Nazareth Living Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain medical records on each resident in accordance with accepted professional standards and practices that are complete; accurately documented and systematically organized for one (Resident #1) of two resident records reviewed for wound care. -The facility failed to ensure LVN L documented Resident #12's bruise by appearance, size, color, and site, when informed of the bruise. -The facility failed to ensure LVN M documented the DON and Administrator were notified of Resident #12's acute change, an observed bruise on the left eye. -The facility failed to ensure an incident report was made once staff was made aware on 01/05/2026, of Resident #12's allegation of a fall that allegedly occurred the night of 01/03/2026 or 01/04/2026.These failures could affect the residents in the facility by placing them at risk of not accurately documenting.Findings included: Record review of Resident #12's face-sheet dated 01/07/2025 revealed resident was an [AGE]…

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

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 4 of 12 residents (Residents #4, #7, #28, and #73) reviewed for transmission based precautions. The facility failed to ensure Resident #4, and 73's nasal canula was placed correctly on resident on 01/06/2026. The facility failed to ensure that Resident #7 and #28's foley catheter bag remained off the floor on 01/06/2026. These deficient practices could place residents at risk of exposing them to care that could lead to the spread of infections. Findings included: Record review of Resident #4's admission Record dated 01/06/2026 revealed an [AGE] year-old male with initial admission date 10/25/2022, and re-admission date 01/05/2026. Record review of Resident #4's Quarterly MDS dated [DATE] revealed no BIMS score, as noted,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and existing staff consistent with their expected roles for 3 of 8 employees (The Administrator, The Dietary Manager, and LVN N) reviewed for personnel files. -The facility failed to ensure The Administrator and LVN N had completed communication training on 01/08/2026 at 1:48 PM when staff had been employed for several months; the Administrator was employed for 2 and a half months and LVN N was employed for 5 and a half months. -The facility failed to ensure the Dietary Manager, the Administrator, and LVN N had completed orientation training for Restraint Reduction on 01/08/2026 at 1:48 PM when staff had been employed for several months; the Administrator was employed for 2 and a half months, the Dietary Manager was employed for 9 months, and LVN N was employed for 5 and a half months These deficient practices could result in staff not being appropriately trained to improve…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility treated each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the residents for 1 of 8 residents (Resident #87) reviewed for dignity. The facility failed to provide a privacy bag for Resident #87's foley bag. It was observed that the foley bag was visible on Resident #87's bedframe from the hallway on 01/06/2026 at 1:46 PM. This failure placed the residents at risk of poor self-esteem and decreased self-worth. Findings included: Record review of Resident #87's admission record dated 01/07/2026 revealed a [AGE] year-old female with an original admission date of 01/05/2026. Record review of Resident #87's MDS dated [DATE] reflected an incomplete MDS. Record review of Resident #87's care plan dated 01/05/2026…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 in response to allegations of abuse, neglect, exploitation, or mistreatment the facility had evidence that all alleged violations were thoroughly investigated and prevent further abuse, neglect, exploitation, or mistreatment while the investigation was in progress for 1 of 10 residents (Residents #12) reviewed for abuse/neglect. The facility failed to investigate an allegation of neglect of Resident #12 on 01/05/2026 when Resident #12 was noted to have bruising to the left eye by LVN L and LVN M. Resident allegedly fell off the bed during an unknown night. These failures could place residents at risk for abuse, neglect, emotional distress, physical harm, and trauma.the findings included: Record review of Resident #12's face-sheet dated 01/07/2025 revealed resident was an [AGE] year-old male with admission date 11/26/25. Record review of Resident #12's admission MDS dated [DATE] revealed a BIMS score of 12, indicating moderate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two of twelve residents (Resident# 6, and Resident #80) reviewed for ADL care. -The facility failed to ensure Resident #6 face was clean and free of facial hair on 01/06/26.-The facility failed to ensure Resident #80's fingernails were clean and free from debris on 01/06/26. This failure could place residents who required assistance with ADL's at risk for unmet care needs. Record review of Resident #6's face-sheet dated 01/07/2026, revealed a [AGE] year-old female with initial admission date 05/20/2022, and re-admission date 08/11/2024. Record review of Resident #6's Quarterly MDS dated [DATE], revealed a BIMS score of 12 indicating moderate cognitive impairment. Section GG-Functional Abilities notated Resident #6 was dependent on assistance, meaning the helper…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1 (Resident #4) of 8 Residents reviewed for professional standards, received care in accordance with professional standards of practice and the comprehensive person-centered care plan. -The facility did not ensure that Resident #4 was provided with repositioning at least every two hours on 01/06/2025, Resident #4 was observed sitting up in his bed, facing the TV placed in front of his bed at the following times: 9:31 AM, 11:38 AM, 1:40 PM, and 3:00 PM. This failure could affect the residents requiring staff assistance for repositioning, placing them at risk for skin breakdown and discomfort. The findings included: Record review of Resident #4's admission Record dated 01/06/2026 revealed an [AGE] year-old male with initial admission date 10/25/2022, and re-admission date 