Franklin Heights Nursing & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility to ensure resident's right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility was changed for 3 (Resident #13, Resident #57, and Resident #111) of four residents reviewed for notification of room change. 1-The facility failed to provide written notice of room transfer on 03/19/25 and 06/27/25 to Resident #13 or their Power of Attorney (POA), 5 days' notice must be given to the resident or responsible party prior to the move.2-The facility failed to provide written notice of room transfer on 04/11/25 to Resident #57 or their Responsible Party, 5 days' notice must be given to the resident or responsible party prior to the move.3-The facility failed to provide written notice of room transfer on 04/13/25 and 04/22/25 to Resident #111, 5 days' notice must be given to the resident or responsible party prior to the move.These facility failures placed all residents at risk of being displaced without…

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 interview and record review the facility failed to ensure the residents had information and contact information for State and local advocacy organizations including but not limited to the State Survey Agency and the State Long-Term Care Ombudsman program in a language understood for 7 of 7 residents (Confidential Group). The facility failed to ensure the Ombudsman information was reviewed with residents in the facility and ensure the information was discussed on how to file a complaint with the State agency when residents interviewed in a confidential group meeting were unaware, they had a Long-Term Care Ombudsman Program, contact information for the Ombudsman or how to file a complaint with the State agency. This failure could affect the residents who reside in the facility, to not be aware of resources that were available to them.Findings included: Record review of monthly resident council minutes for the last 6 months on 7/24/2025 at 8:40 am revealed no documentation of discussion regarding information on filing a complaint directly with the state agency or review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide ADL care for 3 of 16 residents (Resident #56, # 94 and #107) reviewed for ADLs.-The facility failed to ensure Resident #56, # 94 and #107's fingernails were clean and free from debris on 07/21/2025.-This failure could place residents at risk of not having their personal hygiene needs met and cause low self-esteem.The findings include: Record review of Resident # 56's admission Record dated 7/23/2025 revealed a [AGE] year-old male with an initial admission date of 07/20/2020 and a readmission date of 08/19/2024. Record review of Resident # 56's health and physical dated 06/20/2025 revealed medical diagnosis of vascular dementia unspecified severity Record review of Resident # 56's quarterly MDS assessment dated [DATE] revealed a BIMS of 03 indicating severe cognitive impairment. Record review of Resident # 56's care plan dated 07/08/2025 revealed the resident had an ADL selfcare performance deficit related to muscle weakness,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen. -The facility failed on 07/21/2025 to seal a container with marinara sauce inside of refrigerator #1. -The facility failed on 07/21/2025 to maintain 1 strawberry ice cream container free from drippings in refrigerator # 3.-The facility failed on 07/21/2025 to close or seal a bag containing frozen egg omelets inside of refrigerator #4. -The facility failed on 07/21/2025 to dispose of rotting and moldy onions and potatoes in the pantry. These failures could place all residents who received meals from the main kitchen at risk of food borne illnesses.During observations on 07/21/2025 at 8:21 AM inside refrigerator #1, a container with marinara sauce was found not properly sealed with the lid not properly closed. At 8:23 AM, a tub of ice-cream was found inside refrigerator #3 that had dried and frozen drippings on its…

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 have complete and accurately documented medical records for two (Resident #13 and #111) of five residents whose clinical records were reviewed for accuracy.-The facility failed to document room transfers and the reason for transfers for Resident #13 on 03/19/25 (Hall 4) and 06/27/25 (Hall 4 to Hall 1).-The facility failed to document room transfer and the reason for transfer for Resident #111's on 04/13/25 and 04/22/25.These failures could affect the residents in the facility at risk of inaccurate or incomplete clinical records. Findings included:Resident #13Record review of Resident #13's face sheet dated 07/22/25 revealed resident was a [AGE] year-old female with an admission date of 03/19/25.Record review of Resident #13's history and physical dated 04/22/25 revealed resident was legally blind and had medical history of physical debility (physical weakness, fatigue, or lack of energy that can impact daily functioning).Record review of Resident #13'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 effective pest control program so that the facility was free of pests and rodents for 1 of 1 kitchen. -The facility failed on 07/21/2025 to effectively remain free of cockroaches in the only kitchen in the facility. These findings placed residents at risk of ill effects of pest infestation.During observation and interview on 07/21/2025 at 8:15 AM with the Director of Food and Nutrition, two dead cockroaches were observed on the kitchen floor in between cooking stations near a water drain. They were in near proximity to cooking utensils, pots and pans. The Director of Food and Nutrition stated that it was likely that cockroaches were present in the kitchen because it had been raining in the area and that made the insects crawl into the kitchen. The Director of Food and Nutrition stated that she would direct her staff to immediately clean and disinfect the kitchen floors. She stated the potential outcome of having insects in 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 observations, interviews, and record reviews, the facility failed to ensure that the resident had the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 1 (Resident #11) of 3 residents reviewed for resident rights. -The facility failed to ensure the urinary collection bag for Resident #11's catheter was covered with a privacy bag. This failure could place residents at risk for a loss of dignity, decreased self-worth and decreased self-esteem. Findings included: Record review of Resident #11's admission Record dated 08/07/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #11's diagnoses included neuromuscular dysfunction of bladder (unable to control bladder due to nerve damage), and history of urinary tract infections (an infection in any part of the urinary system). Record review of Resident #11's MDS dated [DATE], reflected a BIMS score of 15, which indicated 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, 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 #10) of 6 residents reviewed for call light placement. -The facility failed to ensure that Residents #10's call light was within her reach. This failure placed residents at risk of not being able to call for assistance when needed. Findings included: Record review of Resident #10's admission Record dated 08/07/2024, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #10's diagnoses included cerebral palsy (congenital disorder of movement, muscle tone, or posture), vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities,…

