Los Arcos Del Norte Care Center

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 kitchen sanitation and food storage. -The facility failed to ensure the kitchen staff used beard restraints to prevent food contamination. -The facility failed to keep a deep fryer covered, free of food particles and burnt oil. -The facility failed to store opened food containers in the food preparation area and dry storage room in sealed containers. -The facility failed to label, and date opened foods stored in the dry storage room and refrigerator. These failures could place residents at risk of food borne illnesses. Findings included: Observation on 03/11/25 at 7:50 a.m. with the Dietary Manager revealed [NAME] D had a short beard and no beard restraint while he was serving breakfast. The Deep Fryer was uncovered, contained burnt oil and the deep fryer basket had food particles around the edges; white plastic container labeled Thickener stored in the food preparation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure a facility with more than 120 beds employed a qualified social worker on a full-time basis. The facility failed to have a full-time social worker since [DATE]. This failure could have placed residents in need of social services at risk of psycho-social decline and poor-quality of life. Findings included: Record review of the Facility Summary Report revealed the facility was licensed for 124 bed capacity. Interview and record review on [DATE] at 4:00 PM, with the HR/Payroll Coordinator revealed the temporary Social Worker permit for Social Worker L had expired on [DATE]. The HR/Payroll Coordinator stated, We have 2 social workers; Social Worker L works at this facility and Social Worker M, works at a sister facility . Record review on [DATE] at 9:05 AM of the Resident's care plans for seven sampled residents, revealed Social Worker L continued to provide services by updating and participating in care plans for the residents in 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.

Based on interviews and record review the facility failed to include effective communication as a mandatory training for direct care staff for 7 of 12 staff (Interim Administrator, Interim DON, Med Aide J, ADON, LVN I, [NAME] D, and LVN A) reviewed for training on effective communication. The facility failed to ensure direct care staff received training on effective communication for the Interim Administrator, Interim DON, Med Aide J, ADON, LVN I, [NAME] D, and LVN A. This failure could place residents at risk of not having a way to effectively communicate their wants or needs. Findings included: Interview and record review on 03/13/25 at 3:40 PM, with HR/Payroll Coordinator revealed she was recently employed, and this was her first-time doing Personnel File Reviews with the State Surveyor. She said she did not keep the training records for the staff in the personnel files and did not know who kept them. She called the ADON to her office and provided the ADON a copy of the list of staff selected to review training records. The ADON said she had just started working at the facility…

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 that all staff members were educated on the rights of the resident and the responsibilities of a facility to properly care for its residents for 8 (Interim Administrator, Interim DON, Med Aide J, ADON, LVN I, Social Worker L, [NAME] D, and LVN A) of 12 employees reviewed for training on the rights of the resident and the responsibilities of a facility to properly care for its residents. The facility failed to ensure the Interim Administrator, Interim DON, Med Aide J, ADON, LVN I, Social Worker L, [NAME] D, and LVN A, received training on the rights of the resident and the responsibilities of a facility to properly care for its residents. This failure could put residents at increased risk of not having their rights respected or not receiving proper care. Findings included: Interview and record review on 03/13/25 at 3:40 PM, with HR/Payroll Coordinator revealed she was recently employed, and this was her first-time doing Personnel File Reviews with the State Surveyor. She said she did not keep the training records 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.

Based on interviews and record review, the facility failed to provide the required annual or new hire abuse training including all activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property, dementia management, and resident abuse prevention for 8 of 12 employees (Interim Administrator, Interim DON, Med Aide J, RN K, ADON, [NAME] D, LVN A, and Social Worker M) reviewed for Abuse and Dementia training. -The facility failed to ensure abuse training including activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property, Dementia management, and resident abuse prevention was provided to Interim Administrator, Interim DON, Med Aide J, RN K, ADON, [NAME] D, LVN A, and Social Worker M upon hire and annually. This failure could affect residents and place them at risk of abuse due to lack of…

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

Based on interviews and record review the facility failed to include as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of the facility's QAPI program for 12 ( Interim Administrator, Interim DON, Med Aide J, RN K, ADON, LVN I, Social Worker L, [NAME] D, LVN A, Maintenance, Social Worker M, and the Dietary Manager) of 12 employees reviewed for QAPI training. The facility failed to include trainings regarding the facility's QAPI program in its training for employees. This failure put residents at risk of receiving poor-quality services because of staff being unaware of quality control concerns the facility was working to address. Findings included: Interview and record review on 03/13/25 at 3:40 PM, with HR/Payroll Coordinator revealed she was recently employed, and this was her first-time doing Personnel File Reviews with the state surveyor. She said she did not keep the training records for the staff in the personnel files and did not know who kept them. She called the ADON to her office and provided the ADON a copy of the list…

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 provide the mandatory training on standards, policies, and procedures for an infection prevention and control program for 11 of 12 staff (Interim Administrator, Interim DON, Med Aide J, RN K, ADON, LVN I, [NAME] D, LVN A, Maintenance, Social Worker M, and the Dietary Manager) reviewed for training. The facility failed to ensure an infection prevention and control training was provided to the Interim Administrator, Interim DON, Med Aide J, RN K, ADON, LVN I, [NAME] D, LVN A, Maintenance, Social Worker M, and the Dietary Manager. This failure could place residents at risk of illness due to lack of staff training. Findings included: Interview and record review on 03/13/25 at 3:40 PM, with HR/Payroll Coordinator revealed she was recently employed, and this was her first-time doing Personnel File Reviews with the state surveyor. She said she did not keep the training records for the staff in the personnel files and did not know who kept them. She called the ADON to her office and provided the ADON a copy of the list of 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.

