Lakewest Rehabilitation and Skilled Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities for 1 (Resident #55) of 2 residents reviewed for prescription eyeglasses. The facility failed to follow up in a timely manner on prescription eyeglasses for Resident #55 after his eye exam was completed on 7/17/25. This deficient practice and failure could place residents at risk for worsening vision and decreased quality of life. Findings included: Record review of Resident #55's face sheet, dated 1/15/2026, revealed a [AGE] year-old male with an admission date of 3/7/22. Pertinent diagnoses included Chronic Kidney Disease, Unspecified Dementia (cognitive decline that severely impairs daily life), Major Depressive Disorder (a mood condition causing persistent sadness, loss of interest and affecting how you feel) and Adult Failure to Thrive (a syndrome of decline, marked by weight loss, poor appetite, inactivity and social…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for two of four residents (Resident #17 and Resident #98) reviewed for quality of care. 1. The facility failed to ensure CNA C provided appropriate perineal care for Resident #17 when she failed to clean the resident's penis downward and the pubic area on 01/12/26. 2.The facility failed to ensure CNA B provided appropriate catheter and perineal care for Resident #98, when she failed to separate the labia and wipe the catheter tubing from the insertion site downward while providing care on 01/12/26. These failures could place residents at risk for not receiving appropriate care to address their incontinence and could increase the risk of urinary tract infections. Findings included: 1. Record review of Resident #17's quarterly MDS assessment, dated 12/11/25, reflected a [AGE] year-old male 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 interview and record review, the facility failed to provide specialized rehabilitative services such as but not limited to physical therapy, speech-language pathology, occupational therapy, respiratory therapy for 1 (Resident #3) of 3 residents reviewed for therapy services. The facility failed to provide physical therapy for Resident #3 after her PT evaluation, recommending therapy, was completed on 8/15/25. This failure could place residents at risk for decline in range of motion, decreased mobility, development of contractures, and a decline in quality of life. Findings included: Review of Resident #3's Face sheet dated 1/13/26 reflected a [AGE] year-old female with an original admission date of 3/25/23 and a readmission date of 10/22/25. Review of Resident #3's Significant Change MDS assessment, dated 10/28/25, reflected her cognition was intact with a BIMS score of 13. The resident had upper and lower extremity impairment on one side and used a walker. Resident #3 was dependent on staff 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 observations, interviews, and record review, the facility failed to incorporate recommendations from a PASRR (Preadmission Screening and Resident Review) evaluation report into a resident assessment, care planning, and transition of care for one (Resident # 22) of one resident reviewed for PASRR services. The facility did not initiate the application process for the Durable Medical Equipment / Customized Wheelchair for Resident #22 within twenty days, per PASRR recommendations made during the PASRR Care plan meeting held on 05/08/2025.This failure could place residents at risk of not receiving specialized PASRR services which would enhance their highest level of functioning and could contribute to residents decline in physical, mental, and psychosocial well-being.Findings included:Record review of Resident #22's quarterly MDS assessment dated [DATE] revealed she was a [AGE] year-old female with an initial admission date of 04/26/2021, diagnoses included unspecified intellectual disabilities (significant…

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 store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one (Resident room [ROOM NUMBER]) of three resident rooms reviewed. The facility failed to ensure Resident #1 swallowed and consumed all of her pills and supplements prior to leaving Resident #1 alone in her room on 06/13/25 with the medications. During a medication pass, medications must be under the direct observation of the person administering the medications. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion. Findings included: Record review of Resident #1's Face Sheet, dated 06/13/25, reflected a [AGE] year-old female, with an initial admission date of 08/09/23 and a re-admission date of 06/10/24. Resident #1 had a diagnosis of Paraplegia (paralysis of lower legs and body), Type 2 Diabetes (body does not produce enough insulin or cannot…

