Park View Care Center

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 received nutrition by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 11 residents (Resident #14) reviewed for enteral feeding.The facility failed to follow physician's orders of providing Resident #14 with her 16 hours of her enteral feeding intake from 02/10/26 to 02/11/26. This failure could place residents at risk for a decline in health or adverse effects due to inappropriate management of G-tube care.Findings included:Record review of Resident #14's quarterly MDS assessment, dated 12/13/25, reflected the resident was an [AGE] year-old female who admitted to the facility on [DATE] and readmitted [DATE]. Resident #14's diagnoses included gastrostomy status (surgical opening (stoma) in the stomach), dysphagia (difficult swallowing) following cerebral infarction (stroke), malnutrition (lack of proper nutrition). Resident #14's BIMS score was…

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

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 2 medication rooms (North medication room) reviewed for pharmacy services. The facility failed to remove expired Bisacodyl suppositories, with an expiration date of 01/21/26 and Acetaminophen suppositories, with an expiration date of 01/09/26, from the North medication room refrigerator.This failure could place residents at risk of receiving medications that were ineffective. Findings included: Observation on 02/11/26 at 3:10 PM of the North medication room refrigerator with LVN A revealed four 10mg Bisacodyl suppositories (medication administered rectally to treat constipation) with an expiration date of 01/21/26, and 11- 650mg Acetaminophen suppositories (medication administered rectally for pain and fever reduction) with an expiration date of 01/09/26. Interview on 02/11/26 at 3:16 PM, LVN A stated 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 maintain an infection prevention and control program, including hand hygiene, 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 4 residents (Resident #45) reviewed for infection control practicesThe facility failed to ensure CNA C performed hand hygiene prior to and during incontinence care for Resident #45. These failures could place residents at risk of cross-contamination and infections. Findings included: Record review of Resident #45's Face Sheet, dated 02/12/26, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. Record review of Resident #45's admission MDS, dated [DATE], reflected the resident's diagnoses included: Cerebral infarction (stroke caused by a blocked blood vessel in the brain), Degenerative disease of nervous system (disease that causes the brain or nerves to slowly…

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 establish policies regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents for 2 of 2 residents (Residents #11 and #72) reviewed for smoking.The facility failed to ensure the quarterly smoking assessments were completed to determine Resident #11 and Resident #72 for capability and safety.This failure could place the residents at risk for unsafe smoking causing harm. Findings include:Record review of Resident #11's face sheet, dated 02/19/2026, revealed resident was a [AGE] year-old male admitted to the facility on [DATE] with a readmission on [DATE]. Resident #11's admitting diagnoses included Unspecified Dementia, Unspecified Severity, without Behavioral Disturbances, Psychotic Disturbances, Mood Disturbances, and Anxiety (decline in cognitive functioning); Peripheral Vascular Disease (a slow-progressing condition involving narrowing blood vessels outside the heart - usually in the legs); and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure full visual privacy for each resident in 6 rooms of 30 rooms (Rooms # 12, # 15, #23, # 71, #72 and #77) reviewed for privacy. The facility failed to maintain functional window blinds to provide privacy for the residents of Rooms #12, # 15, #23, # 71, #72 and #77. This failure could place residents at risk for exposure and decreased sense of dignity. Findings included:Observation on 12/22/25 at 9:45 AM in room [ROOM NUMBER] revealed the window blinds had 8 slats that were broken, allowing visualization of the bed from outside the facility. Observation on 12/22/25 at 9:53 AM in room [ROOM NUMBER] revealed the window blinds had 4 slats that were broken, allowing visualization of the bed from outside the facility.Observation and interview on 12/22/25 at 10:00 AM in Room # 77 revealed the window blinds had 12 slats that were broken, allowing visualization of the bed from outside the facility. The resident stated the blinds had been…

