Gilmer Nursing & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 1 of 2 residents (Resident #63) reviewed for baseline care plans.The facility failed to address Resident #63's dialysis on his baseline care plan.This deficient practice could place residents at risk of missed care or not receiving necessary care and services.Findings included:1. Record review of Resident #63's face sheet, dated 03/16/26 indicated Resident #63 was a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis which included renal failure or kidney failure (occurs when kidneys cannot adequately filter waste from the blood, often resulting from diabetes or high blood pressure).Record review of Resident #63's medical record revealed the resident did not have an MDS in his medical record.Record review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure the services provided, as outlined by the comprehensive care plan, met professional standards of quality, for 2 of 6 residents (Residents #47, and #7) reviewed for services provided to meet professional standards. 1. The facility did not ensure LVN A administered 2 puffs of Albuterol (medication used to prevent and treat wheezing, difficulty breathing, chest tightness and coughing) HFA Sulfate Inhalation Aerosol Solution instead of 1 puff to Resident #47. 2. The facility did not ensure LVN A primed Resident #7's Novolog FlexPen (insulin medication) according to the manufacturer's instructions. These failures could place residents at risk of inaccurate drug administration and not receiving the care and services to meet their individual needs. Findings included:1. Record review of Resident #47's face sheet, dated 03/12/26, reflected Resident #47 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnosis which…

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, based on comprehensive assessment of resident, that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choice for 1 of 6 residents (Resident #42) reviewed for quality of care. The facility failed to ensure LVN F clarified orders for ibuprofen (a non-steroidal anti-inflammatory drug used to decrease pain and swelling), after Resident #42 had oral surgery on 03/10/26, and her postoperative recommendations indicated to administer ibuprofen for pain and swelling. This failure could place residents at risk of a delay in treatment for the residents' conditions.Findings include: Record review of Resident #42's face sheet, dated 03/12/26, indicated a [AGE] year-old female who was re-admitted to the facility on [DATE]. Resident #42 had diagnoses which included dementia (a progressive decline in mental ability that interferes with daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the resident environment was as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #2) reviewed for accidents and hazards. The facility failed to ensure Resident #2's fall mat on her left side of her bed was in place on 03/11/26 while she was in her room lying in bed. This failure could place residents at risk of accidents that could result in serious injury, harm, impairment, or death.Findings included: 1. Record review of Resident #2's face sheet, dated 03/12/26, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included dementia (a progressive decline in mental ability that interferes with daily life), bipolar disorder (chronic mental health condition characterized by extreme mood swings), and high blood pressure. Record review of Resident #2's quarterly MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 2 of 6 residents (Resident #'s 7 and 39) reviewed for medications.1.The facility failed to administer Refresh Tears Ophthalmic Solution 0.5 % (quickly alleviates dryness, irritation, and discomfort by replenishing moisture to the eyes) for Resident #39 on 03/10/26.2. The facility did not ensure LVN A primed Resident #7's Novolog FlexPen (insulin medication) according to manufacturer's instructions.This failure could place residents at risk for not receiving the therapeutic effects of their medications to include a diminished health status. Findings included:1.Record review of Resident #39's face sheet, dated 03/16/26 indicated Resident #39 was an [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE] with 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 its medication error rate was not 5 percent or greater. The facility had a medication error rate of 10%, based on 2 errors out of 30 opportunities, which involved 2 of 6 residents (Residents #47 and #7) reviewed for medication administration. 1. The facility did not ensure LVN A administered 2 puffs of Albuterol (medication used to prevent and treat wheezing, difficulty breathing, chest tightness and coughing) HFA Sulfate Inhalation Aerosol Solution instead of 1 puff to Resident #47. 2. The facility did not ensure LVN A primed Resident #7's Novolog FlexPen (insulin medication) according to the manufacturer's instructions. These failures could place residents at risk of not receiving therapeutic effects of their medications and possible adverse reactions. Findings included:1. Record review of Resident #47's face sheet, dated 03/12/26, reflected Resident #47 was a [AGE] year-old female, admitted to the facility on [DATE] with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food that accommodated resident allergies, intolerances, and preferences for 1 of 1 resident (Resident #54) reviewed for food preferences and the accommodation of resident's meal choices. The facility failed to ensure Resident #54's preference for dislike of corn was honored on 03/10/26. This failure could result in a decrease in resident choices, diminished interest in meals, and weight loss. Findings include: Record review of Resident #54's face sheet, dated 03/12/26, reflected Resident #54 was an [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included Alzheimer's (progressive disease that destroys memory and other important mental functions). Record review of Resident #54's quarterly MDS assessment, dated 01/29/26, reflected Resident #54 usually made herself understood, and usually understood others. Resident #54's BIMS score was 4, which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure each resident received it and the facility provided food prepared in a form designed to meet individual needs for 1 of 6 residents (Resident's #38) reviewed for food and drinks.The facility failed to ensure Resident #38, received her health shake on 03/10/26.This failure could place residents at risk for weight loss, and unmet nutritional needs.Findings Included:Record review of Resident #38's face sheet, dated 03/16/26, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #38 had diagnoses which included malnutrition (a critical health condition caused by a diet lacking, or excessive in, nutrients and calories, leading to deficiencies, obesity, or chronic health issues), dementia (loss of memory), and dysphagia (problem swallowing).Record review of Resident #38's quarterly MDS assessment, dated 1/26/26, indicated Resident #38 was usually understood and was usually…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #4) reviewed for infection control. The facility failed to ensure the Wound Treatment Nurse donned a gown when she provided wound care to Resident #4 on 3/12/2026. This failure could place residents at risk for cross-contamination and the spread of infection. Findings include: 1. Record review of Resident #4's face sheet, dated 3/13/2026, indicated an [AGE] year-old male who re-admitted to the facility on [DATE]. Resident #4 had a diagnosis which included non-ST elevation myocardial infarction (a heart attack caused by a partial blockage of a coronary artery, restricting blood flow and causing heart muscle damage). Record review of Resident #4's MDS admission assessment dated [DATE],…

