Estates Healthcare and Rehabilitation Center

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 includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 8 residents (Resident #1) reviewed for comprehensive care plans. The facility failed to develop a comprehensive care plan for Resident #1 to address the resident's recent significant weight loss. This failure could place residents at risk for missed care needs and continued decline in health.Findings include: Record review of Resident #1's Annual MDS Assessment, dated 03/15/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. He had a BIMS score of 9, which indicated moderate cognitive impairment. Section I-Active Diagnoses reflected Resident # 1's active diagnoses included non-Alzheimer's Dementia (brain disorder that affects memory, thinking, and behavior),…

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, based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 10 residents (Resident #2) reviewed for quality of care. The facility failed to treat Resident #2's constipation as ordered by the physician.This failure could place residents at risk of developing an obstruction, or a rupture of the intestines. Findings include:Record review of Resident #2's admission MDS assessment, dated 01/14/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included diabetes, amputation of both legs above the knees, heart failure, and constipation . His BIMS score was 15, which indicated he was cognitively intact. His Functional Ability assessment indicated he needed partial assistance with toileting. Record review of Resident #2's…

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 maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for 1 of 5 residents (Resident #1) facility reviewed for nutrition. The facility failed to recognize, evaluate and address Resident #1's weight loss when there was a documented 15.9 % loss from 02/10/26-03/09/26. This failure could place residents at risk for malnutrition or mismanagement of underlying medical conditions.Findings include: Record review of Resident #1's Annual MDS Assessment, dated 03/15/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. He had a BIMS score of 9, which indicated moderate cognitive impairment. Section I-Active Diagnoses reflected Resident # 1's active diagnoses included non-Alzheimer's 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.

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Residents #9) reviewed for environment. 1. LVN-W, CNA-R, and MA failed to ensure the linen cart located on the 100 hall was covered when not in use. 2. LVN-W and CNA-U failed to properly discard a red biohazard bag, after providing care when the bag was left in the hallway of Hall 300 outside Resident #9's room. This deficient practice placed staff and residents at risk for infections and human body fluids.Findings included:During an observation and interview on 09/01/2025 at 1:15 PM revealed the clean linen cart located on Hall 100 had the cover up and over the top of the cart, which left the linen exposed to the environment and contamination. LVN-W and MA were observed working on the hall and passing the linen cart. The MA stated the cart was left by CNA-R, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure the assessments accurately reflected the resident's status for 2 of 4 residents (Residents #1 and #2) reviewed for accuracy of assessments. The facility failed to ensure Resident #1 and Resident #2's MDS assessments were accurate and coded for behavior and mood. This failure could place residents at risk for receiving inadequate care and services based on an inaccurate assessment. Findings included:Record review of Resident #1's face sheet dated 09/19/2025 reflected the resident was a [AGE] year-old male, who admitted to the facility on [DATE]. The face sheet reflected he was discharged on 09/17/2025 to the hospital. The resident's current diagnoses included: Chronic Respiratory Failure, Unspecified Whether with Hypoxia or Hypercapnia (a condition where the lungs fail to adequately exchange oxygen and carbon dioxide over a prolonged period) Need for Assistance with Personal Care (staff assistance with ADL's); Anxiety (fear and worrying)…

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 2 of 4 residents (Residents #4 and #8) reviewed for respiratory care. 1. The facility failed to ensure Resident #4's nasal cannula and tubing were bagged when not in use. 2. The facility failed to ensure Resident #8's CPAP mask was bagged when not in use. These failures could place residents at risk for respiratory infection. Findings included:Record review of Resident #4's face sheet dated 09/19/2025 reflected the resident was a [AGE] year-old-female, who admitted to the facility on [DATE] and initially on 04/10/2025. The resident's diagnoses included: Heart Failure, asthma (chronic lung condition that causes inflammation in the airway) and COPD (an ongoing lung condition caused by damage to the lungs. The damage results…

