Autumn Leaves Nursing And Rehab INC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 22 residents (Residents #13 and Resident #11) reviewed for infection control practices.1. The facility failed to properly store or dispose of a used feeding tube syringe for Resident #13.2. The facility failed to ensure Resident #11's catheter bag was not lying on the floor on 05/04/26.These failures placed residents at risk for cross contamination and infection.Findings include: 1. Record review of the face sheet indicated Resident #13 was [AGE] years old and was admitted on [DATE] and most recently re-admitted on [DATE] with diagnoses including Autistic Disorder (a neurodevelopmental condition affecting communication, social interaction, and behavior), Intermittent Asthma (a mild form of asthma characterized by…

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 promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and providing written rationale, by the provider, when an antibiotic was used despite criteria, to determine the appropriate use of an antibiotic for 2 of 9 residents reviewed for antibiotic use (Resident #16 and Resident #68). 1. The facility failed to ensure Resident #16 did not have an order for Cephalexin (an antibiotic used to treat a variety of bacterial infections) for prophylactic antibiotic use. 2. The facility failed to ensure Resident #68 did not have an order for Macrobid (an antibiotic used to treat bacterial infections) for prophylactic antibiotic use. These failures could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections. Findings included: 1. Record review of Resident #16's face sheet, dated 05/06/26, reflected that she was an [AGE] year-old female,…

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 records review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 6 residents (Resident #1) reviewed for Resident Rights. The facility failed to ensure Resident #1 was treated with respect and dignity when CNAs spoke rudely and disrespectfully to him. This failure could place residents at risk of psychosocial harm, self-isolation, and diminished quality of life.Findings included: 1.Review of the admission Record for Resident #1 dated 4/22/26 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of prostate cancer, secondary bone cancer, and brain cancer. Review of the significant change MDS assessment for Resident #1 dated 3/6/26 indicated he had moderately impaired cognition with a BIMS score of 7. He required substantial/maximal assistance with all ADLs. He was always incontinent…

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 develop and implement a comprehensive person-centered care plan for 1 of 4 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's comprehensive care plan was implemented on 1/7/2026 and 1/10/2026 by having two people provide incontinent care to Resident #1.This failure could place residents at risk of not receiving care and services to meet individualized medical and nursing needs.Findings included: Record review of Resident #1's Face Sheet, dated 1/15/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (her right side was weak and paralyzed), and contracture of the left hand (fingers and wrist stuck in a fixed position). Record review of Resident #1's MDS assessment dated [DATE] indicated that Resident #1 did not speak and required substantial assistance for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #1) reviewed for accident hazards. CNA A and CNA B failed to lock Resident #1's bed wheels before they raised Resident #1's bed, before they performed peri-care (removal of soiled brief, the cleaning of the genital/ anal areas and placement of a clean brief which required turning Resident #1 side to side in the bed) and pulling Resident #1 up in the bed on 10/23/25. This failure could place residents at risk of significant injury.Findings included: Record review of Resident #1's face sheet, dated 10/23/25, indicated she was 81- years- old female who was re-admitted to the facility on [DATE]. Resident #1 had with diagnoses which included hemiplegia (paralysis) and hemiparesis (weakness) following stroke affecting the right dominant side…

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 records review the facility failed to ensure residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 5 residents (Resident #1) reviewed for Dialysis. The facility failed to ensure the appropriate dialysis port care was provided to Resident #1 on 8/5/25, 8/7/25, 8/9/25, 8/16/25, 8/19/25, and 9/6/25 when the facility failed to remove the dialysis port (access point for dialysis) dressing as ordered by the dialysis center. This failure could place residents at risk of infection, hospitalization, and diminished quality of life.Findings include: Record review of Resident #1's admission Record dated 10/13/2025, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included end stage renal disease (kidney failure), type 2 diabetes, and schizophrenia (mental condition characterized by…

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 had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 3 of 19 (Resident #64, Resident #74 and Resident #76) residents reviewed for call lights. The facility failed to ensure call lights were within reach while Resident #64, Resident #74 and Resident #76 were in bed. This failure could place residents at risk for a delay in assistance and decreased quality of life, self-worth, and dignity. Findings included: 1. Record review of Resident 64's face sheet dated 03/18/25 indicated he was [AGE] years old and admitted to the facility on [DATE]. Resident #64 had diagnoses which included hemiplegia (paralysis of one side of the body), hemiparesis (weakness on one side of the body, affecting muscles and motor function), acquired absence of left leg above the knee, and depression. Record review of Resident #64's quarterly MDS 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.

