White Acres Wellness & Rehabilitation

Based on observation, and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for four halls (100-hall, 200-hall, 300-hall, and day-living area) reviewed for environment.The facility failed to maintain intact ceiling tiles in the 100-, 200-, and 300-, halls, and the day-living area, located next to the resident halls, on 01/27/2026.The facility failed to maintain stain-free ceiling tiles in the hall leading to the main dining area on 01/27/2026.These failures could place residents at risk of an unsafe, unsanitary, and uncomfortable environment. Observation on 01/28/2026 at 10:30 AM of the facility's ceiling tiles revealed they had cracks, and were bent, in the 100-, 200-, and 300- halls, and the day-living area located next to the resident halls.An observation on 01/28/2026 at 10:50 AM, of the hall leading to the main resident dining area was observed with stained ceiling tiles.In an interview on 01/29/2026 at 12:24 PM with the Maintenance Supervisor, he stated there was no policy regarding the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement quality of life for one resident (Resident #62) of eight residents who was reviewed for dignity.The facility failed to cover Resident #62's foley catheter with a privacy bag, while resident was out of bed on 01/27/26.This failure could place the residents at risk of poor self-esteem and decrease of self-worth. Findings include:Record review of Resident #62's admission record, dated 01/29/26, revealed a [AGE] year-old male with initial admission date of 09/11/23, and re-admission date of 08/04/25.Record review of Resident #62's PPS MDS dated [DATE] revealed that the BIMS was not conducted because Resident #62 was not able to participate as he is never/rarely understood. The MDS noted under Section H- Bladder and Bowel, that the resident was marked with an indwelling catheter (including…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 used in the facility was labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 10 residents (Resident #62) reviewed for enteral feedings.The facility failed to label Resident #62's enteral feeding on 01/27/26.This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects.The findings include:Record review of Resident #62's admission record, dated 01/29/26, revealed a [AGE] year-old male with an initial admission date of 09/11/23, and re-admission date of 08/04/25.Record review of Resident #62's Prospective Payment System MDS, dated [DATE], revealed the BIMS was not conducted because Resident #62 was not able to participate and was never/rarely understood. Section K- Swallowing/Nutritional Status, noted Resident #62…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 have a discharge summary that included a recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment and/or therapy, and pertinent lab, radiology, consultation results and final summary of resident status at the time of discharge for three (Residents #1, #2, and #3) of three residents reviewed for discharge summaries. The facility failed to complete a concise discharge summary of the residents stay and course of treatment in the facility for Residents #1, #2, and #3. This failure could place residents at risk of not receiving continuation of care to reduce the risk of complications and adverse events during the resident's transition to a new setting. Findings included:1. Review of the admission Record dated 11/13/25 for Resident #1 revealed, admission date 06/10/25; discharge date [DATE]. Review of the History & Physical dated 06/12/25 for Resident #1 revealed, [AGE] year-old female status post…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a comprehensive person-centered care plan were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessment for 1 of 6 residents (Resident #6) reviewed for care plans.The facility failed to invite hospice as part of the IDT team to help develop and implement a comprehensive person-centered care plan for Resident #6 who was on hospice.Findings include:Record review of Resident #6's face sheet dated 08/07/25, revealed, admission on [DATE] to the facility. Record review of Resident #6's hospital history and physical dated 03/31/25, revealed, a [AGE] year-old male diagnosed with Diabetes Mellitus and on hospice.Record review of Resident #6's quarterly MDS dated [DATE], revealed, a moderately impairment cognition BIMS of 12 to be able to recall or make daily decisions. Section O (Special Treatments, Procedures, and Programs) - was coded K1. Hospice Care. 