Based on record review and interviews, the facility failed to ensure all staff received training in compliance and ethics for 8 of the 12 staff members (Interim Administrator, Interim DON, Med Aide J, ADON, LVN I, COOK D, LVN A, and Social Worker M) reviewed for mandatory training. The facility failed to ensure an ethics training was provided to Interim Administrator, Interim DON, Med Aide J, ADON, LVN I, COOK D, LVN A, and Social Worker M. This failure could place residents at risk of receiving inadequate care from staff who are uneducated on compliance and ethics. Findings included: Interview and record review on 03/13/25 at 3:40 PM, with HR/Payroll Coordinator revealed she was recently employed, and this was her first-time doing Personnel File Reviews with the state surveyor. She said she did not keep the training records for the staff in the personnel files and did not know who kept them. She called the ADON to her office and provided the ADON a copy of the list of staff selected to review training records. The ADON said she had just started working at the facility in March…

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 record reviews and interviews, the facility failed to maintain a training program to ensure staff were trained for 12 of 12 (Interim Administrator, Interim DON, Med Aide J, RN K, ADON, LVN I, Social Worker L, [NAME] D, LVN A, Maintenance, Social Worker M, and the Dietary Manager) reviewed for behavioral health training. The facility failed to ensure behavioral health training was provided to Interim Administrator, Interim DON, Med Aide J, RN K, ADON, LVN I, Social Worker L, [NAME] D, LVN A, Maintenance, Social Worker M, and the Dietary Manager. This failure could place residents at risk of not receiving care from incompetent/untrained staff. Findings included: Interview and record review on 03/13/25 at 3:40 PM, with HR/Payroll Coordinator revealed she was recently employed, and this was her first-time doing Personnel File Reviews with the state surveyor. She said she did not keep the training records for the staff in the personnel files and did not know who kept them. She called the ADON to her office and provided the ADON a copy of the list of staff selected to 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 provide reasonable accommodation of resident needs and preferences for 2 of 10 residents (Resident #41 and #246) observed for call lights: - The facility failed to ensure Resident #41 had access to his call light which was lying on the floor at the foot of his bed. - The facility failed to ensure Resident #246 had access to his call light which was lying on the floor next to his bed. This deficient practice could affect the residents by not maintaining and/or achieving independent functioning, dignity, and well-being. Findings included: Resident #41 Record Review of Resident #41's admission Record dated 3/11/25 revealed he was a [AGE] year-old male with an initial admission of 08/23/19 and a readmission on [DATE]. His diagnoses included: Alzheimer's disease (a type of brain disorder that affects memory, thinking, and behavior), Attention and concentration deficit, history of falling, muscle weakness, Cognitive communication deficit,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident medical, nursing and mental and psychosocial needs for 1 (Resident #52) of 8 residents reviewed for care plans. -The facility failed to ensure Resident # 52's dialysis was addressed on her care plan. This failure could place the resident at risk for not having their individual needs met in a timely manner and communicated to provide and could result in injury and a decline in physical well-being. Findings included. Review of Resident # 52 face sheet, dated 03/13/2025, reflected an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Arteriovenous fistula, acquired, Atherosclerotic heart disease of native coronary artery without angina pectoris, and Essential (primary) hypertension. Review of Resident #52's Five Day Scheduled MDS, dated [DATE], reflected Resident #52 had a Brief…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 9 residents (Resident #43 and Resident #46) reviewed for nail care. The facility failed to trim Resident # 43 and Resident #46's fingernails. This failure could place residents at risk of cross contamination and skin scratches that could result in infection. Findings include: Resident #43 Record review of Resident #43 ' s face sheet dated 03/13/2025 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included, Cerebral infarction, hemiplegia, unspecified affecting left nondominant side, muscle weakness and cerebral aneurysm. Record review of Resident #43 ' s admission MDS assessment dated [DATE] revealed a brief interview for mental status score of 15 (cognitively intact). Resident #43 required substantial/maximal…

