Windsor Atrium

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 incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for 1 of 5 resident (Resident#91) reviewed for indwelling catheters. The facility failed to prevent Resident#91's urinary catheter tubing (bag) from touching the floor. This failure could place residents at risk for cross contamination and urinary tract infections. Findings included: Record review of Resident#91's face sheet revealed a [AGE] year-old male originally admitted on [DATE]. Resident#91 had primary/admitting diagnoses of metabolic encephalopathy (a condition where the brain's function is impaired due to metabolic or systemic illness affecting other body systems, rather than a direct brain injury), obstructive and reflux uropathy (when flow of urine is blocked in the bladder, ureter, or urethra). Record review of Resident #91's MDS dated [DATE], Section…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 of 5 (Resident #10 and Resident #13) residents reviewed for respiratory care. 1. The facility failed to ensure Resident #10's oxygen was administered at the correct setting of 2 liters per minute on 08/3/2025 as ordered by the physician. 2. The facility failed to ensure Resident #13's oxygen was administered as ordered by the physician. These deficient practices could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care. The findings included: 1.Record review of Resident #10's admission record dated 08/3/2025 reflected a [AGE] year-old male with an admission date of 6/18/2025. Pertinent diagnoses included Tracheostomy status (the presence or…

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

Based on observation and interview, the facility failed to ensure that diabetic equipment were stored in a locked compartment for 1 of 4 medication carts. The facility failed to ensure a (diabetic) lancet, sitting on top the unattended medication cart, was secured. This failure could place residents at risk of access or injury from a lancet.Findings were: During an observation on 08/06/2025, at 12:05 PM, revealed on top of the 600 hall medication cart sitting in the 600 hallway unattended, there was a diabetic lancet. During an interview on 08/06/2025 at 12:07 PM, RN J walked up to cart. RN J stated the (diabetic) lancet was supposed to be secured in the medication cart. RN J stated the negative outcome could be someone could come by and grab it off the cart. RN J secured the lancet in the medication cart. During an interview on 08/07/2025 at 5:34 PM, the DON stated the lancet should be kept in the medication cart until use. She said it would be a safety issue if it were left on top the medication cart unattended. During an interview on 08/07/2025 at 06:30 PM, LVN H stated the…

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

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure foods were properly stored, labeled, and dated.2. The facility failed to ensure the DM's hands were washed and gloves was worn during the assistance of food preparation. These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings Include:Observation of the kitchen counter on 08/03/25 at 9:20 AM revealed the following:1. 1 container of Thick-It (a brand of food and beverage thickener designed to help people with swallowing difficulties) covered with foil. Observation of the walk-in refrigerator on 08/03/25 at 9:26 AM revealed the following:1. 1 bag of sliced melons - date was not legible 2. 1 crate of onion which had loose onions out of the bag - not labeled or dated 3. 1 bell pepper in a cardboard box - not labeled or dated In an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 (Resident #16) of 4 residents reviewed for medical records accuracy, in that: The facility failed to provide any documentation in the Progress Notes for Resident #16's from 01/31/2025 through 06/04/2025. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care, and treatment.The findings included: Record review of Resident #16's admission record dated 08/04/2025, revealed a [AGE] year-old female with an admission date of 03/20/2023. Resident #16's diagnoses included amnesia (the loss of memories, including facts, information and experiences), anxiety disorder, history of falling, and chronic obstructive pulmonary disease (a lung disease characterized by persistent airflow limitation and chronic inflammation of the airways 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 observation, interview, and record review, the facility failed to maintain an infection prevention and control program which ensured standard and transmission-based precautions were followed to prevent the spread of infection, for 2 (Resident#39 and Resident #47) of 5 residents reviewed for infection control issues. 1. The facility failed to prevent family members from entering R#39's isolation room without donning PPE. 2. The facility failed to ensure the dressing on Resident #39's peripheral intravenous line (a short flexible tube inserted into a vein to administer fluids and medications) was dated and initialed. 3.CNA C failed to remove contaminated gloves after catheter care prior placing clean brief on Resident #47. These failures could place residents at risk of cross contamination and infection. Record review of Resident #39's Face Sheet revealed Resident #39 was a [AGE] year-old male admitted to facility on 07/11/25 for diagnoses of sepsis (a life-threatening medical emergency caused by 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 ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 3 residents (Resident #1) reviewed for wound care. LVN A failed to communicate and provide treatment for the Resident #1's skin tear. This failure could place residents at risk for not receiving the appropriate care and services to maintain their health and safety. Finding included: Record review of Resident #1's face sheet dated 07/3/25 indicated Resident #1 was a [AGE] year-old female and admitted on [DATE] with diagnoses including diabetes mellitus type 2 (a chronic metabolic disorder where the body either doesn't produce enough insulin or can't effectively use the insulin it produces, leading to high blood sugar levels), essential hypertension (a condition where blood pressure is consistently elevated without a known underlying medical cause). Record review of Resident #1's MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 2 residents (Resident #1) reviewed for clinical documentation and medical records accuracy. The facility failed when Resident #1's June 2025 MAR order for Midodrine was inaccurately dated, as well as the ADON had never signed the MAR that Resident #1's Midodrine was administered on 06/13/2025. This deficient practice could place residents at risk for incomplete or inaccurate clinical records, which could lead to miscommunication, a delay in services, or a potential decline in the resident's health. The findings included: Record review of Resident #1's face sheet, dated 06/21/25, revealed a [AGE] year-old male with an original admission date of 08/01/24, and a recent admission date of 05/23/25. Diagnoses included Chronic Pulmonary Edema (a condition characterized by abnormal buildup of fluid in the lungs), Adult…

