Mountain View Health & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for 1 resident (Residents #63) of 6 residents reviewed for care plans.The facility failed to have a comprehensive person-centered care plan for Resident #63 by showing a resolved wound as active.These failures could affect residents and put them at risk for not receiving care and services to meet their needs.Record review of Resident #63's admission Record dated 03/26/2026 revealed a [AGE] year-old female with admission date 11/07/2025.Record review of Resident #63's History and Physical dated 03/06/2026 revealed a medical history of Type II Diabetes Mellitus (a chronic condition that happens when the body cannot use insulin correctly and sugar builds up in the blood).Record review of Resident #63's Quarterly MDS dated [DATE] revealed a BIMS score of 11, indicating…

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, 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 1 of 4 residents ( Resident #40) reviewed for ADL care.- The facility failed on 3/24/2026 to ensure Resident #40's fingernails were trimmedThis failure could place residents who required assistance with ADLs at risk for unmet care needs.Findings include:Resident #40Record Review of Resident #40's admission Record dated 03/26/2026 revealed a [AGE] year-old female with an initial admission date of 01/12/2023 and a readmission date of 10/13/2025.Record review of Resident #40's History and Physical dated 03/05/2026 revealed a diagnosis of a cerebral vascular accident (blood flow to a part of the brain is interrupted or reduced) and chronic vegetative state.Record review of Resident #40's Quarterly MDS dated [DATE] revealed no BIMs score. Section GG revealed personal…

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, interview, and record review, the facility failed to ensure that resident receive proper treatment and care to maintain mobility and good foot health for 1 of 1 residents (Resident #119) reviewed for foot care.The facility failed on 3/24/2026 to ensure Resident #119's toenails were trimmedThis failure could place residents who required specialized foot care at risk for unmet care needs, infections, and health complications.Resident #119Record review of Resident #119's face sheet dated 3/26/2026 revealed a [AGE] year-old female with an original admission date on 04/01/2020 and a readmission date on 11/13/2023.Record review of Resident #119's quarterly MDS dated [DATE] revealed the resident had a BIMS score of 15 indicating the resident was cognitively intact. Section GG - Functional Abilities revealed the resident could not complete lower body dressing, personal hygiene, oral hygiene, upper body dressing, putting on/removing footwear, and transfers due to medical conditions or safety…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review the facility failed to ensure the resident's environment remained as free of accident hazards as was possible for 1 of 7 residents (Resident #123) reviewed for Accidents-the facility failed from 03/24/2026 to 03/26/2026 to ensure Resident #123 did not have a mini fridge resting on top of a wobbly table.This failure placed the resident at risk for injury from a foreseeable and avoidable hazard.Findings include:Record review of Resident #123's face sheet dated 03/26/2026 revealed a [AGE] year-old female with an original admission date on 08/03/2021 and a readmission date on 02/16/2023.Record review of Resident #123's Quarterly MDS dated [DATE] revealed BIMS score of 14 indicating cognitively intact. Revealed under Section GG-Functional Abilities the resident utilized a manual wheelchair for mobility needs. Under section I- Active Diagnoses, the resident was coded for muscle wasting and atrophy in multiple sites, unsteadiness on feet, and other abnormalities of…

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

Based on observation and interview the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 of 4 medication carts (500 Hall nurse cart) reviewed for cleanliness.The facility failed to ensure bottles of liquid medication (milk of magnesia and lactulose), stored in medication cart on the 500 hall did not have dried drippings on the sides of the bottles.This failure could affect residents by placing them at risk of cross contamination. The findings included:An observation of the medication cart in the 500 hall and interview on 03/26/2026 at 11:50p.m., with LVN I revealed medication 1 bottle of lactulose, and one bottle of milk of magnesia to have dried drippings on the side of the bottles. [NAME] colored spots were observed on the side of the medication drawer and on the lids of one bottle of MiraLAX, and 3 bottles of lactulose. LVN I stated that medication bottles were to be cleaned after each use. He stated the bottles could be wiped down with the wipes available in the cart. He stated that it 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 observations, interviews, and record reviews the facility failed to provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals for 1 of 8 (Residents #12) residents reviewed for special eating equipment.-The facility failed to provide Resident #12's physician ordered cup with lid for drinking fluids on 03/24/2026, 03/25/2026 and 03/26/2026.This failure could place residents at risk for harm by weight loss, diminished independence, and self-esteem.Findings included:Record review of Resident #12's admission Record dated 03/26/2026 revealed a [AGE] year-old male with an original admit date of 06/03/2021 and a readmission date of 12/08/2025.Record review of Resident #12's History and Physical dated 12/08/2025 revealed a diagnosis of chronic schizophrenia (mental disorder characterized by disruptions in though process), and polyneuropathy(neurological condition characterized by numbness,…