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 #11) of 3 residents reviewed for catheter care. -The facility failed to ensure Residents #11's catheter leg strap was in place to secure the catheter. This failure could place residents with foley catheters at risk of catheter pulling causing pain. Findings included: Record review of Resident #11's admission Record dated 08/07/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #11's diagnoses included neuromuscular dysfunction of bladder (unable to control bladder due to nerve damage), and history of urinary tract infections (an infection in any part of the urinary system). Record review of Resident #11's MDS dated [DATE], reflected a BIMS score of 15, which indicated the person is intact cognitively. 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 that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 1 (Resident #12) of 3 the residents reviewed for respiratory care. -The facility failed to ensure Residents #12 did not have an empty oxygen humidifier bottle on the oxygen concentrator dated 07/20/2024 while in use. This deficient practice could place residents who received oxygen therapy at risk for an increase in respiratory complications. Findings included: Record review of Resident #12's admission Record dated 08/07/2024, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #12's diagnoses included pulmonary hypertension (type of high blood pressure that affects arteries in the lungs and in the heart), chronic obstructive pulmonary disease (lung disease that block airflow and make it difficult to breathe), pulmonary fibrosis (lung disease that occurs when lung tissue…

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 keep 1 gallon bottle of Soy sauce stored on a metal rack in the walk-in refrigerator free of dried drippings around the lid. -The facility failed to keep one plastic container with jelly stored on a metal rack in the walk-in refrigerator free of dried food residue on the lid. -The facility failed to store foods in the refrigerator in sealed containers. There was ground beef thawing inside the refrigerator and blood drippings were found on the floor where the meat was placed. This failure could affect residents by placing them at risk of food borne illness. Findings include: Observation and interview on 5/28/24 at 8:15 a.m., the Dietary Manager in the walk-in refrigerator, revealed that 1 plastic gallon of Soy Sauce had dried drippings around the cap. One large plastic container that was labeled with Jelly and dated with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident ' s individuality for 4 (Resident #16, #54, #58, and #89) of 10 reviewed for dignity and 2 (the DON and CNA A) of 7 staff reviewed for Resident dignity. The facility failed to ensure staff were not standing up and feeding the residents in the main dining room. The facility failed to ensure that Resident #54 was offered a clothing protector resulting in his clothing being soiled during meals. The facility failed to ensure that Resident #58's privacy was respected by not covering his Foley bag with a privacy bag. The facility failed to provide personal hygiene for Resident #89 by not removing her facial hair. These failures could result in residents having decreased self-esteem and sense of worth. Findings included: Resident #16 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 ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 2 (Resident #88 and Resident #196) of 5 residents observed for oxygen management. Resident #88 and Resident #196 were on oxygen and did not have oxygen signs posted outside their bedrooms (room [ROOM NUMBER] and room [ROOM NUMBER]). This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health. Findings included: Resident #88 Record review of Resident #88 ' s face sheet dated 05/29/24, revealed an admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #88 ' s facility history and physical dated 03/22/24, revealed, a [AGE] year-old male diagnosed with tongue and thyroid cancer and alcohol cirrhosis. Record review of Resident #88 ' s admission MDS dated [DATE], revealed severely impaired cognition to be…

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 ensure nurse staffing data was posted and readily accessible to residents and visitors for thirty-two of fifty-two days reviewed for nurse staffing information. The facility failed to post the required staffing information for [NAME] & East Wings– East Wing - 10/07/23, 10/21/23, 10/22/23. West Wing - 10/07/23, 10/21/23, 10/22/23. East Wing - 11/04/23, 11/18/23, 11/25/23, 11/26/23. West Wing - 11/04/23, 11/12/23, 11/18/23, 11/19/23, 11/25/23, 11/26/23 East Wing - 12/01/23, 12/02/23, 12/09/23, 12/10/23, 12/23/23, 12/24/23, 12/30/23, 12/31/23. West Wing - 12/02/23, 12/03/23, 12/09/23, 12/10/23, 12/23/23, 12/24/23, 12/30/23, 12/31/23. This failure could place residents, their families, and facility visitors at risk of not having access to information regarding staffing data and facility census. Findings include: Observation on 05/31/24 at 9:26 AM, of staffing posting revealed, missing information of number of RNs and LVNs scheduled to work and RN and LVN hours worked for both facility wings (West and East Wing).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, safe and secure storage of medications for 1 (Resident #10) of 6 residents reviewed for medication administration; and 1 of 3 medications carts (used in Zone 4 & Zone 5) reviewed for medication storage. -The facility failed to administer medication to Resident #10, according to physician ' s order. -The facility failed to follow the facility ' s policy and procedure on drug destruction by not providing the administrator copies of Individual Control Drug Records for 21 of 31 controlled substances to reconcile with the pharmacist at time of drug destruction. -The facility failed to keep medication drawers free of dust and paper particles in medication. These failures could place residents at risk of inadequate therapeutic outcomes and worsened health conditions; could place residents at risk of drug diversion. The findings include: Resident #10 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 all drugs and biologicals in accordance with manufacturer ' s specifications for of 3 medication carts (Zone 4 /Zone 5) reviewed for medication storage and handling of medications. -The facility failed to date Glucometer Normal/High Control Solutions when opened according to manufacturer specifications in Zone 4/Zone 5. These failures could affect diabetic residents that received medications from the facility. The findings include: Observation and interview on [DATE] 3:42 PM, LVN N revealed Glucose Control Solutions had not been dated when opened. LVN N confirmed that the manufacturer ' s specification on the Glucose Control Solution bottles documented to discard testing solutions 3 months after first opening. LVN N, stated licensed staff had been trained to write the date on the box and/or the control solution bottles when opened. Interview on [DATE] at 3:00 PM, the DON revealed licensed staff had been trained to date the bottles…