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 assistance to resident who required dental care for 1 of 8 residents (Resident #20) reviewed for dental services. The facility failed to assist in providing routine dental services for Resident #20. This failure could affect residents by placing them at risk for oral complications and diminished quality of life. Findings Included: Record Review of Resident #20's face sheet dated 03/13/25 revealed an [AGE] year-old female with admission date 07/14/16 and readmission date 09/18/24. Her diagnoses included: disorder of tooth development and dysphagia (difficulty swallowing). Record Review of Resident #20's Annual MDS revealed a score of 15, indicating little to no cognitive impairment. MDS revealed Resident #20 was dependent for all ADL's, meaning helper does all the effort and resident does none of the effort to complete the activity. Record Review of Resident #20's Care Plan last edited 02/18/2025 revealed resident was limited in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined the facility failed to ensure a resident who is incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 resident (Resident #13) reviewed for incontinent care. CNA G failed to perform hand hygiene after disposing dirty briefs and before putting on new clean briefs for Resident #13. This practice had the potential to affect residents identified by the facility as incontinent of bladder by putting them at risk for skin breakdown, cross contamination, and urinary tract infections. Findings include: Record Review of Resident #13's face sheet dated 03/13/25 revealed an [AGE] year-old female with admission date 07/14/16 and readmission date 09/18/24. Her diagnoses included: unspecified dementia, Alzheimer's disease (neurological disorder that causes irreversible changes in memory, thinking, and behavior), generalized muscle weakness, and cognitive communication deficit. Record Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to have a safe, clean , comfortable and homelike environment including but not limited to receiving treatment and supports for daily livening safely for 4 (hall 100, hall 200, hall 300, hall 400) of 4 hallways reviewed for infection control in that: The facility failed to pick up the trash in the resident rooms and in the hallway(s). This failure could have placed residents at risk for of residing in an unsafe, unsanitary, and uncomfortable environment. Findings included: Observation of hall 100 on 01/28/25 at 8:11 AM, revealed the following: *room [ROOM NUMBER] had trash (pieces of white paper(s) and a Styrofoam cup) on the floor, * room [ROOM NUMBER] had clear medical gloves on the floor, *room [ROOM NUMBER] had food on the floor, and *room [ROOM NUMBER] had 2 blue packets of sugar on the floor. Observation of hall 200 on 01/28/25 at 8:15 AM, revealed in the following: *room [ROOM NUMBER] had trash on the floor. *The nurse's station was 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 assess the resident for risk of entrapment from an enabler (bed rail) prior to installation or review the risks prior to installation for 1 (Resident #1) of 4 residents reviewed for enablers (bed rails). Resident #1 did not have a Bed Rail Assessment done to ensure the bed rails (enablers) were appropriate for the use of Resident #1's needs. Resident #1 did not have orders for the bed rail (enablers) use. This failure could place residents who have bed [NAME] (enablers) at risk of having inappropriate or unnecessary enablers in place increasing their risk of injury. Findings included: Record review of Resident #1's face sheet dated 01/31/25, revealed, admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #1's hospital history and physical dated 10/25/24, revealed, a [AGE] year-old male diagnosed with Dementia and falls. Record review of Resident #1's quarterly MDS dated [DATE], revealed, a severe impact…

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 the MDS assessment accurately reflected the resident's status (use of bed rails) for 1 (Resident #1) of 4 residents reviewed for accuracy of MDS assessment. Resident #1's quarterly MDS dated [DATE], did not accurately reflect the residents' use of bed rails (enablers). This deficient practice could place residents at risk of not receiving adequate care. Findings included: Record review of Resident #1's face sheet dated 01/31/25, revealed, admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #1's hospital history and physical dated 10/25/24, revealed, a [AGE] year-old male diagnosed with Dementia and falls. Record review of Resident #1's quarterly MDS dated [DATE], revealed, a severe impact cognition BIMS score of 8 to be able to recall and make daily decisions. Resident #1's functional ability indicated to be independent to be able to roll left or right on bed, sit to lying, lying to sitting…

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 1 of 4 residents (Resident #1) reviewed for care plans. The facility failed to implement a comprehensive person-centered care plan for Resident #1's use of bed rails (enablers). This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. Findings included: Record review of Resident #1's face sheet dated 01/31/25, revealed, admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #1's hospital history and physical dated 10/25/24, revealed, a [AGE] year-old male diagnosed with Dementia and falls. 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 the observation, interview, and record review the facility failed to ensure that the residents environment remains free of accidents hazards as was possible and each resident received adequate supervision to prevent accidents for 1 (Resident #15) of 2 resident reviewed for accidents. CNA G and CNA H were observed 01/28/2025 using the mechanical lift to lift Resident #15 without engaging the brakes as the mechanical lift was observed moving slightly. This failure could affect residents who required the use of a mechanical lift for transfers, by placing them at risk of improper transfers resulting in injury. Findings included: Record review of Resident #15's face sheet dated 01/29/25, revealed, a [AGE] year-old male who was admitted on [DATE] to the facility. Resident #15 was diagnosed with muscle wasting, abnormalities of gait and mobility, lack coordination, muscle weakness, and paralytic gait. Record review of Resident #15's payment assessment MDS dated [DATE], revealed, a severely impaired cognition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 5 (Resident #14) reviewed for pharmacy services. The facility did not provide Resident #14's Cilostazol (vasodilator medication) 100 mg tablet given two times a day on 12/21/24 per physician orders. These failures could place residents at risk for a delay in medication administration and could place residents at risk for medical complications due to missed doses. Findings include: Record review of Resident #14's face sheet dated 02/03/25, revealed, admission on [DATE] and re-admitted on [DATE] to the facility. Record review of Resident #14's facility history and physical dated 12/20/24, revealed, an [AGE] year-old female diagnosed with Diabetes and hypertension. Record review of Resident #14's admission MDS dated [DATE], revealed, an…