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 care plan for each resident that includes the instructions needed to provide effective and person-centered care of the residents that meet professional standards of quality care for 6 (Residents #1, #2, #3, #7, #8 and #9) of 14 residents reviewed for care plans and assessments. -The facility failed to conduct a safety smoking assessment for Residents 1, 2, 3 and 8. -The facility failed to update Residents 1, 2, 3 and 8's care plans to include they smoked and were able to safely smoke. These failures could place residents at risk of not having care needs met regarding smoking supervision which could result in health complications.Findings included: 1. Record review of Resident #1's face sheet, dated 02/13/2026, revealed a [AGE] year-old male admitted [DATE] and readmitted [DATE]. Record review of Resident #1's history and physical, dated 01/26/2026, revealed a social history of daily tobacco use. The assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents choices for 7 (Residents #1, #2, #3, #5, #7, #8 and #9) of 14 residents reviewed for quality of care. The facility failed on 02/12/2026 to ensure CNA C communicated to the Charge Nurse or DON of Resident #5's fall.This failure could place residents at risk of not having care needs met, which could result in health complications.Findings included: Resident #1: Record review of Resident #1's face sheet dated 02/13/2026 revealed a [AGE] year-old male with an initial admission date of 03/31/2022 and readmitted on [DATE]. Record review of Resident #1's history and physical dated 01/26/2026 revealed a social history of daily tobacco use. The assessment included Osteomyelitis with Amputation of 3rd Toe Right Foot (bone infection requiring removal of toe), Hypertension (high blood pressure), Dyslipidemia…

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 residents' environment remained as free of accident hazards as was possible and each resident received adequate supervision to prevent accidents for 5 (Resident #1, Resident #2, , Resident #8, Resident #7 and Resident #9) of 14 residents reviewed for smoking safety. -The facility failed to conduct a safe smoking assessment for Resident #1.-The facility failed to update Resident #2's care plan for smoking.-The facility failed to ensure Resident #7 had cigarettes in his room. -The facility failed to ensure Resident #8 had a safe smoking assessment and a care plan for smoking.-The facility failed to ensure Resident #9 had a cigarette lighter in his room.-The facility failed to assess and supervise residents who smoked.Findings included: Record review of Resident #1's face sheet, dated 02/13/2026, revealed a [AGE] year-old male with an initial admission date of 03/31/2022 and readmitted on [DATE]. 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 interview and record review, the facility failed to ensure the resident's right to make choices regarding aspects of his daily life, including beverage preference, for 1 of 6 residents reviewed for resident rights (Resident #6). The facility failed to honor Resident #6's wishes by not providing him with the beverage of his choice.Findings included: Record review of Resident #6's admission Record, dated 05/24/2025, revealed an [AGE] year-old male admitted [DATE] and readmitted [DATE]. Record review of Resident #6's History and Physical, dated 05/27/2025, revealed diagnoses including vascular dementia (decline in thinking ability due to reduced blood flow to the brain), type 2 diabetes mellitus (chronic condition affecting blood sugar control), hypertension (high blood pressure), chronic systolic congestive heart failure (condition where the heart does not pump blood effectively), chronic obstructive pulmonary disease (long-term lung disease causing breathing difficulty), seizure disorder (episodes 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, interviews, and record review, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing and prevent infections for 1 of 2 (Resident #2) residents reviewed for quality of care.The facility failed on 11/17/2025 to ensure the pressure ulcer on Resident #2's right glute was covered with a dressing as ordered.This deficient practice could affect residents who receive wound care treatments by placing them at risk for receiving inadequate treatments resulting in the worsening of the wounds. The findings included: Record review of Resident #2's face sheet dated 11/17/25 revealed a [AGE] year-old male with an admission date of 1/5/25.Record review of Resident #2's History and Physical dated 6/19/25 revealed the resident had a diagnosis of chronic right gluteal pressure ulcer (an injury to the skin and underlying tissue over the buttocks (gluteal area) caused by prolonged…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #2) of 2 residents reviewed for infection prevention and control. LVN J and CNA K failed on 11/17/25 to use PPE (special equipment that protects the wearer's body from infection) during wound care for Resident #2 as the resident was on EBP.LVN J and CNA K failed on 11/17/25 to wash their hands prior to having contact with the resident. These failures could place residents at risk of infections, cross contamination, secondary infections, tissue breakdown, and communicable diseases. Findings include:Record review of Resident #2's face sheet dated 11/17/25 revealed a [AGE] year-old male with an admission date of 1/5/25.Record review of Resident #2's History and Physical dated 6/19/25 revealed the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 10 residents (Resident #4) reviewed for infection prevention and control. 1. The facility failed to implement precautions and interventions after Resident #4 was sent out to the hospital for isolation due to a positive AFB (a type of bacteria causing tuberculosis) to ensure there was no spread of infection or disease. These failures could place residents at risk for infections, secondary infections, communicable diseases due to improper care practices.Findings include: Record review of Resident #4's face sheet, dated 09/03/25, revealed an admission date of 07/15/24 and re-admission on [DATE] to the facility. Record review of Resident #4's hospital history and physical. dated 08/18/25, revealed a [AGE] year-old…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a notice of rights and services were provided to residents prior to or upon admission and during the resident's stay and ensure receipt of such information, and amendments to it were acknowledged in writing for 1 of 3 Residents (Resident #1) reviewed for Resident Rights. The facility failed to provide Resident #1 with an admission packet and notice of Resident Rights upon admission. This deficient practice could place residents at risk of not being aware of their rights, responsibilities, and the facility's policies.The findings were:Record review of Resident #1's face sheet, dated 09/03/25, revealed [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #1 was diagnosed with psychoactive substance abuse (the harmful or excessive use of substances that alter brain function and affect mood, behavior, and cognition), traumatic brain injury (an injury to the brain caused by an external physical force, such…

