Pebble Creek Nursing Center

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 6 of 15 residents reviewed (Resident #25, Resident #37, Resident #40, Resident #58, Resident #67, and Resident #76) for residents' rights, in that: The facility staff failed to knock before entering the room of Resident #25, Resident #37, Resident #40, Resident #58, Resident #67, and Resident #76. This failure could affect residents' self-esteem and dignity. The findings include: Resident #25 Record review of Resident #25's face sheet dated 05/15/25 revealed she was admitted on [DATE] to the facility and readmitted on [DATE]. Record review of Resident #25's history and physical dated 10/24/24 revealed a [AGE] year-old female diagnosed with major depressive disorder, insomnia and anxiety disorder. 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 observation, interview, and record review, the facility failed to ensure residents receive services in the facility with reasonable accommodation of resident needs and preferences for 2 of 11 residents (Resident #22 and #88) reviewed for call light placement. The facility failed to ensure call lights were within reach for Residents #22 and #88. This failure could affect residents by not having access to call for assistance resulting in needs not being met. Findings included: Record review of Resident #22's face sheet dated 05/13/25 revealed resident was an [AGE] year-old female with admission date 10/09/24. Record review of Resident #22's history and physical dated 04/10/25 revealed the resident's following medical diagnoses: dementia, high blood pressure, hyperlipidemia (high cholesterol levels), chronic kidney disease (a condition that affects your kidneys' ability to filter waste from your blood), and obsessive-compulsive disorder (a mental health condition characterized by unwanted thoughts 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 the resident's environment was as free of accident hazards as possible for 3 of 30 residents (#18, #48, and #75) reviewed for accidents. -The facility failed to properly dispose of a retractable lancet device (small, pen like tool that holds a lancet (a small needle) used to prick the skin for blood sampling) in sharps container in one room (resident# 75). -The facility failed to properly dispose of a razor in one room (rResidents #18 and #48's room) This deficient practice could place residents at risk of harm or injury and contribute to avoidable accidents. The findings included: Resident #18 Record review of Resident #18's face sheet dated 05/16/2025 revealed a [AGE] year-old female that was admitted to the facility on [DATE]. Record review of Resident #18's History and Physical dated 03/25/25 revealed, Resident #18 was diagnosed with unspecified dementia with behavioral disturbance. Record review of Resident #18's Quarterly MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature, for one test tray reviewed and for 3 residents (Resident #6, Resident #40 and Resident #41) of 18 residents interviewed in hallways 100 and 500. The facility failed to maintain food hot on regular diet, puree diet, renal diet, test trays and served cold meals to Resident #6, Resident #40 and Resident #41. This failure could place residents who ate in their rooms at risk of poor intake and/or foodborne illness. The findings included: Resident #6 Record review of Resident #6's face sheet dated 05/15/25 revealed she was originally admitted on [DATE] to the facility and readmitted on [DATE]. Record review of Resident #6's history and physical dated 10/30/24 revealed a [AGE] year-old female diagnosed with major depressive disorder, gastro-esophageal reflux disease without esophagitis (a condition where stomach contents, including acid, frequently flow back…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 out of 1 kitchen . The facility failed to cover and seal the meal carts containing the residents' meal trays while transporting them through four out of four hallways in the facility. The facility failed to ensure staff wore hairnets in the kitchen. The facility failed to maintain 1 ranch dressing container and 1 mayonnaise container free from drippings during the initial kitchen tour The facility failed to thaw ground meat under running cold water per policy during initial kitchen tour. The facility failed to maintain clean grease filters over the stovetop during the initial kitchen tour. The facility failed to maintain 2 of the 3 compartments' sinks within the appropriate temperature. These failures could place all residents who received meals from the main kitchen and place them at risk for food borne illness. The findings were: Meal Carts During observations on 05/13/25 at lunchtime, meal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 4 residents (Resident #16) reviewed for clinical records, in that: The facility failed to ensure that LVN C documented completely and accurately in the resident's clinical record when Resident #16 had a seizure on 03/10/25. This deficient practice could affect residents that had history of seizures and at place them at risk of having incomplete and inaccurate medical records . The findings were: Record Review of Resident #16's face sheet dated 05/15/25 revealed resident was a [AGE] year-old female with admission date 05/14/2024. Record Review of