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, and comfortable environment for 1 (Resident #2) of 2 residents reviewed for resident rights. The facility failed to move Resident #2 to a temporary room on the nights of 5/12/2025 and 5/13/2025 when Resident #2 complained that the room was too hot. This failure could place residents at risk for living in an uncomfortable and unhomelike environment which could cause a diminished quality of life. Findings included: Record review of Resident #2 face sheet, dated 06/09/25, reflected an [AGE] year-old male, who admitted to the facility on [DATE]. Resident #2 had diagnoses of Vascular Dementia (progressive cognitive disorder that damages brain tissue due to reduced blood flow), Encephalopathy (broad range of brain disorders that affect the brain's function and/or structure) and Major Depressive Disorder (persistent feelings of sadness, emptiness, and a loss of interest or pleasure in activities). Record review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #24) of 5 residents reviewed for pharmacy services. The facility failed to correctly transcribe Resident #1's medication changes when he returned to the facility on [DATE] after hospitalization. The incorrectly transcribed medication was administered from 03/2025 to 05/13/25. These failures could place residents at risk for medication errors, ineffective relief from pain medication, and drug diversion of controlled substances. Findings included: Record review of Resident #1's admission record, dated 05/13/25 revealed a [AGE] year-old male with an initial admission of 08/31/24 and readmission of 03/20/25. His primary diagnosis was chronic obstructive pulmonary disease with acute exacerbation (a lung disease that blocks airflow and makes 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers from developing for 4 (Resident #2, Resident#3, Resident#4 and Resident#5) of 5 residents reviewed for pressure ulcers. The facility failed to ensure Resident#2's pressure relieving mattress functioned properly on 03/20/25. The facility failed to have pressure relieving mattress set to the correct weight settings for Resident #3's, Resident#4, and Resident#5 to prevent pressure ulcers or skin breakdown on 03/20/2025 and 03/21/25. These failures could affect residents at risk for pressure ulcers of developing new or worsening existing pressure ulcers. Findings included: Record review of Resident #2's face sheet, dated 03/21/25, reflected a [AGE] year-old female, with an initial admission date of 10/31/23, and a re-admission date of 01/24/24. Resident #2 had diagnoses of disorder of the skin and subcutaneous tissue unspecified, local…

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 maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of five residents reviewed f1or infection control. On 03/20/25 and 03/21/25 CMA E, CNA F and HK G failed to put on PPE before entering Resident#1 room. This failure could place residents at risk of cross contamination of infections from other residents. Findings included: Record review of Resident #1's face sheet dated 03/20/25, reflected a [AGE] year-old male, with an admission date of 03/04/25. Resident#1 had diagnoses of amputation of limbs as the cause of abnormal reaction of the patient, or of later complication, without misadventure at the time of the procedure and tobacco use. Record review of Resident #1s annual MDS Assessment, dated 03/10/25, reflected Resident #1 had a BIMS score of 11, which meant…

