involving Resident #1 to the State Agency immediately but no later than 2 hours on 09/05/2024. The Abuse Coordinator was notified on 09/05/24 at 8:25 AM about the allegation of sexual abuse. The Abuse Coordinator self-reported the allegation of sexual abuse to the State Agency on 09/05/24 at 2:25 PM. This failure could place residents at risk of abuse and neglect. Findings included: Review of Resident #1's Quarterly MDS assessment dated [DATE] revealed…

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, including but not limited to receiving treatment and supports for daily living safely for 1 (Resident #1) of 7 resident rooms reviewed for environment. The facility failed to ensure the call light system in Resident #1's room (Room L080) was in good repair. This failure placed residents at risk of possible injury due to an unsafe environment. The findings included: Record review of Resident #1's face sheet, printed on 07/03/24, revealed a [AGE] year-old female who admitted to the facility on [DATE], with diagnoses of cerebrovascular disease (conditions that affect blood flow and vessels to the brain), protein-calorie malnutrition, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side (paralysis and partial weakness), encephalopathy (brain dysfunction), and vascular dementia (changes to memory, thinking, and behavior resulting…

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 interviews and record review, the facility failed to ensure all alleged violations involving abuse and neglect were reported immediately but not later than 24 hours if the events that cause the allegation did not involve abuse and did not result in serious bodily injury to the State Survey Agency for 1 of 1 facility reviewed for reporting. The facility failed to report to the State Survey Agency when the facility was without power from 05/28/24 to 05/31/24. This failure could place residents at risk for harm to include neglect and diminished quality of life. Findings included: In an observation on 05/31/24 at 9:30 AM the fire truck was observed leaving the facility. In an interview on 05/31/24 at 9:32 AM the Front Desk Receptionist revealed the electricity turned on 15 minutes before surveyor entered. The Front Desk Receptionist revealed the electricity had been off since Tuesday because of the inclement weather. In an interview on 06/03/24 at 11:15 AM, with the DON revealed the facility lost power on 05/28/24 and power returned on 05/31/24. The DON revealed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to immediately notify the resident representative for 1 of 4 residents (Resident #1) reviewed for changes in condition. The facility failed to notify Resident # 1's family member of continued emesis and a subsequent order for Resident # 1 to be sent out to the hospital. This deficient practice could result in denial of resident rights of family to be notified with any change of status. Failure to notify family members of significant change of status could affect any resident at risk for hospitalization. Findings included: Record review of Resident # 1's admission Record dated [DATE] revealed a 53- year-old male who admitted to the facility on [DATE] and expired on [DATE]. His diagnoses included chronic obstructive pulmonary disease (causes airflow blockage and breathing problems), Type 1 Diabetes (chronic condition in which the pancreas produces little or no insulin), Type 2 Diabetes (chronic condition that affects the way the body processes blood sugar),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to provide a safe, sanitary, and homelike environment for 4 residents (Residents #24, #143, #144 and #344) of 25 residents reviewed for environment. 1. The facility failed to ensure Residents #24, #143 and #144 were comfortable with temperature in their rooms. 2. The facility failed to ensure Resident #344's room was sanitary and homelike. Theses failures could place residents at risk of an unsanitary, uncomfortable and lack of a homelike environment in their rooms. Findings Included: 1. Review of Resident #24's face sheet dated 08/24/23 reflected Resident #24 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of malnutrition, chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), diabetes and heart failure. Review of Resident #24's annual MDS assessment dated [DATE] reflected Resident #24 had a BIMS of 8 indicating she was moderately cognitively…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 4 (Resident #60, Resident 86, Resident #89, and Resident #114) of 8 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #60 had his fingernails trimmed and cleaned. 2- Resident #86 had her fingernails' bed cleaned. 3- Resident #89 had her fingernails trimmed. 4- Resident #114 had his fingernails trimmed and cleaned. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: 1- Review of Resident #60's Quarterly MDS assessment dated [DATE] reflected Resident #60 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses included cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it),…

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

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 food items in the refrigerator were dated, labeled and sealed appropriately. 2. The facility failed to discard food stored in the dry storage that should no longer be consumed. These failures could place residents at risk for food contamination and food-borne illness. Findings included: Observations on 08/22/2023 at 10:06 am in one of the two walk-in refrigerators revealed 1.shredded cheeses was sealed but not dated. 2. Collard greens was rotten and spoiled. Observations on 8/23/2023 at 10:28 am in the dry storage area revealed 5-6 tortilla packets were not dated and were observed lying outside of the original box. Temperature in the dry storage was observed to be 89 F. Observations on 8/24/2023 at 10:02 AM revealed opened soy sauce bottle left in the dry storage area. Observation revealed the soy sauce was dated. Observation and review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 6 (Resident #78, Resident #29, Resident #71, Resident#123, Resident#25, and Resident#26) of 32 residents reviewed for infection control. 1. The facility failed to ensure CMA C disinfected the blood pressure cuff in between blood pressure checks for Residents #78 and #29. 2. The facility failed to ensure CNA H did hand hygiene between entering rooms of Resident #71 and Resident #123. 3. The facility failed to ensure CMA L disinfected the blood pressure cuff in between blood pressure checks for Residents #25 and #26. These failures could place residents at-risk of cross contamination which could result in infections or illness. Findings included: 1. Record review of Resident #78's face sheet, dated 08/24/23, reflected she was 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, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for one (L200) of six halls reviewed for physical environment. 1. The facility failed to ensure resident room bathroom shared between L218 and L219 had working hot water and did not drip in bathroom sink. 2. The facility failed to ensure resident room bathroom shared between L216 and L217 did not drip from bathroom faucet. 3. The facility failed to ensure resident room [ROOM NUMBER]'s chiller did not have exposed wires underneath. These failures could place facility at risk for unsanitary and hazardous living conditions. Findings included: 1. Observations on 08/22/23 at 11:00 AM and 2:15 PM revealed bathroom sink faucet between resident rooms [ROOM NUMBERS] was dripping. The left faucet turned but no water came out. Observation and Interview on 08/24/23 at 2:05 PM with Maintenance Assistant P revealed the bathroom sink between resident rooms [ROOM NUMBERS] shared bathroom…