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 #58) of 12 residents reviewed for infection control; and 2 of 6 linen carts observed for infection control; 2 of 2 crash carts observed for infection control. The facility failed to ensure Resident #58's foley bag was not hanging from the trash can near the floor. The facility failed to keep linen cart covers in the laundry room free of tears. The facility failed to keep linen cart covers used to store clean linen free of stains. The facility failed to ensure staff were not storing clean eating utensils in linen cart. The facility failed to ensure linen carts were covered when left unattended in resident-use areas. The facility failed to keep 2 of 2 crash carts free of dust, paper particles, and dried stains This…

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 all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen reviewed for safe operating equipment; failed to maintain 1 of 6 linen carts in safe operating condition. The facility failed to maintain the oven in operational condition. The facility failed to maintain a working trash can next to the hand washing sink in the kitchen. The facility failed to correctly wash cookware using the three-compartment sink. The facility failed to maintain 1 of 6 clean linen carts in safe operating conditions. 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 05/28/24 at 8:31 AM, the Dietary Manager revealed 3 of 5 stove knobs were missing. The oven door was being held closed by a bungie cord. The Dietary Manager stated that the hinges to the oven door were not working, and the oven would not stay…

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

Based on interviews and record review the facility failed to implement written policies that prohibit and prevent abuse for misappropriation of property for 1 (alleged allegation of unknown resident) of 1 alleged allegation reviewed for abuse. The facility failed to implement their abuse policy when they failed to report, investigate, and protect residents from further potential abuse when it was reported on 05/30/24 to the DON by LVN D that LVN K was stealing resident (unknown who the resident(s) were) medications. This placed residents at risk for misappropriation of property and other abuses by not immediately following the facility abuse policy and procedure manual of recognizing, reporting, investigating, and allegations of misappropriation and other abuses. Finding included: During an interview on 05/30/24 at 2:32 PM, with the DON, revealed she had received a report from LVN D. The DON stated LVN D made malicious allegations about other nurses. The DON stated LVN D made a malicious report regarding LVN K taking medications from the residents. The DON stated she followed 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.

Based on interviews and record review the facility failed to ensure alleged violations involving abuse, neglect, exploitation, or mistreatment, including misappropriation were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility, and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 (DON) of 1 DON reviewed for reporting. The DON was reported on 05/30/24 to by LVN D that an unknown nurse was stealing medications from an unknown resident(s) and failed to report it to the administrator which was not reported to the state agency. This failure could place all residents at risk for misappropriation of property by not immediately…

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

Based on interviews, and record review the facility failed to ensure violations were thoroughly investigated with results of the investigations presented to the administrator and to other officials in accordance with state law including to state survey agency, within 5 working days of the incident and if the alleged violation was verified appropriate corrective action must be taken for 1 (stealing of medications) of 1 facility medication reviewed for incidents. The facility failed to thoroughly investigate the stealing of medications reported on 05/30/24 to the DON. This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property and decreased quality of life. Findings included: During an interview on 05/30/24 at 2:32 PM, with the DON, she stated she had received a report from LVN D. The DON stated LVN D tenses to makes malicious allegation towards other nurses. The DON stated LVN D made a malicious report to her on 05/28/24, regarding LVN K taking medications from the residents. The DON stated she followed up with LVN K and no one had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure that resident assessments were accurate for 3 (Resident #88, Resident #196, and Resident #198) of 5 residents reviewed for accuracy of resident assessments. The facility failed to accurately identify the need for oxygen therapy for Resident #88 admission MDS dated [DATE] and Resident #196 ' s admission MDS dated [DATE]. The facility failed to accurately identify the need for intervenors therapy for Resident #198 ' s admission MDS dated [DATE]. This deficient practice could place residents at risk of not receiving a completed initial assessment which could result in necessary care and services based on their individually assessed needs. Findings included: Resident #88 Record review of Resident #88 ' s face sheet dated 05/29/24, revealed admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #88 ' s facility history and physical dated 03/22/24, revealed a [AGE] year-old male diagnosed with tongue…

