Vintage Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 7 (Resident #10, Resident #12, Resident #49, Resident #56, Resident #63, Resident #64, and Resident #80) of 8 resident rooms observed and reviewed for grab/assist bars. The facility failed to have evidence of informed consent for Resident #12, Resident #49, Resident #56, Resident #63, Resident #64, and Resident #80, for grab/enabler bars (smaller bars used by the person in bed to reposition themselves) to be placed on the bed. The facility failed to have evidence of assessment for Resident #10, Resident #12, Resident #49, Resident #56, Resident #64, and Resident #80, for risk of entrapment and ability to safely use the grab/enabler bars. The facility failed to follow assessment recommendations for Resident#10 and Resident #62 which indicated the residents were not appropriate for grab/assist bars.…

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 in accordance with currently accepted professional principles for three (Residents #44, #48, and #62) of twelve residents reviewed for pharmaceutical services. The facility failed to ensure MA C documented in the controlled medication logbook immediately after administering Hydrocodone to Resident #44 on 02/11/2026.The facility failed to ensure MA C documented in the controlled medication logbook immediately after administering Clonazepam to Resident #48 on 02/11/2026.The facility failed to ensure MA C documented in the controlled medication logbook immediately after administering Pregabalin to Resident #62 on 02/11/2026.This failure could place residents at risk of not receiving their medications as ordered by their physician. Findings include:Resident #44Record review of Resident #44's Face Sheet, dated 02/12/2026, reflected a [AGE] year-old male who admitted on [DATE]. He was diagnosed with unspecified…

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, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure all food items in the facility kitchen were dated and discarded prior to their use-by date.The facility failed to ensure all canned items in the dry storage area were dated and discarded prior to their use-by date. These failures could place residents at risk for food contamination and food-borne illness.Finding included: During observation(s) on 02/10/2026 and 02/11/2026 between 9:15 AM and 9:50 AM in the facility's kitchen revealed: One Gallon size freezer bag containing several small plastic cups of ketchup, located in the refrigerator with a preparation date of 02/02/2026 and a use-by date of 02/09/2026. One Gallon size freezer bag containing several small plastic cups of orange colored sauce located in the refrigerator with a preparation date of 02/02/2026 and a use-by date of 02/09/2026. One Gallon size freezer bag…

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 right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one (Resident #14) of sixteen residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #14's room was in a position that was accessible to the resident on 02/10/2026.This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings include: Record review of Resident #14's Face Sheet, dated 02/10/2026, reflected a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. She was diagnosed with dementia and hearing loss.Record review of Resident #14's Comprehensive MDS Assessment (tool used to measure health status), dated 12/24/2025, reflected severely impaired cognition with a BIMS (tool used to measure cognitive status) score 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 observations, interviews, and record reviews, the facility failed to ensure the residents had the right to personal privacy and confidentiality of his or her personal space for 1 of 4 residents (Resident #63) reviewed for privacy. The facility failed to ensure that the roommates of residents with AEM had signed consents in the active section of the EHR from the roommate or their RP acknowledging the AEM in the shared room since 01/28/2026. This failure could place residents at risk of having medical or personal information or conversations recorded or exposed to others, and cause residents to feel a loss of privacy, dignity, and decreased self-worth and self-esteem.Findings included: Observation on 02/10/2026 at 9:20 AM of the shared room door for Resident #10 and Resident #63 revealed a sign stating This room is being electronically monitored. Observation on 02/11/2026 at 1:45 PM of the shared room door for Resident #10 and Resident #63 revealed a sign stating This room is being electronically…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #38) of six residents reviewed for respiratory care.The facility failed to ensure Resident #38's nasal cannula was stored properly when not in use on 02/10/2026.This failure could place residents at risk for respiratory infection and not having their respiratory needs met.Findings include: Record review of Resident #38's Face Sheet, dated 02/10/2026, reflected a [AGE] year-old male who initially admitted on [DATE] and readmitted on [DATE]. A related diagnosis was shortness of breath on exertion. Record review of Resident #38's Comprehensive MDS Assessment, dated 11/11/2025, reflected intact cognition with a BIMS score of 15. Section O (Special Treatments, Procedures, and Programs) did not reflect the 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 observation, interview and record review the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for one (Resident #31) of twelve residents reviewed for medication storage. The facility failed to ensure Resident #31 did not have a topical analgesic ointment on her bedside table on 02/10/2026.This failure could place residents at risk of not receiving the full benefit of the medications or misuse of medications that could lead to adverse reactions or overdose.Findings include: Record review of Resident #31's Face Sheet, dated 02/10/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with osteoarthritis and blindness in one eye with low vision in the other eye. Record review of Resident #31's Comprehensive MDS Assessment, dated 11/17/2025, reflected intact cognition with a BIMS score of 15. She required assistance with…