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 establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also took into account nonsmoking residents for 1 of 1 facility reviewed for smoking policies. The facility failed to ensure Dietary Aide H followed the smoking policy, when she did not use the facility's assigned smoking area to smoke on 03/12/2026. This failure could place residents at risk of an unsafe smoking environment and an increased risk of injury related to smoking.Findings included: During an observation on 03/12/2026 at 11:38 AM, Dietary Aide H was smoking a cigarette on the sidewalk located in front of the facility that led up to the kitchen's back door. Dietary Aide H extinguished her cigarette on the ground in the dirt and went inside the kitchen. During an interview on 03/12/2026 at 1:11 PM, Dietary Aide H said when she smoked, she went inside her truck to smoke, or she could sit in the rocking chairs in front of the facility to smoke.…

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 each resident had the right to make choices about aspects of his or her life in the facility that were significant to the resident for 1 of 6 residents (Resident #1) reviewed for self-determination.The facility failed to ensure Resident #1 was provided with showers during the day shift instead of showers at nighttime per Resident #1's family's request. This failure could place residents at risk of being denied the opportunity to exercise his or her own rights regarding the things that were important in their life and decrease their quality of life.Findings included:Record review of a face sheet, dated 02/11/2026, indicated Resident #1 was a [AGE] year-old female, admitted [DATE], re-admitted [DATE], with diagnoses including Alzheimer's early onset (a brain disease that slowly damages your memory, thinking, learning and organized skills), muscle weakness, abnormalities of gait and mobility, other lack of coordination, hypertension (high 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 observation, interview, and record review, the facility failed to promptly resolve grievances for 1 of 6 residents (Resident #1) reviewed for grievances.The facility failed to ensure a grievance was filed when Resident #1's family member reported to the ADON a request for Resident #1's showers be given on the day shift to accommodate Resident #1's sleep schedule was not honored. This failure could place residents at risk for grievances not being addressed or resolved promptly. Findings included: Record review of a face sheet, dated 02/11/2026, indicated Resident #1 was a [AGE] year-old female, admitted [DATE], and re-admitted [DATE], with diagnoses including Alzheimer's early onset (a brain disease that slowly damages your memory, thinking, learning and organized skills), muscle weakness, abnormalities of gait and mobility, other lack of coordination, hypertension (high blood pressure). Record review of the Comprehensive MDS assessment, dated 01/29/2026, indicated Resident #1 was able to make herself…

