Downtown Health and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure the resident's right to be free from abuse for one (Resident #1) of 4 residents reviewed for abuse, in that: On 09/16/2025 the facility failed to ensure that Resident #1 was not spoken to in a verbally abusive way by CNA A who called Resident #1 an expletive. This failure could result in resident abuse and mental decline. Findings included:Record review of Resident #1's admission record revealed a [AGE] year-old female admitted on [DATE] with a primary diagnosis of [NAME]-[NAME] Syndrome (a rare genetic disorder characterized by a constant feeling of hunger (hyperphagia), which leads to obesity if not managed.)Review of Resident #1's Quarterly Minimum Data Set, dated [DATE] revealed a BIMS score of 09(Moderate cognitive impairment.) Review of Resident #1's Care Plan dated 11/24/2025 revealed Focus: Behavior: Resident #1 exhibits maladaptive behavior at times r/t intellectual disability poor coping skills behave at an age lower than her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury for 1 of 3 (Resident #2) residents reviewed for abuse and neglect. The facility LVN A, LVN B, CNA C and CNA D did not report Resident #2's allegations of abuse and neglect to the Admin who was the abuse coordinator. This failure could place residents at risk of injuries, abuse, and/or neglect. Findings Include: Record review of Resident #2's face sheet, dated 01/16/25, reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses which included: paraplegia unspecified (the symptom of paralysis that mainly affects your legs though it can sometimes affect…

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 provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (medication cart) of 1 medication cart on the memory care unit reviewed for pharmacy services The facility failed to ensure discontinued medication were removed from the medication cart. Resident #1's Diazepam that was DC on 12/30/24 was in the narcotic box on the secure unit medication cart. This failure could place residents at risk of unnecessary medication error and/or lead to possible harm or drug diversion. The findings included: Interview on 5/13/25 at 9:50 PM LVN A stated when medications were wasted, they should be crushed and disposed of and two people, 2 nurses, were to sign off on the narcotics sheet and document medication was wasted. Observation and record review on 05/13/25 at 11:00 PM revealed a secure unit narcotic sheet that was not filled out completely for Resident #1's Diazepam 5 mg tablet. 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 interview and record review, the facility failed ensure residents were free of any significant medication errors for one (Residents #1) of four residents reviewed for medications. 1. Resident #1's Lisinopril and Metoprolol (medications used to lower blood pressure) were not held per physician's order on 07/13/25, 07/21/25, 07/23/24, and 07/25/24 when the resident's blood pressure was below parameters. These failures could place residents at risk of not receiving their medications as ordered or possible illness. Findings included: Record review of Resident #1's face sheet reflected a [AGE] year-old female, with an admission date of 07/11/24. Resident #1 had a diagnoses of Multiple Sclerosis (chronic disease that affects the brain and spinal cord), Cognitive Communication Deficit (communication difficulty), Essential Hypertension (high blood pressure), and History of Transient Ischemic Attack (brief interruption of blood flow to the brain). The face sheet noted a discharge date of 09/17/24. 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 develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident 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 1 of 4 residents, (Resident #1) reviewed for care plans. 1. The facility failed to address Resident #1's multiple refusals of care and services on the comprehensive care plan This failure could place residents at risk of not receiving the necessary care and services. Findings included: Record review of Resident #1's face sheet reflected a [AGE] year-old female, with an admission date of 07/11/24. Resident #1 had diagnoses of Multiple Sclerosis (chronic disease that affects the brain and spinal cord), Cognitive Communication Deficit (communication difficulty), and History of Transient Ischemic Attack (brief interruption of blood flow to the brain). The face…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #2) of 3 residents reviewed for infection control. 1. The Treatment Nurse failed to discard contaminated gauze after performing wound care on Resident #2 on 05/07/25. This failure could put residents at risk of infection from cross contamination. Findings included: Record review of Resident #2's face sheet dated 05/08/25, reflected a [AGE] year-old female, with an admission date of 05/05/25. Resident #2 had diagnoses of Chronic Venous Hypertension with Ulcer of Bilateral Lower Extremity (damaged leg veins that causes blood pressure build up and skin breakdown), and Type 2 Diabetes with foot ulcer (body cannot regulate blood sugar levels). In an observation and interview on 05/08/25 starting at 8:40…

