Briarcliff Health Center Of Greenville

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 3 (Resident #1) resident reviewed for infection control. The facility failed to immediately implement Enhanced Barrier Precautions (EBP) for Resident #1 when she admitted on [DATE]. These deficient practices placed residents at risk for cross contamination and spread of infection.Findings included:Record review of Resident # 1's EMR and face sheet dated 10/08/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] and discharged on 09/05/2025. Her diagnoses included: Right femur (thigh bone) fracture, sacral region (area of the back and buttocks) pressure ulcer, right buttock pressure ulcer, left buttock deep tissue injury, MRSA (Methicillin Resistant Staphylococcus Aureus, a type of bacteria that is…

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 effective pest control program so that the facility was free of pests and rodents for 1 of 3 residents (Resident #1) reviewed for pest control.The facility failed to ensure Resident #1's room remained free from ants. Resident #1 had ants in her bed on 07/27/25.This failure could place residents at risk of injury or infection related to ant bites, unsanitary environment, and decreased quality of life. Findings include: Record review of Resident #1’s face sheet, dated 7/28/25, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included lack of coordination, abnormal posture, abnormalities of gait and mobility. Record review of Resident #1’s admission MDS, dated [DATE], indicated she was cognitively intact with a BIMS score of 14. Resident #1 was dependent on staff for transfers. She required substantial to maximal assist with bed mobility with the helper doing more than half of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 4 of 24 residents (Residents #90, Resident #95, Resident #203, Resident #98) reviewed for care plans. 1.The facility failed to include Resident #90's diagnosis and interventions for the medication Eliquis Oral Tablet 2.5 MG (Apixaban) (an anticoagulant used for preventing coagulation of blood) in his comprehensive care plan. 2. The facility failed to ensure Resident #95's diagnosis of Clostridioides difficile also known as C-diff (a very contagious bacterium that can cause diarrhea and colitis) and precautions was on her care plan. 3. The facility failed to ensure Resident #98's Eliquis (a medication used to reduce the risk of stroke and blood clots), and interventions was on his care plan. 4. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure that the comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, for 3 residents (Resident #90, Resident #203, and Resident #8) out of 24 sampled residents whose care plans were reviewed for timing and revision. The facility failed to ensure Resident #90's care plan was updated and accurate by not resolving the care plan for a PICC line and antibiotic administration that resident no longer had an order for. The facility failed to ensure Resident #203's care plan was updated by resolving her melatonin and rash in which she no longer had those orders. The facility failed to ensure Resident #8's care plan was updated by resolving her antibiotics and IV fluids in which she no longer had those orders. These failures could place residents at risk for not receiving the care and services to meet their needs. Findings include: 1.Record review of Resident #90's face sheet indicated he was a [AGE] year-old…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 reviewed for 7 of 24 residents (Resident's#95, #203, #64, #20, #21, #74, #98) reviewed for infection control. 1. The facility failed to ensure CNA F, LVN C, and therapist E were following contact isolation for Resident #95 who had Clostridium difficile, also known as C-diff (a very contagious bacterium that can cause diarrhea and colitis). 2. The facility failed to ensure the treatment nurse performed hand hygiene while performing wound care, and CNA B was following Enhanced Barrier Precautions (EBP) for Resident #203 who had wounds. 3. The facility failed to ensure CNA D changed gloves or performed hand hygiene while providing incontinent care for Resident #64. 4. The facility failed to ensure CMA S used proper…

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 2 of 24 residents (Resident #20 and Resident #74) reviewed for resident rights. The facility did not ensure Laundry Aide N knocked, introduced herself, and explained what she was doing prior to entering Resident #20's and Resident #74's room. This failure could place residents at risk for diminished quality of life, loss of dignity and loss of self-worth. Findings included: 1.Record review of the face sheet, dated 11/18/2024, revealed Resident #20 was a [AGE] year old female with diagnoses which included type 2 diabetes mellitus with diabetic neuropathy (diabetic neuropathy was a common and serious complication of type 2 diabetes that occurs when high blood sugar damages nerves over time), acute respiratory failure with hypoxia (a medical emergency where the lungs are unable to adequately…