Resident #16's annual history and physical dated 05/16/25 revealed Resident #16 was non-verbal and was prescribed Levetiracetam 100mg/ml solution 7.5ml by mouth twice a day for seizures. Record Review of Resident #16's annual MDS dated [DATE] revealed there was no BIMS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 (Resident #44) of 12 residents observed for oxygen management. -Resident #44 utilized oxygen in his room and did not have an oxygen sign posted outside of the room. This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health and at risk of fire hazards by not posting oxygen signs outside the residents' rooms. Findings include: Record review of Resident #44's face sheet dated 05/15/25 revealed he was admitted on [DATE] to the facility and readmitted on [DATE]. Record review of Resident #44's history and physical dated 05/05/24 revealed a [AGE] year-old male diagnosed with shortness of breath, sleep apnea (a common sleep disorder characterized by repetitive pauses in breathing or periods of shallow breathing during sleep), and acute…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 (Residents #75) of 31 residents reviewed for infection control. The facility failed to keep rResident #75's bed sheet clean and free of blood stains. These deficient practices could place residents at risk for infection due to improper care practices. Finding included: Record review of Resident #75's admission record dated 05/16/2025 revealed a [AGE] year-old male that was initially admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #75's history and physical dated 04/08/25 revealed, Resident #75 was diagnosed with Diabetes mellitus type 2. Record review of Resident #75's five-day MDS assessment dated [DATE] revealed a BIMS score of 14 indicating intact cognitive function. 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 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 1 of 4 (Resident #1) residents reviewed for telephone use. The facility failed to provide a place for Resident #1 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 #1's admission Record, dated 01/14/2025, reflected [AGE] year-old female admitted on [DATE]. Record review of Resident # 1's History and Physical dated 10/13/2024, revealed diagnoses of schizoaffective disorder (mental health condition with symptoms of schizophrenia and a mood disorder where person may experience depression, mania and psychosis), anxiety (feeling of worry, nervousness, or unease, typically about an imminent event or something with 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 observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident's medical and nursing needs and described the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #1 and Resident #8) of 9 residents reviewed for care plans. -The facility failed to follow the comprehensive person-centered care plan for Resident #1's and #8's fall risk, by failing to have fall mats in place next to bed while residents were lying down in bed. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services as indicated in their comprehensive person-centered plans developed to address their needs. Findings include: Resident #1: Record review of Resident #1's admission Record, dated 01/14/2025, reflected [AGE] year-old female admitted on [DATE].…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good grooming and personal and oral hygiene for 2 of 5 (Resident #2, Resident #7) residents reviewed for assistance with peri-care. CNA A failed to provide perineal care with professional standards to ensure Resident #2 was clean, free of contamination. CNA K failed to provide perineal care with professional standards for Resident #7 to ensure they were clean, free of contamination. This failure could place residents who were dependent on staff for ADL care at risk for infections. Findings include: Resident #2 Record review of Resident #2's face sheet dated 09/17/24, revealed, admission on [DATE] to the facility. Record review of Resident #2's facility history and physical dated 05/15/24, revealed, a [AGE] year-old female diagnosed with Down Syndrome (a condition in which a person has an extra chromosome or an extra piece 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 that the residents environment remains as free of accidents hazards as is possible and each resident receives adequate supervision to prevent accidents for 1 (Resident #2) of 6 residents, and one (room [ROOM NUMBER]) of 5 rooms observed. During observations conducted on 05/14/24 at 9:08 am, the sharps container located in room [ROOM NUMBER] occupied by Resident #2, had two disposable razors exposed and reachable on top of the box. During observations conducted on 05/14/24 at 10:24 am, the sharps container located in room [ROOM NUMBER] had one syringe exposed and reachable on the top of the box. This failure could place residents at risk of accidents, and potential harm. Findings include: Record review of Resident #2's face sheet dated 05/16/24, revealed Resident #2 was admitted on [DATE] and that he was a [AGE] year-old male with diagnoses that included cerebral infarction due to occlusion or stenosis (abnormal narrowing of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents reviewed for infection control. LVN E failed to use gown prior to providing care