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 needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 5 of 11 residents (Resident #42, Resident #246, Resident #16, Resident #9, and Resident #33) reviewed for respiratory care and services. The facility failed to properly store Resident #246's Nasal Cannula. The facility failed to change the dirty filters for Resident #16. The facility failed to ensure Resident #42's oxygen concentrator was set at 2 LPM, as ordered by the physician. The facility failed to ensure Resident #9's oxygen concentrator filter was without white fuzzy particles. The facility failed to ensure Resident #33's oxygen concentrator filter was without white fuzzy particles. This failure could place residents at risk for developing respiratory complications. Findings included: 1. Record review of Resident #246's face…

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 drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 1 medication storage rooms and to provide pharmaceutical services including procedures that assure the accurate administering of all drugs and biologicals, to meet the needs of 2 of 19 residents (Resident #50 and Resident #47) reviewed for medications storage and pharmacy services. 1. The facility failed to remove expired over the counter medications from the Medication Storage room. 2. The facility failed to ensure narcotic counts were accurate for Resident # 50's Belsomra 10 mg (medication used for insomnia) for medication cart on Hall 100 at shift change on [DATE]. 3. The facility failed to ensure Resident #47 Midodrine (is used to treat low blood pressure (hypotension)) had hold blood pressure (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 observations, interviews, and record review, the facility failed to ensure in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments for 5 of 29 residents (Residents #29, #39, #42, #55, and #84) reviewed for storage of medication. 1. The facility failed to securely store Resident #29's Benadryl and Neosporin cream found at her bedside table on 3/17/2025. 2. The facility failed to securely store Resident # 39's Systane eye drops found at her bedside table on 3/17/2025. 3. The facility failed to securely store Resident #42's Oxymetazoline HCL 0.05% (nasal decongestant) and a powdery substance in a medication cup located on beside table on 3/17/2025. 4. The facility failed to securely store Resident # 84's Visine eye drops located on her bedside table on 3/17/2025. 5. The facility failed to securely store over the counter medications for Resident #55. These failures could place residents at risk for adverse reactions to medications or overdose. Findings…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to ensure residents had the right to a clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safety, for 1 of 4 halls (Hall 200) reviewed for a homelike environment. The facility failed to ensure Hall 200's armed exit door near the designated smoke area and laundry, was functioning correctly and not alarming on 3/17/25 and 3/18/25. This failure could place residents at risk for diminished quality of life in an environment that is not homelike. Findings included: During an observation on 3/17/25 at 11:11 a.m., the Hall 200 exit door was entered by a staff member. The Hall 200 exit door shut behind the staff member. The Hall 200 exit door started alarming. The staff member who entered the exit door was partially down the hall when the Hall 200 door alarmed. A housekeeping staff member securely shut the exit door previously entered by another staff member. The Hall 200…

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 promote resident self-determination through support of resident choice for 1 of 19 residents reviewed for resident rights. (Resident #64) The facility did not assist Resident #64 out of bed as often has he preferred. This failure could place dependent residents at risk for feelings of depression, lack self-determination and decreased quality of life. Findings included: Record review of Resident 64's face sheet dated 03/18/25 indicated he was [AGE] years old and admitted to the facility on [DATE]. Resident #64 had diagnoses which included hemiplegia (paralysis of one side of the body), hemiparesis (weakness on one side of the body, affecting muscles and motor function), acquired absence of left leg above the knee, and depression. Record review of Resident #64's quarterly MDS assessment dated [DATE], indicated he had a BIMS score of 10, which indicated she had moderate cognitive impairment. Resident #64 was totally dependent on staff 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 interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 19 residents reviewed for assessments. (Resident #48) The facility failed to ensure Resident #48's MDS dated [DATE], was coded for receiving an anticonvulsant medication (help treat and prevent seizures). The facility failed to ensure Resident #48's MDS dated [DATE], was coded for receiving a hypoglycemic medication (used to lower blood sugar levels in individuals with diabetes). These failures could place residents at risk of not having individual needs met. Findings included: Record review of Resident #48's face sheet dated 3/18/25 indicated Resident #48 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #48 had diagnoses including Type 2 diabetes (is a chronic condition in which the body does not use insulin properly or does not produce enough insulin) and multiple sclerosis (is a disease that causes breakdown of the protective…