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 who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 1 (Resident #1) of 1 resident reviewed for tracheostomy care. The facility failed to ensure Resident#1's oxygen concentrator was functioning properly on 03/20/25 and 03/21/25. This failure could place residents at risk of serious injury or hospitalization. Findings included: Record review of Resident #1's face sheet, dated 03/20/25, reflected a [AGE] year-old male, with an admission date of 03/04/25. Resident#1 had diagnoses of amputation of limbs as the cause of abnormal reaction of the patient, or of later complication, without misadventure at the time of the procedure and tobacco use. Record review of Resident #1s annual MDS Assessment , dated 03/10/25, reflected Resident #1 had a BIMS score of 11, which meant Resident #1 had 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 observation, interview, and record review, the facility failed to ensure an effective pest control program was implemented so the facility was free of pests and rodents for the facility's one of four halls (Hall 100) reviewed for pest control. The facility failed to keep an effective pest control program to ensure the residents' rooms of resident room [ROOM NUMBER] and 115 including bathrooms were free of roaches and water bugs. This failure could place residents at risk for reduced quality of life and poor sanitary environment. Findings included: Interview on 02/24/25 at 2:42 PM with Resident #5 (room [ROOM NUMBER] ) revealed she had roaches in her room in her bathroom at night constantly. She stated it bothered her to have the roaches in her room. Interview on 02/24/25 at 2:44 PM with Housekeeper I revealed she had seen roaches and water bugs in resident rooms including bathrooms and closets. Housekeeper I stated she had seen roaches in room [ROOM NUMBER]'s closet before and needed to clean room [ROOM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free from abuse for one (Resident #1) of four residents reviewed for abuse. The facility failed to protect Resident #1 from physical and verbal abuse by CMA C. On 09/18/24 at 7:30 PM, CMA C threw a pitcher of water at Resident #1 which caused him to get wet. CMA C also used profanity at Resident #1. The noncompliance was identified as Past Noncompliance (PNC). The noncompliance began on 09/18/24 at 7:30 PM and ended on 09/30/24. The facility had corrected the noncompliance before the Incident investigation began on 02/24/25. This failure could place residents at risk for serious injury or harm. Findings included: Record review of Resident #1's face sheet, dated 02/24/25, revealed Resident #1 was a [AGE] year-old male, with original admission date of 09/06/2024 with diagnoses that included: Aphasia , Dysarthria (difficult or unclear articulation of speech), Hemiplegia (paralysis of one side of the body), Bipolar disorder, Major…

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 reviewed for kitchen sanitation. 1. The facility failed to ensure food items in walk-in refrigerator were sealed and produce did not show signs of expiration. 2. The facility failed to ensure food temperatures of hamburger patties, chicken nuggets, fries, ice cream and gelatin dessert were obtained prior to serving lunch on 11/06/24. 3. Dietary Aide N, LVN J and Dishwasher O wore effective hair restraints during lunch meal service on 11/06/24. These failures could place residents at risk for food contamination and food-borne illness. Findings included: 1. Observation in the facility's kitchen walk-in refrigerator on 11/05/24 at 9:32 AM revealed a stainless-steel square container labeled Burger Toppings. The container was not sealed properly, and the lettuce was turning brown. Observation in the facility's kitchen walk-in refrigerator on 11/05/24 at 9:35 AM 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 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 #69, Resident #86, Resident #47, and Resident #33) of 14 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #69 had his fingernails cleaned and trimmed. 2- Resident #86 had his fingernails cleaned and trimmed. 3- Resident #47 received shower on his scheduled day. 4- Resident #33 had his fingernails cleaned. 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-Record review of Resident #69's Quarterly MDS assessment dated [DATE] reflected Resident #69 was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included degenerative disease of nervous system (a condition where the cells of the brain and spinal cord…

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

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 3 medication carts (Nurses cart hall 300, Med Aide cart hall 300/400, and Nurses cart hall 400) of 3 medication carts reviewed for pharmacy services. The facility failed to ensure: 1- LVN D, responsible for Nurses Cart Hall 300, removed medications in unsecure blister packs from the Nurses Cart. 2- MA E, responsible for Med Aide Cart Hall 300/400, removed medications in unsecure blister packs from the Med Aide Cart. 3- LVN F, responsible for Nurses Cart Hall 400, removed medications in unsecure blister packs from the Nurses Cart. These failures 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: 1- Record review and observation on 11/05/24 at 12:40 PM of Nurses Cart…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 2 residents (Resident #3 and Resident#83) of 4 residents observed for infection control. The facility failed to ensure: 1- CNA A performed hand hygiene between change of gloves during incontinent care for Resident #3. 2- LVN C and CNA B donned the appropriate PPE during wound care for Resident #83 who was on enhanced barriers precautions. These failures could place residents at risk for infection and cross contamination of pathogens and illness. Findings included: Resident #3 Record review of Resident #3's Quarterly MDS assessment dated [DATE] reflected Resident #3 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included need for assistance with personal care, dementia, and cognitive communication deficit. Resident #3 had a BIMS score of 3, which indicated Resident #3's cognition was severely 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 observation, interview, and record review, the facility failed to ensure that residents receive proper treatment and care to maintain good foot health for 1 (Resident #40) of 8 residents reviewed for quality of care. The facility failed to ensure Resident #40 received foot care and treatment for her dry, flaky skin on her feet. These failures placed all residents at risk for not receiving foot care which is consistent with professional standards of practice. Findings include: Review of Resident #40's quarterly MDS assessment dated [DATE] reflected she was a [AGE] year-old-female initially admitted to the facility on [DATE] and readmitted on [DATE]. Her BIMS score was 15 out of 15 which indicated she was cognitively intact, required extensive, one-person assistance for ADLs. Her diagnoses included hypertension (high blood pressure), diabetes mellitus (elevated blood sugar), Non-Alzheimer's Dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often…