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 maintained acceptable parameters of nutritional status for one (Resident #1) of two residents reviewed for nutrition. The facility failed to ensure Resident #1 maintained acceptable parameters of nutritional status as demonstrated by Resident #1 experiencing a 25.96% weight loss in 4 months. She had an active decline in her weight from 01/08/25 - 04/15/25. This failure could place residents at risk for decreased nutritional status, decline in health, malnutrition, or hospitalization. Findings included: Review of Resident #1's admission record reflected she was a [AGE] year-old female who admitted to the facility on [DATE], with diagnoses including protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), diabetes mellitus (a group of metabolic diseases characterized by high blood sugar levels), dependence on renal dialysis (when a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Residents #6) of four reviewed for adequate supervision. LVN R failed to complete a fall assessment and implement interventions for Resident #6 after a fall, to prevent reoccurrence. The facility failed to ensure an updated fall assessment was complete for Resident #6. This failure could affect residents by not having the necessary resources to ensure appropriate care, interventions, and supervision were provided. Findings included: Review of Resident #6's Face Sheet dated 04/01/2025 revealed the resident was a [AGE] year-old female was initially admitted on [DATE], and again on 08/20/2024. Relevant diagnoses were alcohol dependence with alcohol-induced persisting dementia, unspecified protein-calorie malnutrition, other reduced mobility, history of falling, other lack of coordination, unsteadiness on feet, muscle weakness (generalized),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #6) of 3 residents reviewed for Respiratory Care. The facility failed to ensure that Resident #6's nasal cannula and tubing was off the floor, properly stored when not in use, and her humidifier bottle water was dated. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: Review of Resident #6's Face Sheet, dated 04/01/25, reflected the resident was a [AGE] year-old female was initially admitted on [DATE], and again on 08/20/2024. The resident was diagnosed with alcohol dependence with alcohol induced persisting dementia (cognitive decline from alcohol use), Chronic pain, History of falling, benign neoplasm of left bronchus…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to ensure that all drugs and biologicals were accurately dispensed and administered to meet the needs of each resident when 1 (Resident #5) of 3 residents were reviewed for pharmaceutical services. The facility failed to ensure Resident #5 did not miss a dose of antibiotic medication that was to be administered on 12/21/24. This failure could place residents at risk of not receiving their medications as ordered by their physician. Review of Resident #5's Face Sheet, dated 12/23/24, reflected Resident #5 admitted [DATE] with paraplegia (paralysis in lower half of body) and right femur (large bone in upper leg) chronic osteomyelitis (bone infection). Review of Resident #5's Physician Order, dated 12/20/24, reflected an order for Vancomycin (antibiotic that treats infection caused by bacteria) intravenous (administer directly into a person's vein) solution 750 mg plus 500 mg = 1250 mg intravenously every 12 hours (at 09:00 AM and 09:00 PM) 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 all drugs and biologicals were stored in accordance with currently accepted professional standard for 1 of 2 medication rooms (Med Room A) reviewed for storage of drugs. ADON A failed to ensure medications were secured and not left out in the open outside Med Room A. This could affect residents by placing them at risk of medication not meeting therapeutic levels, misuse and diversion. Findings included: Review of Resident #12's face sheet, dated 12/19/24, revealed the resident was a [AGE] year-old male readmitted on [DATE] with the diagnoses of epilepsy (seizure disorder), schizophrenia ( a serious mental health condition that affects a person's thoughts, feelings and behaviors), and essential hypertension (high-blood pressure). Review of Resident #51's face sheet, dated 12/19/24, revealed the resident was a [AGE] year-old male admitted on [DATE] with the diagnoses of type 2 diabetes, heart failure, and personal history of transient…