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 were maintained on each resident that were complete and accurately documented for 2 (Resident #6 and Resident #11) of 11 residents reviewed for administration. -The facility failed to document in Resident #6's medical records the resident's desire to transfer from the facility. -The facility failed to ensure Resident #11's Care Plan intervention tasks regarding falls, was free of error. These failures could place residents at risk of not receiving needed services or errors in treatment based on incorrect information. Findings included: Resident #6: Review of Resident #6's Face Sheet dated 08/22/2024, revealed a [AGE] year-old female who was admitted to the facility on [DATE] and discharged [DATE]. Resident #6 diagnoses included unilateral primary osteoarthritis of left knee (a type of arthritis that affects one side of a joint, resulting from a previous traumatic injury), and depression (constant feeling of sadness and loss 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 interviews and record review, the facility failed to send a copy of the notice of transfer or discharge and the reasons for the transfer or discharge in writing to the Office of the State Long-Term Care Ombudsman for one (Resident #1) of two residents reviewed for transfer and discharge. The facility failed to send a transfer or discharge notice in writing to the facility's Ombudsman as soon as practicable when Resident #1 was discharged home on 5/10/24. This failure could affect residents at the facility by placing them at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and the appeal processes. Findings included: Record review of Resident #1's electronic face sheet, dated 7/11/24 revealed he was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses to include depressive disorder, anxiety disorder, and aggressive behaviors. Review of Electronic communication via email dated 7/10/24 from the Ombudsman wrote: I checked my…

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 environment remained free of accidents hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #7) of 5 residents reviewed for accidents hazards. -The facility failed to ensure that Resident #7's fall mat was positioned bedside while resident was lying in bed. This failure could place residents at risk of falls and/or injuries. Findings included: Review of Resident #7's face sheet dated 05/22/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included unsteadiness on feet, acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity (blood clot forms in one or more of the deep veins in the body, usually in the legs), hypotension (low blood pressure which can cause fainting or dizziness because the brains does not receive enough blood), dementia (group of thinking 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 that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 (Resident #8) of 3 residents observed for oxygen management. -The facility failed to ensure Resident #8 had an oxygen sign posted outside of her bedroom. This failure could place residents on oxygen therapy at risk exposure to a fire hazard if staff and visitors are not aware of oxygen present. Findings included: Review of Resident #8's face sheet dated 05/22/2024, revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia (condition where you don't have enough oxygen in the tissues in your body). Review of Resident #8's quarterly MDS dated [DATE], revealed Resident #8 had a BIMS score of 02 indicating severe cognitive impairment. Section O - Special Treatments, Procedures, and Programs revealed Resident #8 on intermittent…

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 #7) of 6 residents reviewed for medical records. -The facility failed to ensure nursing documentation was accurate for Resident #7. This failure could lead to errors in treatment based on incorrect information. Findings included: Review of Resident #7's face sheet dated 05/22/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included unsteadiness on feet, acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity (blood clot forms in one or more of the deep veins in the body, usually in the legs), hypotension (low blood pressure which can cause fainting or dizziness because the brains does not receive enough blood), dementia (group of thinking and social symptoms that interferes with daily functioning),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan for 2 (Resident #3 and Resident #5) of 4 residents reviewed for neurological checks. -The facility failed to ensure Resident #3 had neurological checks done after a fall on 02/25/24. -The facility failed to ensure Resident #5 had neurological checks done after a fall on 03/13/24. This failure could affect others by placing them at risk of changes in condition due to not conducting neurological checks. Findings included: Resident #3 Record review of Resident #3's face sheet dated 04/02/24, revealed admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #3's clinic history and physical dated 01/22/24, revealed, a [AGE] year-old male diagnosed with Dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure that the residents environment remains free of accidents hazards as was possible and each resident received adequate supervision to prevent accidents for 1 (Resident #1) of 4 residents reviewed for accidents and hazards. The facility failed to use the Hoyer lift (a patient lift used by caregivers to safely transfer patients) to transfer Resident #1. The noncompliance was identified as past noncompliance. The noncompliance began 02/20/24 and ended on 02/21/24. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of having an improper transfer used on them. Findings included: Record review of Resident #1's face sheet dated 04/02/24, revealed, admission on [DATE] to the facility. Record review of Resident #1's facility history and physical dated 12/15/23, revealed, an [AGE] year-old female diagnosed with chronic pain (long standing pain that persists beyond the usual recovery period…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one resident (Resident #4) of four residents observed for infection control. Resident #4's catheter drainage collection bag was left on the floor. This deficient practice could affect residents with catheters and could result in cross contamination of germs and could result in a urinary tract infection (a painful infection of the urinary system, which includes the kidneys, bladder, urethra, and ureters). The findings included: Review of Resident #4's face sheet dated 04/05/2024, revealed resident was admitted to the facility on [DATE]. Review of Resident #4's History and Physical dated 12/15/2023, revealed diagnoses to include hepatitis C (an infection caused by a virus that attacks the liver and leads to inflammation) 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 Resident #4 PASARR 12/06/23 10:08 AM PASSAR I 08/03/2022 - No evidence of MI New PASSAR I submitted 1/27/23 showing Yes to MI with diagnosis of Schizophrenia 8/11/2022; Schizoaffective Disorder - 8/22/2022 Form 1012 - Completed 1/27/2023- Primary diagnosis is not dementia. Diagnosis of Schizophrenia and of Schizophrenia Diagnosis PASSAR Eval dated 1/30/2023 - does not meet PASSR definition of MI. Based on observation, interview, and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 16 (Resident #10 and Resident #69) residents reviewed for accuracy of MDS assessments. 1. The facility failed to ensure Resident #10's MDS reflected her refusal of care and treatments. 2. The facility failed to ensure Resident #69 MDS assessment documented the use of wander guard. These failures could put residents at increased risk of not having their treatment needs identified and met. Findings include: Resident #10 Record review of Resident #10's face sheet dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 4 (Resident #69, Resident #35 , Resident #32 and Resident #54) of 24 residents reviewed for care plans in that: 1.-The facility failed to implement a comprehensive person-centered care plan for Resident #69 history of wandering and/or elopement behavior and wander guard. 2.The facility failed to include the Resident #35's psychiatric diagnosis, use of antipsychotic medications, or for COVID-19 on her care plan. 3.The facility failed to implement the accurate code status for Resident #32 and Resident #54. These deficient practices could place residents in the facility at risk of not receiving the necessary care or services for psychiatric diagnoses or…