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 is offered sufficient fluid intake to maintain proper hydration for one (Resident #5) of six residents reviewed for quality of care. The facility failed to ensure Resident #5 was provided adequate hydration on 11/05/24. This failure could place residents at risk of dehydration and decline in nutritional status. Findings included: Review of Resident #5's Quarterly MDS assessment dated [DATE] reflected Resident #5 was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] to the facility with diagnoses of Hemiplegia (partial or complete paralysis or weakness) on left side, hypertension, Type 2 Diabetes, wound infection, Respiratory Failure and Dysphagia (difficulty swallowing). Resident #5 had a BIMS score of 10 indicating she was moderately cognitively impaired. Resident #5 required set-up assistance with eating. Resident #5 was on hospice services. Resident #5 had a mechanically altered diet and 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 food that was at an appetizing temperature and palatable for one (11/06/24) of one meal reviewed for food palatability and temperature. The facility failed to serve hamburger at an appetizing temperature and vegetables at a palatable texture during the lunch meal on 11/06/24. This failure could affect residents by placing them at risk of weight loss, altered nutritional status, and a diminished quality of life. Findings included: In a confidential group interview on 11/06/24 at 10:00 AM revealed residents complained about the food not being cooked properly it can be overcooked. Observation on 11/06/24 at 1:02 PM revealed nurse was walking down 400 hall to give last meal tray down to resident on end of 400 hall. 400 hall trays were the last to be served. Observation at 11/06/24 at 1:05 PM revealed lunch test tray of vegetable medley including cauliflower and green beans were harder and undercooked. The Hamburger was cold. Interview on 11/06/24 at 12:48 PM with Dietary [NAME] Q revealed he should have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that a Resident who needs respiratory care was provided such care, consistent with professional standards of practice for 1 of 2 (Resident #1) reviewed for respiratory care The facility failed to ensure Resident #1 Oxygen humidity bottle and nasal cannula were labeled or dated. These failures could place the resident at risk for respiratory infection and not having their respiratory needs met. The findings were: Review of Resident # 1's admission MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old female re-admitted to the facility on [DATE]. Relevant diagnoses included, Anemia, Cirrhosis (a condition in which the liver is scarred and permanently damaged), hepatic failure without Coma and Septicemia ( a condition of liver failure without changes in mental status and without infection). Resident had BIMS Score of 14 which signifies Resident #1 had intact cognition. Review of Resident #1's care plan dated 9/4/2024…