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 develop and implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for three (Residents #16, #49, and #89) of 18 residents assessed for comprehensive person-centered care plans. The facility failed to ensure that Resident #16's Care plan reflected interventions in place to address his frequent falls. The facility failed to ensure that Resident #49 had a care plan in place to address chronic pain. The facility failed to ensure that Resident #89 did not have a care plan in place to address potential trauma from use of a urinary catheter. These failures could put residents at increased risk of not having their care needs met. Findings included: Resident #16 Record review of Resident #16's face sheet dated 05/29/2024 revealed he was [AGE] years old, was initially admitted to the facility on [DATE] 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 review the facility failed to provide necessary services to maintain good grooming and hygiene for a resident who was unable to carry out activities of daily living for 2 residents (Residents #89 and #77) out of 12 reviewed for services to maintain good grooming and hygiene. The facility failed to provide Resident #89 with removal of facial hair. The facility failed to provide personal hygiene for Resident #77 by not trimming his fingernails. This deficient practice placed residents at risk of poor hygiene and decline in residents' self-esteem. Findings included: Record Review of Resident #89's Face Sheet dated 05/30/2024 revealed she was [AGE] years old, admitted to the facility on [DATE]. Record review of Resident #89's history and physical dated 03/18/2024 revealed she had a diagnosis of dementia, hypertension, and dyslipidemia (elevated cholesterol or fats in the blood). Resident #89's activities for daily living (ADL) assistance was set up to one-person physical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to provide the necessary 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 1 (Resident #198) of 3 residents reviewed for pressure ulcers. LVN E failed to notify the Wound Care Nurse that Resident #198 ' s dressing for his right heel and calf was not placed according to physician orders exposing the unstageable right heel. This deficient practice could place residents at risk for worsening pressure injuries, pain, and a decline in health. Findings included: Record review of Resident #198 ' s face sheet dated 05/29/24, revealed an admission on [DATE] to the facility. Record review of Resident #198 ' s hospital history and physical dated 05/14/24, revealed a 67-year –old male diagnosed with Diabetes, End-stage renal disease, and chronic right foot wounds. Record review of Resident #198 ' s admission MDS dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review the facility failed to ensure that a resident who was continent of bladder and bowel on admission received services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence was not possible to maintain for 1of 5 (Resident #89) residents reviewed for urinary catheter. The facility failed to ensure Resident #89's catheter leg strap was in place to secure the catheter. This failure could place residents with foley catheter at risk of catheter pulling causing pain and/or infection. Findings include: Record Review of Resident #89's Face Sheet dated 05/30/2024 revealed she was [AGE] years old, admitted to the facility on [DATE]. Record review of Resident #89's history and physical dated 03/18/2024 she had a diagnosis of dementia, hypertension, and dyslipidemia (elevated cholesterol or fats in the blood). Resident #89's activities for daily living (ADL) assistance was set up to one-person physical assist from staff.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure residents received parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders for 1 (Resident #198) of 2 residents reviewed for Midline/PICC (Peripherally Inserted Central Catheter) care. Resident #78 midline (intravenous catheter) dated 05/20/2024, the dressing edges where loose and coming off, dressing had dried blood towards the bottom of the dressing, and was dated 05/20/24. This failure placed residents at risk of developing an infection. Findings included: Record review of Resident #78 ' s face sheet dated 05/28/24, revealed an admission on [DATE] to the facility. Record review of Resident #78 ' s facility history and physical dated 06/08/23, revealed, a [AGE] year-old male diagnosed with borderline Diabetes and total knee replacement, and infection of prosthesis (a device such as an artificial leg, that replaces a part of the body). 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 interview and record review the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice and the residents' goals and preferences for one (Resident #49) of 12 residents reviewed for pain control . The facility failed to ensure that Resident #49's request, and physician's order to administer Tylenol 4 (Acetaminophen-Codeine Oral Tablet 300-60 MG) were carried out in a timely manner. This failure could put residents at increased risk for pain and decreased quality of life. Findings included: Record review of Resident #49's face sheet dated 05/31/2024 revealed she was [AGE] years old and was initially admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #49's History and Physical dated 4/4/2024 revealed she had a past medical history of chronic pain in her lower extremities (legs). She had paraplegia (paralysis of the lower body) and polyneuropathy (damaged nerves) for which she…

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

Based on interviews and record review the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 1alleged allegation of stealing of medications reviewed for allegations of misappropriation of property. The facility failed to ensure the DON followed the internal abuse policy, report allegations of abuse to State Office, and conduct thorough abuse allegation investigation. These failures could place all residents at risk of continued abuse by not immediately following the facility policy of abuse, neglect, exploitation, or misappropriation - reporting and investigating. Findings included: During an interview on 05/30/24 at 2:32 PM, with the DON, she stated she had received a report from LVN D. The DON stated LVN D tends to makes malicious allegation towards other nurses. The DON stated LVN D made a malicious report to her on 05/28/24, regarding LVN K taking medications from the residents. The DON stated 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 observation, interview and record review the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents in one of six zones (Zone 1 Rooms 1 -12) reviewed for effective pest control. The facility failed to ensure that two live cockroaches were not found in Zone 1 (Rooms 1 -12) of the facility. This failure put residents at increased risk of transmission of vermin-borne illness. Findings include: Observation on 05/29/2024 at 11:09 AM, in room [ROOM NUMBER] revealed two large cockroaches (1.5 to 2 inches long) crawling on the floor. Surveyor R stepped on one of the roaches that was running quickly out of room [ROOM NUMBER] and into the hallway. In an interview and observation on 05/29/2024 at 11:12 AM, the Administrator came to room [ROOM NUMBER] and observed the live roach in room [ROOM NUMBER] and the dead roach in the hallway. She said that there should not be roaches in the facility because they were a contamination risk. She said the facility had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to provide reasonable accommodation of resident needs for one out of seven Residents (Resident #6) reviewed for resident rights. On two occasions 05/11/2024 and 05/13/2024 Resident #6 was left alone in her room on the bed without being able to reach her call light. This deficiency could put other residents who are unable to use their call lights at risk of not having their care needs met by not having access to call lights to communicate their needs. Findings Included: Review of the face sheet for Resident #6 dated 05/13/2024 revealed a [AGE] year-old female and who was admitted to the facility on [DATE], with a diagnoseis of Cerebral Palsy (a congenital disorder of movement, muscle tone, or posture), muscle weakness (decreased strength in muscles), and contracture of muscle (a permanent tightening of muscles, tendons, skin, and nearby tissues that cause joints to shorten and become very stiff) . Review of the History and Physical for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to communicate with hospice representatives for 1 of 7 (Resident #1) residents reviewed for hospice services. The facility failed to notify Hospice of Resident #1's acute glucose level increase on 05/04/24. This deficient practice could place residents who receive hospice services at risk of receiving substandard care due to miscommunication between their hospice and facility care givers. The findings included: Record review of Resident #1's face sheet dated 5/16/24 revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of DM II (long-term condition in which the body has trouble controlling blood sugar and using it for energy), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and anxiety. Record review of Resident #1's physician order dated 09/27/23 revealed an order for accucheck daily for DM II, notify MD if blood glucose levels less than 70 or over…