01/05/2026. Record review of Resident #4's Quarterly MDS dated [DATE] revealed no BIMS score. As noted, Resident #4 was rarely/never understood. Section GG-…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 of 1 facility dumpster. The facility failed to ensure the facility dumpster was closed by the 2 top lids and 2 sliding metal side doors on 01/07/2026 at 1:15 PM. The facility failed to ensure the surrounding area was free of debris as observed on 01/07/2026 at 1:17 PM where a mattress, hospital bed, and wooden pallet were abandoned on the exterior of the facility dumpster. This failure could result in an infestation of rodents and insects in the dumpster and facility. Findings included: An observation conducted on 01/07/2025 at 1:15 PM of the exterior dumpster revealed 3 of the 4 access points (2 side sliding metal doors, 1 plastic overhead lid) to the dumpster were left open. Additional observation revealed a mattress, a hospital bed, and wooden pallet were left as waste around the exterior of the facility dumpster. In an interview conducted on 01/07/2026 at 1:16 PM with the Dietary Manager who stated the dumpster was not in appropriate condition because 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 observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 of 6 residents (Resident #12 and Resident #13) reviewed for dignity with meal assistance. The facility failed to ensure that Residents #13 and #14 were assisted with eating while staff were seated at eye level. This failure posed a risk of inadequate monitoring during feeding, which could result in, reduce dignity during mealtime, and hinder the ability to respond promptly to signs of distress. Findings included: Record review of Resident #12's face sheet dated 6/18/25 revealed an [AGE] year-old male was admitted to the facility on [DATE] with diagnoses of COPD (long term lung condition that makes it hard to breathe), dementia, (condition that affects the brain and makes it harder for a person to remember things, think…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (Resident #14) reviewed for care plans. The facility failed to the implement a comprehensive person-centered care plan that addressed Resident #14's history of wandering. 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 #14's face sheet dated 06/18/25, revealed, admission on [DATE] to the facility. Record review of Resident #14's facility history and physical dated 02/12/25, revealed, an [AGE] year-old female diagnosed with altered mental status and UTI. There was no diagnoses 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 records were maintained that were complete and accurately documented for 1 of 6 residents (Resident #1) reviewed for accuracy of records. The facility failed to ensure that LVN A completed a personal inventory sheet for Resident #1 upon admission. This failure posed a risk of loss, misplacement, or unaccounted personal belongings, which could lead to resident dissatisfaction, grievances, and limited the facility's ability to verify personal items during the resident's stay or upon discharge. Finding included: Record review of Resident #1's face sheet dated 6/18/25 revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of age-related cognitive decline. Record review of Resident #1's admission MDS assessment dated [DATE] revealed a BIMS score of 02, her cognition was severely impaired. Record review of Resident #1's admission packet dated 2/13/25 revealed page 8: The Resident/Responsible Party shall complete 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 observations, interviews, and record review the facility failed to provide treatment and care based on the comprehensive plan of care for 1 (Resident #1) of 5 residents reviewed for pressure ulcers. The facility failed to provide and assess care on 11/01/24 for Resident #1's Arterial ulcer to her right foot big toe. This deficient practice could place residents at risk for worsening pressure injuries, pain, and a decline in health. Findings included: Resident #1 Record review of Resident #1's face sheet dated 11/22/24, revealed, admission on [DATE] to the facility. Record review of Resident #1's facility history and physical dated 10/30/24, revealed, a [AGE] year-old female diagnosed with Peripheral Artery Disease, Gastric ulcer, and pain to the right foot. Record review of Resident #1's quarterly MDS dated [DATE], revealed, a moderately impaired cognition, BIMS score of 12, and was able to recall and make daily decisions. Record review of Resident #1's Orders dated 10/30/24, revealed, Arterial ulcer to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the observations, 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 #4) of 4 residents reviewed for accidents. The facility failed to make sure the fall mat for Resident #4 was in good condition and not torn or ripped apart. This failure could place residents at risk of falling and injuries. Findings included: Record review of Resident #4's face sheet dated 11/22/24, revealed, admission on [DATE] to the facility. Record review of Resident #4's facility history and physical dated 11/06/24, revealed, an [AGE] year-old female diagnosed with dementia, bipolar, and a fall. The plan was to place Resident #4 on fall precautions. Record review of Resident #4's orders dated 11/20/24, revealed, there were no orders for a fall mat. Record review of Resident #4's care plan dated 11/15/24, revealed, was at risk for falls and injuries.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 1 (Resident #5) of 4 residents observed for oxygen management. Resident #5 was being given oxygen without physician orders from 10/20/24-10/25/24. 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 #5's face sheet dated 11/20/24, revealed, admission on [DATE] to the facility. Record review of Resident #5's facility history and physical dated 10/07/24, revealed, a [AGE] year-old female not diagnosed with anything at the time that would warrant oxygen use. Indicated Resident #5 denied any SOB or wheezing. The plan was to monitor oxygen and maintain adequate oxygen saturation. Keep saturation above 90 percent. Record review of Resident #5's admission MDS dated [DATE], revealed, a…