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 ensure residents had the right to receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 24 residents (Resident #65) reviewed for accommodation of needs. The facility treatment nurse failed to ensure Resident #65's call light was in reach for her to use when assistance was needed on 11/17/24-11/19/24. This failure could have placed resident at risk of having needs gone unmet. Findings Included: Record review or Resident #65's face sheet dated 11/25/24 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with the diagnoses Alzheimer's (a progressive disease that destroys memory and other mental functions), high blood pressure, history of falling, and anxiety (a mental health characterized by worry, anxiety, or fear). Record review of Resident #65's MDS dated [DATE] indicated she could usually understand others and usually made 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, personal and oral hygiene for 1 of 24 residents (Resident #59) reviewed for ADL (activities of daily living) care. The facility failed to provide nail care by removing black material from under fingernails for dependent female Resident #59 on 11/17/2024,11/18/2024, and 11/19/2024. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: Record review of the face sheet, dated 11/18/2024, revealed Resident #59 was a [AGE] year old female with diagnoses which included traumatic subdural hemorrhage without loss of consciousness, subsequent encounter (a medical situation where a patient has experienced a brain bleed (subdural hemorrhage) due to a head injury, but did not lose consciousness at the time of the injury, and was now being seen 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 observations, interviews, and record reviews, the facility failed to ensure that the resident environment remained as free of accident hazards as possible for 1 of 24 Residents (Resident #98) reviewed for accidents and hazards. The facility failed to ensure Resident #98's fall mat was beside his bed on 11/17/24, 11/18/24 and 11/19/24. This deficient practice could place residents at risk of harm or injury and contribute to avoidable accidents. Findings included: 1.Record review of Resident #98's face sheet, dated 11/20/24 indicated he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included muscle weakness, dementia (loss of memory), atrial fibrillation (a common type of irregular heartbeat), and high blood pressure. Record review of Resident 98's 5-day MDS assessment, dated 10/22/24, indicated Resident #98 understood and was understood by others. Resident #98's BIMS score was a 03 indicating his cognition was severely impaired. The MDS indicated Resident #98 required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 residents (Resident's #205) reviewed for respiratory care. The facility failed to date and follow the physician's order to change oxygen tubing weekly on Saturday nights for Resident #205. This failure could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care. Finding included: Record review of Resident #205's face sheet, dated 11/20/24 indicated an [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis of congestive heart failure also known as CHF (a chronic condition that occurs when the heart can't pump enough blood to meet the body's needs), Atrial fibrillation also known as AFib (is a heart…

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

Based on observation, interview, and record review, the facility failed store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 medication cart (Hall 100 medication cart) of 5 medication carts. The facility failed to ensure LVN R the 100 Hall medication cart was locked when it was left unattended in the hallway with the door closed while he provided a treatment for a resident. This failure could place residents at risk for overdose or injury from sharp needles. Findings included: During an observation on 11/18/24 at 09:56 AM, LVN R left the treatment cart unlocked and unattended on the A hall with door closed while he provided a wound treatment to a resident who resided on A hall. During an observation and interview on 11/18/24 at 10:03 AM, LVN R walked out of the resident's room and locked the treatment cart that was left open and unattended. He said he was responsible for locking the cart, but he forgot to lock the cart because he got distracted. LVN R said he normally would have…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen reviewed for food and nutrition services. 1. The facility failed to ensure hair restraints were worn appropriately by dietary staff. 2. The facility failed to ensure the interior of the microwave was free of brown debris. These failures could place residents at risk for foodborne illness. Findings include: An observation in the kitchen on 11/17/2024 at 10:20 a.m., revealed [NAME] L was not wearing a hair restraint appropriately while preparing the lunch meal. [NAME] L hair was visible outside of the hairnet in the back approximately four inches. An observation in the kitchen on 11/17/2024 at 10:28 a.m., revealed dietary [NAME] M was not wearing a hair restraint while in the kitchen washing dishes. An observation in the kitchen on 11/17/2024 at 10:45 a.m., revealed the interior of the microwave was covered with a brown debris. During an interview on 11/18/2024 at 10:00 a.m.,…