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's right to personal privacy and confidentiality of his or her personal and medical records for fifteen (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15) of twenty five resident reviewed for privacy and confidentiality. 1. The facility failed to ensure a list of residents who were using oxygen (Resident #1, #2, #3, #4, #5, and #6) was not left unattended on top of a nurse's cart on 11/04/2025. 2. The facility failed to ensure a list of residents who had a Foley (device used to help drain urine from bladder) (Resident #7) was not left unattended on top of a nurse's cart on 11/04/2025. 3. The facility failed to ensure a list of residents who were on dialysis (Residents #8, #9, and #10) was not left unattended on top of a nurse's cart on 11/04/2025. 4. The facility failed to ensure a list of resident (Resident #11) who had a g-tube (gastrostomy feeding tube: a tube that is surgically…

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, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for four (Resident #1, #2, #3, and #4) of ten residents reviewed for medication storage. 1. The facility failed to ensure zinc oxide (medicated cream used to prevent skin irritation) was not left inside the Resident #1's room on 10/08/2025. 2. The facility failed to ensure zinc oxide was not left inside the Resident #4's room on 10/08/2025. 3. The facility failed to ensure a vial of solution used for breathing treatment was not left inside Resident #2's room on 10/08/2025. 4. The facility failed to ensure a tube of topical pain reliever was not inside Resident #3's room on 10/08/2025. These failures could place residents at risk of misuse of medications that could lead to overdosing or underdosing.Findings included: 1. Record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #2) of eight residents reviewed for respiratory care. The facility failed to ensure Resident #2's breathing mask (medical device used to deliver medication in a form of mist) was stored properly when not in use on 10/08/2025. This failure could place residents at risk for respiratory infection and not having their respiratory needs met.Findings included: Record review of Resident #2's Face Sheet, dated 10/08/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). 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 observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #4) of eight residents observed for infection control. Based observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #4) of eight residents observed for infection control. The facility failed to ensure that CNA E changed gloves and performed hand hygiene while providing incontinent care to Resident #4. These failures could place the residents at risk of cross-contamination and development of infections. Findings included: Review of Resident #4's Face Sheet, dated 06/27/2025,…