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) and failed to keep drug records to account of all controlled drugs to be maintained and periodically reconciled for 2 (Resident #289 and Resident #48) of 5 residents and 1 out of 4 (300 Hall) hallways reviewed for pharmacy services. -MA K administered the incorrect dosage of Aspirin medication to Resident #289. -LVN L failed to stay in the room and assess Resident #48 while breathing treatment was being administered per facility policy. -The facility failed to ensure the narcotic count sheet for the 300 hall was accurate for one controlled medication. This deficient practice could place residents at risk of medication errors and a decline in health due to inaccurate count of controlled medications. Findings included: Resident #289 Record review of Resident #289 ' s face sheet dated 12/08/2023…

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 did not receive psychotropic drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for one (Resident #35) of 5 residents reviewed for unnecessary medications. The facility failed to ensure Resident #35 did not receive the antipsychotic Risperidone for the diagnosis of depression. This failure puts residents at increased risk of side-effects of antipsychotic medications and receiving unnecessary medications. Findings include: Record review of Resident #35 ' s face sheet dated 12/05/2023 revealed she was [AGE] years old and was admitted to the facility on [DATE]. Record review of Resident #35 ' s History and physical dated 11/17/2023 revealed the resident had diagnoses including high blood pressure (hypertension), diabetes, stroke, neuropathy (weakness, numbness and pain from nerve damage) damage to and stroke. She was receiving 2 MG of risperidone (an antipsychotic)…

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 that food and drink that is palatable, for one (pureed enchiladas) of three pureed food items reviewed for palatability, in that: Pureed enchiladas lacked flavor found in regular texture enchiladas. This failure puts residents who receive pureed foods at risk of dissatisfaction with food and decreased desire to eat. Findings include: Observation of puree meal trays on 12/05/2023 at 12:40 PM revealed that most of the food on some puree trays on tray carts had not been eaten. Observation on 12/06/2023 at 12:10 PM by three surveyors of puree and regular texture test trays containing enchiladas, rice and beans revealed that the puree enchiladas lacked the chili flavor of the regular texture enchiladas. In an interview and observation on 12/06/2023 at 12:24 PM the Administrator sampled enchiladas, rice and beans from puree and regular texture meals. He was observed to have pursed his lips and squinted his eyes and said the pureed enchiladas and pureed rice did not taste the same as the regular texture…