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

Based on observations, interviews, and record reviews the facility failed to ensure that resident had the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility for all facility residents (65) and their families. -The facility failed to make the results of the most recent survey of the facility available to residents, and family members and legal representatives of residents. This failure placed residents and family members and legal representatives of residents at risk of not being able to fully exercise their rights to be informed of the facility's survey citation history. Findings included: During observations and interview on 10/29/24 at 11:08 AM revealed that at the right side of the receptionist's desk, there was an empty clear storage bin mounted on the wall and above it, there was a sign that said, State Survey Inspections. The surveyor asked the receptionist if there was supposed to be a document in the clear plastic storage bin and she stated that 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 ensure services were provided or arranged by the facility, as outlined by the comprehensive care plan, that met professional standards of for 1 of 10 resident (Resident #6) reviewed for services that met professional standards. -The facility failed to ensure licensed staff administered medications via nebulizer according to accepted standards of clinical practice by not assessing the respiratory status for Resident #6 before and after treatment. -The facility failed to ensure LVN B performed hand hygiene and/or used PPE while administering medications via nebulizer. This failure could place residents at risk for inaccurate drug administration, not receiving the care and services to meet their individual needs, and the spread of infection. Findings included: Record review of Resident #6's admission Record, dated 10/30/24, reflected 94-year-female who was admitted on [DATE]. Record review of Resident #6's Physician's Follow Up Visit, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 2 (Resident #8 and Resident #6) of 2 residents observed for oxygen management. -The facility failed to keep the oxygen machine and filters clean for Resident #6. --The facility failed to ensure licensed staff administered medications via nebulizer according to accepted standards of clinical practice by not assessing the respiratory status for Resident #6 before and after treatment. -The facility failed to post oxygen sign on in Resident #8's door. These failures could place residents at risk of a significant reduction in the quality of oxygen being delivered, inadequate oxygen support, decline in health, and expose them to oxygen hazards without oxygen signs being posted outside of their rooms. Findings included: Resident #6 Record review of Resident #6's admission Record, dated 10/30/24, reflected 94-year-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 observations, interviews, and record review the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, safe and secure storage of medications for 1 (2nd Floor) of 2 medication rooms reviewed for medication storage and 32(Residents #1, and #48) of 10 residents reviewed for medication administration. -The facility failed to administer Resident #1 Gabapentin according to physician's order. - The facility failed to dispose medications for Resident #48 when medication was not administered as ordered. - The facility failed to ensure LVN B signed off on the Controlled Drugs-Count Record after verifying all controlled substances in the medication cart were accounted for with the on-coming nurse at the change of shift. These failures could place residents at risk for not receiving the intended therapeutic response of prescribed medications and drug diversion of controlled substances. Findings included: 1. Record review of Resident #1's admission Record,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the medication error rate was not five percent or greater. The facility had a medication error rate of 14% based on 4 errors out of 27 opportunities, for three residents (Resident #1, Resident #41, and Resident #48) of ten residents observed for medication administration, by two (LVN A and LVN B) of seven staff reviewed for medication errors. -The facility failed to ensure LVN A administered medication to Resident #1 according to physician's orders. -The facility failed to ensure LVN A administered medication to Resident #41 according to physician's orders. -The facility failed to ensure LVN C administered medications to Resident #48 according to physician's orders. These failures had the potential to affect facility residents by placing them at risk of not achieving the therapeutic effects of ordered medications to manage their medical conditions and decline in health. Findings include: 1. Record review of Resident #1's admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with manufacturer's specifications for of 2 of 3 medication carts (Hall 101-124 and Hall 210-244) reviewed for medication storage and handling of medications; 1 (Hall 245-276) of 5 medication carts reviewed for controlled substances; 1 of 1 medication room reviewed for storage of medications. -The facility failed to ensure licensed staff did not store medications after they had been poured in medication cart. -The facility failed to ensure Licensed Staff signed the form after counting and verifying that all controlled substances in the medication cart had been accounted for with the on-coming nurse at the change of shift. -The facility failed to date Glucometer Normal/High Control Solutions and Glucose Test Strips when opened according to manufacturer recommendations. - The facility failed to keep the tile floor in the medication room free of full of dust, dried brown stains, 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.

Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 3 of 3 diet test trays reviewed for food temperatures. -The facility failed to maintain food hot on diet serve test trays. -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 included: Observation on 10/28/24 at 12:08 PM on the first floor of the facility, revealed that the CNAs were leaving the doors open to the insulated meal cart while they were distributing the trays and assisting residents with tray set-up. It was observed that the CNAs wheeled the insulated meal cart down the hallway without closing the doors until it was time for them to go to the other hallway at the other side of the facility to pass meal trays to the residents. It was observed that the doors to the insulated meal cart were left open for a total of seven minutes in the first hallway until all resident trays had been passed out which left the 3 test…

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

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation and food storage. 1. - The facility failed to keep the tile floors free of dust, dried stains, and disposable cups on the floor. 2. - The facility failed to keep the refrigerator shelve free of dried food particles. 3. - The facility failed to keep food containers stored in the kitchen free of dust and food particles. 4. - The facility failed to discard perishable foods stored in the walk-in refrigerator. The multiple Jalapeno peppers had wrinkles, and one Jalapeno pepper had a black substance; Cabbage was mushy, and the edges of the leaves were brown. 5. - The facility failed to keep the kitchen equipment free of grease build-up and food particles. 6. - The facility failed to keep spice bottles, and a shaker free of residual and grease build-up. 7. - The facility failed to keep plastic bottles free of grease build-up and free of dried drippings. 8. -…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain accurate medical records on each resident in accordance with accepted professional standards and practices that were: Complete; Accurately documented; Readily accessible; and systematically organized for 2 (resident #55 and #60) of 3 residents. The facility had incomplete documentation for the treatment of Resident #55 and #60's restorative therapy care. This failure could delay identification of problems with the restorative therapy, resulting in a delay in treatment. The findings included: Resident #60 Record review of Resident #60 History and Physical (H&P) dated 10/31/2024 revealed an [AGE] year-old male with diagnoses of PE (Pulmonary Embolism) on anticoagulation and Lewy body dementia. (Lewy Body Dementia is when protein deposits called Lewy bodies develop in nerve cells in the brain, where it affects brain regions such as thinking, memory, and movement.) Record Review of Resident #60 Care plan dated August 2024 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.

Based on interviews and records review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to take actions aimed at performance improvement and after implementing those actions, measure its success, and track performance to ensure that improvements were realized and sustained. The facility failed to address concerns regarding foods that were not kept hot when served to the residents. This failure could place residents at risk of weight loss and unresolved dietary concerns. Findings included: Observation on 10/28/24 at 12:08 PM on the first floor of the facility, revealed that the CNAs were leaving the doors open to the insulated meal cart while they were distributing the trays and assisting residents with tray set-up. It was observed that the CNAs wheeled the insulated meal cart down the hallway without closing the doors until it was time for them to go to the other hallway at the other side of the facility to pass meal trays to the residents. It was observed that the doors to the insulated meal cart were left open for a total of seven minutes 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.

