Avir at Patriot

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide ADL care for 2 of 16 residents (Resident # 99 and #156) reviewed for ADLs.-The facility failed on 08/26/2025 to ensure Resident #99 and #156's fingernails were trimmed, clean and free from debris.-This failure could place residents at risk of not having their personal hygiene needs met and cause low self-esteem.The findings include: Resident # 99.Record review of Resident # 99's admission Record dated 8/27/2025 revealed a [AGE] year-old male with an admission date of 12/11/2023.Record review of Resident # 99's health and physical dated 08/11/2025 revealed medical diagnoses of anxiety disorder, panic attacks, depression, and hypertension. Record review of Resident # 99's quarterly MDS assessment dated [DATE] revealed a BIMS score of 14 indicating the resident was cognitively intact. It indicated the resident required supervision or touching assistance with his personal hygiene. MDS indicated the resident required substantial to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who are incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #39) of 6 residents reviewed for incontinent care. The facility failed to ensure adequate bladder incontinence absorbent products were provided to address urine leakage and dignity for Resident #39. This deficient practice could place residents at-risk for infection; skin break down and decrease in self-worth due to improper care practices. Findings included: Record review of Resident #39's admission record dated 08/29/2025 revealed a 69 y/o male admitted on [DATE]. Record review of Resident # 39's diagnosis report dated 08/29/2025 revealed diagnosis of cognitive communication deficit and Benign prostatic hyperplasia with lower urinary tract symptoms. Record review of Resident # 39's quarterly MDS dated [DATE]th, 2025, revealed a BIMS of 15…

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 reviews the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 of the facility's laundry department reviewed for patient care equipment in safe operating condition. -The facility failed to maintain 1 of 3 washers in operating condition.The failure could place residents at risk for harm by the facility's inability to provide clean sanitary linens and could place residents at risk for poor hygiene and health.Findings include: During an observation on 08/28/25 at 1:30 PM, of the facility's laundry department revealed 1 commercial washer that was not operational. During an interview on 08/28/25 at 1:32 PM with the Housekeeping Supervisor revealed that the washer had been out of service for a year now. She stated that it broke down when the other company had ownership of the facility. She stated that when the new company took over, the parts for the washer were ordered. She stated that she believed that the parts for the washer were already received by the facility. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the prompt resolution of all grievances to include providing a written summary of investigation to resident or resident representative filing the grievance for 1 (Resident #114) of 6 residents reviewed for resident rights. -The facility failed to provide a written summary of the investigation to resident or resident representative who filed the grievance as per facility policy for Resident #114. - The facility Administrator failed to follow up on grievances related to misappropriation of personal property for Resident # 114.This failure could place residents at risk of not receiving resolutions to their grievances. Findings included: Record review of Resident #114's face sheet dated 08/29/2025 revealed a 77 y/o female admitted on [DATE]. Record review of Resident #114's history and physical dated 07/23/2025 revealed Resident #114 with a diagnosis of dementia. Record review of Resident #114's quarterly MDS assessment dated [DATE] revealed a 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 observation, interview and record review, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 1 (Resident #131) of 6 residents reviewed for oxygen use. The facility failed to maintain Resident #131's oxygen concentrator filter free from lint and dust. This deficient practice could place residents who receive continuous oxygen at risk for not having their air properly filtered. Findings Include:Record Review of Resident #131's face sheet dated 08/27/25 revealed a [AGE] year-old female with admission date 08/12/25. Record review of Resident #131's Nursing Home PPS (Prospective Payment System) MDS dated [DATE] revealed a BIMS score of 14, which indicated the resident was cognitively intact. Record review of Resident #131's history and physical dated 08/21/25 revealed a medical history which included: Hypertension (high blood pressure), Chronic Pain, impaired mobility and cognition. Record review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 nurse medication carts (400) reviewed for medication storage. The nurse medication cart used for hall 400 was inspected on [DATE] and had an insulin vial that had an open date of [DATE] which meant the insulin had already expired. This failure could place residents at risk of receiving medications that were expired and not produce the desired effect.The findings were: During an observation and interview on [DATE] at 11:46 AM revealed the nurse medication cart for hall 400 was inspected with LVN B present. In the top drawer of the medication cart was a 10ml insulin vial that had been opened and had an open date of 06-30-25. LVN B said she had not noticed the vial had expired and that it was each nurse's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #44) reviewed for incontinent care in that; CNA A failed to change her gloves after they became contaminated during incontinent care while assisting Resident #44. The failure could place resident's risk for cross contamination and the spread of infection.Finding included: Record review of Resident #44's electronic admission record dated 08/26/2025 indicated she was admitted to the facility on [DATE] with diagnoses of muscle weakness, muscle wasting and atrophy (waste away). She was [AGE] years of age. Record review of Resident #44's quarterly MDS dated [DATE] indicated in part: BIMS = 15 indicating the resident was cognitively intact. Bladder and bowel: Urinary continence = Always incontinent. Bowel…