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, and accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services. 1. The facility failed to ensure stored food was properly labeled (marked or identified with the contents in the bag), dated ( date the item was received into the facility) . These failures could place all residents at risk of cross contamination and food-borne illness. Findings include: Observation on 12/17/2024 at 8:47 AM, during initial kitchen rounds of 1 of 1 walk-in freezer revealed: 1. An unopened bag of 8 pack of pre-made frozen pancakes, a unopen bag of broccoli were not labeled (marked or identified with the contents in the bag) and not dated (date the item was received into the facility) and not in the original box. 2. Open cardboard box contained individual 4 fl oz magic cup ice cream containers the top of the box had ice crystal conduction collected on top. Interview on 12/19/2025 at 9:42 AM with Dietary Manager revealed the expectation is staff are to close…

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 specialized rehabilitative services such as but not limited to physical therapy, speech therapy-language pathology, occupational therapy, respiratory therapy, and rehabilitative services for mental illness and intellectual disability or services of a lesser intensity as required in the resident's comprehensive plan of care for 2 of 2 residents (Resident #1 and Resident #111) reviewed for specialized rehabilitative services. The facility failed to screen Resident #1 and Resident #111 for physical therapy. This failure could place residents who required rehabilitative services at risk of a decline or decrease in their physical capabilities. Findings included: Review of Resident # 1's face sheet, dated 12/19/2024, revealed a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, personal history of transient ischemic attack (stroke), heart failure and chronic obstructive pulmonary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 30 residents reviewed for infection control (Resident 34, #59, #88, and #369) 1. The facility failed to follow EBP (Enhanced Barrier Precautions) procedures for Resident #34 when LVN Failed to wear PPE while administering medications to Resident #34. 2. The facility failed to follow contact isolation precautions (this is a precaution used to prevent the spread of germs that are spread by touching a person or their belonging) when ADON A and the wound care physician failed to don (to put on) PPE while providing wound care for Resident #369. 3. CNA C failed to sanitize her hands in between feeding Resident #59 and Resident #88. These failures affected residents by placing them at an increased and unnecessary risk of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to care for residents in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for two of four residents (Resident #59 and 88) reviewed for resident rights. CNA C failed to ensure the dignity of Residents #59 and #88 was respected during the breakfast meal when CNA C yelled in front of the residents at Laundry Aide D while they were being fed. This failure could place residents who need assistance with eating at risk for weight loss and a decreased quality of life. Findings included: Review of Resident #88's face sheet, dated 12/18/24, revealed the resident was a [AGE] year-old female admitted on [DATE], with the diagnoses of cognitive communication deficit, dysphagia (difficulty swallowing), and legal blindness. Review of Resident #88's quarterly MDS assessment, dated 11/15/24, revealed the resident was rarely/never understood. Resident #88 was dependent on staff on eating. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #115) reviewed for accidents and supervision. The facility failed to ensure Resident #115 received adequate supervision when he went out into the courtyard to smoke during non-smoking times. This failure placed residents who required supervision at risk of injury or accidents. Findings included: Review of Resident #115's face sheet, dated 12/18/24, revealed the resident was a [AGE] year-old male admitted on [DATE] with diagnoses of staphylococcus arthritis, right knee, methicillin resistant staphylococcus aureus infection as the cause of disease (MRSA - a type of bacteria that many antibiotics don't work on), and hypertension (high-blood pressure). Review of Resident #115's initial MDS Assessment, dated 12/08/24, revealed the resident had a BIMS score of 15, which indicated the resident was cognitively intact.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for two (Resident #34 and Resident #74) of five residents reviewed for pharmaceutical services. LVN E failed to hold medication Furosemide 40 MG with parameter to hold at SBP less than110 when Resident #34's BP was 95/84. LVN E failed to check vancomycin blood level (trough) results for Resident #74 before administering vancomycin antibiotic. These failures placed residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. Findings included: Review of Resident #34's face sheet, dated 12/18/24, revealed the resident was an [AGE] year-old female readmitted on [DATE] with the diagnoses of type 2 diabetes, sepsis, and hypertension. Review of Resident #34's physician…