Based on interviews and record review, the facility failed to ensure the QA committee developed and implemented appropriate plans of action to correct identified dietary concerns reported in the group interviews and Satisfaction Survey completed by the consultant dietitian. The facility failed to ensure that the QA committee developed a plan of action to ensure the food complaints or grievances were addressed and resolved. This failure could place residents at risk of weight loss and unresolved dietary concerns. Findings included: Observation on 10/28/24 at 12:08 PM on the first floor of the facility, revealed that the CNAs were leaving the doors open to the insulated meal cart while they were distributing the trays and assisting residents with tray set-up. It was observed that the CNAs wheeled the insulated meal cart down the hallway without closing the doors until it was time for them to go to the other hallway at the other side of the facility to pass meal trays to the residents. It was observed that the doors to the insulated meal cart were left open for a total of seven minutes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (Resident #60, Resident #55, and Resident #6) of fifteen residents observed for Infection Control. -CNA D failed to perform hand hygiene between passing out food trays in between residents. - CNA D failed to perform hand hygiene between helping a Resident #60 out of bed to sit and eat and providing feeding assistance to Resident #55. -The facility failed to ensure licensed staff washed hands between residents when administering medication. -The facility failed to ensure LVN B performed hand hygiene and/or used PPE while administering medications via nebulizer treatment. -The facility failed to store a plastic container off the floor in the medication room. -The facility failed to ensure opened packages of gauze…

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

Based on observations, and interviewsthe facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen reviewed for safe operating equipment; and 1 of 1 laundry room reviewed for safe operating equipment. -The facility failed to maintain the stove in operational condition. -The facility failed to maintain washers and dryers in operational condition. This failure could place residents at risk of foodborne illnesses. Findings included: Kitchen: Observation and interview 10/28/24 at 8:55 AM, with the Dietary Manager revealed Robot Coupe's blade broke; stove was missing three control knobs. The Dietary manager stated the knobs kept falling off, so they kept them on the shelf on top of the stove; oven doors were missing the handles; multiple control knobs on the stove were cracked, had grease build-up and were dusty since she started working at the facility a couple of months ago. Laundry Room: Observation and interview on 10/30/24 at 10:19 AM, with the Maintenance Director revealed Dryer #1 was missing the metal cover…