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 two of five residents (Residents #2 and #3) reviewed for Enhanced Barrier Precautions. The facility failed to implement their policy on Enhanced Barrier Precautions for residents with wounds and/or indwelling medical devices. These failures could place residents at risk for healthcare associated cross-contamination and at risk of the transmission of multi-drug-resistant organism (MDROs).The findings included: Resident #2 Review of Resident #2's admission Record, dated 07/30/25, revealed an [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Review of Hospital Physician Progress Note dated 07/07/25 for Resident #2 revealed, [AGE] year-old female with a history of dementia…

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 residents who entered the facility received care and treatment consistent with professional standards of practice to prevent pressure ulcers and a resident with pressure ulcers receives necessary treatment and service to promote healing and/or prevent further development of skin breakdown or pressure ulcers, for one (Resident #2) of four residents reviewed for prevention and maintenance of pressure ulcers. The facility failed to ensure Resident #2's dressing was replaced when it became dislodged, allowing the sacral wound to be exposed to potential contamination with urine and fecal matter. This failure could place residents at risk of worsening of existing pressure ulcers and risk of infection. The findings included:Review of Resident #2's admission Record, dated 07/30/25, revealed an [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Review of Hospital Physician Progress Note 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 maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1) of 6 residents reviewed for accuracy and completeness.The facility failed to ensure that LVN A completed a weekly skin assessment for Resident #1 on 7/22/25 in accordance with facility policy. This failure placed residents at risk for unmet care needs, as services may be documented as provided when they were not, potentially leading to delays in treatment or unidentified changes in condition. Findings include:Record review of Resident #1's face sheet dated 07/30/25 revealed an [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. Record review of Resident #1's history and physical dated 6/22/25 revealed diagnoses of malfunction of nephrostomy tube (the tube placed into the kidney to drain urine isn't working properly. It might be clogged,…

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 coordinate assessments in which a PE was not conducted after the pre-admission screening indicated a yes for intellectual disability and resident review (PASARR) program under Medicaid for 1 (Resident #1) of 3 residents reviewed for PASRR. The facility failed to submit a complete and accurate request for NFSS in the LTC online portal within 20 days after the IDT meeting on 05/28/24. This failure could place residents who were PASRR positive at risk of not getting the PASARR services for a better quality of life and could lead to a decline in health. Findings included: Record review of Resident #1's face sheet dated 4/16/25 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 12, indicating her cognition was intact and diagnoses of cerebral palsy (a condition that affects muscle control, movement, and posture due…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, which included injuries of unknown source and misappropriation of resident property, were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials, which included the state survey agency, in accordance with State law through established procedures for 2 of 3 residents (Residents #2, and #3) reviewed for abuse and neglect. The facility did not report to the State Survey Agency when Residents #2 and #3 eloped from the facility and staff were unaware the resident was missing. This failure could place residents at risk of elopement or injury. Findings include:…

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 nurse aides were able to demonstrate competency in skills and techniques to care for residents' needs for 1 (Resident #11) of 3 residents reviewed for accidents and supervision. CNA B failed to place brakes on the mechanical lift when lifting Resident #11 from her bed and CNA J failed to place brakes on the wheelchair when the resident was lowered down. These failures placed residents at risk of injuries. The finidings include: Record review of Resident #11's face sheet dated 3/7/25 revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of dementia, muscle weakness, and cognitive communication deficit. Record review of Resident #11's quarterly MDS assessment dated [DATE] revealed her cognition was severely impaired and she was dependent on staff for transfers . Record review of Resident #11's care plan dated 6/5/24 revealed a focus area for resident has an ADL self-care performance deficit 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 review, the facility failed to ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 (Residents #5) of 5 residents reviewed for call light button placement and 2 (Hall 300 and Hall 400) of 4 hallways reviewed for call light response. The facility failed to ensure that Residents #5's call light was within reach on 12/10/24 and on 12/11/24, while he was in bed. It was observed on 12/11/24, in Hall 300, room [ROOM NUMBER]'s call light was on for 26 minutes while facility staff walked up and down the hallway without entering the resident room. It was observed on 12/11/24, in Hall 300, Room call light was on for 21 minutes while facility staff walked up and down the hallway without entering the resident room. It was observed on 12/11/24, in Hall 400, room [ROOM NUMBER]'s call light was on for 31 minutes while no facility staff was seen in the hallway. This failure put residents 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 the observation, interview, and record review, the facility failed to ensure residents had the right to be treated with respect and dignity, including the right to be free from any physical restraints imposed for purpose of discipline or convenicence, and not reuqired to treat the residnet's medical symptoms for 2 (Resident #4 and Residnet #5) of 5 residents reviewed for physical restraints. The facility failed to ensure Resident #4 and Resident #5 were not restrained in bed by use of a fall mat being propped up next to the bed being held in place by faciliy furniture. This failure could place residents at risk of unnecessary restriction of their freedom of movement, decrease quality of life, injury, suffocation, and falling. Findings include: Resident #4 Record review of Resident #4's face sheet dated 12/11/24, revealed, admission on [DATE] to the facility. Resident #4 was a [AGE] year-old female diagnosed with Dementia, muscle weakness (reduced muscle strength) muscle wasting (decrease in size 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 the observation, interview, and record review, the facility failed to ensure that the residents environment remains free of accidents hazards as possible and each resident receives adequate supervision to prevent accidents for 2 (Resident #4 and Resident #5) of 2 residents reviewed for accidents and supervision. The facility failed to put appropriate fall precautions in place when staff blocked residnets in bed with furniture and fall mats for Resident #4 and Resident #5. Resident #4 was in bed lying on her rights side with her legs curled up against the blue fall mat. Resident #4 had her right arm up and her right hand over her eyes with her mouth open. Right hand was touching the blue fall mat. On the left side of the Resident #4's body were pillows, yellow blankets between the mattress and bar rail, and blankets rolled up and placed on her left side bed underneath the white sheet. The left side bed was close to the wall. On the other side 2 folded up blue fall mats were placed sideways standing up…