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

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 staff (Treatment Nurse) viewed for infection control. The facility failed to ensure the Treatment Nurse performed changed gloves and performed hand hygiene after moving a dirty napkin from the bedside table, picking oxygen tubing up out of the floor, and before starting wound care. These failures could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. Findings Include: During an observation on 4/23/24 at 8:51 a.m. the Treatment Nurse grabbed a dirty napkin off the bedside table and threw it away in the Resident #1's trash, then picked up the Resident #1's oxygen tubing out of the floor. The Treatment Nurse did not change his gloves or perform hand hygiene prior to starting wound care after picking up these…

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 store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure: *food items were dated and sealed appropriately. *expired food items were discarded. *a dented can was stored separately. *the can opener was clean. *the pantry was clean. *Hydrion test strips (test strips used to measure the concentration of chemicals in sanitizing solution) were not expired. *the dishwasher reached 120 F. These failures could place residents at risk for foodborne illness. Findings included: During an observation of the kitchen on 09/18/2023, starting at 10:12 AM, accompanied by the Dietary Manager the following observations were made: Reach in refrigerator: *Multiple half sandwiches in plasic bags with no date *Multiple cups of apple juice, cranberry, and orange juice with no date *A container filled with puddings, protein shakes, gelatin had crumbs and 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.

Based on interview, and record review, the facility failed to ensure residents had the right to send and receive mail, and to receive letters, packages, and other materials delivered to the facility for the resident through the means other than a postal service for 8 of 8 confidential residents reviewed for weekend mail delivery. The facility failed to ensure residents received their mail on the weekend. This failure could place residents at risk for not receiving mail in a timely manner that could result in a decline in resident's psychosocial well-being and quality of life. Findings included: During a confidential group interview 8 of 8 residents stated mail was not distributed on Saturdays. They stated mail did not get delivered until Monday or even picked up until Monday. The residents stated the little mailbox inside the facility even had a note on it to that effect. During a telephone interview on 9/19/2023 at 1:56 p.m., the Postmaster stated mail was not delivered to this facility on Saturdays. The supervisor for the mail carriers indicated the business was considered closed…

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 interviews and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for 5 of 22 employees (DON, ADON, Dietician, Social Worker and Housekeeping Supervisor) reviewed for freedom from abuse, neglect, and exploitation . The facility failed to ensure the Human Resource (HR) Coordinator completed an Employee Misconduct Registry (EMR) check annually for the for the DON, ADON, Dietician, Social Worker. This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property. Findings included: Record review of the facility's Abuse/Neglect policy revised on 9/2014, indicated, the facility, will do all that can reasonably be done to prohibit, report and prevent abuse, neglect, exploitation and involuntary seclusion of residents through the implementation of this policy. This policy consists of several components. The Facility Abuse and neglect policy did not mention annual checks of the State nursing registry. Procedure I. Screening of potential employees. A. 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 assess the residents for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation of bed rails for 3 of 3 residents (Resident #78, Resident #36, Resident #2) reviewed for bed rails. The facility failed to ensure Resident #78, Resident #36, and Resident #2 had assessments or informed consents for the use of bed rails. This failure could place the residents at risk for entrapment, injury, or harm. Findings included: 1. Record review of Resident #78's face sheet dated 09/20/23, indicated an [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #78's diagnoses included periprosthetic fracture (fracture and breaks of the bone around a total knee replacement) around internal prosthetic right knee joint, transient cerebral ischemic attack (mini stroke),…

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 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 changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 1 of 3 residents (Resident #190) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Resident #190 was given a SNF ABN when discharged from skilled services at the facility prior to covered days being exhausted. This failure could place residents at risk for not being aware of changes to provided services. Findings include: 1. Record review of Resident #190's face sheet, dated 09/21/2023, indicated Resident #190 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included encephalopathy (brain disease that alters brain function or structure), and type 2 diabetes mellitus (chronic condition that affects the way…