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 nursing staff demonstrated appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for one (Resident #1) of six residents reviewed for quality of care The facility failed to ensure WCN A treated Resident #1's wound on her left buttock per doctor's order. This failure had the potential to affect residents receiving wound care could experience infection, worsening of the wounds, and pain. The findings included: Record review of Resident #1's Face Sheet, dated 08/19/2024, revealed a [AGE] year old female admitted on [DATE] with the diagnoses of: Diverticulosis of large intestine (a medical condition that causes small pouches, called diverticula, to form in the walls of the gastrointestinal tract, usually in the large intestine), Type 2 Diabetes Mellitus (a metabolic disease,…

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, record review and interview the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 4 residents observed for catheter use. Resident #1's catheter urine drainage port was draped over the side rail (above the body) restricting flow of urine to the collection bag. This failure could place residents who use cathethers at risk for potential complications or infections related to obstructed urine flow. The finding were: Review of admission record revealed Resident #1 was an [AGE] year-old female with the following diagnoses: Alzheimer's Disease, Muscle Wasting, Dehydration, need for assistance with personal care, lack of coordination and functional urinary incontinence. Resident #1's Minimum Data Set, dated [DATE] section H revealed resident #1 had an indwelling catheter and a BIMS of 0 indicating resident was unable to complete assesment.…

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 and interview, the facility failed to ensure that the residents' right to review survey results were readily accessible to residents, family members and legal representatives of residents. For 1 of 1 survey books. The facility failed to make the results of the survey readily accessible for examination to residents and failed to post a notice of availability of the survey results. This failure could prevent residents from exercising their rights to view the survey results and the plan of correction. The findings were: In a confidential interview on 06/11/24 at 2:00 PM, six Confidential Interviewees said that they were not aware of the location of the results of Federal or State surveys and were not aware of their right to review the results of the surveys. Observation on 06/12/24 at 10:00 AM of the reception area and on top of and inside the bureau revealed there was no surveyor binder. Further observation of the facility revealed there was no posted notice of the location for the survey binder. In an interview on 06/12/24 at 10:03 AM Receptionist said the Survey…