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 all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Evaluation assessment for 1 of 4 residents (Resident #5) reviewed for preadmission screenings. The facility failed to refer Resident #5 for PASRR Evaluation after a positive Level 1 PASRR 1 screening. This failure could place residents at risk of receiving inadequate care. The surveyor was unable to interview and observe Resident #5, as he was discharged on 11/02/24. Record review of Resident # 5's face sheet dated 12/04/24 revealed that he was a 68 -year-old male who admitted to the facility on [DATE] and discharged on 11/02/24. His active diagnosis included: cognitive communication deficit (difficulty communicating caused by cognitive impairment), anxiety disorder (fear and worrying) and depression disorder (mood of sadness). Record review of Resident #5's admission MDS dated [DATE], reflected a BIMS score of 12 indicating…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care that was developed within 48 hours of resident's admission for 1 (Resident #5) of 4 residents reviewed for baseline care plans. The facility failed to ensure Resident #5's baseline care plan addressed his Level 1 PASSR, mental illness, anxiety, and depression within 48 hours of resident's admission. This failure could place the residents at increased risk of not having their individual needs identified, met and a decreased quality of life. Findings included: The surveyor was unable to interview and observe Resident #5, as he was discharged on 11/02/24. Record review of Resident # 5's face sheet dated 12/04/24 revealed that he was a 68 -year-old male who admitted to the facility on [DATE] and discharged on 11/01/24. He had an active diagnosis of cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible to prevent accidents for 4 (Resident#1, Resident#2, Resident#3, and Resident#4) of 6 residents reviewed for hazards. The facility failed to ensure Resident#1 and Resident#4 did not keep cigarettes and lighters on themselves. The facility failed to ensure (Resident#2 and Resident#3) did not pick up cigarette butts left on the ground to reuse. These failures placed residents at risk of being burned. Findings included: Record review of Resident#1's face sheet dated 09/11/24 reflected he was a [AGE] year-old, male admitted to the facility on [DATE]. Resident#1 was diagnosed with unspecified Dementia, syncope and collapse, anxiety disorder, history of falling, and nicotine dependence. Record review of Resident#1's Quarterly MDS dated [DATE] reflected: Resident#1 had a BIMS score of 13 which indicted cognition intact. Record review of Resident#1's care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure that residents received proper treatment and care to maintain mobility and good foot health, and failed to provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) for 1 of 1 resident (Resident #1) reviewed for foot care. The facility failed to ensure Resident #1 had her toenails trimmed by a podiatrist. This failure could place residents at risk of discomfort, poor foot hygiene, or a decline in residents' physical condition. Findings included: Record review of Resident #1's admission record, dated 09/05/2024, revealed an [AGE] year-old female who admitted on [DATE] with diagnoses that included Alzheimer's Disease, muscle wasting and atrophy, muscle weakness, and cognitive communication deficit. Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 00, indicating severe cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 2 of 3 residents (Resident #2 and Resident #3) reviewed for ADL care. The facility failed to ensure Resident #2 and Resident #3 were provided nail care as needed. These failures could place residents at risk of not receiving services and a decreased quality of life. Findings included: Record review of Resident #2's admission Record, dated 09/05/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included cerebral infarction, vascular dementia, contracture, left hand, and cognitive communication deficit. Record review of Resident #2's quarterly MDS assessment, dated 08/27/2024 revealed a BIMS score of 9, indicating moderate cognitive impairment. Record review of Resident 21's care plan, dated 11/23/2023, revealed Resident #1 had an ADL Self Care Performance…

