Simpson Place

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to conduct a comprehensive, accurate assessment within 14 days after the facility determined or should have determined there had been a significant change in the resident's physical or mental condition for 1 (Residents #1) of 2 residents reviewed for Resident Review. The facility failed to complete the significant change MDS assessment for Resident #1 was hospitalized for atypical chest pain, Hypoxia, and altered mental status, and Leukocytosis (elevated white blood cell count) on [DATE].The facility failed to complete the significant change MDS assessment for Resident #1 was hospitalized for Hypernatremia (elevated sodium in the blood) on [DATE]. These failures could prevent residents from obtaining services and equipment to improve and maintain their level of functioning and well-being. Record Review of Resident #1's face sheet dated [DATE], reflected he was a [AGE] year-old male that was admitted on [DATE]. The resident was diagnosed with: Metabolic…

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 reviews, the facility failed to ensure the assessment accurately reflected the status for 1 (Resident #1) of 4 residents reviewed for accuracy of assessments in that: Resident #1's quarterly MDS dated [DATE], did not address his diet in Section K with changes to thickened liquids and his respiratory treatments in Section O. The failure place residents at risk for missed treatments, aspiration, and changes in health that could result in death.Record Review of Resident #1's face sheet dated 01/15/2026, reflected he was a [AGE] year-old male that was admitted on [DATE]. The resident was diagnosed with: Metabolic Encephalopathy (brain disorder that mimics dementia due to memory loss), Diabetic Mellitus ( unstable blood sugar levels) type Hyperosmolality (high concentration in blood.like sodium, sugar, and urea (compound produced by the liver) and Hypernatremia (elevated sodium levels), Acute and Chronic Respiratory failure with Hypoxia (low blood oxygen) 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 maintain an Infection Prevention and Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #1, and Resident#3) of two residents observed for infection control during incontinent care. 1-The facility failed to ensure LVN A, CNA C, CNA D, CNA E wear proper PPE while caring for Resident#1 in EBP Isolation. 2-The facility failed to ensure CNA F performed hand hygiene between glove changes, and LVN B did not put the dirty linen on the floor while providing incontinent care to Resident #3. These failures could place residents at risk for spread of infection through cross-contamination.1- A record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including obstructive uropathy (a condition where urine…

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, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 1 resident (Resident #2), reviewed for care plan development. The facility failed to ensure Resident #2's comprehensive care plan included a plan of care for ADLs. This failure could place residents at risk of not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health.Record review of a face sheet dated 10/14/25 revealed Resident #2 was 90-years-old and was admitted on [DATE] with diagnoses including other idiopathic peripheral autonomic neuropathy (damage to the nerves that control involuntary bodily functions), depression (mental health condition), secondary hypertension (high blood pressure ), unspecified atrial…

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 a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of five residents reviewed for catheter and incontinence care. The facility failed to ensure CNA G provided timely incontinence care for Resident #2 on 10/14/25. This failure could place residents at risk for not receiving appropriate care to address their incontinence and could increase the risk of urinary tract infectionRecord review of a face sheet dated 10/14/25 revealed Resident #2 was a [AGE] year-old female who was admitted on [DATE]. Resident #2 had a BIMs score of 15, which indicated she was cognitively intact. Resident #2's diagnoses included other idiopathic peripheral autonomic neuropathy (damage to the nerves that control involuntary bodily functions), depression (mental health condition), secondary hypertension (high blood pressure), unspecified atrial fibrillation (an irregular rapid heart rate), 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 a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one resident (Resident #1) reviewed for catheter care. The facility failed to ensure CNA C maintained Resident #1's indwelling urinary catheter (a tube that drains urine from the bladder) drainage bag below the bladder level during transfer from bed to Geri-Chair (a supportive, reclining chair designed for individuals with limited mobility, offering more comfort and stability than a traditional wheelchair) on 10/15/25. This failure placed residents at risk for infection. A record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including obstructive uropathy (a condition where urine flow is blocked, leading to the accumulation of urine in the urinary tract), and cancer (a group of diseases…