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 was treated with the respect and dignity and care for each resident in a manner that promoted the maintenance of her quality of life for one (Resident #11) of 5 residents reviewed for dignity. The facility failed to provide dignity and respect for Resident #11 by ignoring her request to go toilet 3 times. These failures could place residents in the facility at risk of feeling low self-worth and disrespected. Findings included: Record review of Resident #11's face sheet revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. The resident's diagnoses included: senile degeneration of brain not elsewhere classified (cognitive decline) Age related osteoporosis (weak bones), bone density disorder (low bone mass), bipolar disease (depression disorder) insomnia (difficulty sleeping). Observation on 08/22/23 at 10:00 AM revealed Resident #11's ambulating in her wheelchair to the nurse…

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 develop and implement a comprehensive person-centered care plan that described the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #32) of three residents reviewed for care plans. 1. The facility failed to care plan significant weight loss of -16.4 pounds (- 7.5%) in 3 months that was triggered on 8/3/2023 for Resident #32. This failure placed residents at risk of not receiving care and services related to their identified needs to maintain or reach their highest practicable physical, mental, and psychosocial well-being. Findings included: Review of MDS assessment dated [DATE] for Resident #32 reflected he was a [AGE] year-old male admitted to the facility on [DATE]. He had diagnosis of Type 2 Diabetes Mellitus, Cognitive Communicative deficit, Muscle weakness, Unspecified Protein Calorie Malnutrition, Unspecified Non-Alzheimer's Dementia, Dysphagia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided with such care, consistent with professional standards of practice for 1 of 5 residents (#343) reviewed for respiratory care in that: The facility failed to ensure Resident #343 nasal tubing and oxygen water container for her oxygen concentrators were dated. These deficient practices could affect residents who received oxygen therapy and serve as a source of infection. Findings included: Record review of Resident #343 Face Sheet, dated 08/23/23, revealed she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included: Cerebral infarction (stroke), bacteremia (bacteria in the blood), pneumonia (infection of the lungs), Type 2 Diabetes Mellitus (changed in sugar levels of the blood) without complications, Acute chronic respiratory failure with hypoxia (not enough oxygen in your blood or too much). Review of Resident #343 Quarterly MDS, dated [DATE] reflected 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.

Based on observation, interview and record review the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for 1 medication cart (medication aide cart Hall N1) of 6 medication carts reviewed for pharmacy services in that: The facility failed to ensure medications in unsecure containers were immediately removed from stock. This failure could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication. Findings Included: An observation on 08/23/2023 at 8:13 AM of the Medication Aide Cart Hall N1 revealed the blister pack for Resident #15's lorazepam 0.5 mg (milligrams) tablet (controlled medication used for anxiety) had 1 blister seal broken and the pill was still inside the broken blister. The blister pack for Resident #64's APAP/codeine 300-30 mg tablet (controlled medication used for pain) had 1 blister seal broken and the pill was still inside the broken blister. In 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.

Based on observation, interview, and record review, the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents for 1 (nurses medication cart Hall L1) of 6 medication carts reviewed for medication storage. The facility failed to ensure: The medication supplies were secured or attended by authorized staff when the nurses' cart in hall L1 was left unlocked and unattended in the hallway L1. This failure could place residents at risk to access and ingest of medications leading to a risk for harm and could lead to missing medication. The findings include: During an observation on 08/23/2023 at 7:13 AM, LVN M was sitting in the nurses station. The nurses medication cart in hallway L1 was unlocked. The lock was in the out position and the drawers were able to be opened, leaving the medications accessible. The medication cart was facing the hallway and it was not at the eyesight of the LVN M. The following medications were in the cart: Insulin, blood pressure medication, and other medication. Two CNAs passed by the medication cart. Also, 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 resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for one (Resident Room L320-A) of 9 residents' rooms reviewed for resident call system in that: The facility failed to ensure Resident Room L320-A's call light was working properly and did not have exposed wires on the wall where call button cord was connected to the wall. This failure could place residents at risk for delay in assistance and decreased quality of life, self-worth, and dignity. Findings included: Review of Resident #23's face sheet dated 08/24/23 reflected Resident #23 was a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of malnutrition, diabetes, lack of coordination, abnormalities of gait and mobility and generalized muscle weakness. Review of Resident #23'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.