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 permit a resident to return to the facility after being hospitalized or placed on therapeutic leave for 1 of 3 residents (Resident #1) reviewed for bed hold. The facility failed to re-admit Resident #1 after he was hospitalized for having shortness of breath. Emergency services attempted to return Resident #1 on 12/18/25 and again on 12/19/25, and the facility sent him back to the hospital. This failure could place residents at risk of not getting the care and services required. Findings included:Record review of Resident #1's nursing home discharge MDS, dated [DATE], reflected Resident #1 was a [AGE] year-old male who was admitted to the facility originally on 08/18/21, readmitted [DATE] and again on 12/09/25. Resident #1's diagnoses included diabetes mellitus (high blood sugar levels), chronic respiratory failure with hypoxia (not having enough oxygen in the blood), chronic obstructive pulmonary disease (group of lung diseases that obstruct airflow…

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 develop and implement a comprehensive person-centered care plan for each resident that describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 resident of 8 residents (Resident #2) reviewed for care plans.The facility failed to address Resident #2's wound, and her non-compliance with care in her care plan.This failure could place residents at risk of not receiving the care they require. Findings included:Record review of Resident #2's quarterly MDS, dated [DATE], revealed Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included a stroke that affected her left side, poor circulation, and nicotine dependence. Her BIMS score was 11, indicating she was moderately cognitively impaired. Her Functional Abilities assessment revealed she was totally dependent on staff for her ADLs. She had no pressure ulcers…

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 staff failed to ensure that clinical records on each resident, in accordance with accepted professional health information management standards and practices were accurately documented for 1 of 4 residents (Resident #1) reviewed for clinical records. The facility failed to code Resident #1's oxygen treatment on his MDS. This failure placed residents at risk of not receiving adequate care and treatment for oxygen. Findings included:During a record review of Resident #1's face sheet dated 10/13/2025 reflected the resident was a [AGE] year-old male, who admitted to the facility on [DATE]. Resident #1's diagnoses included: acquired absence of unspecified leg below knee; Schizophrenia (chronic mental health illness that affects a person's thoughts, feelings and behaviors); major depressive disorder, single episode (chronic mental health condition charactered by multiple episodes of major depression); age- related osteoporosis without current…

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 a safe, functional, sanitary, and comfortable environment for 1of 3 shower rooms (located on Central Station) reviewed for physical environment.The facility failed to ensure a shower room on the Central Station had two working shower curtains, a working shower head, and a clean toilet. The failure placed residents at risk for illness and decreased quality of life. Findings included:Observation on 10/07/25 at 11:40 AM of the shower room revealed the toilet was blocked by equipment inside the shower room. The toilet had a dark substance with an odor. The shower on the right side had a curtain that was torn resulting in limited privacy for showering. The shower on the left side did not have a shower curtain resulting in residents not having privacy for showering and the shower head hose had holes which resulted in the water leaking out the side of the hose. Interview on 10/07/25 at 11:47 AM with CNA E revealed she had worked on Central Station for some time providing showers in this shower room; she…

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 effective pest control program to ensure the facility was free of pests for 3 of 3 hall locations (North Station, Central Station, South Station), nurse's stations, Central Station dining room and 1 of 1 biohazard closet reviewed for physical environment.The facility failed to ensure North Station, Central Station, South Station, and nurses' stations, Central Station dining room, and the biohazard closet were free from gnats. This failure could place residents at risk for the potential spread of infection, cross-contamination, and decreased quality of life. Findings included:Observation on 10/07/25 at 11:50 AM of Central Station shower room revealed gnats circling the shower room. Observation on 10/07/25 at 12:00 PM at the Central Station nursing station revealed gnats and flies flying. Interview on 10/07/25 at 12:03 PM, with Resident #2 revealed Flies and gnats are bad here. I try to keep my door closed to keep them out of my room. According to Resident #2, residents were seen swatting flies…