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 the necessary services to maintain personal hygiene for 2 of 4 residents reviewed for ADLs (Residents #246 and Resident #18.) The facility did not change the adult brief for Resident #246 in a timely manner leaving her in a urine-soaked brief. The facility failed to shave Resident #18 facial hair. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health. The findings were: 1. Record review of Resident #246's Face sheet dated 3/17/2022 indicated the resident was a 74 year- old female who admitted to the facility on [DATE] with diagnoses of Chronic Obtrusive Pulmonary Disease (a group of lung diseases that cause ongoing inflammation and damage to the airways and air sacs in the lungs, leading to breathing difficulties), Cerebral…

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 had a urinary catheter received appropriate treatment and services to prevent urinary tract infections to the extent possible for 1 of 5 residents reviewed for catheter care. (Resident #24) The facility failed to drain urine from Resident #24's urinary catheter bag. The facility failed to keep Resident #24's urinary catheter bag off the floor. These failures could place residents at risk for the spread of urinary tract infections, making the residents high risk for pain, confusion and sepsis (infections that spread to the blood) from severe urinary tract infections. Findings included: Record review of a face sheet dated 03/18/25 revealed Resident #24 was [AGE] years old and was admitted on [DATE] with diagnoses including multiple sclerosis (a chronic, autoimmune disease that affects the central nervous system (brain and spinal cord), flaccid neuropathic bladder (a condition where the bladder muscles do not contract…

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 appropriate treatment and services to prevent complications was provided for 2 of 3 residents reviewed for feeding tube management. (Resident #47 and Resident #52) The facility failed to ensure Resident #47 and Resident #52 had a physician order for the volume, frequency, and type of flush to administer via the feeding tube. The facility failed to ensure Resident #47 and Resident #52 had a physician order on the frequency of cleaning and the care of the site on the feeding tube. The facility failed to ensure Resident #47 and Resident #52 had a physician order on the frequency of residual checks (assess the rate of gastric emptying) for the feeding tube. The facility failed to ensure Resident #47 and Resident #52 had a physician order on the frequency of checking placement for the feeding tube. These failures placed residents at risk for clogged tubing, trapped air, vomiting, and aspiration. Findings included: Record review of Resident #47's…

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's drug regimen was free from unnecessary medications (is a medication used: In excessive doses (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued) for 1 of 5 residents (Resident #22) reviewed for unnecessary medications. The facility failed to ensure Resident #22 did not received Nitrofurantoin Macrocrystal (is used to treat urinary tract infections (is a bacterial infection in the urinary system)) for prophylactic use. This failure could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections (happens when germs like bacteria and fungi develop the ability to defeat the drugs designed to kill them). Findings included: Record review of Resident #22's face…

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 29 residents (Resident # 20) reviewed for infection control practices. 1. The facility failed to ensure LVN O applied enhanced barrier precautions while providing medication administration to Resident # 20 on 3/18/2025 at 1:18 PM. These failures could place residents at risk of cross-contamination and infections leading to illness. Findings included: Record review of Resident #20's Face sheet dated 3/19/2025 indicated the resident was a 49-year- old male who was readmitted to the facility on [DATE] with diagnoses of cerebral palsy (a group of conditions that affect movement and posture), Dysphagia (a term for difficulty swallowing), Aphasia (a disorder that affects how you communicate, usually after a 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 observation, interview, and record review, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and providing written rationale, by the provider, when an antibiotic was used despite criteria, to determine the appropriate the use of an antibiotic for 1 of 2 residents reviewed antibiotic use. (Resident #47) The facility failed to ensure Resident #47 received the appropriate antibiotic to treat her urinary tract infection on 2/22/25. This failure could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections. Findings included: Record review of Resident #47's face sheet dated 3/18/25 indicated Resident #47 was a [AGE] year-old female admitted on [DATE]. Resident #47 had diagnosis including urinary tract infection (is a bacterial infection in the urinary system), severe sepsis (is a serious condition in which the body responds improperly to an infection)…