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 right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one (Resident #2) of five residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #2's room was in a position that was accessible to the resident on 05/20/2025. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings included: Record review of Resident #2's Face Sheet, dated 05/20/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with spondylosis (degeneration of the spine that could cause pain and stiffness) and legal blindness (a person's vision that could not be corrected beyond a certain level even with glasses or contact lenses). Record review of Resident #2's Quarterly MDS Assessment, 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 observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (Resident #1 and Resident #2) of four residents reviewed for respiratory care. 1. The facility failed to ensure Resident #1's humidifier bottle (a medical device designed to increase the moisture level in supplemental oxygen) had water in it on 05/20/2025. 2. The facility failed to ensure Resident #2's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) were properly stored when not in use on 05/20/2025. These failures could place residents at risk for respiratory infection and not having their respiratory needs met. Findings included: 1. Record review of Resident #1's Face Sheet, dated 05/20/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The 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 observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes 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 resident (Resident#1) of 3 residents reviewed for Care Plans. The facility failed to ensure Resident #1 was care planned for indwelling foley catheter. This failure could place residents at risk of needs not being met. Findings include: Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected that Resident #1 was a [AGE] year-old female initially admitted to facility on 10/23/24 and readmitted [DATE]. Relevant diagnoses included Cancer, Cerebrovascular accident (CVA), metabolic encephalopathy (a condition where brain dysfunction occurs due to underlying metabolic disturbances, not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #2, and Resident#3) of 8 residents reviewed for ADLs. The facility failed to ensure Resident#2 had his fingernail cleaned and trimmed. The facility failed to ensure Resident#3 had his toenails trimmed. 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: A record review of Resident #2's admission MDS assessment dated [DATE] reflected Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with the diagnosis of: cerebrovascular accident, muscle weakness, and personal history of other mental and behavioral disorders. Resident#2's has a BIMS score of 08/15 indicating moderate cognitive impairment. The review further reflected the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, 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 and to restore continence to the extent possible for 1 resident (Resident #1) of 1 reviewed for catheter and incontinence care. The facility failed to ensure Resident#1 urine catheter bag was off the floor when she was lying in bed, and the tubing was properly strapped to her leg. These failures could place residents at risk for not receiving care appropriate to address their incontinence and could increase the risk of urinary tract infections. Findings included: Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected that Resident #1 was a [AGE] year-old female initially admitted to facility on 10/23/24 and readmitted [DATE]. Relevant diagnoses included Cancer, Cerebrovascular accident (CVA), metabolic encephalopathy (a condition where brain dysfunction occurs due to underlying 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 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 #08, Resident #38) of four residents observed for infection control. 1. The facility failed to ensure MA X sanitized the blood pressure device between contact and care of Resident #08 and Resident #38on 11/06/2024. 2. The facility failed to ensure RN K and CNA G sanitized their hands during the distribution of lunch trays on 11/05/2024. These failures could affect resident's health and place them at risk of illness and exposure to diseases. Findings included: 1. Review of Resident #08's Face Sheet, dated 11/06/2024, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included major depressive disorder, type 2 diabetes (insulin resistance,) hypertension (high blood presure,)…

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 a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care that was developed within 48 hours of resident's admission for one (Resident #99) of six residents reviewed for baseline care plans. The facility failed to complete a sufficient baseline care plan that identified her surgical incision site care needs for Resident #99 within 48 hours of resident's admission. This failure placed the facility care staff and Resident #99 at risk of not being informed of their initial goals and services, receiving continuity of care and communication among nursing home staff, increase resident safety and safeguard against adverse events that are most likely to occur right after admission. Findings included: Record review of Resident #99's face sheet, dated 11/07/2024, reflected a [AGE] year-old female who was 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 observation, interview, and record review the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers for one (Resident #44) of five residents reviewed for wound care treatment and services. The facility failed to ensure Resident #44 wore her heel protector on 11/05/2024 per physician order to prevent the re-development of a previous pressure ulcer. This failure could place the residents at risk for the development, re-development, or worsening of pressure wounds . Findings included: Review of Resident #44's Face Sheet on 11/05/2024 revealed a [AGE] year-old resident admitted on [DATE] from an acute care hospital. She was admitted on hospice. Relevant diagnoses included dementia, anxiety disorder, pain, and pressure ulcer of the right heel. Review of Resident #44's Comprehensive Care Plan, dated 09/09/2024, revealed she had impaired visual function and had a communication problem related to her dementia. Resident #44 was at risk…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one (Resident #44) of five residents reviewed for accidents, hazards, and supervision. The facility failed to ensure Resident #44's fall mat was placed appropriately on the floor by her bed on 11/05/2024. This failure could place residents at risk for serious injury. Findings included: Review of Resident #44's Face Sheet on 11/05/2024 revealed a [AGE] year-old resident admitted on [DATE] from an acute care hospital. She was admitted on hospice. Relevant diagnoses included dementia, anxiety disorder, pain, and pressure ulcer of the right heel. Review of Resident #44's Comprehensive Care Plan, dated 09/09/2024, revealed she had impaired visual function and had a communication problem related to her dementia. Resident #44 was at risk for falls related to her dementia, poor balance, weakness and interventions included the need for a safe environment,…