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 written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents, establish policies and procedures to investigate any such allegations for two (Residents #1 and #2) of eleven residents reviewed for abuse. 1. The facility failed to implement and follow their abuse, neglect, and exploitation policy to ensure Resident #1 was safe from abuse when CNA A reported that Resident #3 was observed touching Resident #1's shoulder area of her body on 08/22/2024. 2. The facility failed to implement and follow their abuse, neglect, and exploitation policy to ensure Resident #2 was safe from abuse when CNA B reported that Resident #4 was observed using his cane to hit Resident #2 over the head on 08/19/24 or 08/20/2024. These failures could place all residents at risk for abuse and psychosocial harm. Findings include: Record review of the facility's policy titled, Abuse, Neglect and Exploitation 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 observation, interview, and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated and prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress for two (Residents #1 and #2) of eleven residents reviewed for abuse. 1. The facility failed to investigate the alleged or suspected abuse of Resident #1 to ensure all resident's safety, when CNA A reported that Resident #3 was observed touching Resident #1's shoulder area of her body. 2. The facility failed to investigate the alleged or suspected abuse of Resident #2 to ensure all resident's safety, when CNA B reported that Resident #4 was observed using his cane to hit Resident #2 over the head. These failures could place all residents at risk for abuse and psychosocial harm. Findings include: Record review of the facility's policy titled, Abuse, Neglect and Exploitation revised 01/08/2023, reflected, All reports of resident abuse . are reported to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to maintain clinical records that were complete and/or accurate for three (Residents #1, #2, #4) of seven residents reviewed for clinical records. 1. Resident #1's Foley catheter (a medical device that helps drain urine from the bladder) volume was not recorded per physician's orders on 10/13/23 and 10/14/23. 2. Resident #1's wound care to her stage four pressure wound to her coccyx (a small triangular bone at the base of the spinal column) was not documented as being completed per physician's orders on 10/06/23 and 10/09/23. 3. Resident #2's treatment administration record reflected he was not administered insulin per physician's orders on 10/02/23, 10/03/23 and 10/09/23. 4. Resident #4's treatment administration record did not reflect wound care was completed per physician's orders to her amputated toe on 10/13/23, 10/16/23 and 10/18/23. These failures placed residents at risk of not having accurate clinical records completed to indicate if a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for two (Resident #2 and Resident #4) of seven residents reviewed for care plans. 1. The facility failed to ensure Resident #2's comprehensive care plan addressed his newly acquired infection of sepsis and pneumonia, his use of antibiotics, and related interventions. 2. The facility failed to ensure Resident #4's comprehensive care plan addressed her wound care on her amputated toe, her blood infection and use of antibiotic via a PICC line. The failures could place residents at risk of receiving inadequate interventions not individualized to their health care needs. Findings included: Record review of Resident #2's Face Sheet dated 10/18/23 reflected he was a [AGE] year-old male admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a discharge summary that included but is not limited to, (i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results; (ii) A final summary of the resident's status; (iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter) for two (Residents #3 and #5) of two residents reviewed for discharge planning. 1. The facility failed to complete a discharge summary for Resident #3 when he had a planned discharge home. 2. The facility failed to complete a discharge summary, discharge plan of care and a reconciliation of medications for Resident #5 when he had a planned discharge home. This failure could place residents at risk of a recapitulation of the stay being unavailable to help ensure continuity of care once they went back home. Findings…

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 housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior for residents, staff, and the public for four (Halls 100, 200, 300, and 400) of four hallways reviewed for housekeeping services. The facility failed to ensure the floors in resident rooms on Halls 100, 200, 300, 400 and the dining hall, were maintained in a clean and sanitary manner. This failure could place residents at risk for diminished quality of life. Findings included: Observation on 10/03/23 at 9:35 AM of all four halls in the facility revealed resident room floors were sticky, with food crumbs and trash. The floors in the dining area were also sticky and with food crumbs on the floor. At the time of this observation, residents were in the dining area participating in activities. Observation on 10/03/23 at 11:20 AM revealed rooms on Hall 300 with floors that were sticky, with trash, and food crumbs. Observation on 10:04/23 at 9:35 AM revealed rooms on Hall 400 with floors that were sticky, with trash 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 interview and record review, the facility failed to ensure all irregularities identified by the Pharmacist Consultant were reported to the attending physician and acted upon to minimize or prevent adverse consequences to the extent possible for 1 (Resident #55) of 24 resident reviewed for drug regimen reviews. The facility failed to have in writing the Pharmacist Consultant's recommendation for a gradual dose reduction for Resident #55's antianxiety medication, in return there was no documentation in the pharmacy review book that the medical director agreed or disagreed. These failures could place residents who require monthly drug regimen reviews and placed them at risk of receiving unnecessary medications and adverse drug consequences. Findings included: 1. Record review of Resident #55's Face Sheet revealed the resident was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #55 had diagnoses that included: Psychotic Disturbance, Mood Disturbance, and Anxiety, Major Depressive…