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 3 of 7 residents (Resident #1, Resident #2, and Resident #3) reviewed for infection control. The facility failed to ensure Residents #1, #2 and #3, who were on Enhanced Barrier Precautions, received proper care from staff donning and doffing personal protective equipment for infection control. This failure could place residents at risk for the spread of infections and decreased quality of life. Findings included:Resident #1 Record review of Resident #1's face sheet, dated 10/10/25, reflected a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses that included: metabolic encephalopathy (change in brain function due to systemic illness), heart…

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 residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 8 residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1 received appropriate monitoring of his condition after the resident refused three consecutive dialysis treatments on 10/04/25, 10/07/25, and 10/09/25. This failure placed residents at risk of a delay in medical evaluation and treatment, which could result in worsening of conditions. Findings included:Record review of Resident #1's face sheet, dated 10/10/25, reflected a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses that included: metabolic encephalopathy (change in brain function due to systemic illness), heart failure, candidiasis (fungal infection), chronic kidney disease, dependence…

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 incorporate the recommendations from the PASRR Level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for 2 of 4 residents reviewed (Residents #2 and #5) for PASRR assessments.1.The facility failed to submit a NFSS form, used to request specialized services for residents, request within 20 from interdisciplinary team meeting dated 03/18/25 for Resident #2. 2. The facility failed to submit a completed a NFSS in the LTC Online Portal within 20 business days of Resident #5's IDT meeting. This failure could place residents at risk of not receiving or benefiting from recommendations for services they may require. Findings included:1. Record review of Resident #2's most recent Quarterly MDS, dated [DATE], reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. Resident #2 had moderate cognitive impairment with a BIMS score of 8. The resident's…