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 effective pest control program to ensure the facility was free of pests in one of one kitchen (Kitchen #1 and one of one dining hall (Dining Hall #2). The facility failed to treat the gnats in the dining hall and kitchen. This failure could place residents at risk for the potential spread of infection, cross-contamination, and decreased quality of life. Findings included: In an observation on 06/12/24 at 12:00 PM, at least 20 gnats were observed in the kitchen of the facility. The gnats were observed flying in the kitchen and on the walls in the kitchen. At least 12 gnats were observed in the nursing dining hall while the residents were eating lunch. Record review of the facility's pest control binder log reflected the pest control company visited the facility on 06/05/24 to treat gnats. Record review of the pest control company's Service Notification dated 06/05/24 reflected the pest control company did an emergency service…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents had the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 2 of 3 residents (Resident #1, and #2) reviewed for restraints. The facility failed to ensure Resident #1 and Resident #2 had physician orders or a physician assessment for a scoop mattress. This failure could place residents at risk of unnecessarily inhibiting the residents' freedom of movement or activity. Findings include: 1. Record review of Resident #1's face sheet, dated 01/30/24, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's relevant diagnoses included dementia (cognitive impairment) and chronic respiratory failure. Record review of Resident #1's Quarterly MDS assessment, dated 01/16/24, reflected the resident had a BIMS score of 11, which indicated cognitively intact cognition. The resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that 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 1 resident (Resident #3) reviewed for respiratory care. 1. The facility failed to ensure Resident #3's tubing on her oxygen concentrator was changed within the facility's policy of 7 days. 2. The facility failed to ensure the humidifier for Resident #3's oxygen concentrator was filled with distilled water. These failures could place residents at risk for respiratory infection and not having their respiratory needs met. Findings include: Record review of Resident #3's face sheet, dated 01/31/24, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had a relevant diagnosis which included Chronic Obstructive Pulmonary Disease (constricted airway). Record review of Resident #3's Quarterly MDS…

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

Based interviews and record reviews, the facility failed to maintain the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 21 days of the 4-month review period, reviewed for RN coverage. The facility failed to ensure the facility maintained the services of a registered nurse for at least 8 consecutive hours a day on Saturdays and Sundays for 21 days of the four months reviewed. This failure placed residents at risk of receiving higher levels of patient care. Findings Included: Review of the facility provided time sheets for Registered Nurses (RN) for the review period from April 2023 to September 2023, the facility failed to have the required RN coverage of at least 8 consecutive hours a day, for the following dates: 04/08/23- (0 hours recorded) 04/09/23- (0 hours recorded) 04/15/23- (0 hours recorded) 04/16/23- (0 hours recorded) 04/22/23- (0 hours recorded) 04/23/23- (0 hours recorded) 04/29/23- (0 hours recorded) 04/30/23- (0 hours recorded) 05/06/23- (0 hours recorded) 05/13/23- (0 hours recorded) 05/14/23- (0 hours recorded)…

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 consult with the resident's physician when there was a need to alter treatment significantly for nine (Residents #3, #54, #52, #51, #33, #27, #60, #4, #14) of 15 residents reviewed for physician notification. 1. The facility failed to notify Resident #3's Physician when their medications, Trileptal and Risperdal, were not available. 2. The facility failed to notify Resident #54 Physician when their medication, Aricept, was not available. 3. The facility failed to notify Resident #52's Physician when their medication, Lunesta, was not available. 4. The facility failed to notify Resident #51's Physician when their medication, isosorbide, was not available. 5. The facility failed to notify Resident #33's Physician when their medication, dicyclomine, was not available. 6. The facility failed to notify Resident #27's Physician when their medication, Depakote, was not available. 7. The facility failed to notify Resident #60's Physician when their…

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 provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for areas in the facility for 6 of 6 rooms (Rooms # 1, 2, 4, 6, 7, and 12) observed for a safe, clean, comfortable, and homelike environment. The facility failed to ensure that resident rooms were cleaned and serviced in accordance with the facility's policy on Housekeeping Services. This deficient practice could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life. Findings include: Observation of room [ROOM NUMBER] on 10/03/23 at 10:48 AM revealed, the air-condition unit had heavy dust in the corner of the vents. Bathroom floor had dirt stains and dirt particles in the corners of the floor and toilet area. Inside the bathroom door was heavily stained with black markings on the bottom of the door. Observation of 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 provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for nine (Residents #3, #54, #52, #51, #33, #27, #60, #4, #14) of 15 residents reviewed for pharmacy services. 1. The facility failed to administer medications as ordered, Trileptal and Risperdal, to Resident #3. 2. The facility failed to administer medications as ordered, Aricept, to Resident #54. 3. The facility failed to administer medications as ordered, Lunesta, to Resident #52. 4. The facility failed to administer medications as ordered, isosorbide, to Resident #51. 5. The facility failed to administer medications as ordered, dicyclomine, to Resident #33. 6. The facility failed to administer medications as ordered, Depakote, to Resident #27. 7. The facility failed to administer medications as ordered, Remeron and Protonix, to Resident #60. 8. The facility failed to administer medications as…