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

Based on observations, and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in three of five halls and 1 of 1 kitchen and 1 of 2 medication rooms reviewed for environmental conditions. - The facility failed to maintain resident halls and kitchen free of dust. --The facility failed to ensure there were paper towels in the towel dispenser in the medication room. This deficient practice could place residents at risk of not living in a safe, functional, sanitary, and comfortable environment Findings included: Kitchen: Observation and interview on 10/28/24 at 8:55 AM, with the Dietary Manager revealed kitchen equipment vents in the food preparation were full of dust. The ceiling by food preparation had a large hole, electrical cover was missing on kitchen light. The Dietary Manager reported water pipes had ruptured, and water was dripping from the ceiling to the kitchen floor by the food preparation area a couple of days ago and the plumbers had to remove part of the ceiling to replace several water…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement a comprehensive person-centered plan of care for 2 (Residents #41, and #48) of 10 residents reviewed for drug regimens. -The facility failed to ensure Resident #41 and Resident #48 were administered medication with meals according to physician's orders. These failures placed residents at risk of not receiving medications according to manufacturer specifications placing them at increased risk of adverse drug effects and decline in their health status. The findings included: 1. Record review of Resident #41's admission Record, dated 10/30/24, reflected 47-year-female who was admitted on [DATE]. Record review of Resident #41's Physician's Follow Up Visit, dated 10/23/24, reflected she had diagnoses which included cerebral arteritis. Record review of Resident #41's admission MDS, dated [DATE], reflected Active Diagnosis cerebral arteritis. Record review of Resident #41's Care Plan, dated 10/25/24, reflected, Resident #41 had Self…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 with Urinary Incontinence received appropriate treatment and services to prevent Urinary tract infections for 1 (Resident #5) out of 3 residents reviewed for quality of care. 1. The facility failed to ensure Resident #5's indwelling catheter tubing was not laying on the floor and he had a privacy bag on 08/07/2024 . 2. The facility failed to ensure Resident #5's subpubic catheter was properly secured to a leg strap on 08/08/2024 . This failure could place residents at risk of a Urinary Tract Infection and injury. Findings include: Record Review of Resident #5's Face Sheet dated 08/08/2024 revealed he was an [AGE] year-old male, admitted to the facility on [DATE] with a readmission on [DATE]. Record review of Resident #5's history and physical dated 02/01/2022, type 2 diabetes mellitus with unspecified complications, benign prostatic hyperplasia without lower urinary tract symptoms (enlarged prostate). 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 interviews, and record reviews the facility failed to ensure that resident receive treatment and care in accordance with professional standards of practice of 1 (Resident #1) of 5 reviewed for quality of care: -The facility failed to follow physician orders to assess vital signs every shift for Resident #1 for several shifts. This failure could cause a decline in residents' health if vital signs are not being monitored as ordered. Findings included: Closed record review of Resident #1's face sheet dated 09/29/2023 revealed an [AGE] year-old female with an admission date to the facility of 09/21/2023. Record review of Resident #1's medical diagnosis list accessed on 09/28/2023 revealed she had medical diagnoses to include Hypertension (high blood pressure), Hypokalemia (low potassium) and dizziness. Record review of Resident #1's History and Physical dated 09/25/2023 revealed Resident #1 had been admitted to the facility from a local hospital after suffering a fall at home. It confirmed her medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 resident (Resident #1) of 5 reviewed for medication orders. The facility failed to administer 3 medications to Resident#1 per physician orders on several shifts. This failure could affect residents and cause a decline in health if medications are not given as ordered. Findings included: Closed record review of Resident #1's face sheet dated 09/29/2023 revealed an [AGE] year-old female with an admission date to the facility of 09/21/2023. Record review of Resident #1's medical diagnosis list accessed on 09/28/2023 revealed she had medical diagnoses to include Hypertension (high blood pressure), Hypokalemia (low potassium) and dizziness. Record review of Resident #1's History and Physical dated 09/25/2023 revealed Resident #1 had been admitted to the facility from a local…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain clinical records that were complete and accurately documented for 1 (Resident #1) of 5 residents reviewed for clinical records. -The facility failed to document vital signs in Resident #1's clinical record for several shifts. Vital signs were blank on his vitals signs data sheet and TARs. This failure could cause a decline in health in residents if vital information is not being documented accurately. Findings included: Closed record review of Resident #1's face sheet dated 09/29/2023 revealed an [AGE] year-old female with an admission date to the facility of 09/21/2023. Record review of Resident #1's medical diagnosis list accessed on 09/28/2023 revealed she had medical diagnoses to include Hypertension (high blood pressure), Hypokalemia (low potassium) and dizziness. Record review of Resident #1's History and Physical dated 09/25/2023 revealed Resident #1 had been admitted to the facility from a local hospital after suffering a fall at home.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clean bath linens for 2 (Resident #41 and Resident #24) of 16 residents reviewed for bath linens. The facility failed to ensure that Residents #41 and #24 had bath towels available to dry off with when bathed. This failure could put residents at increased risk of discomfort and embarrassment due to not having bath towels to dry off with after bathing. Findings included: Resident #41 Record review of Resident #41's face sheet date 09/08/23 revealed resident was a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #41's History and Physical dated 06/21/22 documented a diagnosis of anxiety and depression. Record review of Resident #41's quarterly MDS dated [DATE] documented resident had a BIMS score of 15 indicating her cognitive status was intact. The MDS assessment documented Resident #41 was able to make her needs understood and could understand others. In section G was documented…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 faciality failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain and/or maintain the resident's highest practicable physical, mental and psychosocial well-being for 1 (Resident #19) of out 8 residents reviewed for care plans. The facility failed to develop and implement a comprehensive person-centered care plan for Resident #19 preferences of showers. This failure could place residents at risk of decreased quality of life due to not having their treatment and preferences met. Findings include: Record review of Resident #19's face sheet dated 09/08/23revealed resident was an [AGE] year-old female with an initial admission date of 03/17/2023 and re-admitted on [DATE] to the facility. Record review of Resident #19's History and Physical dated 06/13/23 documented a diagnosis of right femoral vein DVT s/p ivc filter, (filter placed in vein in leg to treat…

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

Based on observation, interviews, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate administering of all drugs to meet the needs of the residents for 1(2nd floor) of 2 medication storage rooms and 1(1st floor) of 3 medication carts. -1st floor medication cart had expired medications. -2nd floor medication room had expired medications. This failure could cause a decline in health in residents if expired medications were to be given. Findings included: Observations on 09/07/23 at 9:19 AM with LVN P in the medication room on the second floor revealed one unopened bottle of multivitamins with iron with an expiration date of 4/23 located on one of the shelves. Inside the refrigerator was a package of Acetaminophen suppositories 650 mg dated 06/2023. Observations on 09/07/23 at 11:20 AM with LVN Q of 1st floor medication cart revealed one bottle of multivitamins with minerals with an expiration date of 08/23. One bottle of multivitamins with iron with an expiration date of 04/23 and one bottle of multivitamins 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.