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 to the Administrator of the facility for 1 of 3 residents (Resident #1) reviewed for reporting abuse and neglect. LVN B failed to report an allegation of verbal abuse to the Administrator, on 09/05/25 when CNA used profanity towards Resident #1. This failure could have resulted in psychological harm to residents. Findings included: Record review of resident #1's face sheet dated 09/09/25, revealed the resident was a [AGE] year-old male with an admission date of 09/04/21 and readmitted on [DATE]. Record review of Resident #1's Annual MDS, dated [DATE], reflected he had a BIMS score of 15, indicating no cognitive impairment. His diagnoses included Type 2 Diabetes Mellitus (A long-term condition in which the body has trouble controlling blood sugar), Chronic Pain Syndrome (Condition characterized by persistent pain lasting longer than 3-6 months, often accompanied…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs, to meet the needs of each resident for 2 of 3 residents (Residents #2 and #3) reviewed for pharmacy services. The facility failed to maintain accurate documentation regarding the administration of Resident #2 and Resident #3's PRN pain medication and failed to ensure LVN C checked the current physician's orders before administering the PRN pain medication, Hydrocodone/acetaminophen 10/325 mg, to Resident #2 on 01/06/25 when the resident had opioid restrictions. The failure placed residents at risk for possible drug overdose and complications. Findings included: Record review of Resident #2's Quarterly MDS Assessment, dated 03/25/25, reflected the resident was a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmission on [DATE] with a BIMS score of 09 revealing her cognation 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 interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 2 residents (Residents #9 and #63) reviewed for dialysis. The facility failed to ensure dialysis communication forms for Residents #9 and Resident #63 were received back from dialysis center after returning from dialysis treatment on the dates mentioned below. The missing communication forms for Resident #9 totaling to 10 days on the following dates: 01/01/25, 01/03/25, 01/06/25, 01/08/25, 01/10/25, and 01/17/25, 02/03/25, 02/05/25, 02/07/25 and 02/10/25. Resident #63 was missing communication forms totaling to 12 days on the following dates: 01/01/25, 01/03/25, 01/06/25, 01/08/25, 01/10/25, 1/20/25,1/24/25, 01/29/25, 02/03/25, 02/05/25, 02/07/25 and 02/10/25. This failure could place residents at risk of inadequate communication between 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 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 on one of three medication carts (300) and 3 of 3 residents (Residents #7,#147, and #178) reviewed for pharmacy services. 1. The facility failed to ensure the 300 Hall nurses' medication cart contained accurate narcotic logs for Resident #7, #147 and #178 on 02/12/25. 2. The facility failed to ensure expired medications , 1 bottles of atropine 0.1% with expiration dates of August 2024 was removed and destroyed form 300 hall nurses cart on 02/12/25. These failures could place residents at risk for medication errors, drug diversion, and ineffective drug therapy. Findings included: 1. Record review of Resident# 7's Quarterly MDS Assessment, dated 12/10/24, reflected the resident was [AGE] year-old female readmitted to the facility on [DATE] with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to immediately consult with the physician of a significant change in the resident's health status; or a need to alter treatment significantly for 1 (Resident #67) of 3 residents reviewed for notification of change. RN C failed to immediately notify the physician that Resident #67 came to the nursing station and stated to RN C that he was not feeling well. RN C stated Resident #67 looked pale, he looked sick. This failure could place residents at risk for delay in treatment, a negative outcome to a resident's physical, mental, and psychosocial health, well-being, or decreased quality of life. Findings included: Record review of Resident #67's face sheet reflected the resident was a [AGE] year old male who admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #67's quarterly MDS assessment, dated 11/28/24, reflected a BIMS score of 14, which indicated his cognition was intact. His diagnoses included paraplegia (the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review the facility failed to ensure all alleged violations involving neglect were reported to the State Survey Agency in a timely manner for 1 (Resident #67) of three residents reviewed for abuse and neglect. The Administrator failed to report Resident #67 fell backwards in his wheelchair (which had not anti-tippers or brakes), hitting his head on the floor of the van during takeoff in the facility parking lot. Resident #67 was sent to hospital resulting in initial encounter with head injury and contusion of right hand. Resident #67 stated his wheelchair was not strapped down correctly and stated he blacked out. The failure could place residents at risk of serious harm or neglect. Findings included: Record review of Resident #67's face sheet reflected the resident was a [AGE] year old male who admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #67's quarterly MDS assessment, dated 11/28/24, reflected a BIMS score of 14, 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 observations, interviews, and record review the facility failed to investigate and report allegation of neglect for 1 (Resident #67) of 3 residents reviewed for accidents and hazards. The Administrator failed to investigate and report the results of the investigation to the state agency when Resident #67 fell backwards in his wheelchair (which had not anti-tippers or brakes), hitting his head on the floor of the van during takeoff in the facility parking lot. Resident #67 was sent to hospital resulting in initial encounter with head injury and contusion of right hand. Resident #67 stated his wheelchair was not strapped down correctly and stated he blacked out. This failure could place residents at risk of harm and injuries related to neglect and a delay in investigating. Findings include: Record review of Resident #67's face sheet reflected the resident was [AGE] years old male who admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #67's quarterly MDS assessment,…

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

Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored securely and had acceptable labeling for one (Halls 200 nurses Medication Cart) of three medication carts reviewed for labeling and storage. The facility failed on 02/12/25 to ensure insulin vials were dated after they were opened and were not dated with wrong dates located on the medication cart for the 200 hall. This failure could place residents at risk of not receiving the therapy needed. Findings included: Observation on 02/12/25 at 1:55 PM of the nurses' medication cart used for Hall 200 back with RN C revealed one insulin vial of Humalog 100 unit/ml which was opened, partially used, and not labeled with the open date. There was also one vial of Levemir dated 5/11/25 that had been opened and partially used on the cart. Interview on 02/12/25 at 2:38 PM with RN C, who was the charge nurse for Halls 200 , revealed she knew insulin pens/vials were supposed to be dated once they were opened or after they were removed from the refrigerator and placed on the cart…