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 a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 (Resident #7) of 4 residents reviewed for ADL care for dependent residents.The facility failed to ensure the Hospice CNA provided perineal care with professional standards to ensure Resident #7 was clean, free of contamination. This failure placed residents who were dependent on staff for ADL care at risk for inappropriate transmission-based precautions to be used.Findings include: Record review of Resident #7's face sheet dated 08/18/25, revealed, admission on [DATE] to the facility. Record review of Resident #7's facility history and physical dated 05/14/25, revealed, an [AGE] year-old female diagnosed with Alzheimer's dementia with aggression and failure to thrive (a syndrome characterized by weight loss, poor nutrition, decreased activity, and a decline in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #8) of 4 residents reviewed for accidents hazards.The facility failed to provide safe transfer assistance, using proper transfer techniques for Resident #8. CNA A and CNA B failed to secure the brakes on the mechanical lift prior to lifting Resident #8 off the wheelchair.This failure placed the resident at risk of injury from improper transfer techniques.The findings included:Record review of Resident #8's face sheet dated 08/18/25, revealed, admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #8's facility history and physical dated 06/05/25, revealed, a [AGE] year-old male diagnosed with dementia, degenerative disease of the central nervous system (a group of disorders where nerve cells in the brain and spinal cord progressively lose function, leading to a decline in physical 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 interviews and record reviews, the facility failed to ensure that the assessment accurately reflected the resident's status for 3 (Resident #7, #8, and #9) of 3 residents reviewed for accuracy of MDS assessment, in that: -The facility failed to ensure Residents #7's, #8's, and #9's MDS accurately reflected the residents' history of falls. This deficient practice could affect residents at the facility who had been assessed for risk of falls and could contribute to inadequate care. Findings included: Resident #7: Record review of Resident #7's admission Record dated 03/19/2025, revealed an [AGE] year-old female was originally admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and unsteadiness on feet. Record review of Resident #7's MDS dated [DATE], revealed a BIMS of 06 indicating that the resident had severe cognitive impairment. Section I - Active Diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to ensure the prompt resolution of all grievances to include ensuring that all written grievances decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent finding or conclusions regarding the resident's concerns; a statement as to whether the grievance was confirmed, any corrective action or to be taken by the facility as a result of the grievance, and the date when the decision was issued for 1 of 4 (Resident #1) reviewed for resident rights. The facility failed to initiate and complete a grievance for Resident #1 who voiced a complaint of the facility response to cable service outage resulting in a delay to resolve the issue. This failure could place residents at risk for grievances not being addressed or resolved promptly. Findings included: Record review of Resident #1's face sheet dated 01/07/25 revealed a [AGE] year-old female who…

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

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 (#1) kitchen reviewed for kitchen sanitation and food storage. 1. -The facility failed to keep the tile floors free of black grease build-up in the dry storage room. 2. -The facility failed to store foods in the dry storage room in sealed containers. 3. -The facility failed to keep food containers free of grease build up, and food particles in the dry storage room. 4. -The facility failed to keep the Sheet Pan Rack in the dry storage room free of stains, dust accumulation directly above the casters. 5. -The facility failed to store food cans separately from chemicals. 6. -The facility failed to keep one 5-gallon plastic water bottle off the floor. 7. -The facility failed to keep stainless steel sheet pans free food particles, black grease build-up and dried white stains. 8. -The facility failed to store food stored in the walk-in refrigerator in sealed containers. 9. -The facility failed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 8 (Resident #22, and Resident #35) residents reviewed for pharmacy services; for 3 of 3 licensed staff (LVN E, LVN C, an LVN D) and 1 of 2 Med Aides (Med Aide B). 1. The facility failed to administer Resident # 22 Lactobacillus on 10/14/24, according to physician's orders. 2. The facility failed to administer Resident # 35 Trelegy Ellipta Inhalation Aerosol Powder on 10/14/24, according to manufacturer's specification. 3. The facility failed to ensure LVN E, LVN C, Med Aide B and LVN D, 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/med aide at the change of shift. These failures could place residents at risk of harm or of not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 4 of 9 staff (Administrator, Receptionist, LVN C, Dietary Manager) reviewed for trainings. The facility failed to ensure staff received training on effective communication for the Administrator, Receptionist, LVN C, and Dietary Manager. This failure could place residents at risk of not having a way to effectively communicate their wants or needs. Findings include: In an interview and record review of the facility employee listing, on 10/16/2024 , the Business Office Manager revealed the following employees had not completed training on effective communication: Administrator hire date 5/7/23, Dietary Manager 5/16/22, Receptionist hire date 12/2/13, LVN C hire date 9/29/23. She said it was important employees were trained to ensure the safety of the residents. She said the risk to residents was that they would be getting treatment from untrained personnel. In an interview on 10/16/24 4:34 PM, the Administrator said it was not acceptable for the…