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 allow residents to obtain a copy of the records or any portions thereof upon request and 2 working days advance notice to the family for 1 of 1 (Resident #1) residents reviewed for the right to access copies of records. The facility failed to provide medical records for Resident #1 to her attorney within two working days of a request on 07/31/2024. This failure could place residents at risk by causing a negative health impact due to not having continuity of care. Findings included: Record review of a face sheet dated 9/16/2024 indicated Resident #1 was an [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of paroxysmal atrial fibrillation (irregular often rapid heart rate that causes poor blood flow), dementia with behavioral disturbance (impaired concentration, apathy, anxiety, and agitation), and asthma (cough, wheeze, shortness of breath and chest tightness). Record review of a the annual comprehensive MDS dated…

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 need 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 3 of 11 residents (Residents #1, Resident #2, and Resident #3) reviewed for respiratory care. The facility failed to ensure Residents #1, #2 and #3's oxygen tubing and humidifier bottle was changed and dated as ordered. These failures could place residents at risk for upper respiratory infections and worsening of their physical condition. The findings included: Resident #1's cannula tubing was not changed as ordered, the concentrator water bottle was dated 06/09/2024 and was empty. Resident #2's cannula tubing was not changed as ordered, the concentrator water bottle was dated 06/19/2024. Resident #3's canula tubing was not changed as ordered, the concentrator water bottle was dated 06/20/2024. Record review of Resident #1's…

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 a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 4 of 18 residents (Residents #3, #7, #58 and #65) reviewed for care plans. The facility failed to care plan the use of oxygen therapy for Resident #3. The facility failed care plan the use of oxygen therapy for Resident #7. The facility failed to care plan the use of oxygen therapy for Resident #58. The facility failed to care plan the use of oxygen therapy for Resident #65. These failures could place residents at risk of not having individual needs met and cause residents not to receive needed services. Findings included: 1. Record review of a facility face sheet indicated Resident #3 was a [AGE] year-old female and admitted to the facility on [DATE] with diagnosis of dementia. Record review of a quarterly MDS assessment dated [DATE] indicted Resident #3 had a BIMS of 05 indicating severe cognitive impairment 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 that residents requiring respiratory care are provided care, consistent with professional standards of practices for 10 of 13 residents reviewed for respiratory care (Residents #3, #50, #62, #65, #43, #7, #25, #58, #66 and #21). 1.The facility failed to ensure Resident #3's had an order for oxygen, the humidifier and tubing for the oxygen concentrator were dated and the filter was clean and free of dust buildup. 2.The facility failed to ensure Resident #50's oxygen concentrator had an external filter and was free of dust buildup. 3.The facility failed to ensure Resident #62's had an order for oxygen, the oxygen tubing was changed per the facility's policy and the concentrator filter was free of dust buildup. 4.The facility did not obtain orders for Resident #65's oxygen. 5.The facility did not clean the oxygen concentrator filter as ordered for Resident #43. 6. The facility failed to ensure the internal filter of Resident #7's…

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 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 #38) and 2 of 6 staff (CNA E and CNA L) reviewed for infection control. CNA E failed to perform proper hand hygiene during meal service on 1/29/2024. CNA L failed to perform proper hand hygiene while providing incontinent care to Resident #38 on 01/30/2024. These failures could place residents at risk of exposure to communicable diseases and infections. Findings: 1. During an observation on 1/29/2024 between 12:33 pm and 12:43 pm revealed CNA E was passing the meal trays for the lunch meal. She was observed entering room [ROOM NUMBER] setting up the resident tray by opening containers and cutting up food, adjusting the resident in the bed and then returned to the hall. CNA E obtained…