for Resident #46 who is on enhanced barrier precautions. RN F failed to use gown prior to providing care for Resident #74 who is on enhanced barrier precautions. This failure could place residents at risk for cross contamination and the spread of infection. Findings Included: Record review of Resident #46's face sheet indicated she was a [AGE] year old female admitted to the facility on [DATE] with diagnoses including gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), cerebral infarction (also known as a stroke, refers to damage to tissues in the brain due to a loss of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to ensure the resident's had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 3 of 20 residents (Resident#29, Resident #46, Resident # 90) reviewed for resident rights. The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #29 prior to administering Lorazepam, an antianxiety medication used to treat anxiety. The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #46 prior to administering Valproic Acid, a mood stabilizer . The facility also failed to obtain informed consent based on information of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review the facility failed to ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 (Residents #1) of 6 residents reviewed for accommodation of needs: Resident #1's call light was not left within his reach or within sight. This failure could place residents at risk of not having their needs met and a decline in their quality of care and life. Findings included: Resident #1 Record review of Resident #1's face sheet dated 05/16/24, revealed Resident #1 was admitted on [DATE] and that he was a [AGE] year-old male with diagnoses that included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, lack of coordination, cognitive communication deficit, cardiac arrhythmia (a condition in which the heart beats with an irregular or abnormal rhythm), muscle wasting and atrophy, difficulty in walking, muscle weakness…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide necessary services to maintain good grooming and hygiene for a resident who was unable to carry out activities of daily living for 2 residents out of 3 (Resident #45, Resident #40). The facility failed to provide personal hygiene for Resident #45 and facial hair care for Resident #40. This deficient practice placed residents at risk of poor hygiene and decline in residents' self-esteem. Findings included: A. Resident #45 Record review of Resident #45's face sheet dated 05/16/2024 revealed admission on [DATE] and re-admission on [DATE] to the facility. Resident #45 was a [AGE] year-old male diagnosed with UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL Primary DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY. Record review of Resident #45's admission MDS dated [DATE] revealed severe cognitive impairment to be able to make daily decisions based on a BIMS (an assessment used to monitor cognition) score…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 During 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 1 (Resident #39). Resident #39's indwelling catheter tubing was laying on the floor. The facility failed to ensure Resident #39's subpubic catheter was properly secured . This failure placed resident at an increased risk of a Urinary Tract infection. The Findings included: Review of Resident #39's face sheet revealed an [AGE] year-old woman, who was admitted into the facility on [DATE]. Record review of Resident #39's history and physical dated 01/16/2023 revealed diagnoses of UTI (urinary tract infection), Alzheimer's, Dementia, Diabetes, Gross Hematuria (Blood in the urine). Record review of Resident #39's MDS dated [DATE] revealed no information regarding resident's daily decision making, or functional abilities and goals. Record review of Resident #39's care plan dated 04/03/2024 revealed she has 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 observation, interview and record review, the facility failed to ensure nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments and described in the plan of care for 1 of 3 (Resident #14) residents reviewed for care, in that: CNA A changed Resident #14's colostomy bag and wafer without being trained on how to perform the procedure. (A colostomy wafer is a plastic ring that adheres to the skin around the stoma which is an opening in the stomach and connects to an ostomy bag. The wafer, also known as a flange, baseplate, or skin barrier, is designed to protect the skin from the stool that passes through the stoma. The ostomy bag collects the stool and can be detached from the wafer for disposal or cleaning).( An ostomy is a surgical procedure that creates an opening in your abdominal wall. This opening goes from an area inside your body to the outside, usually through your abdominal muscles and skin. Ostomy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 under proper temperature controls and permit only authorized personnel to have access to medications in medication cart 1 of 4 reviewed for label and storage of drugs and biologicals. The facility failed to ensure medication cart #1 was locked when unattended. The facility failed to ensure discontinued medication was locked in medication rooms. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions. Findings included: During an observation and interview on 05/14/24 at 11:00am the medication cart #1 was left unattended and unlocked by LVN E. LVN E failed to lock medication cart #1 as she walked away from the medication cart to administer insulin. Medication cart #1 was unattended from 11:05 am to 11:13 am until she noticed and locked the cart. During an interview on 5/14/24 at 11:15 am LVN E stated that she must have overlooked the unlocked cart. LVN E stated that she was aware…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for Food safety. The facility failed to close and seal food and seasonings, dispose of expired foods, and maintain a vent free of dust build up. This failure could affect residents by placing them at risk of food borne illness. Findings include: Observation and interview on 05/14/24 at 08:07am with dietary staff L. Observed the Cream of Tartar, Salt, and Dill weed seasonings are all opened. Dietary staff L stated they should not be opened and closed them correctly. Observation on 05/14/2024 at 09:09 am: inside the dry storage room they had about 6 bags of expired instant pudding that was dated February 22, 2024. Observation on 05/14/2024 at 08:59 am. Inside the walk-in refrigerator there was a cheese bag that was left opened and not sealed correctly. Observation on 05/14/2024 at 11:15 am: Dietary staff K was wearing crocs with the holes open on the side while preparing 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 interviews, and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 (Resident #82) of 6 residents reviewed for accuracy of MDS assessments. - The facility failed to ensure that Resident #82's MDS accurately reflected resident's behaviors related to physical behaviors directed toward others. This deficient practice could affect residents who receive MDS assessments and could cause residents not to receive correct care and services. The findings were: Record review of Resident #82's admission record, dated 05/15/2024, revealed Resident #82 was a [AGE] year-old male with admission date of 02/03/2023. Resident diagnoses included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident 82's care plan last…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs for 2 (Residents #3 and #5) of 16 residents reviewed for call light button placement. -The facility failed to ensure that Residents #3's and #5's call lights were within their reach. This failure could place residents at risk of not being able to have their needs met. Findings included: Resident #3: Record review of Resident #3's face sheet dated 02/15/2024, revealed a [AGE] year-old female, with an initial admission date of 05/11/2020 and readmission date of 11/08/2023. Resident #3's diagnoses included: dementia (loss of cognitive functioning - thinking, remembering, and reasoning- to such an extent that it interferes with a person's daily life and activities), gastrostomy status (surgical procedure used to insert a tube through the abdomen and into the stomach), seizures (sudden uncontrolled burst of electrical activity in the brain), lack of coordination, and history of falling. Record review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs, and services to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 of 5 (Resident #2) residents reviewed for care plans. -The facility failed to implement a comprehensive person-centered care plan for Resident #2 to include head of bed to be elevated 30 degrees due to continuous enteral feeding (nutrition delivered using the gut). This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and not having personalized plans developed to address their needs. Findings included: Record review of Resident #2's face sheet dated 02/14/2024 revealed a [AGE] year-old female who was readmitted to the facility on [DATE] with diagnoses of schizophrenia, contracture…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2 of 5 (Resident #2 and Resident #15) reviewed for enteral feeding. -The facility failed to ensure that Resident #2 and Resident #15's head of bed was maintained at 30 degrees elevated according to physicians' orders. The failure could place residents receiving enteral feedings at risk of aspiration (when food or liquid goes into the lungs or airway). Findings include: Record review of Resident #2's face sheet dated 02/14/2024 revealed a [AGE] year-old female who was readmitted to the facility on [DATE] with diagnoses of schizophrenia, contracture of muscle on multiple sites, gastronomy status (surgical procedure used to insert a tube through the abdomen and into the stomach), muscle weakness, dysphagia (swallowing difficulties), and moderate protein calorie malnutrition. Record review of Resident #2's annual MDS 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 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 3 (Resident #1, Resident #2, and Resident #4) of 7 residents reviewed for call light response time. The facility failed to respond in a timely manner to Resident #1, 2, and 4's call lights. Staff failed to respond to Residents #2's call light notification for 47 minutes. This failure puts residents at risk of not being able to get assistance when using the call light system whatever needs or incidents occur. Findings included: Record review of Resident #1's face sheet dated 10/27/23 revealed admission on [DATE] and readmission on [DATE] to the facility. Record review of Resident #1's history and physical dated 07/06/23 revealed a [AGE] year-old female diagnosed with cognitive decline, anxiety, and generalized weakness with activities of daily living. Record review of Resident #1's quarterly MDS…