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

Based on observation, interview, and record review the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel, and labeled and dated correctly for 1 of 3 medication carts (Treatment Cart) reviewed for pharmacy services. 1. The facility failed to ensure the Treatment Cart was properly secured when it was left unattended on 01/29/26. 2. The facility failed to ensure the wound cleanser left on top of the Treatment Cart was properly secured on 01/29/26. These failures could place residents at risk for not receiving drugs and biologicals as needed and a drug diversion.Findings included: During an observation on 01/29/26 at 10:46 a.m., the Treatment Cart was observed on Hall A unlocked with a wound cleanser bottle sitting on top. The Treatment Cart was able to be opened by the surveyor and triamcinolone cream tubes (prescription cream applied to the skin to help redness and itchiness) were noted in the top drawer. Observation indicated no staff noticed or attempted to stop the surveyor from opening the cart. Residents and staff…

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 promptly notify and follow-up with the ordering physician regarding laboratory results outside of clinical reference range for 1of 6 residents (Resident #3) reviewed for laboratory services.The facility failed to notify the physician promptly on 12/29/2025 at 01:32 p.m. of Resident #3's Urine Culture and Sensitivity laboratories results. This failure could place residents at risk of not receiving and managing medications at a therapeutic level. Findings included:Record review of Resident #3's face sheet, dated 01/06/2026, indicated an [AGE] year-old female, admitted to the facility on [DATE] and readmitted [DATE], with diagnoses including cerebrovascular disease (stroke), candidiasis (fungal infection), muscle weakness, abnormalities of gait and mobility, and dementia (memory loss).Record review of Resident #3's quarterly MDS assessment, dated 11/20/2025, indicated Resident #3 understood others and was understood by others. Resident #3 had a BIMS score…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #2).The facility failed to ensure CNA B and CNA C changed their gloves and performed hand hygiene after removing Resident #2's soiled brief and before applying barrier cream when they provided incontinent care on 01/29/26.This failure could place residents at risk of exposure to communicable diseases, cross-contamination, and infections.Findings Included:Record review of a face sheet, dated 02/11/2026, indicated Resident #2 was a [AGE] year-old female, admitted [DATE], with diagnoses including congestive heart failure (heart does not pump effectively), abnormalities of gait and mobility, chronic pulmonary edema (a buildup of fluid in the lungs resulting in breathing difficulty), Type 2…

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 there was an RN for 8 consecutive hours 7 days a week for 1 of 1 facility reviewed for RN coverage. The facility did not have RN coverage for 8 consecutive hours on 11/28/24 (Thanksgiving Day). This failure could place residents at risk of lack of nursing oversight and a higher level of care. Findings included: Record review of the RN time sheets indicated there was no RN working on 11/28/24 (Thanksgiving Day). During an interview on 12/10/24 at 03:15 p.m. the DON said she did not work on Thanksgiving Day (11/28/24) and she was not sure if any other RN was assigned to work. She said there should be an RN 8 hours a day or any situation of a resident requiring an RN would not be done. During an interview on 12/11/24 at 10:15 a.m. the Administrator said the DON did not work on 11/28/24 and they did not get any RN to cover the day. She said ultimately it was her responsibility to ensure they had the RN coverage. During the exit on 12/11/24 at 02:55 p.m. the Administrator said they did not have a policy regarding RN…

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 coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort for 1 of 6 residents reviewed for PASRR services. (Resident #1) * The facility did not have Resident #1's hospice representative present for the PASRR IDT meeting dated 04/09/24 requesting specialized PT services. * The facility did not have Resident #1's hospice representative present for the PASRR IDT meeting dated 10/25/24 requesting specialized OT services. These failures could affect the residents with intellectual and developmental disabilities by placing them at risk of a delay in or not receiving specialized services that would enhance their highest level of functioning. Findings included: Record review of a face sheet dated 12/11/24 indicated Resident #1 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included seizures 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 develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 3 of 15 residents. (Resident #11, #28, and #34) The facility failed to develop a care plan for Resident #11, #28, and #34's PASRR (Preadmission Screening and Resident Review) positive status. This failure could place the residents at risk of not receiving care and services to maintain their highest level of well-being. Findings included: 1. Record review of a face sheet dated 10/10/24 indicated Resident #11 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), and bipolar type (a disorder associated with episodes of mood swings ranging from depressive lows 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, observations, and record review, the facility failed to ensure each resident was informed before or at the time of admission, and periodically during the residents stay, of services available in the facility and of charges for those services, which included charges for services not covered under Medicare/Medicaid or by the facility's per diem rate for 1 of 3 residents (Resident #54) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Resident #54, was given a SNF ABN (a document that informs a Medicare beneficiary that Medicare will no longer pay for skilled services) when discharged from skilled services at the facility. This failure could place residents at risk for not being aware of changes to the services provided. Findings included: Record review of a face sheet dated 12/11/24 indicated Resident #54 was admitted on [DATE] and was an [AGE] year-old male with diagnoses of dementia (a group of thinking and social symptoms that interferes with daily functioning), high…