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 store all drugs and biologicals in locked compartments and assure only authorized personnel to have access to the keys for 1 (Resident #42) of 7 residents reviewed for pharmacy services, in that: 1. The facility failed to ensure Resident #42 eye drops were stored in a secured place. 2. The facility failed to ensure the Nurse Medication Cart for Hall 300/400 was locked when unattended. This failure could place residents at risk of not receiving the therapy needed. Findings included: 1. Review of Resident #42's face sheet, dated 10/05/23, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Dry eye syndrome of bilateral lacrimal glands (is a condition that affects your tear film, the three layers of tears that cover and protect the surface of your eyes)and dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life 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 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 disease and infection for 4 (Resident #26, Resident #65, Resident #31, and Resident #25) of 7 residents reviewed for infection control during medication administration. 1. MA D failed to disinfect the blood pressure cuff in between blood pressure checks for Resident #26, Resident #65, and Resident #31. 2. The facility failed to ensure that its infection control policy was followed in Resident #25's room. These failures could place residents at-risk of cross contamination which could result in infections or illness. Findings included: 1. Review of Resident #26's MDS assessment, dated 09/22/23, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. Resident #26 had diagnoses which included hypertension (high blood pressure) 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 interview and record review, the facility failed to ensure residents had the right to be treated with respect and dignity for 1 of 32 residents (Resident #96) reviewed for dignity. CNA A failed to use privacy curtain or close the door when providing incontinent care for Resident #96. This deficient practice could place residents at risk for psychosocial harm due to a diminished quality of life. Findings included: Record review of Resident #96's face sheet, dated 10/05/23, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included encephalopathy (brain disease), essential hypertension (high blood pressure), heart failure and pain. Record review of Resident #96's admission MDS assessment, dated 09/06/23, revealed Resident #96's BIMS score was 14, which indicated her cognition was intact. MDS assessment revealed Resident #96 needed extensive assistance of two or more persons physical assist with bed mobility, transfer, dressing and toilet use. Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, disposition, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #27) of 7 residents and one cart for hall 300 reviewed for pharmacy services. 1.MA D did not check Resident #27's blood pressure or pulse rate before administering Lisinopril 10mgs 1 tablet (blood pressure medication), as ordered by Resident #27's physician. 2.The facility failed to dispose of one expired bottle of docusate 100mgs tablets from hall 300 cart. This failure could place residents who take blood pressure medications at risk for hypotension (low blood pressure) and resident on hall 300 at risk of receiving expired medications. Findings included: Review of Resident #27's MDS assessment, dated 07/16/23, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #27 had…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure food items were properly labeled, dated, and thawed in accordance with professional standards. These failures could place residents, who receive food from the kitchen, at risk for food contamination and food-borne illness. Findings included: Observation of the kitchen refrigerator on 10/03/23 at 9:26 AM revealed the following: - Chicken thighs and chicken legs, packaged, uncooked, completely thawed (not frozen) undated and unlabeled. - Bacon pulled from the freezer and dated with the date it was removed from the freezer of 9/25/2023. Interview on 10/04/23 at 10:35 AM with the [NAME] E revealed he had worked at the facility since February 2019. He stated that there was no Dietary Manager currently employed with the facility. He stated he had been trained in the past on how to properly store and thaw food items. [NAME] E revealed all stored foods had…

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