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 safe, clean, sanitary, comfortable, and homelike environment for 1 of 1 of 21 (Resident #29) resident reviewed for environment. The facility failed to replace Resident #29's over the bed light bulb when burned out. The facility failed to ensure Resident #29's light cover was covering the fluorescent light bulbs in the over the bed lighting. These failures could potenially cause a skin injury. Findings included: Record review of Resident #29's face sheet dated 9/21/2023 indicated Resident #29 was an [AGE] year-old female who originally admitted on [DATE], and then readmitted on [DATE] with the diagnosis of heart failure, heart attack, and low blood pressure. Record review of an annual MDS assessment dated [DATE] Resident #29 was usually understood by others and usually understood others. The MDS indicated Resident #29's vision was severely impaired. The MDS indicated Resident #29's BIMS score was a 3 indicating a severe cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure assessments accurately reflected the resident status for 3 of 21 residents (Resident #49, Resident #84, and Resident #61) reviewed for MDS assessment accuracy. 1. The facility inaccurately coded Resident #49 having a foley catheter on his admission MDS assessment. 2. The facility did not ensure Resident #84's admission MDS identified a medication as an anti-platelet instead of an anticoagulant. 3.The facility did not acccurately code Resident #61 receiving hospice services on her admission MDS assessment. These failures could place residents at risk for not receiving care and services to meet their needs. Findings included: 1. Record review of Resident #49's face sheet dated 09/21/23, indicated he was an [AGE] year-old male who admitted to the facility on [DATE]. Resident #49's diagnoses included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), emphysema (lung…

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 2 of 21 residents (Resident #49 and Resident #36) reviewed for comprehensive person-centered care plans. 1. The facility failed to develop a care plan for Resident # 49's urostomy (surgical procedure that creates a stoma (artificial opening) for the urinary system). 2. The facility failed to care plan Resident #36's side rails. These failures could place residents at risk for unmet care needs and decreased quality of care. Findings included: 1. Record review of Resident #49's face sheet dated 09/21/23, indicated he was an [AGE] year-old male who admitted to the facility on [DATE]. Resident #49's diagnoses included chronic obstructive pulmonary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure necessary services to maintain grooming and personal hygiene were provided for 1 of 21 residents (Resident #32) reviewed for ADLs. 1. The facility failed to provide assistance with facial hair removal for Resident #32. 2. The facility failed to ensure Resident #32 received her shower as scheduled. These failures could place residents at risk of not receiving services and care, and a decreased quality of life. Findings included: Record review of Resident #32's face sheet dated 09/20/23, indicated a [AGE] year-old female who initially admitted to the facility 03/27/23 and readmitted on [DATE]. Resident #32's diagnoses included metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood), Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), depression (persistently depressed mood) and orthostatic hypotension (a form of low blood pressure that…

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 requiring respiratory care were provided such care, consistent with professional standards of practices for 1 of 87 residents (Resident #73) reviewed for respiratory care. The facility failed to ensure Resident #73's oxygen was administered at 2.5 liters per minute via nasal cannula as prescribed by the physician. This failure could place residents who receive respiratory care at risk for developing respiratory complications. The findings included: Record review of the order summary report, dated 03/01/23, revealed Resident #73 had a physician's order, which started on 02/06/23, for Oxygen at 2.5 liters per minute via nasal cannula continuous. Record review of the face sheet, dated 09/20/23, revealed Resident #73 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD; an inflammatory lung disease that causes obstructed 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 interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #84) of 21 residents reviewed for pharmacy services. The facility did not ensure Resident #84 amlodipine (blood pressure medication) and lisinopril (blood pressure medication) was held when her blood pressure was outside of parameters. This failure could place the resident at risk of low blood pressure, dizziness, or fall. Findings include: Record review of Resident #84's face sheet, dated 09/21/2023, indicated Resident #84 was an [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included essential hypertension (high blood pressure). Record review of Resident #84's order summary report, dated 09/21/2023, indicated Resident #84 was prescribed amlodipine besylate 10mg, 1 tablet by mouth one time a day related to essential hypertension,…

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 1 resident (Resident #61) reviewed for hospice services. The facility did not ensure Resident #61's hospice records were a part of their records in the facility. This failure 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 #61's face sheet, dated 09/21/2023, indicated Resident #61 was an [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included Alzheimer's (progressive disease that destroys memory and other…

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.