Marine Creek Nursing & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensurethat a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility failed to obtain physician orders with specific non-rebreather (this is a mask that delivers high concentration oxygen with a minimum of 10 to 15 Liters/minute of Oxygen flow via a mask and has a valve that ensures air only comes in or out one way) amount on resident #1 from 11/11/24 to 11/14/24. This failure could place the resident at risk for receiving inaccurate oxygen therapy and retention of too much carbon dioxide in residents with COPD. Findings Included: Record review of Resident #1's admission record dated 04/23/25 revealed a [AGE] year-old female with an admission date of 01/16/24. Her primary diagnosis 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, interviews and record reviews the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility failed to ensure RN A was trained on using a non-rebreather on Resident #1 and what parameters are required and when to discontinue use of the non-rebreather. This failure could place the resident at risk for receiving inaccurate oxygen therapy and retention of too much carbon dioxide in residents with COPD. Findings Included: Record review of Resident #1 ' s admission record dated 04/23/25 revealed a [AGE] year-old female with an admission date of 01/16/24. Her primary diagnosis was unspecified dementia (a brain disease that alters brain function and causes a cognitive decline), and her secondary diagnoses were Myxedma coma (this is a rare life threatening endocrine…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 3 residents (Resident #1) reviewed for enteral nutrition. The facility failed to ensure the date and time was written on Resident #1's formula and water bag . This failure could place residents at risk of malnutrition and dehydration. Findings included: Record review of Resident #1's admission record, dated 12/12/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia (when body tissues do not have enough oxygen), tracheostomy status (a surgical hole made in the windpipe to help with breathing), and gastrostomy status (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 interview and record review, the facility failed to ensure residents had the right to retain and use personal possessions for one (Resident #1) of five residents reviewed for personal property. The Administrator took Resident #1's cell phone away from her because she had called 911 several times. This failure could place residents at risk of not being able to retain and use personal property. Findings included: Record review of Resident #1's undated admission Record reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] and expired on [DATE]. Resident #1 had diagnoses which included congestive heart failure, respiratory failure requiring the use of a tracheostomy, and ventilator dependence. (The resident's heart was failing, she developed breathing issues, was intubated and placed on a ventilator. The resident could not breathe without the ventilator, so a breathing tube was placed in her neck and she continued to rely on the ventilator to breathe.) Record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the right to be free from verbal abuse for 1 of 1 resident reviewed for mistreatment, (Resident #1). The facility did not prevent CNA B from mistreating Resident #1. CNA B yelled at Resident #1 during the early morning of 10/31/2024 trying to force resident to go to bed causing Resident #1 to become angry. This failure could place residents at risk for staff mistreatment. Findings included: Record review of Provider Investigation Report dated 11/06/2024 revealed: On the morning of 10/31/2024 at 12:35 AM, Resident #1 was refusing to go to bed. Resident #1's family had a video camera in resident's room and witnessed a confrontation between resident and CNA B. CNA B was trying to force resident to go to bed by grabbing resident's arm and yelling at resident. Resident was resisting going to bed. LVN A was summoned by CNA B to assisting with resident to get her to go to bed. Resident #1 was placed in bed and covered with blanket. Record review of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure residents' environment remained as free of accident hazards as is possible for 1 of 6 residents (Resident #2) reviewed for environmental hazards. The facility failed to ensure Resident #2's bedframe and mattress were maintained to prevent accidents. This failure could place residents at risk of accidents and injury. Findings included: Record review of Resident #2's admission record dated, 11/19/2024, reflected a [AGE] year-old-male who admitted to the facility on [DATE] with a primary diagnosis of legal blindness. Record review of Resident #2's Quarterly MDS assessment, dated 10/25/2024, reflected a BIMS score of 15, indicating intact cognition. Record review of Resident #2's Care Plan revised on 11/15/2024 revealed Resident #2 required supervision with bed mobility. Observation and interview on 11/19/2024 at 9:48 AM, in Resident #2's room, revealed Resident #2 sitting up on the side of his bed. The bed appeared lopsided; with 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 observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for 1 of 1 facility reviewed for effective pest control. 1. The facility failed to effectively treat for flies. 2. The facility failed to effectively treat for roaches. These failures could place all residents at risk for the potential of a decreased quality of life. Findings included: Interview on 11/19/2024 at 9:48 AM, Resident #3 stated he had seen roaches and killed one yesterday on his dresser during the 10-6 night shift. Observation on 11/19/2024 at 11:46 AM in Resident #4's room revealed resident was not in room. Resident #4's mattress had no sheets, and a yellowish-brown stain was in the center of the mattresss. Four live flies were observed on the mattress near the stain. Interview on 11/19/2024 at 11:50 AM, Resident #5 stated a roach had crawled on her, and on top of her bed. She stated that happened about 2 Sundays ago (November 3rd) and 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 observations, interviews, and record review the facility failed to ensure that residents requiring respiratory care were provided care, consistent with professional standards of practices for 2 of 7 residents reviewed for respiratory care (Residents #5 and #16). 1. RN K staff failed to ensure Resident #5's and Resident #16's nasal cannula was bagged for sanitation when not in use per the facility's policy on 10/09/24. 2. RN K failed to ensure Resident #5's oxygen concentrator and filter were free of food crumbs, debris (dust gray fuzzy participles) and spilled brown liquid on 10/09/24. 3. RN K failed to ensure Resident #16's nasal cannula was bagged for sanitation when not in use per the facility's policy on 10/09/24. 4. LVN J failed to ensure Resident #16's oxygen concentrator and filter were free of food crumbs, debris (dust gray fuzzy participles) spilled brown liquid on 10/09/24 and 10/15/24. These failures could place residents who require respiratory care at risk for respiratory infections,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents had a right to personal privacy for 1 of 5 residents (Resident #1) reviewed for personal privacy. LVN P failed to ensure Resident #1's dignity and privacy was provided when he failed to use the privacy curtain as she laid naked and exposed. This failure placed the residents at risk of not having their privacy respected. The findings included: Record review of Resident #1's face sheet dated 10/09/24 reflected a female age [AGE] year-old that was admitted on [DATE] with the current DX: Dementia with other behavioral disturbances (disease causing cognitive decline), Cognitive communication deficit (difficulty with language), Basal Cell Carcinoma of skin of other part of trunk (a type of skin cancer that causes bumps, lumps or lesions). Record review of Resident #1's admission MDS dated , 09/10/24, revealed a BIMS score of 02, indicating the resident was severely cognitively impaired. Resident #1's required maximal assistance…