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 establish and implement admission policies for 1 of 3 residents (Resident#1) reviewed for admission. The facility failed to ensure Resident #1 and/or Resident #1's family members completed a signed admission agreement upon admission to the facility on [DATE]. This deficient practice could place residents at risk of not being made aware of their rights, the facility characteristics and services provided by the facility or policies of the facility. The findings include:Record review of Resident #1's face sheet, dated 09/03/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #1 had diagnoses which included psychoactive substance abuse (the harmful or excessive use of substances that alter brain function and affect mood, behavior, and cognition), traumatic brain injury ( an injury to the brain caused by an external physical force, such as a blow, hit, fall, or car accident), traumatic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the resident and the resident's representative(s) of the a transfer or discharge were notified and the reasons for the move were in writing and in a language and manner they understood and a copy of the notice was sent to the a representative of the Office of the State Long-Term Ombudsman and the notice of transfer or discharge required was made by the facility at least 30 days before the resident was transferred or discharged for 1 of 3 residents (Resident #1) reviewed for discharges. 1. The facility failed to provide a 30-day written discharge notice to Resident #1 and/or Resident #1's Responsible Party when he was discharged on 08/10/25. 2. The facility failed to provide the Ombudsman with a notification of Resident #1's discharge on [DATE]. This failure could place residents at risk of improper discharges which could result in experiencing psychosocial harm due to inappropriate discharges and place residents at risk of being discharged…

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 #5) of 3 residents reviewed for foley catheter. The facility failed ensure Resident #5's indwelling catheter bag was kept from touching the floor. This deficient practice could place residents with indwelling catheters at risk of disease and infection. Findings included:The facility failed to ensure on Resident #5's catheter bag was hooked on his bed instead of lying on the facility floor, on 09/03/25.Record review of Resident #5's face sheet, dated 09/03/25, revealed an admission date of 04/09/25 to the facility. Record review of Resident #5's facility history and physical, dated 04/09/25, revealed a [AGE] year-old male. Resident #5 had diagnoses which included Diabetes Mellitus (a disease in which the body's ability to produce or respond to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed provide each resident with the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 1 of 3 residents (Resident #1) reviewed for behavioral health services.The facility failed to use the on-call psychiatric service on 08/09/25 to refer Resident #1 for psychiatric services/evaluation after showing increasing signs of behaviors, verbalized suicidal ideation, physical aggression, and agitation on 08/09/25. This deficient practice could place residents at risk of not maintaining a sense of well-being that could affect their health. The findings were:Record review of Resident #1's face sheet, dated 09/03/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #1 had diagnoses which included psychoactive substance abuse (the harmful or excessive use 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, interviews and record reviews, the facility failed to implement policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety for 4 (Resident #1, Resident #2, Resident #3 and Resident #4) out of 10 residents reviewed for smoking.The facility failed to implement their smoking policy by allowing Resident #1, #2, #3, and #4, to smoke indoors in an undesignated smoking area on 08/07/25.This failure could place residents who smoke at risk of physical harm and lead to an unsafe smoking environment.Findings include:Resident #1Record review of Resident #1's face sheet dated 08/11/25 revealed resident was a [AGE] year-old female with an original admission date 01/30/25, and re-admission date 05/10/25.Record review of Resident #1's admission MDS dated [DATE], revealed a BIMS score of 12, which indicated moderate cognitive impairment. MDS revealed resident used tobacco.Record review of Resident #1's care plan 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 implement written policies and procedures that prohibit and prevent neglect of residents, and failed to establish policies and procedures to investigate such allegation for 1 of 9 residents (Residents #1) reviewed for neglect. The facility failed to ensure the Administrator followed the facility's abuse/neglect policy, by not completing an investigation and reporting an allegation of neglect involving Resident #1. The Hospice Aide failed to transfer Resident # 1 on 04/23/25 with a Mechanical lift and two-person assistance that resulted in a fall. The resident sustained a 2 cm laceration to the right side of the forehead and a dense fracture of C1 and C2 (a broken bone in the neck, specifically on second vertebra, breaks at its base). These failures could place residents at risk of not being provided services to meet their needs. Findings include: Record review of Resident #1's admission Record, dated 04/29/2025, revealed a [AGE] year-old…