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, observation, 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 one (Resident #1) of three residents reviewed for infection control. The facility failed to ensure Resident #1, who was on enhanced barrier precautions for ESBL, received tracheostomy care via sterile technique. This failure placed all residents at risk for the spread of infections and decreased quality of life. Findings included:Record review of Resident #1's face sheet, dated 10/30/2025, reflected the resident was a [AGE] year-old female, admitted [DATE], re-admitted [DATE] from an acute care hospital. Her DX included, malignant (cancerous) neoplasm (tumor) of upper lung lobe, hemiplegia (paralysis on one entire side of the body), cerebral infarction (stroke), dysphagia (difficulty swallowing), aphasia…

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 provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident for 1 of 3 residents (Resident #2) reviewed for medically related social services. The facility failed to ensure Resident #2's colonoscopy referral was followed-up on to ensure an appointment was scheduled for her to receive the procedure. This deficient practice could place residents at risk for their medical needs not being met and a decreased quality of life. Findings included: Review of Resident #2's admission Record, dated 04/24/25, reflected the resident was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #2's Quarterly MDS Assessment, dated 03/11/25, reflected she had a BIMS score of 15, indicating no cognitive impairment. Her active diagnoses included diabetes mellitus (a group of diseases that affect how the body uses blood…

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 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 2 residents (Resident #1) observed for infection control. The Wound Care Nurse failed to wear a gown while providing care for Resident #1, who was on enhanced barrier precautions. This failure could lead to the resident being exposed to infections from other residents. Findings included: Review of Resident #1's admission Record, dated 04/22/25, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. Review of Resident #1's Quarterly MDS Assessment, dated 01/28/25, reflected he had a BIMS score of 15, indicating no cognitive impairment. His active diagnoses included cellulitis of right lower limb (a common, potentially serious bacterial skin infection), lymphedema (tissue swelling caused…

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 assist residents in obtaining routine and 24-hour emergency dental care for 1 of 5 residents (Resident #3) reviewed for dental care. The facility failed to assist Resident #3 obtain a follow-up appointment with the Dentist for a root canal by failing to ensure payment was made to the Dentist. This failure could cause the resident unnecessary dental pain. Findings included: Record review of Resident #3's undated admission Record reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included vehicle accident causing a brain bleed and subsequent build up of fluid in the brain, seizures, and lack of coordination. Record review of Resident #3's quarterly MDS, dated [DATE], reflected a BIMS score of 7 indicating he had severe cognitive impairment. His Functional Ability assessment indicated he was independent with his ADLs. Record review of Resident #3's care plan, dated 01/12/25, reflected he…

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 were not given psychotropic medications unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 6 residents (Resident #25) reviewed for psychotropic medications. The Psychiatric NP prescribed Resident #25's seroquel for a medical condition the resident did not have. This failure could place residents at risk of receiving psychotropic medications unnecessarily. Findings included: Record review of Resident #25's undated admission Record reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia, stroke, and unspecified psychosis. Resident #25 had no diagnosis of Schizoaffective disorder. Record review of Resident #25's quarterly MDS, dated [DATE], reflected a BIMS score of 13 indicating he was cognitively intact. His Functional Status assessment indicated he required limited assistance with his ADLs.…

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

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free of roaches for 6 of 15 residents (Residents #56, #62, #99, #106, #114 and #121) reveiwed for pest control. The facility failed to ensure the facility was free of roaches. This failure could affect residents by placing them at risk for the potential spread of infection, cross-contamination, food-borne illness, and decreased quality of life. Findings included: Observation and interview on 12/03/24 at 11:34 AM revealed there were roaches along the baseboards in Resident #56 and Resident #99's room, and there were roaches behind Resident #99's dresser. Resident #56 was lying in Bed A, Resident #99 sitting on the side of her bed (Bed B). Resident #56 stated she had concerns with roaches in her room. She and Resident #99 had reported the roaches several times to aides, nursing staff, housekeeping, and to the maintenance department. According to Resident #99, she liked to get ice water in the mornings and have found 4-5 roaches in her cup 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.