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

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 7 residents (Resident #7) reviewed for care plans in that: The facility failed to implement a comprehensive person-centered care plan for Resident #7's oxygen therapy. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. Findings include: Record review of Resident #7's face sheet dated 10/25/23 revealed admission on [DATE] and readmission on [DATE] to the facility. Record review of Resident #7's history and physical dated 10/27/23 revealed an [AGE] year-old female diagnosed with muscle weakness (reduced muscle strength) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 2 (Resident #6 and Resident #7) of 10 residents observed for oxygen management. The facility failed to ensure Resident #6 and Resident #7 had an oxygen sign posted outside their bedrooms. This failure could place residents at risk of being exposed to combustion or flammability. Findings include: Record review of Resident #6's face sheet dated 10/25/23 revealed admission on [DATE] to the facility. Record review of Resident #6's history and physical dated 07/19/23 revealed an [AGE] year-old female diagnosed with shortness of breath, pulmonary effusion (occurs when fluid builds up in the space between the lung and the chest wall), and pulmonary embolism (sudden blockage in your pulmonary arteries, the blood vessels that send blood to your lungs). Record review of Resident #6's admission MDS 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 observation, interview, and record review the facility failed to provide care that in accordance with professional statndards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 9 (Resident #8) residents reviewed for medication administration. The facility failed to administer diarrhea medication (Imodium) as prescribed for Resident #8 who had history of loose stools on: 09/21/23 at 1:59 pm and 9:39 pm, 09/22/23 at 12:23 am, 12:04 pm, 9:48 pm, 09/23/23 at 12:04 pm and 9:48 pm, 09/25/23 at 9:59 pm, 09/26/23 at 12:59 pm. This failure could place residents at risk for not receiving their medications, not receiving the intended therapeutic effects of their medication and could contribute to possible adverse reactions. Findings included: Record review of Resident #8's face sheet dated 09/28/23 revealed a [AGE] year-old female who was readmitted on [DATE] with diagnoses of dementia (group of conditions characterized by impairment of at least two brain functions, 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 provide written notice, including the reason for the change, before the resident's room or roommate in the facility is changed for 1 of 9 (Resident #9) residents reviewed for room changes. The facility failed to notify Resident #9's RP of room changes on 06/24/2023. This failure could place residents at risk for decrease quality of life being in a new environment. Findings include: Record review of Resident #9's face sheet dated 09/28/23 revealed a [AGE] year-old female who was readmitted on [DATE] with diagnoses of dementia (group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment). Family member was listed as Emergency Contact #1 and as Responsible Party (RP). Record review of Resident #9's MDS significant change in status assessment dated [DATE] revealed a BIMS score of 03, indicating she was severely cognitive impaired. Record review of Resident #9's progress note dated 06/24/23 written by LVN…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 consult with the resident's physician when there is a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for 1 of 9 (Resident #8) residents reviewed for notification to NP/MD. The facility failed to notify NP/MD of Resident #8's unresolved loose stools. This failure could affect residents by placing them at risk of delay in medical treatment, hospitalization, and decline in condition. Findings include: Record review of Resident #8's face sheet dated 09/28/23 revealed a [AGE] year-old female who was readmitted on [DATE] with diagnoses of dementia (group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), anxiety (feeling of fear, dread, and uneasiness), gastrointestinal hemorrhage (blood often appears in stool or vomit). Record review of Resident #8's MDS significant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1 of 9 (Resident #8) residents reviewed for care plans. The facility failed to develop a care plan addressing Resident #8's history of loose stools. This failure could place residents at risk of not having their individual care needs met, which could cause a decline in physical health, psychosocial health, and quality of care. Findings include: Record review of Resident #8's face sheet dated 09/28/23 revealed a [AGE] year-old female who was readmitted on [DATE] with diagnoses of dementia (group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), anxiety (feeling of fear, dread, and uneasiness), gastrointestinal