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

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for professional standards for food service safety. The following were observed: -1 flat of raw pasteurized in-shell eggs with four cracked eggs stored over another flat of eggs. -1 opened, unsealed package of aged Mexican cheese with a date opened label of 10/27/2023 without facility use by date and manufacturer best by date of 12/01/2023. These failures could place residents at risk of food-borne illness. Findings included: Interview and observation on 12/05/2023 at 8:06 AM with [NAME] O revealed a case of pasteurized in-shell eggs in which two flats of eggs remained. The first remaining flat of eggs was observed to contain four cracked eggs and to be stored on top of stored over another flat of eggs. The cook said the broken eggs would need to be thrown away. An open bag of aged Mexican cheese with a date of 10/27/2023 written on it in marking pen was observed. [NAME] O…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 of 24 (Resident #44, Resident #35) residents reviewed for infection control -The facility failed to ensure Resident #44 who was in isolation precautions for Covid-19, door was closed. -The facility failed to ensure that Resident #35 was placed in an isolation room when she returned from the hospital with diagnosis of COVID-19. These deficient practices could place residents at risk for infection due to improper care practices. Findings include: Resident #44 Record review of Resident #44 ' s face sheet dated 12/07/2023 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #44 ' s history and physical dated 09/25/2023 revealed diagnoses of hepatic steatosis (increased buildup of fat…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews the facility failed to ensure the residents has the right to be informed of the risks and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or options he or she preferred, for 1 of 8 (Resident #69) reviewed for resident rights. The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available for Resident #24's prior to placing wander guard bracelet on. This failure placed residents at risk of unnecessary restriction of their freedom of movement and diminished quality of life. Findings include: Record review of Resident #69's face sheet dated 12/05/2023 revealed a [AGE] year-old male who was admitted on [DATE]. Record review of Resident #69's history and physical dated 08/03/2023 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to promote and facilitate resident self-determination through support of resident choice for 1 of 8 (Resident #69) residents reviewed for physical restraints. The facility failed to remove a wander guard bracelet from Resident #69 although the resident was not at risk of elopement and requested its removal numerous times. This failure placed residents at risk of unnecessary restriction of their freedom of movement and diminished quality of life. Findings include: Record review of Resident #69's face sheet dated 12/05/2023 revealed a [AGE] year-old male who was admitted on [DATE]. Record review of Resident #69's history and physical dated 08/03/2023 revealed diagnoses of chronic kidney disease stage 4 (last stage before kidney failure), hypertension (defined as blood pressure above 140/90, and is considered severe if the pressure is above 180/120), and peripheral artery disease (narrowing or blockage of the vessels that carry blood from the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents have the right to receive visitors of his or her choosing at the time of his or her choosing for 1 of 10 (Resident #25) residents reviewed for residents' rights. The facility failed to ensure Resident #25 had the right to receive visitors inside the facility. This failure placed residents at risk of isolation, decreased emotional well-being, and diminished quality of life. The findings include: Record review of Resident #25's face sheet dated 12/07/2023 revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Record review of Resident #25's history and physical dated 03/30/2023 revealed diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that a resident with urinary incontinence received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #21) of 12 residents reviewed for urinary catheters. The facility failed to follow physician ' s orders to change Resident #21 ' s urinary catheter. This failure could result in an increased risk for urinary tract infections. Findings include: Record review of Resident #21 ' s face sheet dated 12/06/2023 revealed he was [AGE] years old and was initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included obstructive and reflux uropathy (blockage causing urine to back up into the kidneys), cystitis with hematuria (inflammation of the bladder with blood in the urine), and urinary tract infections. Record review of Resident #21 ' s history and physical dated 10/27/2022 revealed he had diagnoses including end-stage renal disease…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services for 1 of 2 residents (Resident #70) reviewed for enteral feeding. -The facility failed to ensure Resident #70 ' s enteral feeding bag label had the date and time the administration of the feeding was begun, the rate of administration, and the initials of who had hung the feeding container. This failure could place residents receiving enteral feedings at risk of insufficient nutritional supplementation and possible weight loss. Findings include: Record review of Resident #70 ' s face sheet dated 12/06/2023 revealed an [AGE] year-old female with an initial admission date to the facility of 10/26/2023 and re-admission date of 12/04/2023. Record review of Resident #70 ' s History and Physical dated 11/29/2023 revealed a diagnosis of oropharyngeal dysphagia with a PEG tube. It also showed she was receiving tube feedings. Record review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 (Resident #289) of 3 residents observed for oxygen management. 1. The facility failed to ensure Resident #289 had an oxygen order for oxygen being administered 2. The facility failed to ensure Resident #289 did not ensure his room had an oxygen sign outside the room. This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and at risk of harm and exposure to a fire hazard if staff and visitors are not aware of oxygen present. Findings include: Record review of Resident #289 ' s face sheet dated 12/08/2023 revealed a [AGE] year-old male with an admission date to the facility of 11/30/2023. Record review of Resident #289 History and Physical dated 11/22/2023 revealed a diagnosis of COPD exacerbation while receiving oxygen therapy. Record review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, 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 #17) of 10 of residents reviewed for call light button placement. The facility failed to ensure that Resident #17 ' s call light was within their reach. This failure put residents at risk of not being able to call for assistance when needed. Findings included: Review of Resident #17 ' s face sheet dated 10/10/2023, revealed a [AGE] year-old female admitted to the facility on [DATE]. Review of Resident #17 ' s history and physical dated 03/29/2023 reflected Resident #17 diagnoses included: myopathy (any disease that affects the muscles that control voluntary movement in the body), need for assistance with personal care, anxiety disorder (mental health disorder characterized by feeling of worry, anxiety, or fear that are strong enough to interfere with one ' s daily activities), Bell ' 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 develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident medical and nursing needs and described the services to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 (Resident #3) of 6 residents reviewed for care plans in that: - The facility failed to follow the comprehensive person-centered care plan for risk of falling by keeping bed brakes locked for Resident #3. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services as indicated in their comprehensive person-centered plans developed to address their needs. Findings include: Resident #3 Review of Resident #3's face sheet dated 10/05/2023, revealed Resident #3 was admitted to the facility on [DATE]. Review of Resident #3's History and Physical dated 09/21/2023, revealed 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 a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #16) of 3 residents reviewed for foley catheter. -The facility failed to ensure Resident #16'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: Review of Resident #16's face sheet, dated 10/10/2023, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #16's History and Physical dated 11/18/2022, revealed Resident #16 diagnoses included cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it.), hemiplegia affecting right dominant side (paralysis of one side of the body), history urinary tract…