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 promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity for 1 of 3 residents (Resident # 58) reviewed for dignity. The facility failed to ensure Resident # 58's urinary drainage bag had a dignity/privacy cover. This failure could place residents in the facility at risk for a diminished quality of life, loss of dignity and self-worth. Findings: Record review of an admission Record dated 1/30/2024 for Resident #58 indicated she admitted to the facility on 3/17.2022 and was [AGE] years old with diagnoses of Chronic respiratory failure (not enough oxygen or too much carbon dioxide in the body), Asthma (narrow airways that make it difficult to breathe), type 2 diabetes, COPD (group of lung diseases that make it difficult to breathe) and neuromuscular dysfunction of bladder (loss of control over the bladder). Record review of a Quarterly/Medicare 5 Day MDS assessment dated [DATE] for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure all residents had the right to a safe, clean, comfortable and homelike environment for 2 of 17 resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) reviewed for homelike environment. The facility failed to ensure the walls in rooms [ROOM NUMBERS] were free from holes. The facility failed to ensure the walls in room [ROOM NUMBER] were kept clean. These failures could place residents at risk for diminished quality of life due to the lack of a well- kept and clean environment. Findings: During initial rounds and observations on 01/29/24 at 9:40 am revealed room [ROOM NUMBER] had a hole in the sheet rock measuring approximately one foot by one foot on the wall next Resident #3's bed and had splatters of a thick brown and tan substance on the same wall. Resident #3 did not have anything to say about the wall. During initial rounds and observations on 01/29/24 at 10:52 am revealed room [ROOM NUMBER] had a hole in the sheetrock…

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 1 of 6 residents (Resident #62) reviewed for MDS assessment accuracy. The facility did not accurately document Resident #62's oxygen therapy on the quarterly MDS dated [DATE]. This failure could place residents at risk of not receiving care and services to meet their needs. Findings: Record review of a facility face sheet indicated Resident #62 was an [AGE] year-old female and admitted to the facility on [DATE] with diagnosis of mild cognitive impairment. During an observation and interview on 1/29/24 at 9:55 am Resident #62 had an oxygen concentrator next to her bed. She stated she used the oxygen every night when she was sleeping. Record review of a quarterly MDS assessment dated [DATE] indicted Resident #62 had a BIMS of 09 indicating moderate cognitive impairment. MDS assessment did no capture oxygen therapy. Record review of comprehensive care plan dated of 11/10/2023…

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 observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain personal hygiene for 2 of 10 residents (Resident #8, Resident #16) reviewed for ADL's. The facility failed to ensure Resident #8's and Resident #16's nails were kept clean. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health. Findings: 1. Record review of a facility face sheet indicated Resident #8 was a [AGE] year-old female and admitted to the facility on [DATE] with diagnosis of autistic disorder (a neurological and developmental disorder that affects how people interact with others, communicate, learn, and behave). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #8 had a BIMS of 00 indicating…

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 and provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 6 ( Resident #70) residents reviewed for pharmaceutical services, in that: Resident #70's medications (Systane ultra pf lubricant eye drops, Pataday once daily relief eye allergy solution, and Systane lubricant eye drops and a bottle of ninety soft gel capsules of PreserVision eye supplements) were found on the bedside table with no attached labels for use. These deficient practices could place residents at risk of not receiving the intended therapeutic effect of the medications resulting in exacerbation of the resident's condition and disease process. Findings included: During a record review physician order summary dated January 2024 for Resident #70 indicated she was [AGE] years old with diagnosis of colostomy and muscle…

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

Based on interview and record review, the facility failed to develop, implement, and maintain an effective training program for 1 of 15 employees (CNA O) new and existing staff reviewed for training. The facility failed to ensure CNA O was trained on fall prevention on hire. This failure could place residents at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being due to lack of staff training. Findings include: Record review of CNA O's personnel file indicated she was hired at the facility on 9/6/2023 and there was no documented evidence the aide completed training on fall prevention on hire. During an interview on 1/31/2024 at 8:47 AM, HR said she had been employed at the facility for 2 years and was responsible for payroll, orientation of new employees and on boarding of new hires along with ensuring they had the required trainings. She said she ensured the trainings were completed and corporate sets up the curriculum with online training. She said all staff should be getting trainings annually and on hire 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.

Based on interview and record review, the facility failed to provide the required education on the rights of the resident and the responsibilities of a facility to properly care for its residents for 1 of 15 employees (LVN N) reviewed for training, in that: The facility failed to ensure required education was provided on the rights of the resident and responsibilities of a facility to properly care for its residents was conducted by LVN N annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. Findings include: Record review of LVN N's personnel file revealed he was hired on 6/17/2020 and had not completed annual training on rights of the resident and responsibilities of a facility to properly care for its residents. The last time he received training on resident rights was on 7/2/2022. During an interview on 1/31/2024 at 8:47 AM, HR said she had been employed at the facility for 2 years and was responsible for payroll, orientation of new employees and on boarding of new hires along with ensuring they had the 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.