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 baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was completed for 1 of 2 residents reviewed for new admissions (Resident #108). The facility failed to include Resident #108's diagnosis of depression and antidepressant medication the baseline care plan. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: Record review of a face sheet dated 12/10/24 indicated Resident#108 was an [AGE] year-old male admitted on [DATE]. Record review of the physician orders dated December 2024 indicated Resident #108 had a diagnosis of depression and an order dated 12/05/24 for Amitriptyline 25mg one time daily for depression. Record review of the baseline care plan dated 12/04/24 for Resident#108. There was no care plan to address his diagnosis of depression or his antidepressant medication Amitriptyline. During an 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) in 1 of 4 medication carts reviewed (Short Hall Nurse medication cart) (Resident #4's medication). A package of Resident #4's 14 one ml syringes filled with ABH gel (a combination medication of Ativan {antianxiety medication}, Benadryl, {medication that relieves symptoms of nausea, vomiting and dizziness, rash, and cough} and Haldol {an antipsychotic medication that calms you down}) for Resident #4 with an expiration date of 09/04/25 and a lot expiration date of 10/04/24, had been expired for 68 days and not removed from use. A package of Resident #4's 24 one ml syringes filled with ABH gel with an expiration date of 10/07/25 and a lot expiration date of 11/06/24 for Resident #4, had been expired for 35 days and not removed from use. This failure could place residents at risk…

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 maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen reviewed for essential equipment. The facility did not ensure the gas stove was in safe operating condition with the pilot light staying lit and allowing gas to leak. This failure could place the residents at risk of a fire and not receiving their meals in a timely manner. Findings included: During an observation and interview on 12/9/24 at 8:00 a.m., [NAME] A lit the burners on the stove. 1 of the 6 burners (back left burner) did not light using the pilot light and then would not light with a long lighter. She said she would report this to the maintenance supervisor. During an interview on 12/9/24 at 10:30 a.m., the maintenance supervisor said the pilot light on the stove required to be cleaned at times and said he would check the stove today. He said if the pilot light did not light the burner the stove would not work right. During an interview on 12/10/24 at 11:00 a.m., the Administrator said…

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 the facility's only kitchen reviewed for food safety requirements. The facility failed to ensure a fan blowing toward the stove was free from dust like material. The facility failed to ensure the microwave was free from a light beige colored material dried to the number pad of the microwave. The facility failed to ensure the can opener blade was free from a rust-colored material. The facility failed to ensure 7 dozen boiled eggs with an expiration date of 10/25/2023 were not available for use. The facility failed to ensure the dishwasher aide was wearing a hair net. The facility failed to ensure a red cleaning bucket had sufficient sanitizing chemical for cleaning. The facility failed to ensure the cereal in the dining room dispensers were dated when filled. These failures could place residents at risk of foodborne illness, and food contamination. Findings included: During initial tour on 10/30/2023…