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. The facility failed to properly seal and date food in the freezer, refrigerator and dry food storage. The facility failed to dispose of expired items in the food prep areas. This failure places residents who eat food prepared by the facility at risk of foodborne illnesses. Findings include: During the initial observation on 09/06/23 at 08:59 AM during initial round with [NAME] and the Dietary manager reveal: Observed in the freezer individual cut rolls dough, frozen sliced carrots, frozen cut green beans, frozen green sweet peas, frozen broccoli cuts, and frozen golden corn?in a box container improperly sealed or labeled with open date. Observed in the refrigerator an improperly label with open date gallon of Worcestershire sauce. Observed in the refrigerator an improperly sealed container with cheese. Observed in the refrigerator a side garden salad…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 trash containers reviewed for food safety requirements. The facility failed to have garbage cans without a lid in the kitchen. This failure could affect residents by placing them at risk of food born illness, illnesses, or be provided with an unsafe, unsanitary and uncomfortable environment. Findings included: Observation on 09/06/23 at 08:59 AM during initial kitchen observation revealed the facility used garbage can containers without lids in the kitchen area and in the area where the dishwasher is located. During an interview on 09/08/23 at 07:20 PM, the Dietary Manager confirmed they were using garbage receptacles without lids in the kitchen and area with the dishwasher. The Dietary Manager stated he wasn't aware the staff were utilizing trash containers that did not have a trash lid, this was not allowed practice and will be correcting it. The Dietary Manager stated this practice can lead to cross-contamination. The facility provided a policy &…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain all mechanical equipment in safe operating condition for one of three washing machines and two of four dryers reviewed for being in operating condition. The facility failed to repair one washing machine and two dryers for a period of one month. This failure placed residents at risk of not having enough towels to dry?with after showers. Findings included. Observations on 09/08/23 at 07:50 AM of the laundry department revealed washing machine #2 was not in working condition. Dryer #1 and Dryer #2 were not in working condition. In an interview on 09/07/2023 at 5:02 PM, the Maintenance Supervisor said the one washer and one dryer that were currently broken had been broken since he had started working at the facility [5/30/23]. He said the other dryer that was currently broken had broken shortly after he started working at the facility. He said he had recently been in touch with the vendor who supplied the machines to ask that they repaired, and that repairs were pending receipt of parts. Documentation of his contact 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 interview and record review the facility failed to include effective communications as mandatory training for direct care staff for 11 (DON, ADON A, LVN C, LVN D, CNA H, CNA I, CNA J, Social Worker, SLP L, O.T. M, and P.T. N) of 17 direct care staff reviewed for training on effective communication The facility failed to ensure direct care staff received training on effective communication?for the DON, ADON A, LVN C, LVN D, CNA H, CNA I, CNA J, the Social Worker, SLP L, OT M, and PT N. This failure could put residents at increased risk of not having a way to effectively communicate their wants or needs. Findings include: In an interview and record review on 09/08/2023 at 8:42 AM, the HR Director revealed the following employees had not completed training on effective communication: the DON hired 12/19/2022, ADON A hired 12/19/2022, LVN C hired 08/26/2023, LVN D hired 05/16/2022, CNA H hired 05/16/2022, CNA I hired 10/01/2022, CNA J hired 05/16/2022, the Social Worker hired on 11/14/2022,? SLP L hired on 08/15/2022, OT M hired on 06/27/2022, and PT N hired on 06/01/2022. He…

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

Based on interview and record review the facility failed to ensure that all staff members are educated on the rights of the resident and the responsibilities of a facility to properly care for its residents for 10 (DON, ADON A, ADON B, LVN D, CNA F, CNA J, the Activity Director, the Maintenance Supervisor, O.T. M, and P.T. N) of 21 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 theDON, ADON A, ADON B, LVN? D, CNA F, CNA J, the Activity Director, the Maintenance Supervisor, O.T. M, and P.T. N 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 include: In an interview and record on 09/08/2023 at 8:42 AM, the HR Director said that following employees did not receive training on the rights of the resident and the responsibilities of a facility to properly care for its…