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 for 1 (Resident #2) of 3 residents reviewed for specialized rehabilitative services. The facility failed to ensure Resident #2 received a speech therapy evaluation as per physician orders dated 01/28/25. This failure could place residents with orders for therapy at risk of not meeting their highest practicable well-being. Findings included: Record review of Resident #2's Nursing Home Comprehensive Item Set MDS dated [DATE] reflected Resident #2's initial admission date of 07/27/21 and readmission date of 04/13/22. Resident #2's diagnoses were non-traumatic brain dysfunction, non-Alzheimer's dementia (common type of dementia), malnutrition, and aphasia (rare type of dementia where language is heavily affected). Resident #2's MDS also reflected that Resident #2 had severe cognitive impairment. MDS reflected that Resident #2 began receiving occupational therapy in 10/17/24 with no end date. MDS did not reflect…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 2 residents (Resident #1) reviewed for comprehensive care plans. The facility failed to ensure Resident #1's comprehensive person-centered care plan was not implemented and did not include measurable outcomes related to signs and symptoms of dehydration such as decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness on sitting/standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, dry/sunken eyes. This failure could place residents at risk of not having their individual needs met, not receiving necessary…

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 who was incontinent of bladder with an indwelling catheter received appropriate treatment and services for 1 of 2 residents (Residents #1) reviewed for incontinent care and for indwelling urinary catheters. The facility they failed to monitor and document signs and symptoms of dehydration, decreased or no urine output, for Resident#1. This failure could place residents at risk of not having their individual needs met, not receiving necessary care and services, and a decreased quality of life. Findings included: Record review of Resident #1's admission record dated 10/04/24 reflected the resident was a [AGE] year-old male, who initially admitted to the facility on [DATE] with a readmission on [DATE]. Resident#1's diagnoses included intellectual disability, acquired absence of right leg below the knee, anemia chronic kidney disease, Type 2 diabetes mellitus with unspecified complications, protein calorie…

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 ensure that drugs and biologicals were stored in locked compartments for 1 of 6 medication carts located on hall 200 observed for drug storage. 1. The facility failed to ensure one medication cart found on 200 hall was not left unlocked and unattended by LVN A on at 10/04/24 at 12:30 PM. 2. The facility failed to ensure one medication cart found on 200 hall was not left unlocked and unattended by LVN B on 10/05/24 at 9:26 PM. This failure could place residents at risk of access and ingestion medications. Findings included: Observation on 10/04/24 at 12:30 PM revealed one medication cart on Hall 200 was unlocked and unattended with the drawers facing the hallway. At 12:45 PM, the DON walked past the medication cart on Hall 200 hall and locked it. Observation on 10/05/24 at 9:10 PM revealed LVN B drove up to the facility at the same time as the surveyor and they walked into the building together. At 9:26 PM, the medication cart on Hall 200 was unlocked and unattended with the drawers facing the hallway.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 10 residents (Resident #2) reviewed for call lights. Resident #2's call light was not within reach. The call button was on the other side of the privacy curtain draped over a vacant bed. This failure could place residents at risk of not having their needs and preferences met and a decreased quality of life. Finding included: Record review of Resident #2's Face Sheet dated 10/01/2024, reflected the resident was an [AGE] year-old female who was originally admitted to the facility at 07/16/2024. Diagnoses included: Unspecified dementia without behavioral disturbance (a group of symptoms that may affect, memory, thinking and interferes with daily life), lack of coordination, anemia (deficiency of healthy red blood cells in the blood), hypothyroidism (decreased productions of thyroid…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 10 residents reviewed for accidents. The facility staff failed to ensure Resident #1 was safe from accidents and hazards when she fell from her bed on 09/28/2024 and was found face down on the floor with a bruise on her forehead. Resident #1 did not have a fall mat placed on both sides of her bed. This failure could place residents at risk of injury and a decreased quality of life. Findings included: Record review of Resident #1's Face Sheet dated 10/01/2024, reflected the resident was a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. The resident's diagnoses included: Alzheimer's disease (brain disorder worsening over time), dysphasia (impacts the ability to speak and understand spoken language), and unspecified dementia without behavioral disturbance (a group 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 each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 shower rooms (Shower room [ROOM NUMBER]) observed for accident and hazards. The facility failed to ensure two disposable razors in Shower room [ROOM NUMBER] were kept out of reach of residents. These failures could place residents at risk for injury. Findings included: Observation and interview on 06/05/24 at 12:35 PM with CNA A of Shower room [ROOM NUMBER], which was to the right of the nursing station, revealed two navy blue disposable razors on top of the sharps container, within reach of residents to access. According to CNA A, razors were locked in a closet in the shower room. After use, the razors were supposed to be discarded in the sharps container. CNA A stated leaving razors on top of the sharps container placed residents at risk of taking the razors for personal use. CNA A stated if residents used razors without supervision,…