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

Based on interview and record review the facility failed to ensure training was provided regarding dementia management and resident abuse prevention for 4 of 9 employees (Administrator, Receptionist, LVN C and dietary manager) reviewed for training. The facility failed to ensure the Administrator, Receptionist, LVN C and Dietary Manager received training on dementia management. This failure could place residents at risk of improper management of dementia-related issues. Findings include: In an interview and record review of the facility employee listing on 10/16/2024, the Business Office Manager, revealed the following employees had not completed training on dementia: Administrator hire date 5/7/23, dietary manager 5/16/22, Receptionist hire date 12/2/13, LVN C hire date 9/29/23. The Business Office Manager said it was important employees were trained to ensure the safety of the residents. She said the risk to residents was they would be getting treatment from untrained personnel. In an interview on 10/16/24 at 4:34 PM, the Administrator said that it was not acceptable for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on, interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were accurately documented for 1 of 8 residents (Resident #22) reviewed for medical records. -The facility failed to ensure LVN A documented in the Nurse's Notes when he called the Nurse Practitioner changed the order for Lactobacillus for Resident #22. This failure could place residents at risk of medication errors. Findings include: Record review of Resident #22's admission Record, dated 10/16/24, reflected 62-year-male who was admitted to the facility on [DATE]. Record review of Resident #22's Hospital History & Physical, dated 06/10/24, reflected he had diagnoses which included constipation and irritable bowel syndrome with diarrhea (is a common digestive disorder that affects the large intestine and causes chronic abdominal pain, bloating and changes in bowel habits. Symptoms can include diarrhea, Constipation, or both…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 7 residents (Resident #7) reviewed for enteral feeding. The facility failed to ensure Resident #7's head of bed was maintained at 30 degrees elevated while receiving continuous feeding. The failure could place residents at risk of aspiration (when food or liquid goes into the lungs or airway). Findings included: Record review of Resident #7's face sheet dated 09/27/24 revealed a [AGE] year old male who was admitted to the facility on [DATE] with diagnoses of anoxic brain damage (brain damage from a lack of oxygen to the brain), persistent vegetative state (condition in which a person is awake but has no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure medical records, in accordance with accepted professional standards and practices, were maintained on each resident that were accurately documented for 1 of 6 residents (Resident #2) reviewed for accuracy of clinical records. The facility failed to ensure Resident 2's treatment administration record accurately documented treatment for orders before 09/13/24, for the Resident #2's wander guard. This failure could place residents at risk of inaccurate medical records that could affect monitoring and medical services provided. Findings include: Record review of Resident #2's face sheet dated 09/25/24, revealed admission on [DATE] and re-admission on [DATE] to the facility . Record review of Resident #2's hospital history and physical dated 05/20/24, revealed a history of falls, failure to thrive, Type 2 Diabetes, muscle weakness, abnormalities of gait and mobility, lack of coordination, and Dementia. Record review of Resident #2's order recap 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 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 1 (Resident #7) of 9 residents reviewed for dignity. Resident #7's catheter bag did not have a privacy bag cover exposing the catheter bag. This failure could place residents at risk of diminished quality of life and compromise residents' dignity for those who require a urinary catheter care. Findings included: Record review of Resident #7's face sheet dated 03/06/24, revealed, admission on [DATE] to the facility. Record review of Resident #7's hospital history and physical dated 12/08/23, revealed, a [AGE] year-old male diagnosed with Neurogenic Bladder (the name given to a number of urinary conditions in people who lack bladder control due to a brain, spinal cord or nerve problem) and Long-Term Foley Catheter…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 #4) of 3 residents reviewed for wanting her room light on at all times in that: The facility failed to ensure that Residents #4 room lights remained on at all times as requested by Resident #4. This failure put residents at risk of their preferneces not being honored. Findings included: Resident #4 Record review of Resident #4's face sheet dated 03/06/24, revealed, admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #4's hospital history and physical dated 03/03/23, revealed, a [AGE] year-old female diagnosed with Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), anxiety disorder (persistent and excessive worry that interferes with daily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 coordinate assessments in ehich a PE was not conducted after the pre-admission screening indacating a Yes for intellectual disability and resident review (PASARR) program under Medicaid for 1 (Resident #6) of 2 residents reviewed for PASRR Evaluation. The failed to conduct a PASRR Evaluation for Resident #6 after coming out positive on the PASRR Level 1. This failure can place residents who are PASRR positive at risk of not getting the PASARR services for a better quality of life and could lead to a decline in health. Findings include: Record review of Resident #6's face sheet dated 03/06/24, revealed admission on [DATE] to the facility. Record review of Resident #6's PASRR Level 1 Screening conducted by RN Case Manager dated 08/11/23, revealed, Resident #6 was positive for intellectual disability. Record review of Resident #6's PASRR Level 1 Screening conducted by admission Coordinator dated 08/17/23, revealed, Resident #6 was positive for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 2 (Resident #4 and Resident #6) of 9 residents reviewed for care plans in that: The facility failed to implement a comprehensive person-centered care plan for Resident #4's history of wanting her room light on all the time. The facility failed to implement a comprehensive person-centered care plan for Resident #6's PASRR positive for services. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. Findings include: Resident #4 Record review of Resident #4's face sheet dated 03/06/24, revealed, admission on [DATE] and re-admission on [DATE] to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 #2 and Resident #7) of 3 residents observed for oxygen management. Resident #2's nasal cannula was not bag while it was not in use. Resident #7's catheter bag did not have a privacy bag cover exposing the catheter bag which could cause infection. This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health. Findings include: Resident #2 Record review of Resident #2's face sheet dated 03/06/24, revealed, admission on [DATE] to the facility. Record review of Resident #2's facility history and physical dated 10/04/23, revealed, a [AGE] year-old female diagnosed with Chronic obstructive pulmonary disease (a common lung disease causing restricted airflow and breathing problems), and history of Covid-19 (an infectious disease caused by…

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

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for professional standards for food service safety. The following were observed: -1 unlabeled package of sliced wheat bread observed on shelf under steam table. -1 unlabeled package of 4 hamburger buns observed on shelf in dry storage room. -1 bottle of vanilla icing dated 03/2023. These failures could place residents at risk of food-borne illness. Findings included: Observation on 08/21/23 at 8:57 AM of kitchen revealed a package of sliced wheat bread on a shelf under steam table. The package was unlabeled and missing the date of when it was opened and expiration date. Observation on 08/21/23 at 9:07 AM of kitchen revealed a package of hamburger bread on a shelf in the dry storage closet. The package was unlabeled and missing the date of when it was opened and expiration date. Observation on 08/21/23 at 9:12 AM of refrigerator revealed a bottle of vanilla icing used for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 #7 and Resident #15) of 10 residents observed for oxygen management. -Resident #7 ' s oxygen tank was empty while being used. -Resident #7 did not have a physcian order for oxygen while receiving oxygen therapy. -Facility failed to follow oxygen policy stating disposable equipment had to be changed weekly and marked with date and initals for Resident #7 and Resident #15. This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health. Findings included: Resident #7 Review of Resident #7 ' s Face Sheet dated 08/24/2023 documented an [AGE] year-old male with an initial admission date to the facility on [DATE] and a re-admission date of 08/18/2023. Review of Resident #7 ' s History and Physical dated 08/10/2023 documented a diagnosis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dispose of garbage and refuse properly for 1 of 1 trash bins located in the dining room and 2 of 3 dumpsters (Dumpster #2 and #3) located outside of the facility. -2 dumpsters located outside the facility were found without covers when not in use. -1 trash bin located in the dining room had trash coming out of the container. These failures could place residents at risk of decreased quality of life due to an exterior environment which could attract pests, rodents, and other animals. Findings included: Observation on 08/21/23 at 12:00 PM in dining room revealed trash bin next to handwashing sink located inside the dining room was overflowing with trash. Observation on 08/22/23 at 2:26 PM, 3 dumpsters were observed outside the facility on the back of the property. Dumpster #2 was covered with one lid with no trash exceeding its limit. Dumpster #3 was uncovered and had trash exceeding its limit. An interview on 08/21/23 at 12:32 PM with the Dietary