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 alleged violations involving neglect or mistreatment, including misappropriation were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 (Resident #2 and Resident #6) of 4 residents reviewed for reporting. Resident #2 reported to facility staff missing $400 from his wallet and the facility failed to report the incident to the state agency. LVN B reported to the Administrator that LVN A was neglecting Resident #6 by not conducting wound care…

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 residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan for 1 (Resident #3) of 4 residents reviewed for wound care. Resident #3 was not given wound care as prescribed to left and right heel to cleanse with normal saline cleanser, pat dry, apply foam heel protector or abdominal pad and wrap with roll gauze dressing every Monday, Wednesday, and Friday for protection as ordered as there was no wound care performed on 03/13/24. This failure could affect residents by placing them at risk of deterioration of the wound. Findings included: Record review of Resident #3's face sheet dated 03/15/24, revealed, admission on [DATE] to the facility. Record review of Resident #3's facility history and physical dated 10/26/23, revealed, a [AGE] year-old male diagnosed with Diabetes Mellitus . Record review of Resident #3's care plan dated 01/15/24, revealed has a pressure ulcer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the resident had a right to be treated with respect and dignity for 1 (Resident #11) of 3 residents reviewed for urinary catheter care. Resident #11's catheter bag did not have a catheter bag cover exposing the catheter bag filled with urine This failure could have compromised residents' dignity for those who require urinary catheter care. Findings include: Record review of Resident #11's face sheet dated 02/14/24 revealed admission on [DATE] to the facility. Record review of Resident #11's facility history and physical dated 11/06/23 revealed a [AGE] year-old male diagnosed with schizophrenia (a serious mental disorder in which people interpret reality abnormally) and bipolar disorder (a serious mental illness that causes unusual shifts in mood, ranging from extreme highs (mania or manic episodes) to lows (depression or depressive episode)). Record review of Resident #11's quarterly MDS dated [DATE] revealed an intact cognition 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, 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 #14) of 16 residents reviewed for call light placement. The facility failed to ensure that Residents #14's call light was within her reach. This failure placed residents at risk of not being able to call for assistance when needed. Findings included: Record review of Resident #14's face sheet dated 02/17/24 revealed admission on [DATE] to the facility. Record review of Resident #14's facility history and physical dated 01/06/23 revealed a [AGE] year-old female diagnosed with severe intellectual disability (major delays in development, and individuals often have the ability to understand speech but otherwise have limited communication skills) and cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture). Record review of Resident #14'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, interviews, and record review the facility failed to ensure that residents received the appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible for 1 (Resident #11) of 5 residents reviewed for indwelling catheters in that: Resident #11's indwelling catheter tubing was full and cloudy and evaluated on a wedge not being able to drain downwards properly. These failures placed residents at risk of collection tube becoming full and allowing urine to flow back into the bladder that could result in a urinary tract infection. Findings include: Record review of Resident #11's face sheet dated 02/14/24 revealed admission on [DATE] to the facility. Record review of Resident #11's facility history and physical dated 11/06/23 revealed a [AGE] year-old male diagnosed with schizophrenia (a serious mental disorder in which people interpret reality abnormally) and bipolar disorder (a serious mental illness that causes unusual shifts…

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 1 (Resident #2) of 5 residents reviewed for medical records. The facility failed to ensure Resident #2's medical record accurately documented Resident #2's sexual abuse/expiation allegation. This failure could place residents at risk of having incomplete and inaccurate medical records possibly resulting inadequate treatment/care. Findings include: Record review of Resident #2's face sheet dated 02/13/24 revealed admission on [DATE] to the facility. Record review of Resident #2's most recent facility history and physical in the system dated 12/21/20 revealed a [AGE] year-old female diagnosed with Osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes), Vascular Dementia (problems with reasoning, planning,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for 2 of 2 residents (Resident #10 and Resident #11) reviewed for environment. The facility did not ensure the foot boards of Resident #10 and Resident #11 were not broken. These failures placed residents and staff at risk of living, working and visiting in an unsafe, unsanitary, and uncomfortable environment. Findings include: Resident #10 Record review of Resident #10 ' s face sheet dated 01/22/24 revealed admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #10 ' s history and physical dated 08/03/23 revealed an [AGE] year-old female diagnosed with Type 2 Diabetes Mellitus, Asthma, Alzheimer ' s Disease, multiple of falls, and Osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes). Record review of Resident #10 ' s quarterly 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 interviews and record reviews, the facility failed to ensure that the assessment accurately reflected the resident ' s status for 2 (Resident #4 and Resident #8) of 5 resident reviewed for accuracy of MDS assessment, in that: Resident #4 ' s annual MDS did not accurately reflect the residents ' behaviors in the annual MDS. Resident #8 ' s annual MDs did not accurately reflect the residents ' behaviors in the annual MDS. This deficient practice could affect residents at the facility who had been assessed for behaviors and could contribute to inadequate care. Findings included: Resident #4 Record review of Resident #4 ' s face sheet dated 01/18/24 revealed admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #4 ' s facility history and physical dated 05/18/23 revealed a [AGE] year-old female diagnosed with psychiatric behavior with aggression and paranoid schizophrenia (a pattern of behavior where a person feels distrustful and suspicious of other people and acts…