hemorrhage…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 1 of 9 (Resident #8) residents reviewed for oxygen therapy. The facility failed to ensure Resident #8's oxygen tank was full while receiving oxygen therapy. This failure could affect residents receiving oxygen therapy at risk for respiratory distress. Findings include: Record review of Resident #8's face sheet dated 09/28/23 revealed a [AGE] year-old female who was readmitted on [DATE] with diagnoses of dementia, anxiety, acute respiratory failure with hypoxia. Record review of Resident #8's MDS change in status assessment dated [DATE] revealed a BIMS score of 03, indicating she was severely cognitive impaired. Was coded with no oxygen use. Record review of Resident #8's physician orders for September 2023 revealed may use oxygen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain an effective pest control program so that the facility is free of pests and rodents for residents for 1 of 9 (Resident #9) residents reviewed for environment. The facility failed to keep Resident #9's room clean to avoid ants in room. This was determined to be past non-compliance at potential for more than minimal harm due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the inspection. Findings include: Record review of Resident #9's face sheet dated 09/28/23 revealed a [AGE] year-old female who was readmitted on [DATE] with diagnoses of dementia (group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment). Family member was listed as Emergency Contact #1 and as Responsible Party (RP). Record review of Resident #9's MDS significant change in status assessment dated [DATE] revealed a BIMS score of 03, indicating she 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.

Based on observation and interview the facility failed to post notice of the availability of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction reports in areas of the facility that were prominent and accessible to the public. 1. The facility failed to verbally inform residents or by posting a sign letting the residents know the location of the most recent survey results. This failure could place residents at risk of not being able to fully exercise their rights to be informed of the facility's survey citation history. Findings include: Observation on 04/03/2023 at 2:25 PM with the Receptionist revealed the state survey book was located on a low shelf in a desk in the front entrance of the facility. No signs were posted to indicate where the state survey book was located. In a confidential interview five of seven residents interviewed did not know they could review past survey reports or where these survey reports could be found. Interview on 04/03/2023 at 2:30 PM, the Receptionist stated she did not know where the results of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents' rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 10 (Residents #3 and #26) residents reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #3 comprehensive care plan addressed Resident #3's oxygen. 2. The facility failed to ensure Resident #26 pommel cushion in was included on her care plan. These deficient practices could place residents at risk of not receiving care and services to meet their needs. Finding include: 1. Record review of Resident #3's face sheet, dated 4/5/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #3's local hospital history and physical, dated 2/7/23,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding which included but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 2 of 10 residents (Resident # 193 and Resident #87) reviewed for enteral feeding. 1. The facility failed to ensure Resident #193 enteral feeding was changed within 48-hour period. 2. The facility failed to ensure Resident #87's enteral feeding bag label had the time the administration of the feeding was begun and did not have the rate of administration. The feeding pump did not correctly reflect the amount of formula that had been delivered to the resident. These failures could place residents at risk of insufficient nutritional supplementation and possible weight loss. Findings include: 1. 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 observation, interview, 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 2 of 10 residents (Resident #197 and Resident #14) reviewed for midline/picc care. 1. Resident #197's midline (intravenous catheter) was dated 3/8/23, edges of dressing were loosened and dry blood around insertion site. 2. Resident #14 picc line dressing was not dated These failures placed residents at risk of developing an infection. Findings included: Record review of Resident #197's face sheet, dated 4/5/23, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #197's local hospital history and physical, dated 2/26/23, revealed a diagnosis of necrosis (death of body tissue) of the left 3rd toe. Record review of Resident #197's admission nurse note, dated 3/7/23, in the cardiovascular section revealed Resident #197 had an IV…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 2 of 10 residents (Residents #3 and Resident #86) reviewed for respiratory care. 1. The facility failed to ensure Resident #3 received oxygen according to physician orders. 2. The facility failed to ensure Resident #86 received oxygen according to physician orders. 3. The facility failed to ensure the residents on oxygen in 4 of 10 rooms (403, 404, 405, 414) had oxygen signs posted outside their bedrooms as there were no signs posted outside of their bedroom for oxygen use. This failure could place residents at risk of receiving incorrect or inadequate oxygen support and decline in health. Findings include: 1. Record review of Resident #3 face sheet, dated 4/5/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE]…