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 residents in need of ADL care the necessary services to maintain good personal hygiene for 1 of 30 residents (Resident #33) reviewed for showers. The facility failed to ensure Resident #33 received showers/baths on scheduled days. This failure could affect residents by putting them at risk for diminished quality of life, hygiene, and self-esteem. Findings include: Record review of Resident #33's face sheet dated 8-22-2024 revealed a [AGE] year-old female who admitted to the facility on [DATE] with a primary diagnosis of Muscular Dystrophy (a hereditary condition marked by progressive weakening and wasting of the muscles) with secondary diagnoses of quadriplegia (a severe medical condition that causes partial or total loss of function in all four limbs and the torso), heart failure, and contracture of right and left ankles. Record review of Resident #33's Quarterly MDS dated [DATE], revealed a BIMS Score of 14 indicating being…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete, accurately documented, readily accessible, and systematically organized for 1 of 5 residents (Resident #106) reviewed for resident records. Facility failed to ensure physician orders were written for ventilator setting for Resident #106 on admission [DATE] to 08-22-2024. This failure could place residents at risk for incorrect treatment decisions, evaluation, and treatment plans compromising patient safety due to insufficient information records. Findings included: Review of Resident #106 admission record dated 08-22-2024 revealed a [AGE] year-old female that was admitted to the facility on [DATE]. Her diagnoses included chronic respiratory failure, sepsis (this is a systemic infection), pneumonia, Amyotrophic Lateral Sclerosis (also known as ALS, a nervous system disease that affects nerve cells…