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, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 6 of 19 residents (Resident #'s 207, 50, 19, 20, 34, and 33) reviewed for comprehensive person-centered care plans. The facility failed to ensure Resident #207's comprehensive care plan addressed that she received olanzapine (antipsychotic medication). The facility failed to ensure Resident #50's siderails, and risk of dehydration were care planned. The facility failed to ensure Resident #19's siderail was care planned. The facility failed to ensure Resident #20's siderails were care planned. The facility failed to ensure Resident #33's Covid 19 infection was care planned. The facility failed to ensure Resident #34's risk of Covid 19 infection 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 observations, interviews, and record review the facility failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 7 of 12 residents reviewed for quality of life. (Resident #'s 7, 11, 19, 20, 33, 34, and 50) The facility failed to provide facial hair removal/shaving for dependent female Resident #7. The facility failed to ensure Resident #'s 50, 33, 34, and 19 received their scheduled baths. The facility failed to ensure Resident #20's nails were clean and free of a brown colored material. The facility failed to ensure Resident #20 was free of facial hair. These failures could place residents who were dependent on staff to perform personal hygiene at risk of embarrassment, decreased self-esteem, or decreased quality of life. The findings included: 1. Record review of Resident #7's face sheet, dated 11/1/2023, revealed Resident #7 was an [AGE] year-old female who admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the resident's drug regimen was free from unnecessary psychotropic drugs and PRN orders for psychotropic drugs were limited to 14 days for 4 of 5 residents reviewed for unnecessary psychotropic drugs (Resident #'s 207, 106, 24, and 1). The facility failed to adequately monitor Resident #207's side effects and behaviors regarding her antipsychotic medication. The facility failed to follow Resident #207's hospital discharge orders for her antipsychotic medication. The facility failed to monitor Resident #106's side effects for the use of Sertraline (Zoloft) and Bupropion (Wellbutrin). The facility failed to obtain appropriate diagnosis for Resident #24's antipsychotic medication. Resident #1 continued to have a PRN order for Lorazepam 0.5mg after 14 days without an evaluation by the physician for continued treatment. These failures could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews the facility failed to ensure the residents has the right to be informed of the risks and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or options he or she preferred, for 2 of 5 residents (Resident #'s 24 and 106) reviewed for resident rights. 1.The facility failed to complete the psychotropic consent for Resident # 24's Risperidone (anti-psychotic) to treat Alzheimer's and Resident #106's Sertraline (antidepressant) and Buproprion (antidepressant) that treat depression. 2.The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available for Resident #24's prior to administering Risperidone and Resident #106 prior to administering Sertraline and bupropion. These failures could place…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide all necessary information and any other documentation to ensure a safe and effective discharge for 1 of 2 residents reviewed for discharge. (Resident #54) The facility failed to document Resident #54's reason for being discharged from the facility. These failures could place residents at risk for not receiving care and services to meet their needs upon discharge. Findings included: Record review of Resident #54's face sheet dated 11/02/23, indicated an [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #54's diagnoses included dementia with behavioral disturbance (memory loss with behaviors), psychotic disorder with delusions (mental disorder characterized by disconnection of reality often accompanied by disturbances of thought and perception), depression (persistent feeling of sadness), and anxiety. Record review of Resident #54's comprehensive care plan dated 09/25/23, indicated 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 interviews and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care for 1 of 6 residents reviewed for baseline care plans. (Resident #106) The facility failed to develop a baseline care plan that addressed Resident #106's risk to fall, use of psychotropic medications, use of an assistive devices, abnormal gait, history of falls, unsteadiness of feet, and muscle weakness. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: Record review of Resident #106'd#106's face sheet dated 11/02/2023 indicated she was a [AGE] year-old female who admitted on [DATE] with the diagnosis of history of falls, abnormal gait, muscle weakness and unsteadiness on feet. Record review of a fall risk assessment dated [DATE] indicated Resident #106 had a history of falls in the last 1-2 months, she was chair bound and required 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 interview, and record review the facility failed to review and revise the person-centered care plan to reflect the current condition for 1 of 4 (Resident #50) residents reviewed for care plan revisions. The facility failed to ensure Resident #50's care plan was updated when she moved from the secured unit to the general community. on 10/19/2023. TThe facility failed to ensure Resident #50's care plan was updated when she was no longer an elopement risk . These failures could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings included : Record review of a face sheet dated 11/02/2023 indicated Resident #50 was an [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of Alzheimer's disease (dementia), muscle weakness, and fracture of the sacrum. The face sheet indicated Resident #50 was residing in room [ROOM NUMBER]. Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #50 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 adequate supervision was provided to prevent accidents for 2 of 9 residents (Resident #'s 19, and 106) reviewed for accidents and supervision. The facility failed to ensure Resident #19 was free from 2 bottles of wound cleanser, and one plastic medication cup with a white cream at her bedside. The facility failed to implement any interventions to prevent Resident #106's fall on 10/25/2023. These failures places residents at risk for injury and serious injuries. The findings included: 1). Record review of a face sheet dated 11/02/2023 indicated Resident #19 was a [AGE] year-old female who originally admitted on [DATE] and readmitted on [DATE] with the diagnosis of unsteadiness on her feet, muscle weakness, fainting and collapse, and paralysis to the left side. Record review of a Quarterly MDS dated [DATE] indicated Resident #19 was understood and understood others. The MDS indicated Resident #19's BIMS score was 15 indicating her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were offered sufficient fluid intake to maintain proper hydration and health for 2 of 2 residents (Resident #'s 21 and 50) reviewed for hydration. The facility failed to ensure Resident #21, and Resident #50 received adequate hydration. This failure could place residents at risk for dehydration, electrolyte imbalance, and infections. Findings included: 1). Record review of a face sheet dated 11/01/2023 indicated Resident #21 was an [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of senile degeneration of the brain (dementia), and diabetes. Record review of the Quarterly MDS dated [DATE] indicated Resident #21 was understood and understood others. Resident #21's BIMS score was 10 indicating moderately impaired cognition. The MDS indicated Resident #21 required extensive assistance of one staff with eating. Record review of the comprehensive care plan dated 7/06/2023 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 respiratory care was provided with professional standards of practice for 2 of 4 resident reviewed for quality of care. (Resident #6 and Resident #18) The facility failed to administer oxygen at 3 liters via nasal cannula as prescribed by the physician for Resident #6. The facility failed to administer oxygen at 2 liters per minute via nasal cannula as prescribed by the physician for Resident #18. These failures could place residents who receive respiratory care at risk for developing respiratory complications. Findings included: 1. Record review of Resident #6's face sheet dated 11/02/23, indicated an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included dementia (memory loss), depression (persistent feeling of sadness), high blood pressure, congestive heart failure (heart does not pump blood as well as it should), and chronic obstructive pulmonary disease (causes obstructive airflow from 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, interview, and record reviews, the facility failed to ensure correct installation, use and maintenance of bedrails for 3 of 3 residents (Resident #'s 19, 20, and 50) reviewed for bedrails. 1.The facility failed to assess Resident #s 19, 20, and 50 for the risk of entrapment from bed rails prior to installation. 2. The facility failed to review the risks and benefits of bed rails with the resident or resident's representative and obtain informed consent prior to installation for Resident #'s 19, 20, and 50. 3. The facility failed to document the attempt of alternatives to meet Resident #'s 19, 20, and 50 needs. These failures could place residents at risk for entrapment with serious injury and even death. Findings included: 1). Record review of a face sheet dated 11/02/2023 indicated Resident #19 was a [AGE] year-old female who originally admitted on [DATE] and readmitted on [DATE] with the diagnosis of unsteadiness on her feet, muscle weakness, fainting and collapse, and paralysis to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 3 residents (Resident #10) reviewed for hospice services. The facility failed to obtain Resident #10's physician's order for hospice services and the most recent hospice plan of care. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. Findings included: Record review of Resident #10's face sheet dated 11/02/23, indicated a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #10 diagnoses included chronic…