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, interviews and record reviews the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. The facility failed to ensure kitchen equipment were clean and sanitary. The Facility failed to ensure prepared food was covered. The facility failed to ensure the Iced Tea dispenser, prepared for residents, was covered, and sealed from air-borne diseases once prepared. The Facility failed to ensure the Ice Scoop Holder and Ice Machine was clean and sanitary These failures could place residents at risk for cross contamination and other illnesses. Findings: Observations on 10/03/23 at 09:15 AM to 09:35 AM in the facility's only kitchen include: The floor throughout the kitchen had dirt debris all over the floor and behind kitchen equipment. There was a chicken tender sitting on the floor behind a stove. The were black dirt markings on the floor near the front of the oven. White storage bins containing flour, thickener, 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 diseases and infections for 2 (Resident #25 and #39) of 3 residents observed for infection control. 1. The facility failed to ensure that the two prongs of Resident #39's nasal cannula (a device used to deliver supplemental oxygen to an individual. It consists of a lightweight tube on which one is connected to the oxygen source and the other end splits into two prongs and are placed in the nostrils) was not on the floor. 2. The facility failed to ensure CNA G changed her gloves and performed hand hygiene while providing incontinence care to Resident #25. These failures could place residents at risk of cross-contamination and development of infection. Findings included: Review of Resident #39's Face Sheet dated 10/03/2023 reflected that resident was an 82…

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 right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #39 and Resident #27) of ten residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Residents #39 and #27's rooms was in a position that was accessible to the resident. This failure could place the residents at risk of being unable to obtain assistance in the event of an emergency. Findings included: Review of Resident #39's Face Sheet dated 10/03/2023 reflected that resident was an 82 -year-old female admitted on [DATE]. Relevant diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) with early onset, major depressive disorder, anxiety disorder, and insomnia. Review of Resident #39's Quarterly MDS assessment dated [DATE] reflected that Resident #39 was unable to complete…

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 had physician's orders for the resident's immediate care for one (Resident #27) of two residents reviewed for admission orders. The facility failed to provide physician's orders for oxygen supplement for Resident #27 at the time of admission. This failure could place the resident at risk of not receiving necessary care and services upon admission that could result to worsen condition. Findings included: Review of Resident #27's Face Sheet dated 10/04/2023 reflected that resident was a 76 -year-old female admitted on [DATE]. Relevant diagnoses included acute sudden onset) respiratory failure with hypoxia (low level of oxygen in the body), unspecified anxiety disorder, hypertensive heart disease with heart failure, unsteadiness on feet, unspecified lack of coordination, and muscle weakness. Review of Resident #27's Quarterly MDS assessment dated [DATE] reflected that Resident #27 has a severe cognitive impairment with…

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 develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for 2 of 6 residents (Resident #27and resident #39) reviewed for Care Plans. The facility failed to ensure Resident #27 and Resident #39 were care planned for oxygen administration. This failure could place residents at risk of needs not being met. Findings include: Review of Resident #27's Face Sheet dated 10/04/2023 reflected that resident was a 76 -year-old female admitted on [DATE]. Relevant diagnoses included acute (sudden onset) respiratory failure with hypoxia (low level of oxygen in the body), unspecified anxiety disorder, hypertensive heart disease with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team for 2 of 6 residents (Resident #23 and #53) reviewed for revised Care Plans. The facility failed to ensure Resident #23 and Resident #53's Do Not Resuscitate (DNR) were updated on the care plan. These failures placed residents at risk of needs not being met. Findings include: Record review of Resident #23's Face Sheet, dated 10/05/23, revealed she was a 68 -year-old female admitted on [DATE]. Relevant diagnoses included Cerebral Infarction (mini strokes), Neuromuscular dysfunction of Bladder (no bladder control), and Anemia (low red blood cells). Record review of Resident #23's DNR revealed on 07/20/23 the facility had a DNR signed on 1/26/23 by the resident's responsible party in their system of records, Point Click Care (PCC). Record Review of Resident #23's Care Plan…