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 disease and infections for 4 (Residents #18, #59, #72, and Resident #437) of 12 residents reviewed for infection control. The facility failed to ensure LVN M disinfected blood sugar monitoring device between use on Resident #18, #59, and Resident #437 and failed to ensure LVN M performed hand hygiene after removing gloves and touching contaminated blood sugar monitoring device between use on Resident #18, #59 and Resident 437. The facility failed to ensure RN G put on PPE for EBP and perform hand hygiene when administering G-tube medication to Resident #72. These failures could place residents at risk for the spread of disease and infections. Findings included: 1. Resident #18 Review of Resident #18's face sheet on 08-21-2024, revealed a [AGE] year-old…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program for 3 of 30 residents (Residents #66, 42, and #103) reviewed for effective pest control. The facility failed to maintain an effective pest control program to ensure the facility was free of flies for Resident #66, #42, and #103 in the facilities only dining room. This failure could place the residents at risk for an unsanitary environment. Findings included: Record review of Resident #66's face sheet dated revealed a [AGE] year-old male who had an original admission date of 3-9-2020 and a re-admission date of 2-9-2024. Resident #66's primary diagnosis was a cerebral infarction (stroke) affecting the left dominant side and secondary diagnoses of cognitive communication deficit, ulcer of the right heel and midfoot, lack of coordination, and contracture of the right knee. Record review of Resident #66's Quarterly MDS assessment dated [DATE], indicated a BIMS score of 13 revealing being cognitively…

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 services in the facility with reasonable accommodation of each resident's needs for 2 of 30 (Residents #17 and #114) reviewed for accommodation in needs. The facility failed to ensure Resident #17 and #114's call lights were within reach of the resident. This failure could have affected residents who needed assistance and could have resulted in their needs not being met. Findings included: Record Review of Resident #17's face sheet dated 8-21-2024, revealed a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with a primary diagnosis of Covid-19 and Schizoaffective disorder (Bipolar type), and secondary diagnoses dementia, fracture of T11-T12 vertebra, difficulty walking, unsteadiness on feet, abnormalities of gait and mobility, and lack of coordination. Record review of Resident #17's MDS dated [DATE] indicated a BIMS score of 9 which revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure the residents had the right to personal privacy and confidentiality of his or her personal space for one of five residents (Resident #18) reviewed for privacy. The facility failed to ensure that the roommates of residents with AEM had signed consents in the active section of their EHR as evidenced by record review for Resident #18. This failure could place residents at risk of having medical or personal information or conversations recorded or exposed to others, and cause residents to feel a loss of privacy, dignity, and decreased self-worth and self-esteem. Findings included: Observation on 8-20-2024, at 9:54AM of the room shared by Residents #18 and #59 revealed an AEM camera placed on a dresser top aimed to capture motion of most of the room and Resident #59's bed area. Record Review of Resident #18's admission Record revealed a [AGE] year-old, divorced, Hispanic male whose primary language was Spanish who had initially…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents who received nutrition by enteral means received the appropriate treatment and services according to professional standards of maintenance for one (Resident #487) of twelve resident reviewed for enteral feeding. The facility failed to ensure Resident #487's G-tube water and enteral administration set (tubing attached to formula and water bottles for continuous G-tube feeding) were changed when his formula was changed on 08-19-2024 and on 08-21-2024 and failed to ensure the water was dated when it was changed. This failure could place residents at risk of infection due to not following appropriate procedures. Findings included: Review of Resident #487's face sheet dated 08-21-2024 revealed a [AGE] year-old male that was admitted to the facility on [DATE]. His diagnoses included acute respiratory failure with hypoxia (low oxygen), bacterial infection, anemia, cerebral palsy (a congenital disorder of movement, muscle…

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 parenteral fluids were administered consistent with professional standards of practice for one (Resident #487) of 2 residents reviewed for intravenous fluids. The facility failed to ensure Resident #487 received PICC line orders to manage, access, flush, and perform dressing changes since admission [DATE]. A Peripherally Inserted Central Catheter -PICC line is a soft, flexible catheter inserted into a central vein used for prolonged antibiotic therapy, giving fluids, and or getting clinical nutrients. This failure could place residents at risk for infection. Review of Resident #487's face sheet dated 08-21-2024 revealed a [AGE] year-old male that was admitted to the facility on [DATE]. His diagnoses included hypotension (low blood pressure), enlarged prostate (this is a condition when the prostate gland becomes larger than normal making it hard to urinate or empty the bladder), pneumonia, nutritional problem or potential…