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

Based on the observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 (kitchen) kitchen reviewed for food and nutrition services 1. The facility failed to ensure food products in the dry storage, freezer, and in the refrigerator were correctly labeled, wrapped, and were not expired. 2. The facility failed to ensure 2 of 6 kitchen staff effectively wore hairnets exposing their hair. These failures could place residents at risk of food borne illness. Findings include: Observations on 04/02/2023 at 8:05 AM with the Dietary Manager revealed in regular the refrigerator there was outdated or not labeled nectar drinks in 4 different containers. The dry storage are had yellow cornbread not labeled, brownie mix was expired, cereal bags not labeled or dated, chocolate chips expired, sugar was left open. The walk-in refrigerator had cheese unlabeled, pork unlabeled, apple sauce was expired, beans was not labeled, oranges, jelly, ranch, salsa de tomato were not labeled 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, interview, and record review the facility failed to ensure residents had the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the residents medical symptoms for one of 10 residents (Resident #26) reviewed for restraints The facility failed to assess and document Resident #26's need for a pommel cushion in her wheelchair. This failure could place residents at risk of having items that restrict their movement without the items having been evaluated for their necessity to treat medical symptoms or conditions. Findings include: Record review of Resident #26's face sheet, dated 04/05/2023, documented [AGE] year old female who was initially admitted to the facility on [DATE], and readmitted on [DATE]. Record review of Resident #26's History and Physical, dated 10/27/2022, documented she had diagnoses which included unspecified fracture of skull, muscle weakness, and unspecified convulsions. 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 observation, interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 2 of 10 residents (Residents #3 and Residents #26) reviewed for accuracy of assessments . 1. The facility failed to accurately reflect Resident #3's oxygen therapy on the Quarterly MDS assessment. 2. The facility failed to accurately reflect Resident #26 use of a pommel cushion in her wheelchair on her Annual MDS assessment. These failures could place residents at risk for inaccurate and incomplete MDS assessment which could cause residents not to receive correct care and services. Findings include: 1. Record review of Resident #3 face sheet, dated 4/5/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #3 local hospital history and physical, dated 2/7/23, revealed diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care and the facility failed to ensure the baseline care plan was developed within 48 hours of a resident's admission for 1 of 6 residents (Resident #197) reviewed for baseline care plan. The facility failed to ensure Resident #197 had a baseline care plan that addressed her midline IV catheter. This failure could place residents at risk of not receiving the care and services and continuity of care. Findings include: Record review of Resident #197's face sheet, dated 4/5/23, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #197's local hospital history and physical, dated 2/26/23, revealed a diagnosis of necrosis (death of body tissue) of the left 3rd toe. Record review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide treatment and services to prevent urinary tract infections for 1 of 12 residents (Resident # 57) reviewed for infection control. 1. The facility failed to ensure Resident #57's catheter bag was not on the floor. This failure place residents at increased risk for urinary tract infections. Record review of Resident #57's face sheet, dated 04/05/2023, documented a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #57's admission History and Physical, dated 05/06/2022, documented she had a Foley (urinary) catheter in place. Her diagnoses included unspecified dementia (memory loss affecting daily activities) and that she had urinary incontinence (involuntary loss of urine from the bladder) . Record review of Resident #57's electronic diagnosis listing, accessed 04/05/2023, documented she had dementia , neuromuscular dysfunction of bladder (lacked bladder control…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, which included procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 resident of 7 residents (Residents #69) reviewed for pharmacy services. 1. The facility failed to ensure LVN D did not administer expired insulin to Resident#69. 2. The facility failed to ensure LVN D administered insulin to Resident #69 according to Manufacturer's Specifications. 