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 develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions for 1 of 6 residents (Resident #63) reviewed for Discharge Planning. The facility failed to address the Resident #63's family request to discharge resident to home healthcare on or around 08/01/23. This failure could place resident at risk of not achieving maximum potential and complicate the resident's recovery. Findings included: Record review of Resident #63's Face Sheet, dated 10/05/23, revealed he was an 85 -year-old male admitted on [DATE]. Relevant diagnoses included Cirrhosis of Live (Liver Disease), Stage 4 Pressure Ulcer (wound) of Right Buttock and Stage 3 Pressure Ulcer of Left Buttock, and Kidney Failure. Record review of Resident #63's Minimum Data Set (MDS) on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 6 residents (Resident #63) reviewed for Pressure Ulcer Services. The facility failed to address the resident's concerns with a faulty air mattress, which went unresolved for 4 days until it was replaced on 09/11/23. This failure could place resident at risk of new pressure wounds developing, or current pressure wounds worsening. Findings included: Record review of Resident #63's Face Sheet, dated 10/05/23, revealed he was a 85 -year-old male admitted on [DATE]. Relevant diagnoses included Cirrhosis of Live (Liver Disease), Stage 4 Pressure Ulcer (wound) of Right Buttock and Stage 3 Pressure Ulcer of Left Buttock, and Kidney Failure. Record review of Resident #63's MDS dated [DATE] revealed the resident's Brief Interview…

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 that 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 1 (Resident #39) of 2 residents reviewed for respiratory care. The facility failed to ensure Resident #39's oxygen concentrator had a humidifier. This failure could place the resident at risk for nasal dryness and nasal irritation. Findings included: Review of Resident #39's Face Sheet dated 10/03/2023 reflected that resident was an 82 -year-old female admitted on [DATE]. Relevant diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) with early onset, major depressive disorder, anxiety disorder, and insomnia. Review of Resident #39's Quarterly MDS assessment dated [DATE] reflected that Resident #39 was unable to complete the interview to determine the BIMS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for one (Resident #27) of nine residents reviewed for significant medication errors. 1. The facility failed to ensure Resident #27 was free of significant medication errors. Depakote was not administerd as ordered. This failure placed residents at risk for not receiving the therapeutic effect of their medications as ordered by the physician. Findings included: 1. Review of Resident #27's Face sheet, dated 10/04/23, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included anxiety. Review of Resident #27's Physician Orders reflected: 07/24/23 Depakote (mood stabilizer) sprinkles 125 mg. Give 2 capsules three times a day for anxiety. Review of Resident #27's MARs for October 2023 reflected the resident did not receive Depakote on 10/01/23 for the night dose, 10/02/23 for the AM dose, and 10/03/23 for evening and night dose. An interview on 10/03/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure each residents discharge or transfer was documented in the resident's medical record and appropriate information was communicated to the receiving health care institution or provider which included information from the resident's physician as why the transfer was necessary for 1 (Resident #1) of 5 residents reviewed for appropriate discharge requirement, in that: Resident #1's record had no documentation related to the discharge, resident care and welfare, what specific needs could not be met by the facility, and what attempts had been made to meet the needs or services of the resident that would be available at the receiving facility to meet the resident's needs. The facility staff witnessed the resident leave the facility with Responsible Party and facility staff did not provide facility discharge information; facility staff did not notify facility administration of the night shift discharge to ensure safe discharge. This failure effected 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological's) to meet the needs of 1 of 5 residents (Resident #1) reviewed for pharmaceutical services. The facility failed to order, acquire and dispense medications to Resident #1 following health assessments, and medications. This failure could place residents receiving medication at risk of inadequate therapeutic outcomes and uncontrolled insulin levels. Findings included: Record review of Resident #1's face sheet dated 08/09/23 revealed a [AGE] year-old female admitted on [DATE] and discharged on 06/14/23 with diagnosis including: cellulitis of left foot (infection) , Diabetes mellitus, type 2 (changes in blood sugar levels) insulin dependent (medication to manage blood sugars), Parkinson's Disease (disorder of the central nervous system, and anxiety (worrying). Record review of Resident #1's base line…

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.