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 evidence that all alleged violations of abuse, neglect, exploitation, or mistreatment are throughly investigated to prevent further potential while the investigation is in progress for 1 of 9 residents (Residents #1) reviewed for neglect. The facility failed to ensure the Administrator followed the facility's abuse/neglect policy, by not completing an investigation and reporting an allegation of neglect involving Resident #1. The Hospice Aide failed to transfer Resident # 1 on 04/23/25 with a Mechanical lift and two-person assistance that resulted in a fall. The resident sustained a 2 cm laceration to the right side of the forehead and a dense fracture of C1 and C2 (a broken bone in the neck, specifically on second vertebra, breaks at its base). These failures could place residents at risk of not being provided services to meet their needs. Findings include: Record review of Resident #1's admission Record, dated 04/29/2025, 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 implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents for 1 of 7 (Resident #2) residents reviewed for abuse. The facility failed to immediately suspend LVN A after Resident #2 reported that one nurse matched the description provided by the Resident #2. This failure could place residents at risk of abuse by not immediately following the facility abuse policy and procedure manual of taking the necessary measures to protect residents from harm during and following an abuse, neglect, exploitation, mistreatment of resident's investigation. Findings included: Record review of Resident #2's face sheet dated 04/24/25, revealed, admission on [DATE] and re-admission on [DATE] to the facility. Resident #2 was a [AGE] year-old male diagnosed with pulmonary hypertension (high blood pressure that affects the arteries in the lungs and the right side of the heart) and Cor Pulmonale…

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 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 2 (DON & ADON) of 2 staff reviewed for reporting. The DON and ADON failed to immediately report to the Administrator that Resident #9 was missing $50 so that the Administrator could report it to the state agency. This failure could place residents at risk for exploitation and/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 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 2 residents (Resident #49 and #68) of 22 residents reviewed for call light placement. The facility failed to ensure call light was placed within reach for Resident #49 and Resident #68 This failure places residents at risk of having needs unmet when they are unable to contact staff. Findings included: Record review of Resident #49's admission Record, dated 12/18/2024, reflected a [AGE] year-old female admitted on [DATE]. Record review of Resident # #49's Hospital History and Physical dated 11/14/23, revealed diagnoses of traumatic brain injury resulting in cognitive impairment, schizoaffective disorder, delusions, hypertension, and cognitive communication deficit. Record review of Resident #49's Annual MDS assessment dated [DATE], revealed a BIMS score of 3 demonstrating she was cognitively…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents had the right to have reasonable access to the use of a telephone and a place in the facility where calls can be made without being overheard for 2 of 22 (Resident #63 and #94) residents reviewed for telephone use. The facility failed to provide a place for Resident #63 and Resident #94 to make telephone calls without being overhead. This failure could place residents at risk of conversations being overheard and privacy rights not being respected. The findings included: Record review of Resident #63's admission Record, dated 12/18/2024, reflected a [AGE] year-old female admitted on [DATE] and re-admitted on [DATE]. Record review of Resident # 63's Hospital History and Physical dated 4/11/24, revealed diagnoses of Type 2 diabetes, hypertension, schizoaffective disorder. Record review of Resident # 63's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 14 demonstrating she was cognitively intact. 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.

Resident #63 Privacy 12/18/24 09:55 AM Record Review of the facility's P&P 5. The resident has the right to have reasonable access to the use of a telephone, including TTY and TDD services, and a place in the facility where calls can be made without being overheard. This includes the right to retain and use a cellular phone at the resident’s own expense. Resident #94 Privacy

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, in that: Dietary Aide G used a pitcher that had been placed in an uncleaned black cart and proceeded to refill it with tea by using the pitcher to scoop tea from the tea container before pouring it into cups. This failure could place residents who received drinks from the kitchen at risk for food borne illness. Findings included: Observation on 12/18/24 at 9:31 am revealed Dietary Aide G used a pitcher to serve tea by placing it inside the premade tea container to fill it with tea, and then poured the tea into cups. Dietary Aide G then placed the pitcher on the clean prepping table. Observation on 12/18/24 at am, Dietary Aide G placed the pitcher on a black cart next to the prepping table. Observation on 12/18/24 at 9:41 am, Dietary Aide G grabbed the pitcher from the black cart and proceeded to refill it with tea by using the pitcher to scoop tea from the tea container before…