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 thoroughly investigate allegations of abuse, neglect, exploitation, or mistreatment for 1 of 10 (Resident #1) reviewed for abuse. The facility failed to implement their abuse policy when they failed to immediately suspend CNA A after an allegation of mistreatment was reported. This failure could place residents at risk of potential continued mistreatment and abuse. Findings included: Record review of Abuse, Neglect and Exploitation policy dated 2024 read in part VI protection of resident: the facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: D- room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator. Record review of Resident #1's face sheet dated 10/31/24 revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of muscle…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure that the assessment accurately reflected the resident's status 2 (Resident #5, and Resident #6) of 5 resident reviewed for accuracy of MDS assessments. Resident #5's quarterly and annual MDS did not accurately reflect the residents use for bed rails (enablers). Resident #6's quarterly MDS did not accurately reflect the residents use for bed rails (enablers). This deficient practice could affect residents at the facility who had been assessed for risk of bed rails (enablers) could contribute to inadequate care. Findings included: Resident #5 Record review of Resident # 5's Face Sheet dated 08/13/24, revealed, admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident # 5's Clinic History and Physical dated 05/29/24, revealed, a [AGE] year-old male diagnosed with Rheumatoid Arthritis (chronic inflammatory disorder that can affect more than just your joints). Record review of Resident #5's annual MDS dated [DATE],…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to assess the resident for risk of entrapment from an enabler (bed rail) prior to installation or review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 2 ( Resident #5, and Resident #6) of 5 residents reviewed for enablers (bed rails). Resident #5 did not have a signed consent form for use of bed rails, nor on-going Enabler Assessments being done to ensure the Enablers (bed rails) were still appropriate for the use of Resident #4's needs. Resident #6 did not have a signed consent form for use of bed rails, nor was an Enabler Assessment conducted to ensure that the bed rails (Enablers) were appropriate for the residents, and on-going Enabler Assessments was not being done to ensure the Enablers (bed rails) were still appropriate for the use of Resident #6's needs. This failure could place residents who have bed [NAME] (enablers) at risk of having…

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 develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident's medical and nursing needs and described the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #9) of 7 residents reviewed for care plans -The facility failed to follow the comprehensive person-centered care plan for Resident #9's fall risk, by failing to have a fall mat in place next to bed while resident was lying down in bed. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services as indicated in their comprehensive person-centered plans developed to address their needs. Findings include: Review of Resident #9's admission Record dated 08/05/2024, revealed an [AGE] year-old female with an admission date of 11/28/2023. Resident #9's diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 (Resident #10) of 3 residents observed for oxygen management. -Resident #10 was on oxygen and did not have oxygen signs posted outside his bedroom. This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health; and place them at risk of an unsafe environment which could lead to accidents and injuries. Findings included: Review of Resident #10's admission Record dated 07/31/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #10's diagnoses included pulmonary embolism (condition in which one or more arteries in the lungs become blocked by a blood clot). Review of Resident #10's initial MDS assessment dated [DATE], revealed a BIMS score of 14 indicating the person is intact cognitively. Section O -…

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 medical records, in accordance with accepted professional standards and practices, were maintained on each resident that were accurately documented for 2 (Resident #1, and #2) of 8 residents reviewed for medical records. -The facility failed to ensure the right diet texture was documented in the orders of Resident #1. -The facility failed to ensure the right diet texture was documented in the care plan of Resident #1. -The facility failed to ensure accurate documentation was reflected in the Medication Administration Record of Resident #2. These failures could lead to errors in treatment and services provided based on incorrect information. Findings included: Resident #1: Review of Resident #1's admission Record printed on 08/02/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 was discharged from the facility on 06/30/2024. Resident #1's diagnoses included gastro-esophageal reflux disease (condition in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure that residents who have not use psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 2 (Resident #274, Resident #111) of 8 residents reviewed for unnecessary medications. The facility failed to ensure Resident #111 had an appropriate diagnosis for the use of Seroquel (an antipsychotic used to treat schizophrenia and bipolar disorder). The facility failed to ensure Resident #274 had an end date for Zyprexa that was ordered PRN (as needed). These failures could place residents at risk for adverse consequences such as impairment or decline in an individual's mental or physical condition of functional or psychosocial status from receiving unnecessary antipsychotic medications. Findings included: Resident #274 Record review of Resident #274's face sheet dated 07/17/24 revealed an [AGE] year-old who was admitted to the facility on [DATE]…