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, 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 for 2 of 2 residents (Residents #82 and #109) reviewed for feeding assistance. 1. CNA A failed to maintain Resident #82's dignity and respect by standing while feeding the resident her lunch meal on 12/03/24 at 12:39 PM. 2. LVN B failed to maintain Resident #109's dignity and respect by standing while feeding the resident her lunch meal on 12/03/24 at 1:00 PM. The failure could negatively affect the mental and psychological well-being of all residents who required the assistance of staff with eating. Findings included: 1. Record review of Resident #82's Quarterly MDS assessment dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of dysphagia (difficulty swallowing) following nontraumatic intracerebral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 2 of 10 residents (Residents #26 and #34) reviewed for accommodation of needs. 1. The facility failed to ensure Resident #26's call light was placed within reach. 2. The facility failed to ensure Resident #34's call light was placed within reach. These failures could place residents at risk of injuries and unmet needs. Findings included: 1. Record review of Resident #26's face sheet, dated 12/05/24, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #26's quarterly MDS Assessment, dated 11/24/24, reflected her BIMS was not completed due to the resident was rarely/never understood. Her diagnoses included cerebral infarction, cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice for 1 of 1 resident (Resident #102) reviewed for oxygen orders. The facility failed to administer oxygen for Resident #102 as ordered by the physician. This failure could place residents at risk of receiving incorrect or inadequate oxygen support, resulting in a decline in health. Findings included: Review of Resident #102's quarterly MDS, dated [DATE], revealed the resident admitted to the facility on [DATE] with diagnoses including respiratory failure (when the lungs cannot release enough oxygen into blood preventing the organs from properly functioning). Resident #102 had intact cognition with a BIMS score of 13. He required oxygen therapy. Review of Resident #102's Care Plan initiated on 04/24/24 reflected a care plan addressing respiratory illness with a goal that reflected: Resident will have no signs or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assured the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 5 (Resident #26)residents reviewed for pharmaceutical services. LVN D failed to follow the facility policy for flushing Resident #26's gastrostomy tube with 5-10 mL (or prescribed amount) of water before, between, and after medications, when she administered Vitamin D 125 mcg, Magnesium Oxide - mg supplement, and Sodium Chloride table 1 gm to the resident. These failures could put residents who received medications via gastrostomy tube at risk for overload and aspiration. Findings included: Record review of Resident #26's face sheet, dated 12/05/24, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #26's quarterly MDS Assessment, dated 11/24/24, reflected her BIMS was not completed due to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure it was free of a medication error rate of five percent (5%) or greater, 3 errors of 33 opportunities for errors leading to 6.06% medication error rates, for one of five staff (LVN D) observed for medication pass. The facility failed to ensure LVN D administered all the crushed medication in the medication cups without leaving residue for Resident #26 and failed to mix prior to administration. These failures resulted in a 6.06% medication error rate and could put residents at risk who received medications via g-tube for tube occlusion, not receiving the correct dose of medication, and those that took orally not getting intended therapy. Findings included: Record review of Resident #26's face sheet, dated 12/05/24, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #26's quarterly MDS Assessment, dated 11/24/24, reflected her BIMS was not completed due to 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 maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 12 residents (Resident #124) reviewed for equipment safety. The facility failed to provide Resident #124 with a bed that had functional wheel locks. This failure could place residents at risk of falls due to unsafe equipment. Findings included: Record review of Resident #124's undated admission Record reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included stroke affecting her speech, and muscle weakness. Record review of Resident #124's admission MDS, dated [DATE], reflected a BIMS score of 15 indicating she was cognitively intact. Her Functional Status assessment reflected she required extensive assistance with her transfers. Record review of Resident #124's care plan, dated 11/26/24, reflected she was a high risk for falls due to right sided weakness. Observation and interview…