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 includes 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 5 (Resident # 3, #4, #5, #7, and #8 ) of 12 residents reviewed for care plans. The facility failed to implement a comprehensive person-centered care plan for Resident #7 ' s history of falls. The facility failed to implement a comprehensive person-centered care plan to address elopement risk for Residents #3, #4, #5, #7, and #8. 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 include: Resident #7 Record review of Resident #7 ' s face sheet dated 01/19/24 revealed admission on [DATE] and re-admission on [DATE] to the facility 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, interview and record review the facility failed to promote and facilitate resident self-determination through support of resident choice for 1 of 10 residents (Resident #11) reviewed for respect and dignity. The facility staff failed to honor Resident #11 ' s request to turn on her TV, instead of going to sleep. This failure could place residents at risk of diminished quality of life. Findings included: Record review of Resident # 11 ' s face sheet dated 01/18/24 revealed, admission on [DATE] and re-admission on [DATE] to the facility. Resident #11 was a [AGE] year-old female diagnosed with Cerebral Palsy (weakness or problems with using the muscles), muscle weakness (no muscle strength), contracture of muscle to right hand, insomnia (a sleep disorder in which you have trouble falling and/or staying asleep), vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain), paraplegia (paralysis…

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 respect a resident's right to personal privacy during personal care for 1 of 10 residents ( Resident #12) reviewed for respect and dignity. The facility failed to close the curtain and provide privacy when changing Resident #12. This failure could place residents at risk of diminished quality of life. Findings included: Record review of Resident #12 ' s face sheet dated 01/19/24 revealed admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #12 ' s quarterly MDS dated [DATE] revealed Resident #12 was cognitively intact to be able to recall and make daily decision BIMS (BIMS a brief cognitive screening measure that focuses on orientation and short-term word recall) score of 12. Functional limitation in range of motion was marked for upper and lower extremity for impairments on both sides. Activities of daily show substantial/maximal assistance for dressing and partial/moderate assistance form nursing staff…

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 report an alleged violation of injury of unknown origin immediately to the administrator of the facility and to other officials (including to state survey agency) in accordance with State law and according to their policy for 1 (Resident # 13) of 2 residents reviewed for allegations of injury with unknown origin. The facility failed to report Resident #13 ' s injury of unknown origin related to her dislocated jaw to State Office. This failure could place all residents at risk for abuse and/or neglect by not immediately reporting allegations of injuries of unknown origin to the proper authorities at the facility. Findings Include: Resident #13 Record review of Resident #13 ' s face sheet dated 01/18/2024 revealed an [AGE] year-old female who was admitted on [DATE]. Record review of Resident #13 ' s history and physical dated 06/08/2023 revealed admitting diagnoses of debility (weakness caused by an illness, injury, or aging) post observation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure all alleged violations involving abuse, neglect, and exploitation and injuries of unknown origin were thoroughly investigated for 1 (Resident #13 ) of 5 residents reviewed for abuse and neglect. The facility did not thoroughly investigate Resident #13 ' s injury of unknown origins. This failure could place residents at risk for abuse, neglect, and decreased quality of life. Findings include: Record review of Resident #13 ' s face sheet dated 01/18/2024 revealed an [AGE] year-old female who was admitted on [DATE]. Record review of Resident #13 ' s history and physical dated 06/08/2023 revealed admitting diagnoses of debility post been seen under observation and isolation due to exposure to coronavirus complicated by underlying dementia and chronic comorbidities. Record review of Resident #13 ' s quarterly MDS dated [DATE] revealed a BIMS score of 04, she was severely cognitive impaired. Required extensive assistance with one-person…

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 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 48 hours of a resident ' s admission for 2 (Resident #2) of 5 residents reviewed for baseline care plan, in that:. Resident #2 did not have a baseline care plan that addressed his history of falls. This failure could have placed newly admitted residents at risk of not receiving the care and services and continuity of care. Findings include: Record review of Resident #2 ' s face sheet dated 01/13/24 revealed admission on [DATE] to the facility. Record review of Resident #2 ' s facility history and physical dated 12/28/23 revealed a [AGE] year-old male diagnosed with Dementia and history of falls. Record review of Resident #2 ' s admission MDS dated [DATE] revealed Resident #2 to be cognitively intact to be able to recall and make daily decision…