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

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 in 1 of 1 kitchen reviewed for sanitation and food storage. The facility failed to store food in sealed containers. The facility failed to keep bottles free of dry drippings. The facility failed to store food above the floor in the walk-in freezer. These failures could affect residents by placing them at risk of food borne illness. Findings include: Interview and observation on 7/16/24 at 8:20 am with cook, revealed a bag of chips open an unsealed inside the pantry. She stated that there was a potential for the contents of the bag to be contaminated and if residents were to eat from those chips, they could get sick, and if chips were mushy, there was a risk of chocking for those who have issues with consistency if they need to be chewing on them. During an observation inside the walk-in freezer revealed a box of frozen vegetables on the floor. The cook stated that the box should not be on the floor…

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 for one (Resident #23) of 24 residents reviewed for accommodation of needs. Resident #23's call light was not within reach and was difficult for him to use. This failure could place residents at risk of not being able to call for assistance when needed. Findings included: Record review of Resident #23's face sheet dated 07/18/2024 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Record review of Resident #23's electronic diagnosis listing dated 07/18/2024 revealed he had diagnoses including metabolic encephalopathy (chemical imbalance in the blood that impairs brain function), cerebral infarction (stroke), and vascular dementia (brain damage caused by strokes). Record review of Resident #23's admission MDS dated [DATE] revealed he had a BIMS score of 6 (Severe Cognitive Impairment). He had functional…

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 that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 (Resident #111) of 7 residents reviewed for treatment and services related to range of motion. The facility failed to ensure that Resident #111 received services to increase or maintain his range of motion. This failure could put residents at risk of decreased range of motion, decreased quality of life, and increased risk of contractures and threats to skin integrity. Findings included: Record review of Resident #111's face sheet dated 07/17/2024 revealed he was [AGE] years old and was initially admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #111's history and physical dated 06/14/2024 revealed he had diagnoses including cerebral infarction (stroke), use of a tracheostomy (opening into the windpipe to breathe through), and a feeding…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 12 residents (Resident #103 and Resident #15) reviewed for supervision and accidents in that: CNA A and NA B transferred Resident #103 from his wheelchair to the bed by grabbing him from the back of his pants and his under arms. The fall mat for Resident # 15 was far away from his bed. These failures could put residents at risk of accidents and serious injuries which could result in a reduced quality of life. Findings included: Record review of Resident #103's admission record dated 07/17/24 indicated he was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease and muscle weakness. He was [AGE] years of age. Record review of Resident #103's MDS dated [DATE] indicated in part: BIMS = 02 indicating resident had severe impairment. Impairment on both sides - upper and lower extremities. Chair/bed-to-chair transfer: 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 that a resident who is fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for one (Resident #111) of 4 residents reviewed for feeding by enteral means. The facility failed to ensure that Resident #111's enteral feeding formula was properly labeled. This failure put residents at risk of not receiving adequate nutrition by way of enteral feeding. Findings included: Record review of Resident #111's face sheet dated 07/17/2024 revealed he was [AGE] years old and was initially admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #111's history and physical dated 06/14/2024 revealed he had diagnoses including cerebral infarction (stroke), respiratory failure with hypoxia (not having enough oxygen in the blood), use of a tracheostomy (opening into the windpipe to breathe through), and a feeding tube. He was unable to speak or communicate his…

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 the comprehensive person-centered care plan, the resident's goals and preferences for 1 of 8 (Resident #19) residents reviewed for respiratory care. The facility failed to ensure Resident #19 had her nasal cannula on per physicians' orders. The findings included: Record review of Resident #19's face sheet dated 07/17/24 revealed an [AGE] year-old female who was re-admitted to the facility on [DATE] with diagnoses of altered mental status, dementia (group of symptoms affecting memory, thinking and social abilities), anxiety (a feeling of worry, nervousness, or unease), cognitive communication deficit. Record review of Resident #19's significant change in status MDS assessment dated [DATE] revealed a BIMS score 05, indicating her cognitive was severely impaired and was on oxygen therapy. Record review of Resident #19's physician orders dated 02/20/24…

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

Based on observations and interviews, the facility failed to dispose of garbage and refuse properly for 1 barrel of used cooking oil outside of the facility. One barrel used to dispose of used cooking oil was open without a lid and it had trash inside. This failure could place residents at risk of decreased quality of life due to an exterior environment which could attract pests, rodents, and other animals. Findings included: Observation and interview on 07/17/24 at 11:21 AM with the DM revealed that the oil dump barrel was not covered . I was almost full to the brim of the barrel, and it had trash and debris inside floating on the used oil. The DM said that by having the barrel uncovered, there was a risk of it spilling and attracting pests such as flies and bugs. The DM said that the potential outcome could be that it affects the residents and staff from the facility and by attracting pests the residents could get sick if food from the kitchen is contaminated. In an interview on 07/17/24 at 12:00 PM with the maintenance director revealed that when the equipment in the kitchen 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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #25) of 12 residents reviewed for infection control in that: NA B failed to wash her hands and change her gloves after they became contaminated during incontinent care while assisting Resident #25. These failures could place resident's risk for cross contamination and the spread of infection. Findings included: Record review of Resident #25's admission record dated 07/17/2024 indicated he was admitted to the facility on [DATE] with diagnoses of dementia, muscle wasting and atrophy (muscle weakness). He was [AGE] years of age. Record review of Resident #25's MDS dated [DATE] indicated in part: BIMS = 00 indicating resident had severe impairment. Bladder and bowel: Urinary/bowel continence = Always incontinent. Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen reviewed for safe operating equipment in safe operating condition. The facility failed to maintain the stove in operational condition. This failure could place residents at risk of foodborne illnesses; and potential for injury to residents and staff by not maintaining essential equipment in safe operating condition. Findings include: Observation and interview on 7/16/24 at 9:20 am with DM revealed that the oven on the right side of the stove was not working. She said it was reported to maintenance and documented in the work order log in the nurse's station. The DM showed the surveyor that she had logged in a request to repair the oven on 3/24/2024. The DM said she did not know what happened and why the oven was not fixed. The DM stated the risk of not having an oven in good condition could impact the residents at the facility who…