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 provide a safe, functional, sanitary, and comfortable environment for 2 (the Main Dining Room and the North Station Dining Room) of 3 dining rooms reviewed for environment. The facility failed to ensure that chairs were in good condition and not in need of repair in the Main Dining Room and North Station Dining Room. This failure could affect residents and the staff by placing them at risk for diminished quality of life due to lack of a well-kept environment. Findings included: Observation on 09/17/24 at 8:56 AM of the Main Dining Room revealed there were six chairs total which all had ripped, cracked, and frayed seat cushions that were indented inwards. Some of the chairs had exposed foam from the cushion. Observation on 09/17/24 at 9:00 AM of the North Station Dining Room revealed there were five chairs total which all had ripped, cracked, and frayed seat cushions that were indented inwards. Some of the chairs had exposed foam from the cushion. Observation on 09/17/24 at 11:40 AM of the Main Dining Room…

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 and interview, the facility failed to provide a safe, clean, comfortable and homelike environment for daily living in 4 resident rooms (Rooms #40, #50, #51, and #76) of 10 resident rooms reviewed for environment. The facility failed to ensure resident rooms, Rooms #40, #50, #51, and #76, were maintained and in sanitary condition. This failure could place all residents at risk for a reduced quality of life and unsanitary and hazardous living conditions. Findings included: An observation on 02/27/24 at 10:15 AM in room [ROOM NUMBER] revealed roach traps along the wall, debris on the floor, and an open bag of tortillas on the floor. There were no observations of roaches in the room. An observation on 02/27/24 at 2:04 PM in room [ROOM NUMBER] revealed a lunch tray with food on the bedside table, debris and food particles splattered on the floor, and an opened pack of crackers on the floor. There were no observations of roaches in the room. An observation on 02/27/24 at 2:07 PM in room [ROOM…

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 provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in 2 dining rooms (North and Central Dining Rooms) of 3 dining rooms reviewed for environment. The facility failed to ensure the North and Central Dining Rooms were maintained and in sanitary condition. This failure could place all residents at risk for a reduced quality of life and unsanitary and hazardous living conditions. Findings included: An observation on 02/27/24 at 1:58 PM in the central dining room revealed trash, debris, food particles on the floor, and food particles on tables. An observation on 02/27/24 at 2:12 PM in the north dining room revealed debris, trash, and food particles on the floor. In an interview on 02/27/24 at 10:45 AM, the Maintenance Director stated he worked at the facility for 5 years. He stated the facility had issues with pests and roaches and was on a weekly services contract with a pest control company. The Maintenance Director stated the weekly treatments were for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 2 of 5 residents (Residents #2 and #3) reviewed for abuse and neglect. 1. CNA F and Housekeeper G failed to immediately report an instance of abuse on 12/10/23 when the Housekeeping Supervisor verbally abused Resident #2. 2. Social Worker A failed to immediately report an allegation of misappropriation of property on 11/20/23 when Resident #3 alleged some of her money was missing from her bank card. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Record review of the facility's policy, dated 10/24/22, and titled Abuse, Neglect and Exploitation reflected: .VII. Reporting/Response; A. The facility reports abuse and abuse allegations that include: 1. Reporting allegations involving staff to-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 interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect and exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, 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 2 of 5 residents (Residents #1 and #2) reviewed for abuse and neglect. 1. The facility did not report to the State Survey Agency when Resident #1 reported allegations of abuse with 2 hours. 2. The facility did not report the allegation of verbal abuse to the State Survey Agency within the allotted time frame for…