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

Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for two of three medication carts and one of one respiratory treatment carts reviewed for medication storage The facility failed to ensure two (Medication Cart#1 and Medication Cart#2) facility medication cart and one (RTC) respiratory treatment cart were locked when unattended on 08/14/24. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions. Findings included: An observation on 08/14/24 at 5:00 AM revealed the medication cart#1 was unlocked at the nursing station with no staff in view of the medication cart. Observation of medication cart#1 revealed the medication cart was facing outward toward the hallway. Observation of the lock mechanism was popped out and revealed a red indicater. Observation revealed LVN A was at the end of hallway 400. An observation on 08/14/24 at 5:06…

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 before a facility transfers or dischargers a resident the facility must send a copy of the notice of transfer or discharge and the reasons for the transfer or discharge in writing to the Office of the State Long-Term Care Ombudsman for one (Resident #1) of eight residents reviewed for transfer and discharge. The facility failed to send a transfer or discharge notice in writing to the facility's Ombudsman as soon as practicable when Resident #1 was discharged to hospital on [DATE]. This failure could affect residents by placing them at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and the appeal processes. Findings included: Record review of Resident #1's admission record dated 07/26/24 revealed she was a [AGE] year-old female who was original admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnosed included: chronic respiratory failure (condition that affects your…

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, before a resident was transferred to a hospital or the resident went on therapeutic leave, provided written information to the resident or the resident representative that specified the duration of the bed-hold policy, if any, during which the resident was permitted to return and resume residence in the nursing facility for 1 of 1 residents (Resident #1) reviewed for transfers: The facility failed to provide Resident #1 with a written bed-hold policy when the resident was transferred out to the hospital. This failure could place residents at risk for not receiving notice of the facility's bed hold policy before being transferred; at risk for of being improperly discharged and placed in unsafe conditions. Findings included: Record review of Resident #1's admission record, dated 07/26/24 revealed she was a [AGE] year-old female who was original admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnosed included: chronic respiratory…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care for 4 of 5 resident's (Resident #1, Resident #3, Resident #5, and Resident #7) reviewed for respiratory care. 1. The facility failed to ensure Resident #1's oxygen tubing was dated, and his CPAP mask and portable nasal cannula on his wheelchair were bagged and dated when not in use. 2. Resident #3, #5, and #7's oxygen tubes were not labeled, stored, and changed for resident. These failures affected resident's and placed them at risk of not receiving the needed services for respiratory care. Findings include: Resident #1 Record review of Resident #1's face sheet, dated on 05/02/24, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of Acute Respiratory Failure (lungs cannot Exchange Oxygen…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to review and revise the person-centered comprehensive care plan to reflect the resident's current status, for 1 (Resident #1) of 5 residents reviewed for care plans. The facility failed to ensure Resident #1's care plan reflected behaviors of not using the call light when he needed assistance, removing his CPAP mask, and throwing both to the floor when agitated. This deficient practice could place residents at risk of not receiving appropriate care and interventions to meet their current needs. Findings include: Record review of Resident #1's face sheet, dated on 05/02/24, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of Acute Respiratory Failure (lungs cannot Exchange Oxygen and Carbon Dioxide) with Hypoxia (low oxygen), Emphysema/COPD (air flow blockage and breathing), Atrial Fibrillation (irregular or rapid heart rhythm), Dementia (cognitive decline). Record review of Resident #1's admission MDS,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to be adequately equipped to allow for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 of 6 residents (Resident #1) reviewed for resident call system, in that. Resident #1s call lights was on the floor and not within reach. This could place the residents at risk of not receiving the care and services to maintain their highest level of well-being. Findings included: Resident #1 Record review of Resident #1's face sheet, dated on 05/02/24, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of Acute Respiratory Failure (lungs cannot Exchange Oxygen and Carbon Dioxide) with Hypoxia (low oxygen), Emphysema/COPD (air flow blockage and breathing), Atrial Fibrillation (irregular or rapid heart rhythm), Dementia (cognitive decline). Record review of Resident #1's admission MDS, dated [DATE], revealed a BIMS score of 02,…