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. The facility failed to ensure food items in the facility kitchen had use-by date. This failure 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: In an Observation on 02/11/25 at 10:00 AM of the facility walk in refrigerator revealed two packets of liquid eggs were opened but did not have use by date. In an interview and observation on 2/11/25 10:05 AM with the Dietary Manager revealed liquid egg packets were opened but not dated. She stated that all open items need to have 'open date' and 'used by date' depending on the food item. She stated that liquid eggs were open for breakfast on 2/11/25 and should have had use by date of 2/14/25 since liquid eggs were good for consuming for 3 days after opening. She stated that everyone in the kitchen…

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 a discharge MDS was electronically completed and transmitted to the CMS System within 14 days after completion for two (Resident #23 and Resident #43) of two residents reviewed for discharge assessments. The facility failed to complete and transmit Resident #23's and Resident #43's discharge MDS assessment within 14 days of completion. This failure could place the residents at risk of having incomplete records. Findings include: Review of Resident #23's face sheet, dated 02/13/25, reflected Resident #23 was an [AGE] year-old female admitted to the facility on [DATE]. Review of Resident #23's facility death record, dated 02/13/25, reflected Resident #23 date of death [DATE]. Review of Resident #23's MDS assessments on 02/12/25 revealed Resident #23 did not have a discharge MDS assessment completed. This MDS record was identified as greater than 120 days late on the resident assessment facility task. Review of Resident #43's face sheet dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 24 residents (Resident #1), reviewed for care plan development. The facility failed to ensure Resident #1's comprehensive care plan included a plan of care for dialysis. This failure could place residents at risk for not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health. The findings included: Record review of a face sheet dated 02/12/25 revealed Resident #1 was an [AGE] year-old male and was admitted on [DATE] with diagnoses including peripheral vascular disease (a circulatory condition), hypotension of hemodialysis (occurs when a large amount of blood is rapidly filtered during dialysis), muscle wasting and atrophy (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 provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 residents (Resident #30 and Resident #19) of 5 residents reviewed for ADLs. The facility failed to ensure Resident #30, and Resident #19 had their fingernails cleaned and trimmed on 2/11/25. These failures could place residents at risk for loss of dignity, risk for infections, and a decreased quality of life. Findings included: 1- Resident #30 Record review of Resident #30's Quarterly MDS assessment dated [DATE] reflected Resident #30 was [AGE] year-old male with initial admission date to the facility of 02/28/2024. His diagnoses included stroke (interrupted blood flow to the brain leading to partial or complete brain damage), hypertension (high blood pressure), hyperlipidemia (high lipid levels), and anxiety. Resident #30 had BIMS of 15 which indicated Resident #30 had intact…