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 respiratory care was provided in a manner consistent with professional standards of practice for 1 (Resident#10) of 2 residents reviewed for respiratory care in that: The facility failed to place Resident #10 ' s nasal cannula in a clear labeled bag while not in use. These deficient practices could place residents at risk for infection due to improper care practices. Findings Include: Record review of Resident #10 ' s face sheet dated 01/22/24 revealed admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #10 ' s facility history and physical dated 08/03/23 revealed an [AGE] year-old female diagnosed with Type 2 Diabetes Mellitus, Asthma, Alzheimer ' s Disease, multiple of falls, and Osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes). Record review of Resident #10 ' s quarterly MDS dated [DATE] revealed a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to 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 3 (Linen Carts #1, Linen #2, and #3) of 4 linen carts and 1 (Resident #1) of 2 residents reviewed for infection control in that: 1. Linen Carts #1, #2, & #3 were not covered and sealed while storing linen, towels, Hoyers (allow a person to be lifted and transferred with a minimum of physical effort) slings, gloves, gowns, and briefs to prevent the spread of infection while in [NAME] Hall High & Low and East Hall Low. 2. Resident #1's nasal cannula fell on the floor in her room and LVN A picked up the nasal cannula and placed it back on Resident #1. These deficient practices could place residents at risk for infection due to improper care practices. Findings include: Linen Carts Observation on 09/14/23 at 1:57 PM revealed in 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 develop and implement comprehensive person-centered care plan that includes 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 2 (Resident #1 & Resident #2) of 4 residents reviewed for care plans in that: 1. The facility failed to develop a comprehensive person-centered care plan for Resident #1's for oxygen use. 2. Resident #2's refusal to be evaluated in bed while eating foods and drinking liquids was not addressed in his comprehensive person-centered care plan. 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 include: Resident #1 Record review of Resident #1's face sheet dated 09/19/23 revealed Resident #1 was admitted on [DATE] and readmitted on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 #1) of 2 residents observed for oxygen management. 1. Resident #1 utilized oxygen in her room did not have an oxygen sign posted outside of the room. These failures could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health. Findings include: Resident #1 Record review of Resident #1's face sheet dated 09/19/23 revealed Resident #1 was admitted on [DATE] and readmitted on [DATE] to the facility. Record review of Resident #1's History and physical dated 03/15/23 revealed a [AGE] year-old female diagnosed with cognitive impairment and traumatic brain injury Record review of Resident #1's quarterly MDS dated [DATE] revealed a [AGE] year-old female diagnosed with stroke, hemiparesis (weakness or the inability to move on one side of the body,…

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 for each resident describing the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and any services that would otherwise be required but are not provided due to the resident's exercise of rights including the right to refuse treatment for one (Resident #1) of 10 residents reviewed for Care Plans. The facility failed to develop a care plan to address resident's refusal of help with activities of daily living. This failure put residents at increased risk of impaired skin integrity, decreased quality of life. Findings include: Record review of Resident #1's face sheet dated 08/03/2023 documented that she was [AGE] years old and most recently admitted to the facility on [DATE]. Record review of Resident #1's History and Physical dated 09/17/2022 documented diagnoses including dementia, diabetes,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a communication process, including how the communication will be documented, between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day for one (Resident #1) of two residents reviewed for administration. The facility failed to ensure accurate and complete documentation of bathing services provided to or refused by Resident #1 by the hospice. This failure put the resident at increased risk of undetected gaps in provision of bathing services which could result in impaired skin integrity and decreased quality of life. Findings include: Record review of Resident #1's face sheet dated 08/03/2023 documented that she was [AGE] years old and most recently admitted to the facility on [DATE]. It indicated that she was receiving hospice services. Record review of Resident #1's History and Physical dated 09/17/2022 documented diagnoses including dementia, congestive heart…

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 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 food and nutrition services, in that: 1. Food products in dry storage, freezer, and in refrigerator were not correctly labeled, wrapped, or were expired. 2. Staff were not wearing hairnets properly. 3. Freezer was dirty. 4. Food temperatures were not taken prior to serving meals. 5. Staff did not wash hands after touching hair on the serving line. These failures could affect residents by placing them at risk of food borne illness. Findings include: Observation and interview on 3/26/23 at 8:03 AM initial tour was conducted with Kitchen Aide P. Kitchen Aide P stated dessert in plastic containers (total of 11) were not labeled and should have been labeled with date they were prepared and chicken wings in freezer and sausages did not have date of when it was opened and should have been dated with 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 reviews, the facility failed to develop and implement a comprehensive person-centered care plan for a resident, consistent with the residents ' rights set forth 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 #26, Resident #2, and Resident #5) of 10 residents reviewed for comprehensive care plans in that: Resident #26 comprehensive care plan did not address pressure ulcers. Resident #2 comprehensive care plan did not address assisted feeding. Resident #5 was not wearing appropriate footwear as listed on comprehensive care plan. This deficient practice could affect residents by placing them at risk of not receiving care and services to meet their needs. Finding included: Record review of Resident #26 ' s Face Sheet admission date was 06/10/21 and readmission was 01/25/2022 to the facility. Record review of Resident #26 ' 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, interviews, and record reviews the facility failed to provide the necessary services to maintain good grooming and personal hygiene care for 4 (Resident #83, Resident #5, Resident #66 and Resident #18) of 5 residents reviewed for ADL care. Resident #18 did not have her brief changed on a timely basis and was not turned as needed. The facility failed to ensure facility staff provided showers, personal grooming for Resident #83, Resident #5, and Resident #14. This failure could place residents at risk of not receiving assistance with personal care which could cause pain, skin breakdown, and low self-esteem. Findings Included: Resident #83 Record review of Resident #83's Face Sheet admission date was 11/21/2022 at the facility. Record review of Resident #83's History and Physical dated 11/22/2022 indicates Resident #83 was a [AGE] year-old female who had a diagnosis of End Stage Renal Disease, hypertension, Type 2 diabetes, and osteomyelitis. Record review of Resident #83's MDS Quarterly 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 observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan for 2 (Resident #2, and Resident #55) of 10 residents reviewed for repositioning. The facility failed to ensure Resident #2, and Resident #55 were repositioned every 2 hours. This failure could affect others by placing them at risk of potential medical complications related to changes in condition. Findings included: Resident #2 Record review of Resident #2's Face Sheet dated 3/28/23 revealed a [AGE] year old female who was admitted on [DATE] and readmitted on [DATE] at the facility. Record review of Resident #2's History and Physical dated 05/26/2022 revealed diagnosis of open wound unspecified, muscle weakness, and dementia. Record review of Resident #2's MDS significant change in condition dated 01/18/2023 revealed she was severely cognitively impaired. It also indicated ADLs as…