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

Based on interview and record review the facility failed to ensure that training was provided regarding dementia management for 9 (Administrator, DON, ADON A, ADON B, LVN C, LVN D, CNA G, CNA H, and CNA J) of 12 employees reviewed for training on dementia management. The facility failed to ensure the Administrator, DON, ADON A, ADON B, LVN C, LVN D, CNA G, CNA H, and CNA J received training on dementia management. This failure could put residents at increased risk of improper management of dementia-related issues. Findings include: In an interview and record review on 09/08/2023 at 8:42 AM, the HR Director said that following employees did not receive training on dementia management: the Administrator hired on 05/23/2023, the DON hired on 12/19/2022, ADON A hired on 12/19/2022, ADON B hired on 12/09/2022, LVN C hired on 08/6/2023, LVN D hired on 05/16/2022, CNA G hired on 04/24/2023, CNA H hired on 05/16/2022, and CNA J hired on 05/16/2022. He said it was important employees were trained to ensure the safety of the residents. He said the risk to residents was that they would be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical status for one (Resident #214) of eight residents reviewed for physician notification. The physician was not notified that Resident #214 had a fall on 08/25/23 and complained of pain to the left hip. This failure put residents at risk of delayed medical treatment. Findings include: Record review Resident #214's face sheet dated 08/08/2023 documented a [AGE] year-old female with an initial admission date of 12/29/2022, and a re-admission date of 08/30/2023 to the facility. Record review Quarterly MDS dated [DATE] for Resident #214 documented she had a BIMS of 7 (severe cognitive impairment). Required extensive assistance of two persons with bed mobility, transfers, and toilet use; requires extensive assistance of one person with locomotion on and off unit. Received scheduled and PRN pain medication. Pain presence - yes; Pain Frequency - occasional.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 8 residents (Resident # 165) reviewed for enteral feeding. -Resident #165's enteral feeding formula was not labeled with time of administration, date it was hung, and rate that formula was given. This failure could place residents receiving enteral feedings at risk of malnutrition if feedings were to be given incorrectly. Findings include: Record review of Resident #165's face sheet dated [DATE] documented a [AGE] year-old female with an admission date to the facility of [DATE]. Record review of Resident #165's History and Physical dated [DATE] documented she had a diagnosis of protein caloric malnutrition and had a PEG tube in place. It also documented that tube feedings were to be given. Record review of comprehensive care plan dated [DATE] documented Resident #165 had tube feedings at night with a goal of remaining free of side…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 received parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders for 1 (Resident #28) of 2 residents reviewed for peripheral intravenous care. - The facility failed to date the intravenous dressing site of Resident #28's central line when it was changed. This failure placed residents at risk of developing an infection. Findings included: Record review of Resident #28's face sheet dated 09/08/2023 documented a [AGE] year-old male with an admission date to the facility of 08/10/2023. Record review of Resident #28's History and Physical dated 08/11/2023 documented a diagnosis of chronic back pain and was status-post back surgery. He was receiving IV antibiotics for his wound and was to continue to do so while at the facility. Record review of Resident #28's MDS comprehensive assessment dated [DATE] documented a BIMS score of 8, indicating a moderate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure that residents who use psychotropic drugs receive gradual dose reductions for 1 (Residents #52) of 6 residents whose drug regimens were reviewed. Resident #52 was receiving an antipsychotic for which no gradual drug reduction had been attempted. This failure puts residents at increased risk of experiencing side effects as a result of taking unnecessary medications. Findings include: Record review of Resident 52's Face Sheet dated 09/07/2023 documented that she was [AGE] years old and was admitted to the facility on [DATE]. Record review of Resident #52's Psychiatric Subsequent Assessment note dated 08/31/2023 documented she had a past psychiatric diagnoses including Anxiety, Bipolar disorder, Dementia and Schizophrenia. Record review of Resident 52's electronic diagnosis listing dated 09/07/2023 documented she had diagnoses including dementia, anxiety disorder, bipolar disorder and schizophrenia. Record review of Resident 52's quarterly Minimum…

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