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 the observations, interviews, and record reviews the facility failed to ensure that the residents environment remains free of accidents hazards as is possible and each resident receives adequate supervision to prevent accidents for 1 (Resident #8) of 8 residents and 1 Employee Lounge of 1 reviewed for accidents. 1.Resident #8 was placed 1:1 supervision for hitting a prior resident and Lead CNA left Resident #8 to go assist another staff and did not ensure another nursing staff member was 1:1 with Resident #8 that lead to Resident #8 hitting another Resident #9. This failure was determined to be past non-compliance on 03/22/24 and ended 03/22/24 the facility implemented action that corrected the non-compliance prior to the beginning of the investigation. 2. The facility Employee Lounge door was left open for anyone to enter the employee lounge. This failure could place residents at risk of lack of supervision, accidents, and potential for harm. Findings include: 1.Resident #8 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.

Based on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 (Hall 100 Nurse station trash can) of 4 trash cans and 1 (Housekeeper ) of 1 Housekeepers reviewed for infection control in that: The hall 100 nurse station trash can was overflowing with trash and it was on the ground. The sick Housekeeper did not follow the Covid policy by calling work to find out if she had to go into work. As stated by the DON stated, anyone feeling sick before work needs to call into work to let someone know they are not feeling well. The Housekeeper failed to follow the employee lounge warning sign of, keep door closed, when she exited the employee lounge. These deficient practices could place residents at risk for infection due to improper care practices. Finding included: Observation on 04/17/24 at 11:24 AM, revealed, 100 hall trash can at the nurse's station to be full 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 treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Resident #2) of 3 residents reviewed for dignity. Resident #2 did not have a privacy bag on his catheter bag. This failure could place residents at risk of diminished quality of life. Findings included: Record review of Resident #2's face sheet dated 04/23/24, revealed, admission on [DATE] to the facility. Record review of Resident #2's facility history and physical dated 03/01/24, revealed, an [AGE] year-old male diagnosed with Dementia, Diabetes, Urinary Tract Infection. Record review of Resident #2's admission MDS dated [DATE], revealed, a severe cognitive impairment to be able to recall and make daily decisions BIMS (used to get a quick snapshot of how well you are functioning cognitively at the moment) score of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to coordinate the assessment following the PASRR Completion PCSP for 1 (Resident #8) of 2 residents with the pre-admission screening and resident review (PASRR) program, of resident assessments reviewed for PASRR services. The facility to provide PASRR services for Resident #8 who was PASRR positive for intellectual disabilities by not submitting a request to the state agency for PASRR services. This failure could affect residents who are PASRR positive of not receiving needed PASRR services which could lead to a decline in health and well-being. Findings included: Record review of Resident #8's face sheet dated 04/17/24, revealed, admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #8's facility history and physical dated 10/02/23, revealed, a [AGE] year-old female diagnosed with Epilepsy (a chronic noncommunicable disease of the brain that affects people of all ages), delusional disorders (an unshakable belief in…

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 treatment and services based on the comprehensive assessment and consistent with professional standards of practice to promote healing and prevent worsening of pressure injuries for 2 (Resident #6 and Resident #3) of 2 residents reviewed for wound care. The Wound Care Nurse grabbed a gaze without gloves and placed it into a clear cup that was soaked in betadine and then used it to provide wound care for Resident #6 who had a right lateral foot wound. The Wound Care Nurse did not date or initial Resident #3's patches after providing wound care. This deficient practice could place residents at risk for worsening pressure injuries, pain, and a decline in health. Findings include: Resident #6 Record review of Resident #6's face sheet dated 04/17/24, revealed, admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #6's facility history and physical dated 02/21/24, revealed a [AGE]…

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 the interview and record review the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in uniform form format according to specifications established by CMS for 1 of 4 quarters (1st Quarter October 1, 2022 to December 31, 2022) reviewed for administration (Fiscal year 2023, for the first quarter October 1, 2022, to December 31, 2022). The facility failed to submit PBJ (Payroll Based Journal) staffing information to CMS for the 1st quarter of the fiscal year 2023. The facility's failure could place residents at risk for personal needs not being identified and met decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. Findings included: Record review of the facility CMS reports for PBJ provided by HR…