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 were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 2 (Resident #10 and Resident #11) of 9 residents reviewed for ADL care. The facility failed to ensure Resident #10, and Resident #11 were provided showers as scheduled. These failures could place residents at risk of not receiving services and a decreased quality of life. Findings included: Record review of Resident #11's admission record, dated 07/23/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure with hypoxia, end stage renal disease, muscle weakness, and dependence on renal dialysis. Record review of Resident #11's Quarterly MDS dated [DATE], reflected a BIMS score of 14, indicating intact cognition. Further review of the MDS revealed Resident #11 required partial/moderate assistance for showering/bathing. Record review of Resident…

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

Based on observations, interviews, and record review the facility failed to ensure the resident environment remained free of accident hazards as was possible for 1 of 1 secured unit dining room reviewed for accidents and hazards. The facility failed to ensure residents who used the dining/activity room in the secured unit were free of hazards, when a window air condition unit cord was loose while plugged into a live extension cord coiled unsecured above a doorway. This failure could place residents at risk for accidents or injuries resulting from hazards in the facility. Findings included: Observation on 07/23/2024 at 12:22PM of the secured unit dining/activity room revealed approximately 22 residents who were seated at tables waiting on lunch trays to be served by staff. A table that was pushed against the wall by the door to the secure courtyard had three residents seated. The window unit was directly beside a resident chair with the loose cord hanging down near the floor and curved upwards attached to an extension cord that could be easily reached by residents. The extra length…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect for one (Resident #1) of one incident reviewed for reporting according to facility policy. CNA A failed to follow the facility's policy to report allegations of abuse when allegedly she observed CNA B hold Resident #1 down in a choke hold on 04/24/24. This failure could place the residents in the facility at risk of abuse and lack of timely reporting of incidents. Findings included: Review of the facility's policy titled Abuse/Neglect, revised 03/29/18, reflected the following: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately to the Administrator of the facility for 1 (Resident #1) of 5 residents reviewed for reporting abuse and neglect. CNA A failed to immediately report to the Administrator an allegation of abuse involving CNA B and Resident #1 that allegedly occured on 04/24/24. The failure placed residents at risk of not having abuse allegations reported. Findings included: Review of Resident #1's face sheet revealed the resident was [AGE] year-old male, admitted on [DATE], with diagnosis of Alzheimer's disease (brain disorder that causes memory loss), muscle weakness, difficulty in walking, abnormalities of gait and mobility, abnormal posture (involuntary position of the body), delusional disorders (one or more persistent beliefs that are not based on reality). Review of Resident #1's MDS dated [DATE] revealed the Resident #1 had a BIMS score of 00, indicating Resident #1 was not able 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 reviews, the facility failed to review and revise care plans for 2 (Residents #1 and #2) of 5 residents reviewed for care plan revision. The facility failed to revise Resident #1 and #2's care plans to reflect their need for direct supervision while smoking. This failure could place the residents at risk of harm to themselves or other residents Findings included: Review of Resident #1's undated admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included paralysis, seizures, stroke affecting left side, and cardiac pacemaker. Review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 15 indicating she was cognitively intact. Her Functional Status indicated she required a wheelchair for mobility, and limited assistance with her ADLs. Review of Resident #1's care plan revealed she did not have a focus area on smoking and/or smoking with supervision. Review of Resident #1's monthly…