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 alleged violations involving neglect, which included injuries of unknown source, were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials, which included the State Survey Agency, in accordance with State law through established procedures for 1 of 6 residents (Resident #1) reviewed for abuse and neglect. 1. Student Nurse Aide A, who worked the 2:00 PM-10:00 PM shift, failed to report to the charge nurse when she found Resident #1 on the floor on 04/09/24 at 9:46 PM resulting in the resident not receiving immediate treatment and care until 4:40 AM on 04/10/24, when 10:00 PM-6:00 AM staff, discovered significant bruising and injury 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 observations, interviews, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices for 2 of 5 residents (Residents #1 and #3) reviewed for quality of care. The facility failed to provide wound care services for Resident #1 as ordered on 11/03/23, 11/06/23, 11/08/23, 11/11/23 (night), 11/12/23 (night), and 11/13/23 (evening and night). The facility failed to provide wound care services for Resident #3 as ordered on 11/06/23 and 11/08/23. This failure could place residents at risk of infection and/or deterioration of their wounds. Findings include: Resident #1: Record review of Resident #1's electronic Facesheet, dated 11/14/23, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's diagnoses included chronic respiratory failure, dependence on ventilator (a machine that helps you breathe or breathes for you), tracheostomy (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 that all residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, and prevent infection for 1 of 5 residents (Resident #2) reviewed for wound care. The facility failed to provide wound care services for Resident #2 as ordered on 11/03/23, 11/06/23, and 11/08/23. This failure could place residents at risk of infection and/or deterioration of their pressure ulcers. Resident #2: Record review of Resident #2's electronic Facesheet, dated 11/14/23, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2's diagnoses included acute respiratory failure, dependence on ventilator (a machine that helps you breathe or breathes for you), and quadriplegia (a form of paralysis that affects all four limbs, plus the torso). Record review of Resident #2's Quarterly MDS Assessment, dated 10/16/23, reflected Resident #2's BIMS 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 orders were provided for the resident's immediate care and needs for 1 of 1 resident (Resident #1) reviewed. LVN B failed to ensure a physician, physician assistant, nurse practitioner, or clinical nurse specialist provided orders for Mupirocin cream applied topically to Resident #1. This failure had the potential to place Resident #1 at risk of an adverse drug reaction. Findings included: A record review on 11/16/23 at 9:13 AM of Resident #1's Quarterly MDS assessment dated [DATE] revealed a 74 y.o. male initially admitted to SNF on 03/09/23 and the most recent reentry into the SNF was 07/19/23. Resident #1 had a primary medical condition of Debility, Cardiorespiratory Conditions with invasive mechanical ventilation (have a tube in the airway connected to a ventilator). Resident #1's diagnoses information included chronic respiratory failure; Neuromuscular dysfunction of bladder (urinary condition when lack of bladder control is due…

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 resided and received services in the facility with reasonable accommodation of resident needs and preferences for 7 (Resident #8, Resident #12, Resident #3, Resident #44, Resident #81, Resident #24, and Resident #62) of 114 residents reviewed for call lights. The facility failed to ensure Resident #8, Resident #12, Resident #3, Resident #44, Resident #81, Resident #24, and Resident #62's call buttons were within reach. This failure could place residents at risk for decreased quality of life, self-worth, and dignity. Findings included: Review of Resident #8's face sheet dated 07/13/23 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease; Major Depressive Disorder; Unspecified Lack of Coordination; and Other Abnormalities of Gait. Review of Resident #8's MDS assessment dated [DATE] reflected the resident was severely cognitively impaired. Resident #8 required…

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 grooming, and personal hygiene for 1 of 23 residents (Resident #97) reviewed for ADLs. The facility failed to provide Resident # 97 with showers/bed baths on a consistent basis. This failure could place residents at risk for poor personal hygiene and a decline in their quality of life and health status. Findings included: Record review of Resident #97's electronic face sheet, dated 07/13/23, revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #97 had diagnoses which included anoxic brain damage (no blood flow to brain tissue), chronic respiratory failure with hypoxia (oxygen is not available in sufficient amounts), tracheostomy status (has an opening through neck into the trachea to allow air to fill the lungs), gastrostomy status (has an opening into the stomach for feeding through a tube), and dependence 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.