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 treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents choices for 2 of 7 (Resident #4 and Resident #5) reviewed for quality of care. The facility failed to complete one quarterly fall assessment for Resident #4. The facility failed to complete two quarterly and/or readmission fall assessments for Resident #5. These failures could place residents at risk for diminished quality of care. Findings included: Record review of Resident #4's face sheet dated 3/18/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of dementia, ither impulse disorders, major depressive disorder, attention and concentration deficit, weakness, muscle wasting and atrophy, unspecified abnormalities of gait and mobility, lack of coordination, generalized anxiety disorder, and age-related osteoporosis. Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that 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 3 (Resident #3, #4, and #7) of 10 residents reviewed for comprehensive care plans. 1. The interdisciplinary team failed to have a care plan in place for Resident #3 refusing to be repositioned. 2. The interdisciplinary team failed to have care plans in place for urinary catheters for Residents #4 and #7. These failures could place residents at risk of not having their catheter care needs met and not having a consistent approach to addressing behavioral issues. Findings included: Resident #3 Record review of Resident #3's face sheet dated 12/16/2023 revealed she was [AGE] years old, was initially admitted to the facility on [DATE] and readmitted [DATE]. Record review of Resident #3's History 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 observations, interviews, and record reviews, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 6 (Residents #3, #4, #5, #6, #8, and #10) of 8 residents reviewed for indwelling catheters, in that: -The facility failed to ensure Residents #3, #4, #5, #6, #8, and #10 foley bags were kept off the floor. -The facility failed to ensure Resident #8's foley bag was kept out of the trash can. - The facility failed to obtain orders to provide urinary catheter care for Residents #2, #4, #6 and #7 who had urinary catheters in place. These failures could place residents at risk for urinary tract infections. Findings included: Resident #3 Record review of Resident #3's face sheet dated 12/16/2023 revealed she was [AGE] years old, was initially admitted to the facility on [DATE] and readmitted [DATE]. Record review of Resident #3's History and Physical dated 03/30/2022 revealed she had diagnoses including…

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 to ensure accurate administration and documentation of medications for 2 residents (Residents #1 and #3) of 10 reviewed for pharmacy services and medication administration in that: The facility failed to obtain and administer Advair Diskus or Fluticasone Propionate (breathing treatments) to Resident #1 as prescribed. The facility failed to obtain orders to hold Levimir (a diabetic medication) for Resident #3 when her blood sugars were low. This failure placed residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health due to not having orders for diabetic medication and respiratory treatments administered as ordered. The findings included: Resident #1 Record review of Resident #1's face sheet dated 12/19/2023 revealed she was [AGE] years old, was first admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #1's physician's progress note…

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 or ensure standard and transmission-based precautions were followed to prevent spread of infections for 6 (Residents #1, #3, #4, #5, #8, and #10) of 10 residents reviewed for infection control, and failed to report a newly detected case of COVID-19 for one resident (Resident #9) of 10 residents reviewed for accurate reporting of communicable diseases. 1. The facility failed to report Resident #9's diagnosis of COVID-19 detected on 12/17/2023 until 12/22/2023 (5 days) 2. The facility failed to ensure Residents #3, #4, #5, #8, and #10 foley bags were kept off the floor. 3. The facility failed to ensure Resident #8's foley bag was kept out of the trash can. 4. The facility failed to ensure Resident's #1 and #6's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement COVID-19 immunizations policies and procedures to ensure that resident's medical record includes documentation that indicates that the resident or resident representative was offered provided education regarding the benefits and potential risks associated with COVID-19 vaccine for 6 (Residents #1, #4, #6, #7, #9 and #10) of 10 residents reviewed for COVID-19 vaccination status. The facility failed to provide documentation that Residents #1, #4, #6, #7, #9 and #10 or their representatives had received education regarding the benefits and potential risks associated with COVID-19 vaccine. These failures placed residents at risk for infections, the transmission of infectious disease, and a decline in health status. Findings included: Resident #1 Record review of Resident #1's face sheet dated 12/19/2023 revealed she was [AGE] years old, was first admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #1) reviewed for care plans in that: The facility failed to develop and implement a comprehensive person-centered care plan for Resident #1's transfer for activities of daily living. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. Findings included: Record review of Resident #1's face sheet dated 11/13/23 revealed admission on [DATE] and readmission on [DATE] to the facility. Resident #1 was a [AGE] year-old female diagnosed with fracture of the neck of left femur and osteoarthritis (degenerative joint disease or wear…

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

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 4 (Clean Linen Closet in hall 100 ) closets reviewed for infection control in that: - The clean linen closet door in hall 100 was propped open by a white towel and not securely closed. These deficient practices could place residents at risk for infection due to improper care practices. Findings included: Observation on 11/16/23 at 9:00 AM revealed a white towel seen folded and placed on top to the right of the door. On the door frame of the strike plate where the door latch ( a device for keeping a door or gate closed, consisting of a metal bar that fits into a hole and is lifted by pushing down on another bar) entered into was taped with white scotch tape (a clear sticky tape that is sold in rolls and that you use to stick paper or card together or onto a wall). At 9:02 AM inside of the closet…