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

Based on observation, interview, and record review, the facility failed to provide a private meeting space for the residents' monthly council meetings for 7 of 7 confidential residents reviewed for resident council. The facility failed to provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy. Findings included: Observation and interview on 10/24/23 beginning at 3:00 PM, during a confidential resident group meeting with 7 residents, revealed the meeting was held in the dining room. There were doors that closed off the space from one hall to another hall; however, in between the hall there was the DON's office, the Administrator office, the HR office, and the Staffing Coordinator's office. There were no signs posted to indicate that a confidential meeting was being held; however, multiple staff walked through the space to get from one hall to the next hall. The Surveyor asked the Administrator if they had a private space for the meeting 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, and interviews the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 3 of 6 residents (Residents #46, #109, and #132) reviewed for safe clean homelike environment. 1. The facility failed to ensure Residents #46, #109, and #132 had toilet paper to maintain hygiene. 2. The facility failed to ensure Resident #132's bathroom was cleaned daily. 3. The facility failed to ensure the floor of the COVID unit was cleaned daily. These failures could place residents at risk of infection and decreased sense of self-worth. Findings included: Review of Resident #132's undated admission Record reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included tumor on the brain, depression, and stroke. Review of Resident #132's quarterly MDS, dated [DATE], revealed a BIMS score of 11 indicating moderate cognitive impairment. His Functional Status revealed he required not…

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

Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of 7 of 7 residents reviewed for activities. The facility failed to ensure there were organized activities provided to the residents during the COVID-19 outbreak according to 7 residents who attended the confidential group interview. The failure placed residents at risk for a diminished quality of life, isolation, lack of stimulation, and a decline in mental status. Findings included: Review of facility's current October 2023 Activities Calendar, revealed on 10/24/23 the planned activities were as follows: 10:00 AM Coffee and Convo 11:00 AM Today's headlines 2:00 PM Bingo 3:00 PM Resident Council Meeting 4:00 PM Ice Cream Pass 7:00 Movie Night Observation on 10/24/23 from 10:55 AM - 2:50 PM non-COVID positive residents were observed in their rooms either sleeping or watching television. Observations of the dining areas located in the North, Central and South sections revealed about 6-8…