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 receives adequate supervision and assistance devices to prevent accidents for 5 (Residents #1, #2, #3, #4, and #5) of 5 residents reviewed for accidents and hazards. The facility failed to ensure Residents #1, #2, #3, #4, and #5 were supervised while smoking This failure could place the residents at risk of injuring themselves or harming another resident. Findings included: Review of Resident #1's undated admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included paralysis, seizures, stroke affecting left side, and cardiac pacemaker. Review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 15 indicating she was cognitively intact. Her Functional Status indicated she required a wheelchair for mobility, and limited assistance with her ADLs. Review of Resident #1's care plan revealed she did not have a focus area on smoking and/or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assure full visual privacy for 2 (Residents #6 and #7) of 5 residents reviewed for privacy. The facility failed to provide privacy curtains for Residents #6 and #7 while their curtains were being laundered. This failure could place the residents at risk of decreased feelings of self -worth. Findings included: Review of Resident #6's undated admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included bone infection, diabetes, amputation of right leg below the knee, and Opioid abuse. Review of Resident #6's admission MDS, dated [DATE], revealed a BIMS score of 15 indicating he was cognitively intact. His Functional Status indicted he was mostly independent in his ADLs. Review of Resident #6's care plan, dated 04/20/24, revealed he had a focus area for a surgical incision to his right toes and left leg requiring wound care and a focus area for the resident's self-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 receive proper treatment and care to maintain good foot health by providing foot care and treatment, in accorance with professional standards of practice, including to prevent complications from the resident's medical condition, for four of eight residents (Residents #1, #2, #3 and #4) reviewed for foot care. The facility failed ensure foot care, specifically trimming of toenails, was provided for Residents #1, #2, and #3. This failure could result in residents developing fungal infections or other podiatric problems. Findings included: Review of Resident #1's undated admission Record revealed the resident was a [AGE] year-old female admitted to that facility on 05/10/23 with diagnoses that included senile degeneration of the brain (severe decline in mental ability), high blood pressure, and delusions. Review of Resident #1's quarterly MDS assessment, dated 02/23/24, revealed a BIMS score not calculated due to her mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 4 residents (Resident's #1) reviewed for abuse. 1. The facility failed to implement their policy on reporting abuse for a resident-to-resident altercation that occurred on 02/18/2024 between Resident #1 and Resident #2. 2. The facility failed to implement their policy and procedures on investigating allegations of abuse for a resident-to-resident altercation that occurred on 02/18/2024 between Resident #1 and Resident #2. These deficient practices could place residents at risk for abuse, neglect, and not having their needs met. Findings include: Resident #1 A record review of Resident #1's electronic face sheet, dated 02/21/24, reflected Resident #1 was a [AGE] year-old male, who was admitted to the facility on [DATE] with diagnoses which included dementia ,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse were reported immediately, but no later than 2 hours after the allegation was made, for 2 of 4 residents (Residents #1 and Resident #2) reviewed for abuse. The facility failed to report a resident-to-resident altercation that occurred on 02/18/24 between Resident #1 and Resident #2 to the State Survey Agency within 2 hours of being notified. This failure could place residents at risk for abuse. Findings include: Resident #1 A record review of Resident #1's electronic face sheet, dated 02/21/24, reflected Resident #1 was a [AGE] year-old male, who was admitted to the facility on [DATE] with diagnoses which included dementia , abnormalities of gait (a change to your walking pattern) and mobility, and muscle weakness. A record review of Resident #1's Quarterly MDS, dated [DATE], reflected Resident #1 was able to complete a BIMS assessment and had a BIMS score of 0, which indicated his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must have evidence that all alleged violations were thoroughly investigated for 1 of 4 residents (Residents #1) reviewed for abuse. The facility failed to thoroughly investigate a resident-to-resident altercation that occurred on 02/18/24 between Resident #1 and Resident #2. This failure could place residents at risk for abuse. Findings include: Resident #1 A record review of Resident #1's electronic face sheet, dated 02/21/24, reflected Resident #1 was a [AGE] year-old male, who was admitted to the facility on [DATE] with diagnoses which included dementia , abnormalities of gait (a change to your walking pattern) and mobility, and muscle weakness. A record review of Resident #1's Quarterly MDS, dated [DATE], reflected Resident #1 was able to complete a BIMS assessment and had a BIMS score of 0, which indicated his cognition was severely…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical and psychosocial needs for one (Resident #2) of 2 residents reviewed for care plans. The facility failed to develop and implement a care plan addressing Resident #2's behaviors. This failures placed residents at risk of not receiving necessary care and services to meet his individual needs. Findings included: Record review of Resident #2's admission record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included unspecified Dementia, unspecified severity, with other behavioral disturbance. Assigned to the secured unit. Record review of Resident #2's quarterly Minimum Data Set (MDS) assessment, dated 12/14/2023 revealed his (BIMS) score was 00 (severe cognitive impairment). Review of Resident #2's care plan dated 10/17/2023 revealed there was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of two residents observed for accidents. Resident #1's bed's wheels failed to lock when placed in the lowest position allowing the bed to roll away from the wall, which caused Resident #1 to fall through the gap. This deficient practice has potential to affect residents by placing them at risk for serious injuries and accidents. Findings included: Record review of Resident #1's current admission record, dated12/19/23, revealed a [AGE] year-old male with an admission date of 11/08/2014. Resident #1's diagnosis included unspecified convulsions (a sudden, violent, irregular movement of a limb or of the body, caused by involuntary contraction of muscles and associated especially with brain disorders). Resident #1 placed on the secured unit. Record review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that a physician signed and dated orders for 2 of 2 residents (Resident #66 and Resident #256) reviewed for medical records. The facility failed to obtain orders for contact isolation for Resident #66 and Resident #256. This failure placed residents at risk for not receiving appropriate care. Findings included: Record review of Resident #66's face sheet, dated 11/15/2023, revealed a [AGE] year-old female with original admission date of 12/22/2023 and readmission date of 10/02/2023. Resident #66's diagnoses included senile degeneration of brain, hemiplegia and hemiparesis following cerebral infarction affecting left side, Chronic Obstructive Pulmonary Disease, and Type 2 Diabetes. Record review of Resident #66's admission MDS, dated [DATE], reflected a BIMS score of 14 indicating intact cognition. Observation on 11/12/2023 at 11:38 a.m., of Resident #66's room revealed signage with report to nurse on door, PPE in organizer hanging on…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen observed for: 1. The facility failed to ensure food items, placed in the refrigerator, were dated, and labeled appropriately. This failure could affect residents by placing them at risk for food-borne illness. Findings included: An observation and interview on 11/12/2023, at 9:37am, revealed two prepared salads, in containers sealed in cellophane, not labeled nor dated. Dietary Aide A stated she put the salads in the refrigerator, got busy with other task, and forgot to date and label the salads. Dietary Aide A stated the importance of dating and labeling food items put in refrigerators, is to inform other staff how long the items have been in the refrigerator so residents will not get food borne illness. In an interview with the Dietary Manager, on 11/14/2023, at 11:55a.m., it was stated that her expectation for her staff is to date, label, and seal foods that are put in the…