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 maintain clinical records that were accurately documented for 3 (Resident #4, Resident #8, and Resident #9) of 15 residents reviewed for clinical records. -The facility failed to document administration of Tramadol on several shifts in Resident #4, Resident #8 and Resident #9's clinical records. This failure could cause an effect in residents if more doses of medication were to be given based on inaccurate documentation of medication administration. Findings include: Record review of Resident #4's face sheet dated 10/13/2023 revealed an [AGE] year-old male with an admission date to the facility of 08/10/2023. Record review of Resident #4's electronic diagnosis sheet revealed a diagnosis of acute cholecystitis (inflammation of the gallbladder). Record review of Resident #4's Comprehensive MDS assessment dated [DATE] revealed a BIMS score of 13, indicating resident was cognitively intact and revealed his diagnosis of cholecystitis. 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 observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 room (room [ROOM NUMBER]) of 12 rooms reviewed for infection control in that: 1. The facility failed to ensure CNA A provided care in COVID positive room [ROOM NUMBER] with proper PPE. This deficient practice could cause the spread of disease and cross contamination in the facility. Findings included: Observations on 10/10/23 at 2:55 PM revealed CNA A in bathroom of COVID positive room [ROOM NUMBER]. She was observed wearing an N-95 mask and gloves while providing a shower to the resident. An interview on 10/10/23 at 3:10 PM with CNA A revealed she had put on a gown before entering the room. She stated that once in the room, the gown had become soiled, and she had removed it while in the room. She revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 resident (Resident #11) of 1 reviewed for discharges. -The facility failed to provide an immediate discharge notice to Resident #11 and failed to notify to the State Ombudsman. This failure could place residents at risk of being wrongfully discharged if the process for discharge is not followed. Findings included: Record review of Resident #11's Face sheet dated 10/13/2023 revealed a [AGE] year-old male with an admission date to the facility of 09/06/2023. Record review of Resident #11's electronic diagnosis list revealed diagnoses of alcohol abuse with alcohol-induced anxiety disorder and schizoaffective disorder. Record review of Resident #11's Discharge MDS assessment dated [DATE] revealed Resident #11 had a BIMS score 7 indicating severe cognitive impairment. It also revealed the resident's return was anticipated after discharge. Record review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop and implement 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 for 1 of 8 (Resident #7) residents reviewed for base line care plans. The facility failed to develop a baseline care plan for Resident #7. This failure could put residents newly admitted at risk of needs not being identified affecting the quality of care they receive. Findings included: Record review of Resident #7's face sheet dated 09/26/2023 revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of hemiplegia (paralysis of one side of the body) and cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). Record review of Resident #7's MDS revealed it was not yet completed, and was still in the 5-day admission window.…

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 an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 1 of 8 (Resident #7) residents reviewed for individual activities. The facility failed to provide Resident #7 with a word search to work on individually in her room per her preference. This failure could result in residents being bored resulting in a diminished quality of life. Record review of Resident #7's face sheet dated 09/26/2023 revealed an [AGE] year-old female who was admitted on [DATE] with diagnoses of hemiplegia (paralysis of one side of the body) and cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 5 (Resident #114, Resident #58, Resident #4, Resident #37 and Resident #41) of 15 residents observed for assistance with ADL's. The facility failed to ensure facility staff provided showers to maintain good grooming, personal and oral hygiene for Resident #114, Resident #58, Resident #4, and Resident #41. The facility failed to ensure staff helped resident #37 to the bathroom in a timely manner resulting in him having to urinate in his brief. This deficient practice could affect residents who were dependent on assistance with ADL's and could result in poor care, skin breakdown, feelings of poor self-esteem, and lack of dignity. Findings included: Resident #114 Record review of Resident #114's Face Sheet dated 05/23/2023 reflected admission on [DATE] to the facility. Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that a resident who was fed by enteral means receives the appropriate treatment and services for 3 of 10 residents (Resident #12, Resident #22 and Resident #70) reviewed for enteral feeding. 1.Resident 12's enteral feeding bag labels did not have the rate of administration, the initials of nurse, amount, and expiration date. The feeding pump did not correctly reflect the amount of formula that had been delivered to the resident. 2.Resident #22's feeding tube valve was not clean as it was dirty. 3.Resident #70's bag of tube feeding formula did not have the rate of administration, the initials of nurse, amount, and expiration date. These failures could place residents receiving enteral feedings at risk of insufficient nutritional supplementation and possible weight loss. Findings included: Resident #12 Record review of Resident #12's Face Sheet admission on [DATE], 12/16/2022, and readmission on [DATE] to the facility. Record review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation , interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 (Resident #271) of 10 residents observed for oxygen management. 1. Resident #271 was using oxygen while his Room (room [ROOM NUMBER]) and did not have an oxygen sign posted outside his bedroom. This failure could place residents on oxygen therapy at risk of a hazard and inappropriate care. Findings included: Record review of Resident #271's Face Sheet admission on [DATE] to the facility. Record review of Resident #271's History and Physical dated 05/17/2023 revealed an [AGE] year-old male with a diagnosis of COVID-19 pneumonia. Record review of Resident #271's admission MDS dated [DATE] indicated a brief interview of mental status score of 15 , diagnosis of pneumonia, cancer, and was on oxygen therapy. Record review of Resident #271's Order Recap dated 05/18/2023 reflected oxygen at 3 liters per minute via…