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 receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 3 of 4 residents (Resident #244, #132, and #136) reviewed for quality of care. 1. The facility failed to elevate Resident #244's bilateral (affecting both sides) lower extremities as ordered by the physician. 2. The facility failed to ensure Resident #132 received his medicated cream for his facial rash. 3. The facility failed to schedule a follow-up appointment with a Neurosurgeon for Resident #136 according to discharge orders by a physician at the local hospital after the resident was seen for generalized weakness due to a traumatic brain injury. This failure could place residents at risk of worsening of their conditions. Findings included: 1. Review of Resident #244's face sheet dated 10/26/23 reflected the resident was a [AGE] year-old male who admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents had a medication error less than 5 percent resulting in an error rate of 18.18% for four of eight residents (Residents #22, #48, # 93, and #132) reviewed for pharmacy services. The facility failed to ensuure LVN A and MA D administered medications appropriately for Residents #22, #48, # 93, and #132. This failure could place residents at risk of a worsening of their medical conditions by not receiving the therapeutic effects of medications prescribed for them. Findings included: Review of Resident #22's undated admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included diabetes, depression, stroke affecting his left side, and placement of a pacemaker. Review of Resident #22's quarterly MDS assessment, dated [DATE], revealed a BIMS score of 9, indicating moderate cognitive impairment. His Functional Status indicated he required limited assistance 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 and interview, the facility failed to ensure medications were stored in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys. The facility failed to ensure all drugs and biologicals were stored securely for 1 of 18 residents (Resident #85) and 2 of 3 medication rooms observed for medication storage. 1. The facility failed to secure the locked medication rooms on Central and North Stations. 2. The facility failed to ensure Resident #30 did not have 1 bottle of nasal spray and two bottles of saline stored at the resident's bedside table not locked in a lock box, or secured in the medication cart or medication room. These failures could place residents at risk of accessing medications not prescribed for them. Findings included: Record review of Resident #85's Face Sheet, dated 10/26/23, revealed the resident was a [AGE] year-old male who was admitted on [DATE], readmitted on [DATE]. Resident #85's diagnoses included acute…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen 1. The facility failed to ensure food stored in the freezer was properly labeled and dated. 2. The facility failed to ensure the dishwasher had an appropriate level of sanitizer. These failures could place residents at risk for food contamination and food borne illness. Findings included: Observation and interview on 10/24/23 at 9:00 AM, during the initial tour through the kitchen, in the freezer with the Dietary Manager, revealed a clear bag of rectangular frozen items measuring about 2 x 3 inches without proper label or date. According to the Dietary Manager, the food items were Barbeque riblets. One big clear bag of slices of bread, and several clear packages of bread slices were observed without proper labels or dates. According to the Dietary Manager, the food items were French Toast. Another large sealed meat item was observed to not be properly labeled or dated. According 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 interviews, record reviews, and observations 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 6 (Residents #54, #64, #95, #137, #134, and #345) of 35 residents reviewed for infection control. 1.The facility failed to test and isolate Resident #137 when she was symptomatic for Covid. 2. The facility failed to clean and disinfect Resident #95's room after he tested positive for Covid placing his roommate at risk for Covid. 3. The facility staff failed to use proper personal protective equipment when entering a positive Covid room to provide lunch to Residents #54 and # 64 These failures could place residents at risk of exposure toCovid. Findings included: Review of Resident #54's undated admission Record revealed she was a [AGE] year-old-female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 7 (Rooms 22, 24, 25, 46, 50, 51, and 61) of 25 rooms reviewed for environment. The facility failed to maintain total visual privacy by allowing the window blinds for rooms 22, 24, 25, 46, 50, 51, and 61 to be missing several slats. This failure placed residents at risk of a lack of privacy, feeling insecure, or uncomfortable in their rooms. Findings included: Observation on 10/24/23 from 11:12 AM - 1:45 PM of the North station revealed room [ROOM NUMBER] and 24's window blinds were broken and were missing several window blind slats, rooms 25 had a broken slat. Observation on 10/24/23 at 1:35 PM of Resident #38 revealed he was lying in bed in room [ROOM NUMBER]. An attempt was made to interview resident. However, the resident would not respond to questions. Interview on 10/26/23 at 10:38 AM with LVN N revealed she was the nurse for North Station. LVN N…

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

Based on interview and record review, the facility failed to ensure each employee received instruction in HIV, falls, restraints, resident rights, dementia, and ANE (abuse, neglect, and exploitation) competency-based training as part of orientation and annually, for 5 of 12 staff (MA, CNA, RN, LVN, and Hospitality Aide) reviewed for training, in that: The facility failed to ensure Reference Checks and Trainings-Resident Rights, Dementia, HIV, Falls, Restraints, and ANE (Abuse, Neglect, and Exploitation) were completed during orientation and prior to start date. These failures could place residents at-risk for abuse and neglect due to lack of training. Findings included: 1. Record review of Staff Roster, undated, revealed the MA W was hired on 03/14/17. Record review of the MA W's training history revealed MA W had not completed fall training in the last year. 2. Record review of Staff Roster, undated, revealed CNA X was hired on 12/23/19. Record review of CNA X's training history revealed CNA X had not completed restraint training in the last year. 3. Record review of Staff Roster,…

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 the right to personal privacy for 1 of 35 residents (Resident #26) reviewed for dignity. CNAs E and G failed to use the privacy curtain or close the door when Resident #26 was lying in bed with no clothes on from the waist down. This deficient practice could place residents at risk for psychosocial harm due to a diminished quality of life. Findings included: Record review of Resident #26's face sheet, dated 10/24/2023, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, major depressive disorder, anxiety disorder, morbid obesity, schizophrenia, and down's syndrome. Record review of Resident #26's admission MDS assessment, dated 08/12/2023, revealed Resident #26's BIMS score was 5 , indicating a low cognitive ability. The MDS assessment revealed Resident #96 needed extensive assistance of two or more persons physical…