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 all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessments for 1 of 3 residents reviewed for PASARR. The facility failed to ensure Resident #33 had an accurate PASARR Level 1 Screening which indicated a diagnosis of mental illness on 12/12/23. This failure could place residents at risk of not receiving specialized services that would enhance their highest level of functioning. The findings were: Record review of Resident #33's admission Record dated 06/12/24 reflected a [AGE] year-old male with a re-admission date of 12/15/23. Resident #33 had diagnoses which included Depression (persistent feeling of sadness and loss of interest), Schizoaffective Disorder Bipolar Type (type of schizophrenia, hallucinations and delusions), Post-Traumatic Stress Disorder, Unspecified (disorder…

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 develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs and describes the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (Resident #31), reviewed for care plans. The facility failed to develop a comprehensive person-centered care plan for Resident #31 addressing fall mat. These failures could affect residents by placing them at risk of not receiving the care and services for health promotion and continuity of care. The findings included: Record review of Resident #31's electronic facility face sheet, dated 9/19/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #31 had diagnoses which included Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills 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 observation, interview and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives grooming and personal care for 1 of 4 residents (#57) reviewed for ADL care. The facility failed to ensure Residents #57 was provided assistance with nail care. These failures could place residents at risk of scratches, infection, and loss of self-esteem. Findings included: Record review of the Face Sheet for Resident #57 dated 6/13/2024 reflected she was a [AGE] year-old female admitted to the facility on [DATE] and has the following diagnosis information Type 2 diabetes mellitus, hepatic failure, dysphagia, abnormalities of gait and mobility, lack of coordination, muscle wasting and atrophy, contracture of left hand, and need for assistance with personal care. Record review of the Quarterly MDS for Resident #57 dated 05/28/2024 reflected she had a BIMS score of 8 indicating moderate cognitive impairment. Her functional abilities and goals reflected she…

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

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 of the resident, for 1 of 6 residents (Residents #2) reviewed for baseline care plan, The facility failed to ensure Resident #2's baseline care plan included information related to the resident's full code status and the use of a Hoyer lift. This failure could affect newly admitted residents and place them at risk of not receiving appropriate interventions to meet their current needs and communication among nursing home staff to ensure their immediate care needs were met. The findings included: Record review of Resident #2 ' s face sheet, dated [DATE] revealed a [AGE] year-old female admitted on [DATE] with diagnoses of Acquired Absence of Right Leg above Knee, Orthopedic aftercare following Surgical Amputation, End Stage Renal Disease (kidney failure), Dependence on Renal Dialysis, Malignant Neoplasm of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 3 residents (Resident #1), reviewed for care plans. Resident #1's comprehensive care plan dated 01/24/2024 incorrectly indicated she was a dialysis patient. The facility failed to ensure Resident #1's comprehensive care plan dated 01/24/2024 indicated she required a mechanical lift to transfer to and from bed. These deficient practices could place residents in the facility at risk of not being provided with the necessary care or services and implementing personalized plans developed to address their specific needs. The Findings included: Record review of Resident #1's face sheet dated 05/06/2024 revealed the resident was a [AGE] year-old female 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.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety for 2 of 2 nutrition/supply rooms reviewed in that: There was unlabeled and undated food and beverages in both nutrition room refrigerators. The refrigerator temperature logs for both nutrition rooms were missing data. The room temperature logs for both nutrition rooms were missing data. These failures could place residents at serious risk for complications from food contamination, and/or foodborne illness. Findings included: Observation of the Long Term Care supply/nutrition room on 04/04/23 at 10:37 AM revealed an unlabeled and undated 8 oz. container of an unidentified white substance, an open and half full, unlabeled pint of ice cream with an expiration date of 04/07/22, and an open, unlabeled 2.85 oz. bag of jerky in the freezer. There was a paper plate covered with foil that had dried food on it and was unlabeled and not dated, an undated and unlabeled sandwich wrapped in foil, a 6oz. container of yogurt 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 ad record review the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 2 of 7 residents ( Resident #35 and Resident #59) reviewed for call lights in that: Residents # 35, and # 59 were observed in their rooms with their call lights not within reach. This failure could affect all residents who needed assistance with activities of daily living and could result in needs not being met. Findings included: 1. Record review of Resident #35's admission record dated 04/04/23 documented a [AGE] year-old female admitted on [DATE]. Resident #35 documented diagnoses included: muscle wasting and atrophy (decrease in size and loss of skeletal muscle mass) , repeated falls, abnormalities of gait and mobility (deviation of normal walking), unsteadiness of feet, lack of coordination). Record review of Resident #35's quarterly MDS dated [DATE] revealed resident had a BIMS score of 14 indicating the resident 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 develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for two residents (Resident #60 and Resident #83) of twelve residents reviewed for care plans. 1. The facility failed to revise Resident #60's comprehensive person-centered care plan to reflect resident's weight loss and dietary plan. 2. The facility failed to develop and implement a comprehensive person-centered care plan for Resident #83 to address physical therapy. This failure could affect residents who receive care at the facility and could result in missed or inadequate care. The findings were: 1. Record review of Resident #60's face sheet dated 04/05/2023, revealed a [AGE] year old female with an initial admission date of 11/28/2022 with diagnoses which included: Gout (a type of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range for 1 (Resident #60) of 6 residents whose records were reviewed for weight loss in that: The facility did not monitor Resident #60's weight to identify a weight loss from 12/1/22 through 3/2/22. This failure could affect any resident and could result in residents' continued weight loss and decline in physical health. The findings were: Record review of Resident #60's face sheet dated 04/05/2023, revealed an initial admission date of 11/28/2022 with diagnoses which included: Gout (a type of inflammatory arthritis that causes pain and swelling in joints), Acute Kidney Failure with tubular necrosis (a kidney disorder involving damage to the tiny ducts in the kidneys that help filter the blood when it passes through the kidneys), Urinary Tract Infection, Chronic Congestive Heart Failure (the heart cannot pump enough blood), moderate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each Resident for 1 (Resident #13) of 5 residents reviewed medications, in that: The facility failed to clarify parameters for administering a blood pressure medication. This failure could place residents at risk for not receiving the therapeutic effects of the medications prescribed and/or received adverse effects from the medication. The findings included: A record review of Resident #13's admission record dated 04/04/2022, revealed an admission date of 12/22/2022, with diagnoses which included dementia (a condition characterize by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), Alzheimer's disease…