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

Based on the 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 hairnets. The Dietary Manager did not wear a hair net when entering the kitchen on 10/5/23. This failure could affect residents by placing them at risk of food borne illness. Findings include: Observation on 10/05/23 at 10:30 AM revealed Dietary Manager was in the kitchen near the dish area talking to Interim Administrator with no hair net on exposing her hair. Interview on 10/05/23 at 10:35 AM with the Dietary Manager stated any staff going beyond the dish room door and kitchen entrance were going inside, the facility de, the facility ar a hairnet. The Dietary Manger stated she was inside the kitchen area near the dish room not wearing the hair net. The Dietary Manager stated hairnets hold a staff ' s hair and the hair needed to be inside the hair net. The Dietary Manager stated the risk of not having a hairnet on could be the hair falling into the food. The Dietary…

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 were maintained on each resident that were accurately documented for 2 of 6 residents (Resident #14 and Resident #5) reviewed for medical records. The facility failed to ensure Resident #14 ' s record accurately documented behavioral monitoring for Resident #14 ' s behaviors. Resident #5 had a resident to resident altercation in which it was not accurately documented in her progress notes of the incident. This failure could place residents at risk of having incomplete and inaccurate records with the risk of not receiving potential needed services. Findings include: Resident #14 Record review of Resident #14 ' s face sheet dated 10/06/23 revealed admission on [DATE] to the facility. Record review of Resident #14 ' s history and physical dated 11/18/22 revealed an [AGE] year-old male diagnosed with diabetes and Alzheimer ' s disease. Record review of Resident #14 ' s quarterly MDS assessment dated [DATE] revealed a brief interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 (Gray Bin) of 2 bin containers and 2 (Residents #16 and #20) of 4 residents reviewed for infection control in that: - One gray bin container full of trash and adult briefs was left open and had a foul odor coming out from it. - Resident #16's and Resident #20's catheter bags were on the floor and not contained. These deficient practices could place residents at risk for infection due to improper care practices and cross contamination. Findings included: One Gray Bin Container Observation on 10/09/23 at 1:39 PM in hallway 300 revealed there was a gray bin container with the lid uncovered. A foul odor was coming out from the bin and it was noticed that there were garbage bags that contained dirty briefs. Unknown Resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the residents receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident ' s comprehensive assessment and plan of care. for 2 (Resident #65 and Resident #13) of 7 reviewed for call light placement. The facility failed to ensure Resident #65 and Resident #13 had call lights within reach. This failure could have placed residents at risk for needs not been met. Findings included: Record review of Resident #65 face sheet dated 10/14/22 revealed a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #65 history and physical dated 4/25/22 revealed diagnoses of dementia and epilepsy (seizure disorder). Record review of Resident #65 quarterly care plan dated 9/15/22 revealed Resident #65 is at risk for falling; approach- keep call light in reach at all times. 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 provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for 2 (Resident #47 and Resident #267) out of 7 residents reviewed for positioning and transfers and 1(Resident #66) out of 6 residents reviewed for intravenous lines in that: A. The facility failed to ensure Resident #47 was repositioned by using a gait belt or two-person physical assist. B. The facility failed to use the proper transferring techniques when providing care for Resident #267 on [DATE]. C.The facility failed to change Resident #66 PICC line dressing within 7 days . This failure could place residents requiring extensive assistance with ADLs at risk for more than minimal physical harm. The finding included: Record review of Resident # 47 face sheet dated [DATE] revealed a [AGE] year-old male admitted to facility on [DATE] and readmitted on [DATE]. Record review of Resident # 47…

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, the comprehensive person-centered care plan, the residents' goals and preferences for 2 (Resident #3 and Resident #44) of 7 reviewed for respiratory care. A. The facility failed to ensure Resident #3 nebulizer mask was kept in a bag while not in use. B. The facility failed to ensure Resident #44 nasal cannula was kept in a bag while not in use. These failures could have placed residents at risk for infections and transmission of communicable diseases. Findings included: Record review of Resident # 3 face sheet dated 10/13/22 revealed a [AGE] year-old female admitted on [DATE]and readmitted to facility on 11/1/19. Record review of Resident # 3 history and physical dated 12/21/21 revealed a diagnosis of chronic obstructive pulmonary disease (a lung disease that block airflow and make it difficult to breathe). 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 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 residents for 4 residents (Resident #17, #118, #66 and #267) of 8 reviewed for medication administration, failed to ensure that medications and supplies were not expired for 2 of 2 medication storage rooms reviewed for expired medications and failed to keep drug records to account of all controlled drugs to be maintained and periodically reconciled for 1 (100 hallway) out of 4 narcotic count sheets reviewed for controlled medications in that: Residents #17 and #118 were administered blood pressure medications although their blood pressures or pulse were too low. Resident #66 was given IV medication at the wrong rate and not per physician order. Resident #267 was given a medication without being told what medication it was before administration. Medication…

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

Based on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for dietary services. Food in the Freezer were open and unsealed properly. Food in the refrigerator were open and unsealed properly. Foods in the Dry Food Storage were open and unsealed properly. Dry Food Storage had items with accumulation of dust, encrusted grease deposits and other soiled accumulations. Food prep areas had items with accumulation of dust, encrusted grease deposits and other soiled accumulations. The refrigerator and Freezer logs did not have a temperature recorded for the dated of 10/10/22 The test strips used to test the chlorine level in the dishwasher were expired. Resident who received a food tray on 10/10/22 for breakfast did not have food temperatures taken to monitor a safe and appetizing temperature. This failure places residents who eat food prepared by the facility at risk of foodborne illnesses. Findings include: During the initial observation 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.