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 follow up with the State mental health authority for 1 of 6 residents (Resident #137) reviewed for preadmission screening for individuals with a mental disorder and individuals with intellectual disability. The facility failed to follow up with the State mental health authority after Resident #137 was found to have a mental illness after admission to the facility. This failure could place residents at risk of not receiving specialized services deemed necessary by the State mental health authority. Findings included: Review of Resident #137's undated admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included stroke affecting her left side, depression, and high blood pressure. On 08/24/23 a diagnosis of Bipolar disorder was added. Review of Resident #137's admission MDS, dated [DATE], revealed a BIMS score of 3, indicating severe cognitive impairment. Her Functional Status indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who are fed by enteral means receive the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, and metabolic abnormalities in that they failed to ensure physician orders were followed for one resident of two residents (Resident #107) reviewed for enteral nutrition. 1. LVN S failed to check for tube placement and residual volume prior to the 9:00 AM bolus feeding as ordered by the physician. 2. LVN S failed to provide Resident #107 his 1:30 PM bolus feeding as ordered by the physician. These failures could affect all residents who receive enteral feeding and place them at risk for metabolic abnormalities, medical complications, or a decline in health due to not following appropriate procedures. Findings included: Review of Resident #107's face sheet, dated 09/28/23, reflected the resident was a [AGE] year-old male…

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 was provided such care, consistent with professional standards of practice for one of three residents (Residents #69) reviewed for oxygen. 1. The facility failed to ensure Residents #69 orders for oxygen administration were being accurately provided. 2. The facility failed to ensure Resident #69 concentrator was with water. This failure placed residents who received oxygen therapy at risk for inadequate or inappropriate amounts of oxygen delivery and ineffective treatment. Findings included: Record review of Resident #69's face sheet, dated 10/26/23, revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: acute and chronic respiratory failure with hypoxia (body is not getting the oxygen it needs), Dementia, lack of coordination, chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes…

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 residents to call for staff assistance through a communication system which relays the call directly to a centralized staff work area, for 2 of 144 residents (Resident #10 and #23) reviewed for call lights. The facility did not adequately equip Resident #10 and Resident #23 with a call light to allow residents to call for assistance. This failure could place residents who rely on the call light system to have a delayed response or no way contact staff to meet their needs. Findings included: Review of Resident #10's Face sheet, dated 10/26/23, revealed the resident was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of essential hypertension (high blood pressure), muscle weakness, and lack of coordination. Review of Resident #10's quarterly MDS assessment, dated 07/15/23, revealed a BIMS score of 13 which indicated the resident's cognition was cognitively intact. The MDS further…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes the measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 7 residents reviewed for comprehensive care plans. The facility failed to implement in Resident #1's care plan about his complaints about not getting medications. The facility failed to develop interventions and goals for seizure and psychotropic medications for Resident #1. This failure could place residents at risk for decreased quality of life and not having their needs met. Findings included: Review of Resident #1's quarterly MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old male admitted to the facility on…

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

Based on observation, interview, and record review the facility failed to properly secure medications in a locked compartment for 1 (East Side) of 2 nurse medication carts on the facility's South Hall. RN A left prescribed nasal spray medication on top of the unlocked and unattended East Side medication cart on the facility's South Hall, for an unknown amount of time. LVN B left the East Side medication cart on the facility's South Hall, unlocked and unattended for an unknown amount of time. These failures placed residents at risk for unauthorized access to the medication cart and consumption of harmful medications. The findings included: An observation on 8/21/2023 at 12:50 PM revealed the medication cart's lock to be in the unlocked position, on the facility's South Hall. A container of nasal spray was on top of the medication cart. The drawers on the cart were facing outward to the hall and residents were passing by. No staff were observed in the hall or near the medication cart. An observation and interview with RN A on 8/21/2023 at 12:55 PM revealed RN A coming down the hall…

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.