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 FACILITY Infection Control Resident # 9 [NAME] TB 2 Step Mantoux Skin Test - Step 2 05/14/2021 Negative (0 mm) System. SARS-COV-2 (COVID-19) - Dose 1 208 06/01/2022 Complete System RSV 306 12/19/2023 Complete System PPSV23 33 12/05/2023 Complete System Fluzone High-Dose 135 Not Eligible System FLUAD QUADRIVALENT 205 09/30/2024 Complete System Covid-19 Spikevax (Historical Use Only) 207 01/10/2024 Complete System Resident # 22 [NAME]: PPSV23 Refused System COVID-19 Pfizer Booster (Historical Use Only) 208 10/30/2024 Historical System FLUAD QUADRIVALENT 205 09/30/2024 Complete System Other Vaccine 216 03/04/2024 Complete System SARS-COV-2 (COVID-19) - Dose 1 208 06/01/2022 Complete System Fluzone Quadrivalent 205 09/04/2021 Complete System Influenza 197 10/05/2019 Complete System TB 2 Step Mantoux Skin Test - Step 1 98 11/02/2018 Positive System Chest X-Ray 11/02/2018 Complete System Resident # 94 [NAME] PPSV23 33 Refused System FLUAD QUADRIVALENT 205 Not Eligible System COVID-19 Pfizer Booster (Historical Use…

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 they followed professional standards of practice in accordance with physician orders and facility policy for care of midline for 1 (Residents #27) of 4 residents reviewed for parenteral and intravenous care. The facility failed to change Resident #27's PICC line dressing as ordered. This failure placed the residents at risk of complications with their midlines needed for infusion therapy. Findings included: Record review of Resident #27's face sheet dated 12/17/24 revealed an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of sepsis (an infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever), hemiplegia (paralysis that affects only one side of your body) muscle weakness, and cognitive communication deficit. Record review of Resident #27's admission MDS assessment dated [DATE] revealed BIMS of 12, his cognition was moderately…

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 8 residents (Resident #27) reviewed for pharmacy services. Resident #27 had an over the counter Selenium 200 mcg bottle and an over the counter Aspirin 81 mg bottle at his bedside. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects. Findings included: Record review of Resident #27's face sheet dated 12/17/24 revealed an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of sepsis (an infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever), hemiplegia (paralysis that affects only one side of your body), muscle weakness, and cognitive communication deficit. Record…

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

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments for 1 of 1 (treatment cart) reviewed for medication storage and security. The facility failed to ensure LVN A secured the facility's only treatment cart when it was left unattended. This failure could place residents at risk for drug diversion or accidental ingestion. Findings included: During an observation and an interview on 12/17/24 at 07:59 AM, the treatment cart was noted to be unlocked and unsupervised on hall 200. Inside the cart were several needles, dressings, and medicated ointments. Approximately 10 minutes later LVN A came out of a residents' room, and said she had stepped away and had forgotten to lock the cart. LVN A said she normally locked the cart whenever she stepped away, but that time, she had forgotten because she had to check on a resident with the doctor present. The LVN said leaving the cart open could pose a hazard to residents and leave access to other staff. During an interview on 12/19/24 at 02:24 PM, the DON was made aware 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 in accordance with professional standards of practices, the medical records on each resident were accurately documented for 1 of 8 (Resident #27) residents reviewed for accurate medical records. RN C documented he had changed Resident #27's PICC line when the task had not completed. This failure could place residents at risk for of having incomplete or inaccurate records and inadequate care. Findings included: Record review of Resident #27's face sheet dated 12/17/24 revealed an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of sepsis (an infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever), hemiplegia (paralysis that affects only one side of your body), muscle weakness, and cognitive communication deficit. Record review of Resident #27's admission MDS assessment dated [DATE] revealed BIMS of 12, his cognition was moderately impaired…

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 comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #5) reviewed for care plans. The facility failed to develop and implement a comprehensive person-centered care plan for Resident #5 who had two different transfers (two-person transfer with mechanical lift and transfer 1 person transfer) implemented at the same time. 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 #5's face sheet dated 09/05/24, revealed, admission on [DATE] and re-admission on [DATE] to the facility. Resident #5 was a [AGE] year-old male…

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 remained free of accidents and hazards as was possible and each resident received adequate supervision to prevent accidents for 1 (Resident #5) of 5 residents reviewed for accidents. The facility failed to ensure that Resident #5 who was a two-person transfer was transferred as a two-person transfer with mechanical lift instead of a one-person transfer . CNA C failed to report Resident #5 had a fall resulting in pain to nursing when Resident #5 was guided down to the floor hitting his right knee and having his left leg extended. This failure could place residents at risk of falls or injuries. Findings included: Record review of Resident #5's face sheet dated 09/05/24, revealed, admission on [DATE] and re-admission on [DATE] to the facility. Resident #5 was a [AGE] year-old male diagnosed with history of other (healed) physical injury and trauma (a serious injury to the body), repeated falls, lack of coordination…