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 that there were sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of eight residents who attended a confidential group meeting, and for 5 (Resident #114, Resident #58, Resident #4, Resident #37, and Resident #41) of 15 residents reviewed for assistance with ADL's. 1.The facility was short of CNA FTEs (Full-time equivalents) on 39 of 51 days reviewed for CNA Per Patient Days 2.Residents who attended a confidential group meeting reported that staff shortages on the weekends resulted in missed showers, missed, or delayed response to call lights, having to eat in their rooms because there were not enough staff member to take them to the dining room and delayed delivery of meals. 3.The facility failed to ensure sufficient staff to provide showers for Resident #114,…

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 and interview the facility failed to store food in accordance with professional standards for food service safety for one of one kitchen observed for safe food storage. Observation of the facility kitchen included: - A large container of salsa was not labeled. - A container of noodle soup was mislabeled and expired. - A tray of individually wrapped peanut butter and jelly sandwiches had no label on the sandwiches or the tray. This failure could put residents at increased risk of food-borne illness. Findings included: In an interview on 05/21/2023 beginning at 8:04 AM when asked which items required labels, [NAME] U said that everything should have labels. She said that labels for items in the refrigerator showed the date the item was opened or prepared, and a date seven days after the first date indicated when the item was expired and should be discarded. Observation of the walk-in refrigerator with [NAME] U at 8:08 AM revealed a clear 12-cup container (no manufacturer label) that held 8 cups of green salsa. When asked, [NAME] U was unable to find a date 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 interview and record review the facility failed to notify the ombudsman of the transfer or discharge and the reasons for the transfer/discharge in writing and in a language and manner they understood for 1 (Resident #116) of 4 Residents reviewed for transfer/discharge. The facility did not send a written discharge notice to the state's long term care ombudsman of the effective date of transfer or discharge, the reason for the transfer/discharge, or the right to appeal. This deficient practice could affect residents at the facility at risk of having their discharge rights violated. Findings included: Record review of Resident #116's Face Sheet dated 05/17/2023 admission was 10/28/2022 to the facility. Record review of Resident #116's History & Physical dated 04/28/2023 revealed a [AGE] year-old male diagnosed with dementia, depression, psychiatric disorders. Record review of Resident #116's Progress Notes dated 02/24/2023 revealed Administrator entered - Resident #116 was being physically aggressive…

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 that new residents with mental disorder were provided with a PASRR Level II Screening for one resident (Resident #43) of 5 residents reviewed for PASARR coordination. - The facility failed to notify the local authority when a PASSR 1 for Resident #43 indicated a positive MI status, a PASRR Level II evaluation was not completed. This failure put residents with mental illness at risk of at risk of not receiving appropriate care and services from the local authority, which could result in failure to maintain or a possible decline in mental health. Findings included: Record review of Resident #43's face sheet dated 05/24/2023 documented that he was [AGE] years old, was initially admitted to the facility on [DATE] and again on 12/02/2022. Record review of Resident #43's History and Physical dated 08/24/2022 documented diagnoses including recurrent chronic major depression and major neurocognitive disorder. Record review of Resident #43's quarterly…

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 an ongoing program of facility sponsored activities designed to meet the mental well-being of 1 (Resident #22) of 6 residents reviewed for facility activities. The facility failed to provide activities program to meet the needs of Resident #22. This failure could result in residents decreased physical, mental, and psychosocial well-being. Findings included: Record review of Resident #22's Face Sheet admission on [DATE] to the facility. Record review of Resident #22's History and Physical dated 09/09/2021 revealed an [AGE] year-old female with a diagnosis of Alzheimer's Dementia and mixed anxiety and depressive disorder. Record review of Resident #22's Order Recap dated 03/06/2023 revealed may participate in social/physical activities as tolerated. Record review of Resident #22's Care Plan dated 03/10/2023 revealed resident needed encouragement to attend activities 1-3 times a week. Encourage resident to become involved 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.

Based on observation, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for 1 of 2 medication carts (100 Hall) reviewed for expired medications. -100 hall medication cart had expired medication. This deficient practice could cause a decline in health in residents if expired medication was to be given. Findings included: Observations on 05/22/23 at 1:22 PM revealed an open package of 3 Monistat (medication for yeast infections) pre-filled tubes with an expiration date of 08/2022. The package had a date of 03/18/2023, indicating it had been opened on that date. In an interview on 05/22/23 at 1:23 PM with LVN P, she revealed all nurses were responsible for checking the medication carts and ensuring all medications were dated, labeled and not expired. She said the expiration date on the medication was 08/2022. She said it should not have been in the medication cart because it was expired. She said she had not been trained in…

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 that a PRN order for psychotropic drugs was limited to 14 days and if the attending physician believed that it was appropriate for the PRN order to be extended beyond 14 days, failed to document their rationale for 1 resident (Resident #114) of 3 reviewed for psychoactive medications in that: The facility failed to ensure that Resident #114 had an order for psychotropic medication (Haldol) that did not contain PRN orders beyond 14 days without an end date. This deficient practice could place residents at risk of receiving unnecessary medication and adverse drug reactions. Findings included: Review of Resident #114's face sheet 05/23/2023 revealed a [AGE] year-old male with an admission date of 04/28/2023. It revealed he had a diagnosis of psychosis. Psychosis occurs when one loses touch with reality with symptoms of delusion. Review of History and Physical dated 04/28/2023 revealed he had a history of alcohol abuse and insomnia. 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.