Based on observation, interview and record review the facility failed to dispose of garbage and refuse properly for 1 out of 1 kitchen observed. The facility failed to properly contain garbage in the kitchen, by using garbage cans with a lid that has a hole cut in the middle for easy access. This deficient practice posed a sanitary and safety hazard which could result in the attraction of vermin and rodents and affect all residents who ate food from the kitchen exposing them to germs and diseases carried by vermin and rodents. Findings included: Observation on 10/10/22 at 08:43 AM during initial kitchen observation revealed the facility uses garbage cans containers with lids that have a hole cut into the middle in the kitchen area and in the area where the dishwasher is located. Further observation revealed there was food waste and trash inside the containers. During an interview on 10/14/22 at 10:47 AM, the Dietary Manager confirmed they were using garbage receptacles that were not properly sealed in the kitchen and area with the dishwasher. The Dietary Manager also confirmed they…

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 residents self-determination through support of resident choices for 1 out of 1 resident reviewed. Resident #44 was given showers on a schedule that disregards her preferences, if Resident #44 was not present for her the facility scheduled shower time Resident #44 was not showered until the next facility scheduled date. This failure could place residents at risk for a decline in health due to loss of self-determination. Findings included: Record review of Resident #44 face sheet dated 10/12/22 revealed a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #44 physician orders dated 06/19/22 revealed Resident #44 an order for baths to be given on Tuesday, Thursday, and Saturday from 2-10 PM. according to Resident #44 preference. Record review indicated LVN I documented on 09/20/22 and 09/22/22 that Resident #44 bathing task not done, the resident receives showers in the AM. Record review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid including referring residents with newly evident or possible serious mental disorder for level II resident review upon a significant change in status assessment for one (Resident #15) of one resident reviewed for PASARR. Resident #15 was admitted to a behavioral health unit because of behaviors and returned with a new psychiatric diagnosis and medication but a new PASARR screen was not conducted. This failure could put residents at risk of not receiving specialized services that may help them attain and/or maintain their highest practicable level of psychosocial functioning. Findings include: Record review of Resident #15's Face Sheet dated 10/10/2022 documented in part that she was [AGE] years old and was admitted to the facility 10/27/2021. Her diagnoses included Unspecified dementia, unspecified severity, without behavioral disturbance,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition for 1 (Resident #44) of 1 resident reviewed Resident #44 routinely misses breakfast due to the facility not assisting Resident #44 out of bed to a sitting position. This failure could place residents at risk for weight loss and choking hazards. Findings included: Record review of Resident #44 face sheet dated 10/12/22 revealed a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #44 care plan revealed Resident #44 was on a Renal Diet and is at risk for malnutrition and/or dehydration. Resident #44 care plan has documented discomfort related to gastric reflux disease, with the intervention of encouraging the resident to not lie down after eating for 1-3hrs. depending on the severity of reflux. Resident #44 meal intake documentation revealed resident had 10 meals in a month period…

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 residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs in 1 (Resident # 56) of 2 residents reviewed for unnecessary medications in that: Resident #56 did not receive GDR for antipsychotic medication she had been receiving for more than 6 months. This failure could cause the resident to have side effects from medication causing a decline in health. Findings included: Record review of face sheet for Resident #56 revealed an [AGE] year-old female with an admission date of 01/29/21. Resident #56 had a diagnosis of Psychotic disorder with delusions and Disruptive mood dysregulation disorder. Record review of History and Physical dated 01/29/21 showed Resident #56 had major depressive disorder. Record review of Psychiatric assessment dated [DATE] showed Resident #56 was being treated for Major depressive disorder and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain medical records on each resident that are accurately documented for 1 (Resident #67) of 7 residents reviewed for physician orders. The facility failed to ensure Resident #67 full code physician order was updated when DNR was signed. This failure could have placed residents at risk for advance directives not been followed. Findings included: Record review of Resident #67 face sheet dated [DATE] revealed an [AGE] year-old female admitted to facility on [DATE]. Record review of Resident #67 electronic physician order dated [DATE] with end date of [DATE] revealed resident was a full code. Record review of Resident #67 OOH- DNR order dated [DATE] revealed it had been signed by two witnesses on [DATE] and signed by MD on [DATE]. Record review of Resident #67 Palliative Care Form dated [DATE] revealed attending physician and responsible party had signed the form on [DATE]. Record review of Resident #67 progress note dated [DATE] revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 (Resident #300) of 6 residents reviewed for infection prevention. The facility failed to discard Resident #300 soiled briefs. This failure could have placed residents at risk for odors, infections and transmission of communicable diseases. Findings included: Record review of Resident #300 face sheet dated 10/11/22 revealed an [AGE] year-old female admitted to the facility on [DATE]. Observation on 10/10/22 at 10:26 AM Resident #300 was in her room, residents' room had a foul odor. Upon entering the room found a used soiled brief in the trash can and another used soiled brief next to her nightstand on the floor. Observed resident, she is able to self-transfer and goes to the bathroom on her own only requires stand-by supervision. CNA C was observed going into the room after and disposing of the dirty soiled brief that was in the trash can, stated she forgot to dispose…

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.