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 one of two residents (Resident #12) reviewed for catheter care. The facility failed to ensure CNA C maintained Resident #12's indwelling urinary catheter (a tube that drains urine from the bladder) drainage bag below the bladder level during wound care on 2/11/25. This failure placed residents at risk for infection. Findings included: A record review of Resident #12's Quarterly MDS assessment dated [DATE] reflected Resident #12 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including malignant neoplasm of prostate (a cancerous tumor that starts in the prostate gland), and pressure ulcer of the sacral region (located at the lower end of the spine). Resident #12 had a BIMS score of 15 which indicated Resident #12's cognition was intact. He required extensive assistance 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 the facility failed to label drugs and biologicals in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date for 1 (nurses cart hall 600 (617 through 631) of 2 medication carts reviewed for labeling of drugs and biologicals in that: The Nurses' Cart on Hall 600 (617 through 631) had 1 insulin pen for Resident #20 with no open date. Observation of the pen reflected it was not full and it was used. This failure placed residents at risk of not receiving the therapeutic benefits of the medications. The Findings included: Observation on 02/11/25 at 10:31 AM of the nurses' cart on hall 600 (617 through 631), with LVN A revealed the pen of insulin Humalog (lispro) 100 unit/ml for Resident #20 with no open date. Observation of the pen reflected it was not full and it was used. Interview on 02/11/25 at 10:35 AM, LVN A stated she gave insulin to Resident #20 in the morning at 7:00 AM and she did not check the pen for the open date. LVN A stated 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 interviews and record review the facility failed to maintain an effective pest control program so that the facility was free of pests of 1 floor (600 floor) of six floors reviewed for effective Pest control. The facility failed to have an effective pest control treatment plan, subsequently, Residents #4 had a reported bed bug in his room on 05/01/24 and Resident #5 had a bed bug report in his room on 05/19/24. The facility failed to follow their Beg bug policy and take actions to eliminate bed bugs reported in two resident's rooms and check all rooms on the 600-hall floor for bed bugs and train all staff on bed bug prevention. These failures could place residents at risk of bed bug bites and skin infections causing allergic reactions, scratch marks and skin tears, which could result in pain and decreased quality of life and psycho-social well-being. Findings included: Record Review of Resident #4's admission MDS assessment dated [DATE] revealed a [AGE] year-old male who admitted [DATE] with a BIMS Score…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure residents had the right to be free from abuse and not use verbal and mental abuse for 1 (Resident #1) of 8 residents reviewed for abuse. The facility failed to ensure CNA A did not snatch the call light out of Resident #1's hand and verbally abuse Resident #1, during patient care in her room on 05/19/24. This failure could place residents at risk of injury causing fractures, bruising, skin tears, and psychological harm resulting in in decreased health and psycho-social well-being. Findings included: Record review of Resident #1's MDS assessment dated [DATE] revealed a [AGE] year-old female who admitted [DATE] with a BIMS Assessment score of 06 (Moderate Cognitive impairment). She did reject care 1 to 3 days with no upper and lower extremity impairments. She used a wheelchair and needed substantial/maximal assistance with toileting, dressing, and personal hygiene. She had medically complex conditions, hypertension, Viral…

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 all assistive devices were maintained and free of hazards for two (Residents #2 and #3) of 8 residents reviewed for medical equipment. The facility failed to properly maintain Residents #2 and #3's wheelchair armrests. These failures could place residents at risk of skin tears, bruises, and falls which could lead to bleeding, and pain resulting in a decline in their health and psycho-social well-being. Findings included: 1) Record review of Resident #2's admission MDS assessment dated [DATE] revealed a [AGE] year-old male who admitted [DATE] with a BIMS Score of 05. He used a wheelchair with an active diagnoses of having a stroke and has had one fall with no injury since he admitted . Review of Resident #'2s plan of care dated 05/14/24 for fall risk related to fall, history of hemiplegia, history of hypertension, fall risk score 7-8 high risk and evidence by joint mobility (joint range and motion) interferes with balance,…

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 (Dietary Aide G) of four dietary staff reviewed for food services. Dietary Aide G failed to properly wear a hair restraint effectively covering all of her hair, while preparing the food for the residents, from the steam table on the 600-hall floor. This failure could place residents at risk for food contamination and foodborne illness which could result in gastro-intestinal issues and loss of desire to eat the food and emotional distress. Findings included: Observation and interview on 05/22/24 at 12:52 pm, Dietary Aide G was on the 600-hall floor standing in front of the mobile food hot cart (Steam table). She was preparing the resident's meal plates and her hair was approximately 3 inches in length. She had a brown 2-inch diameter hair net on top of the right side of her head, a 2-inch diameter hair net on top of the left side of her head, and the front sides and back of her hair was loose…