3. The facility failed to maintain an accurate record of controlled drug destruction. These deficient practices could result in a decline in health due to incorrect monitoring of medication after administration and an accurate record of controlled drug destruction could result in drug diversion. Findings include: 1. Record Review of Resident #69's face sheet, dated 04/05/23, revealed an [AGE] year-old female with an admission date of 05/13/21. Record Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the pharmacist reported any irregularities to the attending physician and the facility's medical director and director of nursing, and failed to ensure these irregularities were acted upon for one resident of five residents (Resident #51) reviewed for Drug Regimen Review. The facility failed to ensure the physician gave a reason for not accepting the pharmacy consultant recommendation in January 2023 that Resident #51 received gradual dose reduction for Risperdal (an antipsychotic). This deficient practice could place residents at risk of receiving unnecessary medications and dosages. Findings include: Record review of Resident #51's face sheet, dated 04/03/2023, documented a [AGE] year-old and female who was admitted to the facility on [DATE]. Record review of Resident #51's History and Physical, dated 09/09/2020, documented she had diagnoses which included schizophrenia (illness where people interpret reality abnormally), depression (persistent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents who used psychotropic drugs received gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for one resident of five residents (Resident #51) reviewed for unnecessary medications. The facility failed to ensure Resident #51 received a gradual dose reduction for Risperdal (an antipsychotic). This deficient practice could place residents at risk of receiving unnecessary medications and dosages. Findings include: Record review of Resident #51's face sheet, dated 04/03/2023, documented a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #51's History and Physical, dated 09/09/2020, documented she had diagnoses which included dementia (problems with memory, thinking and social abilities that interfere with daily life), schizophrenia (illness where people interpret reality abnormally), depression (persistent sadness and loss of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure medication error rates were not 5 percent or greater. There were 2 errors out of 27 opportunities which resulted in a 7.41 percent error rate which involved 1 of 7 residents (Residents #69) reviewed for medications. 1. The facility failed to ensure LVN D did not administer expired insulin to Resident#69. 2. LVN D failed to ensure Resident #69 received a nutritional snack/meal within 15 minutes according to manufacturer's specifications . These failures could place residents at risk of not receiving medications according to physician orders. Findings include: Record review of Resident #69's face sheet, dated 04/05/23, revealed an [AGE] year-old female with an admission date of 05/13/21. Record review of Resident #69's History and Physical, dated 10/26/22, revealed a diagnosis which included Diabetes. Record review of physician orders, dated 4/5/2023, revealed NovoLog Flex Pen (Insulin Aspart) inject as per sliding scale,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 of significant medication errors for 1 of 7 residents (Resident #69) reviewed for significant medication errors. LVN D failed to administer insulin to Resident #69 according to Manufacturer's Specifications. This deficient practice could place residents' at risk of hypoglycemia . The findings include: Record review of Resident #69's face sheet, dated 04/05/23, revealed an [AGE] year-old female with an admission date of 05/13/21. Record review of Resident #69's History and Physical, dated 10/26/22, revealed a diagnosis which included Diabetes. Record Review of Resident #69's quarterly MDS assessment, dated 01/14/2023, revealed Resident #69 had a BIMS score of 7, which indicated she had severe cognitive impairment. In section, I of the MDS assessment Resident #69 had an active diagnosis of diabetes, malnutrition (lack of proper nutrition), and anemia (lack of red blood cells in the blood). Record Review Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure medical records , in accordance with accepted professional standards and practices, were maintained on each resident that were accurately documented for 1 of 6 residents (Resident #197) reviewed for medical records. The facility failed to ensure Resident #197's treatment administration record accurately documented treatment for the residents midline dressing. This failure could place residents at risk of infection by not receiving treatment as ordered by physician. Findings include: Record review of Resident #197's face sheet, dated 4/5/23, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #197's local hospital history and physical, dated 2/26/23, revealed a diagnosis which included necrosis (death of body tissue) of the left 3rd toe. Record review of Resident #197's admission nurse note, dated 3/7/23,in the cardiovascular section revealed Resident #197 had an IV access, midline…

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