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 the competency of a certified nurse aide for 6 of 13 CNA's reviewed (SNA D, I, J, L N, and O.) They failed to ensure the nurse aides were certified, and or trained in a state approved training program. They failed to provide evidence the nurse aide had received proficiency training and passed their test for SNA D and SNA J prior to 9/10/23 as required by the waiver program. They failed to ensure SNA I, L, N, and O were certified nurse aides prior to assuming full CNA duties without the oversite of another CNA. This failure placed residents at risk of not receiving proper ADL care. Findings included: Record review of employee files indicated: SNA D had a hire date 3/10/21 had LTCR form 3767 for Nurse Aide Work Training and Work Experience indicated she had training between 5/12/22 and 6/22/22. The form was notarized on 8/24/22. SNA J had a hire date 2/25/22- had LTCR form 3767 for Nurse Aide Work Training and Work Experience indicated she had training between 5/12/22 and 6/8/22. The form was notarized on 8/24/22. SNA…

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 a resident with a diet that met his daily nutritional and special dietary needs for 1 of 5 residents reviewed for diet (Resident # 4.) The facility did not ensure Resident #4's physician ordered diet of no bread and no pasta was followed. This negative finding could cause residents discomfort and digestive issues. Findings Included: Record review a Resident #4 face sheet dated 9/20/23 indicated he was an [AGE] year-old male admitted to the facility on [DATE]. Some of his diagnoses were depression, Alzheimer's, disease, constipation, and muscle weakness. Record review of an admission MDS dated [DATE] indicated Resident #4 did not have any cognitive impairment. Resident #4 required supervision with eating with set up help only. Record review of Resident #4 care plan dated 6/8/23 indicated he had a focus area of ADL self-care performance deficit. One of the interventions were the resident required assistance by staff to turn in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain personal hygiene were provided for 1 of 5 residents reviewed for ADLs (Resident # 2). The facility did not provide Resident #2 with her scheduled showers/baths. This failure could place dependent residents at risk for poor personal hygiene, skin infections and decreased quality of life. Findings Included: Record review of the face sheet for Resident #2 indicated she was [AGE] years old admitted to the facility on [DATE] with diagnoses including cerebral palsy (condition marked by impaired muscle coordination and/or other disabilities, typically caused by damage to the brain before or at birth), type II diabetes, muscle weakness, depression, anxiety, and obesity. Record review of the MDS dated [DATE] indicated Resident #2 made herself understood and understood others. The MDS indicated Resident #1 had intact cognition (BIMS…

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 necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new pressure injuries from developing was provided for 1 of 3 residents reviewed for pressure injuries (Resident #1). The facility did not complete weekly skin assessments on Resident #1. The facility did not promptly identify and initiate treatment for the Stage II pressure injury to Resident #1's sacrum. These failures could place residents at risk for new development or worsening of existing pressure injuries, pain, and decreased quality of life. Findings included: Record review of the face sheet for Resident #1 indicated she was [AGE] years old, readmitted to the facility on [DATE] with diagnoses including Alzheimer's disease, depression, anxiety, lack of coordination, High blood pressure, malnutrition, muscle weakness and unstageable pressure ulcer of the left heel. Record review of the MDS dated [DATE]…

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 treat residents with respect and dignity and care for them in a manner and in an environment that promoted maintenance or enhancement of their quality of life for 1 of 5 residents (Resident #2) reviewed for resident rights. The facility did not ensure Resident #2 was assisted out of bed at her request on 8/27/23. This failure could place residents at risk for diminished quality of life, loss of dignity and loss of self-worth. Findings included: Record review of the face sheet for Resident #2 indicated she was [AGE] years old, admitted to the facility on [DATE] with diagnoses including cerebral palsy (condition marked by impaired muscle coordination and/or other disabilities, typically caused by damage to the brain before or at birth), type II diabetes, muscle weakness, depression, anxiety, and obesity. Record review of the MDS dated [DATE] indicated Resident #2 made herself understood and understood others. The MDS indicated Resident #2…

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 treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 20 residents reviewed for resident rights. (Resident #2) The facility failed to pull the curtain between Resident #2 and his roommate with open window blinds while providing incontinent care to Resident #2. This failure could place residents at risk for decreased quality of life, decreased self-esteem and increase anxiety. Findings included: Record review of Resident #2's face sheet dated 8/9/23 indicated Resident #2 was a [AGE] year old male and admitted initially on 9/14/17 with diagnoses including chronic obstructive pulmonary disease (constriction of the airways and difficulty or discomfort in breathing), diabetes, morbid obesity (80 to 100 pounds overweight), Alzheimer's (progressive mental deterioration due to degeneration of the brain), and schizoaffective disorder bipolar type…

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 an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 resident reviewed for incontinent care. (Resident #2) The facility failed to ensure CNA A changed her gloves and performed hand hygiene appropriately while providing incontinent care to Resident #2. The facility failed to ensure CNA B performed hand hygiene prior to donning (putting on) gloves. The facility failed to ensure CNA A changed her gloves after providing incontinent care to Resident #2 prior to touching Resident #2's clean brief, bedding, pillow, and bed remote. The facility failed to ensure CNA A changed her gloves after providing incontinent care to Resident #2 and then using soiled gloved finger to poke unused wipes back into wipe container located on top of the resident's bed and closed lid to container. This failure could…

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.