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

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 maintained acceptable parameters of nutritional status, for 1 resident (Resident #64) of 21 residents reviewed for weight loss. The facility failed to monitor, document, care plan, and implementplace interventionss for Resident #64 significant weight loss. This failure could place all residents in the facility at risk for weight loss, and not maintaining their highest practicable level of health. The findings included: Record Review of Resident #64's Face Sheet dated 3/27/23 documented in part resident is a [AGE] year-old female admitted on [DATE] to the facility. Record Review of Resident #64's History and Physical dated 07/06/22 established diagnoses of anemia, prediabetic, gastroesophageal reflux disease, and hyperlipidemia. Record Review of Resident #64 Referral History and Physical dated 6/24/22 from doctor visit documented in part resident weight as 181 lbs. Record Review of Resident#64 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 interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 resident (Residents #83) of 8 reviewed for medication administration. MA S administered Resident #83 medication prior to taking blood pressure. This deficient practice could cause a decline in health of residents who receive medication that are not according to physician orders. Findings included: Review of Resident #83's face sheet dated 03/28/23 revealed a [AGE] year-old female with an admission date of 11/21/22. Review of Resident #83's History and Physical dated 02/27/23 revealed she was diagnosed with hypertension (high blood pressure). Review of physician orders dated 3/28/2023 revealed an order for Lisinopril Tablet 10 MG Give 1 tablet by mouth one time a day for hypertension hold if SBP <110mm/Hg, pulse <60. Observations during medication pass on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 2 (Resident #2 and Resident #67) of 2 meals reviewed for residents with a diet order for nectar consistency reviewed for provision of food in a form designed to meet individual needs. 1. Resident #2 and Resident #67 received liquids of the wrong consistency. 2. Residents #2 and #67 had meal tickets that had not been updated and contained old information regarding dietary orders for liquid consistency. 3. Resident #2 and Resident #67 meal tickets were not updated. This failure could place residents who received liquid consistency diets at-risk of inadequate nutrition, choking, and aspiration. Findings include: Resident #2 Record review of Resident #2's Face Sheet admission was on 03/28/2012 and readmitted on [DATE] at the facility. Record review of Resident #2's History and Physical dated 05/26/2022 had a [AGE] year-old female with a diagnosis of dysphagia (difficult…

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 maintained acceptable parameters of nutritional status, for 1 resident (Resident #64) of 21 residents reviewed for weight loss. The facility failed to monitor, document, care plan, and implementplace interventionss for Resident #64 significant weight loss. This failure could place all residents in the facility at risk for weight loss, and not maintaining their highest practicable level of health. The findings included: Record Review of Resident #64's Face Sheet dated 3/27/23 documented in part resident is a [AGE] year-old female admitted on [DATE] to the facility. Record Review of Resident #64's History and Physical dated 07/06/22 established diagnoses of anemia, prediabetic, gastroesophageal reflux disease, and hyperlipidemia. Record Review of Resident #64 Referral History and Physical dated 6/24/22 from doctor visit documented in part resident weight as 181 lbs. Record Review of Resident#64 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 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 2 of 6 residents (Residents #55 and #64) reviewed for dignity. The facility did not provide Resident #55 or Resident #64 personal clothing to wear instead of hospital gowns. This failure could place residents at risk of diminished quality of life. Findings included: Record review of Resident #55's face sheet dated 3/28/23 revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Record review of Resident #55's history and physical dated 5/5/22 revealed diagnoses of depression and schizoaffective disorder (may include delusions, hallucinations, depressed episodes, and manic periods of high energy.) Record review of Resident #55's quarterly MDS assessment dated [DATE] revealed a BIMS score of 13, which…

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 the assessment accurately reflected the resident's status for 1 (Resident #26) of 5 resident reviewed for accuracy of MDS assessment, in that: Resident #26's quarterly MDS did not accurately reflect the residents' significant changes in pressure ulcers and in bathing in the quarterly MDS. This deficient practice could affect residents at the facility who had been assessed for pressure ulcers and bathing and could contribute to inadequate care. Findings included: Record review of Resident #26's Face Sheet admission date was 06/10/21 and readmission was 01/25/2022 to the facility. Record review of Resident #26's History and Physical dated 09/20/2022 indicates Resident #26 was a [AGE] year-old male was a diagnosis with a stroke, hemiplegia (paralysis of one side of the body), and Atrial fibrillation is an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart). Record review of Resident #26's MDS…

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