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 were free from physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 1 of 5 residents (Resident #16) reviewed for freedom from physical restraints. -The facility failed to obtain consent, physician's order, and care plan for Resident #16's full bed rails in which the resident movements were restricted and there was no documentation the restraints were required to treat her medical symptoms. This failure could put residents at risk of unnecessary restriction of their freedom of movement (any change in place or position for the body or any part of the body that the person is physically able to control). Findings included: Record review of Resident #16's admission record dated 05/06/2024, revealed a [AGE] year-old female admitted to the facility 03/22/2024. Record review of Resident #16's H&P dated 03/28/2024, revealed a [AGE] year-old…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 7 (Resident #7) residents reviewed for Covid-19. The facility failed to ensure Resident #7's, who was isolated for Covid-19, door was kept closed. This failure could put residents at risk of exposure to Covid-19. The findings included: Record review of Resident #7's face sheet dated 5/7/24 revealed a [AGE] year-old female with diagnoses of COPD, asthma, and schizoaffective disorder. Record review of Resident #7's quarterly MDS assessment dated [DATE] revealed a BIMS score of 4, indicating her cognitive was severely impaired. Record review of Resident #7's progress note dated 5/1/24 read in part [Resident #7] tested positive for Covid-19. Room change for Covid-19 precautions. Observation on 5/6/24 at 10:11 am, 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 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 2 (Resident #16, and Resident #17) of 5 residents reviewed for quality of care. 1. The facility failed to ensure Residents #16's and #17's catheter leg strap was in place to secure the catheter. 2. The facility failed to ensure Resident #17's drainage bag was off the floor. This failure could place residents with foley catheters at risk of catheter pulling causing pain and/or infection and risk for infection due to improper care practices and cross contamination. Findings include: Resident #16: Record review of Resident #16's admission record dated 05/06/2024, revealed a [AGE] year-old female admitted to the facility 03/22/2024. Record review of Resident #16's H&P dated 03/28/2024, revealed a [AGE] year-old female with a past medical history of atrial…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 resident (Residents #9) of 10 residents reviewed for infection control. - The facility failed to ensure staff followed infection control practices of washing hands after glove use during medication administration. These deficient practices could place residents at risk for infection due to improper care practices. Findings included: Record review of Resident #8's face sheet dated 01/29/2024, revealed a [AGE] year-old female, with an admission date of 03/04/2022. Resident #8's diagnoses included: Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills and eventually the ability to carry out the simplest tasks), major depressive disorder (mood disorder that causes a persistent feeling of sadness 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 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 1 (Resident #1) of 4 residents reviewed for quality of care. 1. The facility failed to ensure Resident #1 had neurological checks done for 3 unwitnessed falls of 5 unwitnssed falls experienced by Resident #1 (2 falls on 11/29/23 and 1 on 12/11/23). 2. The facility failed to ensure Resident #1 had weekly skin assessments done for 1 of 4 weeks and failed to identify Resident #1 had scars, marks, or scabs. These failures could affect residents by placing them at risk of potential medical complications related to changes in condition. Findings included: Record review of Resident #1's face sheet, dated 12/21/23, revealed admission on [DATE], to the facility. Record review of Resident #1's facility history and physical, dated 12/01/23, revealed a [AGE] year-old male diagnosed with vascular dementia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that the assessment accurately reflected the resident's status for 1 (Resident #1) of 5 residents reviewed for accuracy of the MDS assessment. Resident #1's quarterly MDS did not accurately reflect the residents' need for the use of a mechanical lift. This deficient practice could place residents at risk of inadequate care. Findings included: Record review of Resident #1's face sheet dated 12/12/23 revealed admission on [DATE] and readmission on [DATE] to the facility. Resident #1 was a [AGE] year old female diagnosed with the presence of a left artificial hip joint, spinal stenosis (happens when the space inside the backbone is too small, , Parkinson's Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), lack of coordination (poor muscle control that causes clumsy voluntary movements), and abnormalities of gait and mobility (weakness of the hip and lower extremity muscles commonly…

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 5 residents (Resident #1) reviewed for care plans. The facility failed to develop and implement a comprehensive person-centered care plan for Resident #1 who had two different transfers (two person transfer with mechanical lift and transfer 1-2 person as needed) implemented at the same time. 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 12/12/23 revealed admission on [DATE] and readmission on [DATE] to the facility. Resident #1 was a [AGE] year old female…

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 remained free of accidents and hazards as is possible and each resident received adequate supervision to prevent accidents for 1 (Resident #1) of 5 residents reviewed for accidents. The facility failed to ensure that Resident #1 who was a two-person transfer was transferred as a two person transfer instead of a one-person transfer. This failure could place residents at risk of falls or injuries. Findings included: Record review of Resident #1's face sheet dated 12/12/23 revealed admission on [DATE] and readmission on [DATE] to the facility. Resident #1 was a [AGE] year old female diagnosed with presence of left artificial hip joint, spinal stenosis (happens when the space inside the backbone is too small, Parkinson's Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), lack of coordination (poor muscle control that causes clumsy voluntary movements),…

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 #2) of 5 residents observed for oxygen management. 1. Resident #2 was receiving oxygen, as needed, without a physician's orders. 2. Resident #2's oxygen tank was empty as it was marked red. This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health. Findings included: Record review of Resident #2's face sheet dated 12/12/23 revealed admission on [DATE] to the facility. Record review of Resident #2's hospital history and physical dated 01/29/23 revealed an [AGE] year-old female diagnosed with coronary artery disease (plaque buildup in the wall of the arteries that supply blood to the heart), hypertension (when the pressure in your blood vessels is too high), and deep vein thrombosis (A blood clot in a deep vein of the leg,…