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 assure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, for 1 (Resident #13) of 5 residents reviewed for labeling and storage, in that: The pharmacy label for Resident #13's prescription showed incorrect parameters for blood pressure. This failure could affect residents prescribed medications in the facility and place them at risk for not receiving the correct medications at the correct times. The findings were: A record review of Resident #13's admission record dated 04/04/2022, revealed an admission date of 12/22/2022, diagnoses which included dementia (a condition characterize by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), Alzheimer's disease (progressive mental deterioration that can occur in middle or 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 interviews and record reviews the facility failed to maintain medical records on each resident that are complete and accurately documented for 1 (Resident #13) of 5 Residents reviewed for complete and accurate medication administration records, in that: The facility did not document physician ordered blood pressure readings for medication administration for Resident #13. This failure could place residents at risk for not receiving care and services and their medications as prescribed. The findings included: A record review of Resident #13's admission record dated 04/04/2023, revealed an admission date of 12/22/2022 with diagnoses which included dementia (a condition characterize by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), Alzheimer's disease (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections, hand hand hygiene procedures, and for establishing a process to make every visiitor entering the facility aware of suspected or confiremd SARS-COV-@2 infection for 1 of 1 staff (ADON) and one of four residents, (Resident #71) reviewed for infection control, in that: 1. The ADON removed sterile packing from its container with bare fingers. The ADON used non-sterile scissors to cut the packing. The ADON applied wound cleanser to sterile gauze in a non-sterile plastic cup. The ADON utilized non-sterile wooden spoons to apply ointments to an open surgical wound. 2. The facility failed to ensure CNA I sanitized her hands between glove changes in a manner that promoted cleanliness and prevented infection while providing incontinent care to Resident #71. 3. 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.