Manager revealed he was responsible for overseeing the trash…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 residents (Resident #9 and Resident #142) reviewed for infection control. -CNA D failed to follow infection control practices when providing perineal care for Resident #9. - The facility failed to follow infection control practice when CNA C did not dispose of Resident# 142 soiled linen correctly. These failures could place residents at risk of infections. Findings included: Review of Resident #9 ' s Face Sheet dated 08/24/2023 documented a [AGE] year-old male with an admission date to the facility of 09/02/2020. Review of Resident #9 ' s History and Physical dated 03/17/2023 documented Resident #9 had a diagnosis of Parkinson ' s Disease; a neurological disease that causes stiffness and tremors. He also had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to notify the resident and the resident ' s representative(s) of the discharge and the reasons for the move in writing and in a language and manner they understand and also failed to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 2 residents (Resident #204 and Resident #30) of 3 reviewed for discharges. -Facility did not provide a 30-day written discharge notice to Resident #204 ' s or Resident #30 ' s family representative or to the State Ombudsman. This failure could place residents at risk of being wrongfully discharged if the process for discharge is not followed. Findings included: Resident #204 Closed record review of Resident #204 ' s Face Sheet dated 08/24/2023 documented a [AGE] year-old male with an admission date to the facility of 04/08/2022. Closed record review of Resident #204 ' s History and Physical dated 05/02/2023 documented a diagnosis of COPD with use of supplemental 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 to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 2 of 6 residents (Resident #7 and Resident #25) reviewed for care plans in that: The facility failed to develop a comprehensive person-centered care plan for Resident #7 to address the resident's need for oxygen and monitoring for signs and symptoms of hypoxia (low levels of oxygen in the body). The facility failed to implement Resident #25's comprehensive person-centered care plan for finger nail care. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. Findings include: Resident #7 Record review of Resident #7's face sheet dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents who are unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 6 residents (Resident #25) reviewed for grooming, and personal and oral hygiene. 1. Resident #25 had long fingernails that were dirty and had a black substance underneath them. This deficient practice could place residents who required assistance with showering and maintaining good personal hygiene at risk for not receiving care and services to meet their needs and avoid ADL decline. Findings include: Review of Resident #25 face sheet dated 08/21/23 revealed admission on [DATE] to the facility. Review of Resident #25 history and physical dated 09//21/22 revealed a [AGE] year-old male diagnosed with dementia. Review of Resident #25 annual MDS assessment dated [DATE] revealed resident #25's cognitive score as a 6 with recall and understanding. Resident #25's ADLs…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administered consistent with professional standards of practice and in accordance with physician orders for 1 (Resident #38) of 2 residents reviewed for peripheral intravenous care. 1. Resident #38 did not have his intravenous tube/dressing dated and orders did not indicate when to change the dressing. This failure placed residents at risk of developing an infection. Findings include: Resident #38 Review of Resident #38's face sheet dated 08/23/23 revealed admission on [DATE] to the facility. Review of Resident #38's history and physical dated 06/22/23 revealed an [AGE] year-old male diagnosed with UTI (urinary tract infection). Review of Resident #38's quarterly MDS assessment dated [DATE] revealed Resident #38's cognition to understand and recall at a score of 12 . Resident #38's IV medication was not indicated as this was administrated after this MDS assessment. Review of Resident #38's care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents were free of significant medication errors for 1 of 7 residents (Resident #39) reviewed for significant medication errors. LVN B failed to administer insulin to Resident #39 according to Manufacturer's Specifications. This deficient practice could place residents at risk of hypoglycemia. The findings include: Record Review of Resident #39's face sheet, dated 08/22/23, revealed an [AGE] year-old female with an admission date of 09/16/21. Record Review of Resident #39's History and Physical, dated 05/03/23, revealed a diagnosis of Diabetes type 2. Record Review of Resident #39's physician orders, dated 1/20/22, revealed order for Insulin Lispro Solution inject as per sliding scale, subcutaneously before meals and at bedtime related to type 2 diabetes. Resident #39 was ordered to receive 2 units according to blood glucose of 172 mg/dl. Record Review of Resident #39's quarterly MDS assessment, dated 06/14/2023, revealed…

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