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 of 5 residents (Resident #2) reviewed for infection control. Resident #2's nasal cannula was hanging on the back of her wheelchair unbagged. These deficient practices could place residents at risk for infection due to improper care practices. Findings included: Record review of Resident #2's face sheet dated 12/12/23 revealed admission on [DATE] to the facility. Record review of Resident #2's hospital history and physical dated 01/29/23 revealed an [AGE] year-old female diagnosed with coronary artery disease (plaque buildup in the wall of the arteries that supply blood to the heart), hypertension (when the pressure in your blood vessels is too high), and deep vein thrombosis (A blood clot in a deep vein of the leg, pelvis, 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 residents had the right to be treated with respect and dignity, including the right to be free from any physical restraints imposed for purpose of discipline or convenience, and not required to treat the resident ' s medical symptoms for 6 (Resident #63, Resident #86, Resident #21 Resident #183, Resident #20, and Resident #53) of 6 reviewed for physical restraints in that: The facility failed to obtain consent for Resident #63, Resident #86, or Resident #20 to have bolsters placed on the bed. The facility failed to obtain a physician ' s order with medical indications for bolsters to be placed on the bed for Resident #63, Resident #20 or Resident #21. The facility failed to assess Resident #86 for the need for bolsters. The facility failed to obtain physician ' s order for Resident #183 to have bolsters. The facility failed to obtain physician order for Resident #53 to have bolsters. This failure placed residents at risk of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure the assessment accurately reflected the resident ' s status for 7 (Resident #20, #31, #63, #86,#21 and #183) of 39 residents reviewed for accuracy of MDS assessments. -The facility failed to ensure Resident #20, Resident #63, Resident #86, Resident #21 ' s and Resident #183 ' s MDS assessments documented the use of restraints. - The facility failed to ensure Resident #31 ' s Quarterly MDS assessment documented her significant weight loss. - The facility failed to ensure Resident #183 ' s MDS assessment adequately documented the resident ' s impaired vision. This failure could put residents at increased risk of not having their treatment needs identified and met. Findings included: Resident #20 Record review of Resident #20 ' s face sheet dated 11/08/2023 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and was re-admitted on [DATE]. Record review of Resident #20 ' s history and physical dated 10/12/2023…

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 observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident ' s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 5 (Resident #21, #63, #86, #124, and #183) of 39 residents reviewed for comprehensive care plans The facility failed to ensure the care plan for Resident #21 addressed his use of psychotropic medications. The facility failed to ensure the care plan for Resident #63 addressed the use of bolsters. The facility failed to ensure the care plan for Resident #86 addressed the re-assessment for use of bolsters. The facility failed to ensure the care plan for Resident #124 addressed her nutritional needs The facility failed to ensure the care plan for Resident #183 addressed her use of bolsters. This failure put residents at increased risk of not having their medical, nursing, and mental…

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 maintained their usual body weight for 2 (Resident #31 and #183) of 12 residents reviewed for maintenance of usual body weight. -The facility failed to ensure that Resident #31 did not have unplanned weight loss of less than 5% in a month, or less than 10% in a 6-month period. -The facility failed to ensure that Resident #183 was administered bolus feeding when less than 50% of a meal was eaten. This failure could result in residents experiencing unplanned weight loss, decreased energy and increased risk of loss of skin integrity. Findings included: Resident #31 Record review of Resident #31 ' s face sheet dated 11/08/2023 revealed a [AGE] year-old female with an admission date to the facility of 01/18/2023. Record review of Resident #31 ' s History and Physical dated 01/19/2023 revealed a diagnosis of cerebral palsy and unhealing pressure wounds. Record review of Resident #31 ' s Quarterly MDS assessment 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 observations, interviews and record reviews the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 2 (Resident # and Resident #245) of 3 residents observed for oxygen management. - Resident #86 did not have extra tracheostomy cannula at bedside. - Resident # 245 was receiving oxygen therapy inappropriately and not according to facility policy. This failure could cause a decline in health in residents receiving oxygen therapy if the necessary equipment was not available and if oxygen therapy was not administered correctly. Findings included: Resident #86 Record review of Resident #86 ' s face sheet dated 11/07/2023 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with re-admission on [DATE]. Record review of Resident #86 ' s history and physical dated 08/15/2023 revealed a diagnosis of anoxic brain injury (is caused by a complete lack of oxygen to the brain, which results in the death…

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

Based on observation, interview, and record review the facility failed to provide food that was palatable and served at an appetizing temperature 2 of 2 meals reviewed for palatability and temperature. -The facility failed to ensure food was served at appropriate temperature. -The facility failed to ensure the puree food served has appetizing flavor. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. The findings include: Record review of weekly diet spreadsheet dated 11/07/023 revealed breakfast consisted of hot cereal, scrambled egg, Mexican red chilaquiles (a dish served heated, consisting of fried corn tortillas mixed with a red chili sauce) , warm tortilla, and whole milk. During observation and interview on 11/06/2023 at 8:20 am, food trays were placed at the beginning of the hallway on the hallway that was last served. 2 staff were seen distributing meal trays to residents' ' rooms. During observation and interview on 11/06/2023 at 8:31 am, the last meal tray was served, and the…