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

Based on observation, interview, and record review, the facility failed to keep garbage storage receptacles in a sanitary condition according to professional standards for 1 of 1 kitchen for kitchen sanitation. The facility failed to keep garbage receptacles covered with lids, in the kitchen area, while food was being prepared. This failure could place residents at risk for contracting food-borne illness. Findings included: During an observation on 11-12-2023, at 9:45am, a large trash can was observed to have a liner, with trash contents, in the kitchen area, without a lid or covering. The trash can was not currently in use. During an interview with the Dietary Manager, on 11-12-2023, at 9:55am, she stated the trash can should have a lid on it. The Dietary Manager then kicked the trash can into another room but still did not put a lid on the receptacle. During an interview with the Administrator on 11-14-2023, at 2:00pm she stated that her expectation is that trash receptacles, in the kitchen area, be always covered with a lid. Review of the facility's Kitchen Waste Control and…

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

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for one (secure unit hall) of three halls reviewed for environment. The facility failed to ensure a safe, functional, sanitary and comfortable environment for residents staff and the public. The facility failed to ensure the secure unit did not have a strong urine odor. This failure could place residents at risk for a diminished quality of life. Findings included: Observation on 11/12/2023 at 10:13 a.m., upon entrance to the secure unit, the hallway near the entrance and towards the middle of the hallway had a urine odor. The floors appeared clean. Residents appeared well groomed and dressed and no residents appeared soiled. Observation and interview on 11/14/2023 at 1:14 p.m., revealed a strong urine odor at the entrance of the secure unit, down the hallway and near the dining room. CNA A stated she noticed the odor and stated residents go to the bathroom anywhere. She stated the rooms and hallway are clean,…

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.