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, the facility failed to designate a registered nurse to serve as the director of nursing on a full time basis for 53 of 65 days (04/13/24-06/05/24) reviewed for DON coverage. The facility failed to designate a RN to serve as DON on a full-time basis since 04/12/24. The failure placed residents at risk of not receiving necessary care and services. Findings included: Interview on 06/05/24 at 3:15 PM with the Administrator revealed the last time the facility had a dedicated DON was on 04/12/24. She stated she had interviewed applicants, but she had not hired anyone yet. Currently the DON responsibilities were being divided up between the ADON, the MDS Coordinator, and the Regional Compliance Nurse. None of the three people were dedicated to the DON position 8 hours a day. The Administrator stated she did not have a policy about DON coverage. Interview on 06/05/24 at 3:30 PM with the ADON revealed she and the MDS Coordinator and the Regional Compliance Nurse were covering for the DON. She stated they were also all performing their regular duties as well.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 9 residents (Resident #1) reviewed for quality of care. The facility failed to ensure hospital discharge orders were followed for Resident #1 to have a follow-up appointment with a primary care physician. This failure could affect residents who receive care from the facility and place them at risk for worsening conditions. Findings included: Record review of Resident #1's face sheet, dated 01/30/24, reflected the resident was a [AGE] year-old female resident who was initially admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses of Alzheimer's disease, abnormalities of gait and mobility, cognitive communication deficit, muscle weakness, lack of coordination, history of falling, abnormal posture, muscle wasting and atrophy (loss of muscle tissue), dementia, 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 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 of 3 ice chests observed for infection control. 1. The facility failed to ensure the ice chests were maintained in a manner to prevent cross-contamination. 2. The facility failed to ensure staff personal food items were not stored in the facility's medication refrigerator in the facility's medication storage. These failures placed residents at risk for the development and spread of infection. Findings included: Observation on 01/03/24 at 9:00 AM revealed the facility had three halls and a secured unit. The three halls each had an ice chest, with ice for the residents' drink cups, located where staff and residents had access to them. Observation on 01/04/24 at 9:10 AM revealed Resident #29 filled his drink cup with ice from the 100 Hall ice chest, using the scoop provided, but placing the scoop…