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

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standers for food services for 1 of 2 kitchen reviewed for dietary sanitation in that: The facility failed to ensure Kitchen Aide O was wearing hairnet while in the kitchen. The facility failed to dispose of expired food in the refrigerator. The facility failed to ensure milk stored in refrigerator was labeled. These failures could place residents at risk for foodborne illness. Findings include: During observation and interview on 11/05/2023 at 7:53 am, an initial kitchen tour was conducted with Kitchen Supervisor. 3 female and 1 male staff were noted in the kitchen downstairs. Kitchen Aide O was inside the kitchen without a hairnet. The Kitchen Supervisor stated he was required to wear a hairnet when inside the kitchen at all times, she then asked him to step outside and place a hairnet. The Kitchen Supervisor opened a refrigerator and stated the cups of milk that were pre-served should have a date of when they were prepared and 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 that facility failed to extend to the resident representative ' s the right to make decisions on behalf of the resident for 1 of 10 (Resident #20) residents reviewed for resident rights in that: The facility failed to inform Resident #20 ' s RP before cutting her hair. This failure could place residents at risk of receiving services without consent. Findings include: Record review of Resident #20 ' s face sheet dated 11/08/23 revealed a [AGE] year-old female who was re-admitted on [DATE], initial admission was 01/19/2022. Resident #20 had RP designated and listed as Emergency contact #1. Record review of Resident #20 ' s history and physical dated 10/12/23 revealed a diagnosis of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Record review of Resident #20 ' s quarterly MDS assessment dated [DATE] revealed a BIMS score of 05, she had severe cognitive impairment. Record review of facility's free…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 (Resident #183) of 39 residents reviewed for accommodation of needs. The facility failed to ensure that Resident #183's call light was within reach and could be used by her. This failure could place residents at risk of not being able to call staff when assistance was needed. Findings included: Record review of Resident #183's face sheet dated 11/08/2023 revealed she was [AGE] years old and was admitted to the facility on [DATE]. Record review of?Resident #183's electronic diagnoses listing accessed 11/08/2023 revealed diagnoses of Unspecified Visual Loss, cerebral infarction (blood clot in the brain), Catatonic Schizophrenia (a mental illness that may result in lack of movement or hyperactivity and agitation), a history of falling, and unspecified convulsions. Record review of Resident…

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

Based on observation, interviews, and record review, the facility failed to label drugs and biologicals in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 (300 Hall) of 4 medication carts reviewed for medication storage. -300 Hall medication cart had expired medication. This deficient practice could cause a decline in health in residents if expired medication was to be given. Findings included: Observations on 11/07/2023 at 8:54 AM of 300 Hall medication cart with LVN D revealed an opened bottle of UTI-Stat (concentrate of nutrients for urinary tract health) with an expiration date of June/2023. In an interview on 11/07/2023 at 8:56 AM with LVN D revealed she had not noticed the bottle was expired. She said that the nurses were supposed to check and monitor the cart daily, but she had not noticed the bottle being there. I apologize for that. She said the risks could be that if the resident was given the medication, they could get sick and could be affected in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident's responsible party has the right to exercise the resident's rights for one (Resident #4) of seven residents reviewed for resident rights. The facility failed to ensure Resident #4's RP was involved in the decision making to discharge resident from facility. This failure could place residents at risk of not having their preferred responsible party represent them in a medical and care decisions. Findings included: Record review of Resident #4's face sheet dated 09/06/2023 revealed a [AGE] year-old female, admitted on [DATE] with diagnosis of nicotine dependance. The FM was designated as RP/POA for medical and was her #1 emergency contact. Record review of Resident #4's history and physical dated 08/24/2023 had diagnoses of Chronic Obstructive Pulmonary Disease (COPD) lung diseases that block airflow and make it difficult to breathe) and dementia. Record review of Resident #4's MDS quarterly assessment 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 maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 7 (Resident #4) residents reviewed for accuracy. The facility failed to document Resident #4's alleged smoking in room incident on 08/23/2023 and having cigarettes in room on 08/24/2023. Findings include: Record review of Resident #4's face sheet revealed [AGE] year-old female was admitted on [DATE] with diagnosis nicotine dependance. Record review of Resident #4's history and physical dated 08/24/2023 had diagnoses of Chronic Obstructive Pulmonary Disease ((COPD) lung diseases that block airflow and make it difficult to breathe) and dementia. Record review of Resident #4's MDS quarterly assessment dated [DATE] revealed a BIMS score of 04, she was cognitively impaired. Record review of Resident #4's care plan dated 03/31/2023 revealed Resident#4 had a focus area for remain in facility long…

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.