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 implement a comprehensive person-centered care plan for each resident, consistent with the rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 4 residents (Residents #1) reviewed for care plans. The facility failed to complete a weekly skin assessment on Resident #1 from 04/14/24 through 04/20/24. This failure could place residents at risk of receiving inadequate care. Finding Included: Record review of Resident #1's Face Sheet dated 05/14/24, reflected a [AGE] year-old female with an initial admission date of 09/03/21 and a re-admission date of 03/29/24. The Face Sheet reflected Resident #1 had a diagnosis of Urinary Tract Infection (inflammation of the urinary tract), Dementia (impaired ability to think, remember, or make decisions), absence of left leg above knee, and Hemiplegia and Hemiparesis following…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #1) of 3 residents reviewed for infection control. 1. RN D failed to not remove his gloves over Resident #1's open wound. 2. RN D failed to not perform hand hygiene with hand sanitizer over Resident #1's open wound. These failures could put residents at risk of worsened or infected wounds. Findings included: Record review of Resident #1's Face Sheet dated 05/14/24, reflected a [AGE] year-old female with an initial admission date of 09/03/21 and a re-admission date of 03/29/24. The Face Sheet reflected Resident #1 had a diagnosis of Urinary Tract Infection (inflammation of the urinary tract), Dementia (impaired ability to think, remember, or make decisions), absence of left leg above knee, 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 be adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area from each resident's bedside for one of twelve rooms (room [ROOM NUMBER]) reviewed for resident call systems. The facility failed to ensure room [ROOM NUMBER] had a working call light. This failure could place residents at risk of not being able to have their needs met and call for staff assistance when they needed it. The findings include: Observation on 04/18/24 at 3:11 PM revealed the call lights in room [ROOM NUMBER] did not work. The State Surveyor pressed both bedside call light buttons in room [ROOM NUMBER], the light outside of the room illuminated but the phone did not ring at the nurse's station to indicate the resident in room [ROOM NUMBER] needed assistance. In an interview on 04/18/24 at 3:11 PM, with the resident who resided in 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.

Based on observation, interview, and record review, the facility failed to provide a private meeting space for the residents' monthly council meetings for 9 of 9 confidential residents reviewed for resident council. The facility failed to provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy. Findings included: Observation and interview on 12/19/23 beginning at 10:00 AM, during a confidential resident group meeting with 9 residents, revealed the meeting was held in the dining room. There were no doors or solid walls to separate the dining hall from the open nurses' station or the hallway between the two areas. There were no signs posted to indicate that a confidential meeting was being held; however, multiple staff walked through the space to get from one hall to the next hall. The Surveyor asked the Administrator if they had a private space for the meeting to be held due to the openness and proximity to the nurse's station. The…

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

Based on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for one (Hall 600) of one hall and one kitchen reviewed for pest control program. The facility had live common house flies, gnats, and roaches in areas of the facility including resident rooms, and the kitchen area. This failure could place residents at risk for spread of infection, cross contamination, and decreased quality of life. Findings include: Observation on 12/18/23 at 9:30 AM revealed a large live roach was observed crawling on the wall behind the automated dishwasher system, in the kitchen. Several live black gnats were observed under the three compartment sink in the dishwashing area. Observation on 12/18/23 at 12:45 PM revealed 2 live house flies and 2 black gnats on a stuffed animal laying on the belly of Resident #26, on the 600 hall Resident #26 was non-interviewable. An interview on 12/18/23 at 12:48 PM with Resident #20 revealed that the resident had seen a live roach in her room on the evening of 12/17/23. She…

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 all drugs and biologicals in locked compartments for one (Med cart 1) of two medication carts reviewed for medication storage. The facility failed to lock Med cart 1 leaving all medications on the cart accessible. These failures could residents by placing them at risk for possible drug diversions. Findings included: Observation of Medication pass on 08/04/23/23 at 10:35 AM of Med aide A passing medication to a resident and leaving the cart unlocked while entering the resident room. Observation on 08/04/23 at 11:33 AM revealed a unlocked med cart on the 600 hall not facing in toward a resident room. All drawers were accessible and able to be pulled open. There was no staff member near the med cart. Med aide A walked out of a resident room and stated it was his cart. Interview on 08/03/23 at 11: 37AM with Med aide A revealed he had worked in the facility for 1 year. Med aide A stated he was aware the med cart should always be locked when he was not present, and the cart should be turned in toward 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.