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 promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Resident #61) of 17 residents reviewed for dignity. The facility failed to ensure a WanderGuard device was not placed on Resident #61 when the resident was not an elopement risk. The failure placed residents at risk of decreased quality of life and lowered self-esteem. Findings included: Record review of Resident #61's face sheet dated 01/07/24 revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included neuropathy (damaged nerves resulting in numbness, burning, or pain in relation to whichever part of the body is damaged), aphasia (language disorder affecting ability to communicate), and chronic kidney disease. Record review of Resident #61's 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 interview and record review, the facility failed to immediately consult with the physician of a significant change in the resident's health status; or a need to alter treatment significantly for 1 (Resident #168) of 4 residents reviewed for notification of change. The facility failed to notify Resident #168's physician that the resident's insulin had been discontinued by the hospital or that the resident had returned from the hospital and failed to follow-up with the physician to obtain new orders. The failure placed residents at risk of not having medical complications and deterioration. Findings included: Record review of Resident #1's face sheet dated 01/05/24 indicated the resident was an [AGE] year-old female, initially admitted on [DATE], and readmitted on [DATE] with diagnoses that included pneumonia, diabetes mellitus with ketoacidosis (potentially life threatening complication of diabetes), dehydration, acute and chronic respiratory failure with hypoxia (not able to keep oxygen and carbon…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 8 residents (Residents #166) reviewed for comprehensive care plans. The ADON failed to ensure Resident #166's care plan was updated to include her use of a Life Vest. This failure could place the residents at risk of deterioration and improper care. Findings included: Review of Resident #166's undated admission Record revealed Resident #166 was [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included heart failure, atrial fibrillation (irregular heartbeat), muscle wasting atrophy (decrease in size and muscle wasting), Type 2 Diabetes Mellitus, hypotension and hypertension (high and low blood pressure), unsteadiness on feet, lack of coordination. Review of Resident #166's admission MDS assessment, dated 12/22/23, revealed the resident's BIMS score was blank. Her Functional Status indicated she substantially/ maximum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that residents received proper treatment and assistive devices to maintain vision abilities for 1 (Resident #45) of 23 residents reviewed for vision services. The facility did not address Resident #45's vision loss and ensure Resident #45 was seen by an ophthalmologist. This failure could place all residents with vision loss at risk of not receiving proper services, decreased ability to communicate and/or a decreased quality of life. Findings included: Record review of Resident #45's face sheet revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included stroke, congestive heart failure, and kidney failure. Record review of Resident #45's MDS assessment dated [DATE] revealed resident had a BIMS score of 13 indicating the resident was cognitively intact and capable to discuss his own plan of care. Resident's MDS also revealed that Resident #45 requires supervision assistance by one person with…

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

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 locked compartments for 1 (Resident #57) of 17 residents reviewed for drug storage. LVN A left two medications at the bedside of Resident #57. This failure could place residents at risk of taking medications not prescribed for them. Findings included: Review of Resident #57's undated admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included schizophrenia, emphysema, muscle weakness and heart attack. Review of Resident #57's annual MDS, dated [DATE], revealed a BIMS score of 9 indicating she was mildly cognitively impaired. Her Functional Status indicated she required limited assistance with her ADLs. Review of Resident #57's care plan, dated 1/03/24, revealed she was at risk of altered breathing status related to her emphysema, with interventions of administering her inhaled medications as prescribed. 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 all mechanical, electrical, and patient care equipment was in safe operating condition for 1 (Resident #22) of 6 residents reviewed for safe, functional equipment. The facility failed to ensure Resident #22's bed was in proper working condition. This failure could place residents at risk for skin tears, injury, falls and discomfort during transfers. Findings included: Record review of Resident #22's face sheet dated 01/05/24 indicated Resident #22 was a [AGE] year-old male and originally admitted on [DATE], readmitted on [DATE] with diagnoses including acquired absence of right leg below the knee, age-related physical debility (affects the persons physical mobility), muscle weakness, lack of coordination, chronic pain, acute pyelonephritis (sudden and severe kidney inflammation due to bacterial infection) Hypertension (high blood pressure), Diabetes Mellitus (high sugar levels). Record review of Resident #22's quarterly MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents has the right to be free from abuse for one (Resident #1) of three residents reviewed for abuse. The facility failed to ensure LVN A did not verbally abuse Resident #1 during their interactions on 08/04/23. This failure placed the resident at risk of decreased feelings of self-worth. Findings included: Review of Resident #1's admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included stroke affecting his right side, bipolar disorder, Moyamoya disease (a rare progressive cerebrovascular disorder caused by blocked arteries at the base of the brain [basal ganglia]), and seizures. Review of Resident #1's annual MDS, dated [DATE], revealed a BIMS score of 15 indicating he was cognitively intact. His Functional Status indicated he required extensive assistance with his ADLs. Review of Resident #1's care plan, dated 07/01/23, revealed he required assistance with most of 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.