Paradigm at Woodwind Lakes

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, consistent with resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for 2 of 3 (Resident #1 and Resident #3) residents reviewed for comprehensive assessments.1. The facility failed to ensure that Resident #1's care plan included the physician ordered hand splint interventions for his hand contractures, and the implementation of the device.2. The facility failed to implement the care plan interventions for Resident #3's persistent wandering when she had an unwitnessed fall and sustained a hematoma to the right side of the forehead, which resulted in hospital treatment.This deficient practice could place residents at risk of not receiving proper care and services.Findings included:Resident #1Record review of Resident #1's face sheet…

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, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 (Resident #54) residents reviewed for comprehensive assessments.The facility failed to ensure that Resident #54's care plan documented interventions for hand contractures.This deficient practice could place residents at risk of not receiving proper care and services. Findings Included:Record review of Resident #54's face sheet dated 01/07/2026 revealed a [AGE] year-old admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease (a progressive brain disorder that slowly destroys memory and eventually the ability to carry out simple tasks), parkinsonism (a nervous system disorder), stroke, muscle weakness and need 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 residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 (Resident #10) of 2 residents reviewed for enteral nutrition. The facility failed to always provide the abdominal binder as a supportive device per physician orders to help prevent dislodgment of Resident #10's G-tube (Gastrostomy feeding tube). These failures could place residents with G-tubes at risk of injuries, hospitalization, and death. Record review of Resident #10's face sheet dated 01/08/2026 revealed a [AGE] year-old admitted to the facility on [DATE] and initially admitted on [DATE]. Her diagnoses included dementia, severe malnutrition, , , gastrostomy status (the presence of a G-tube which is a hollow device inserted through the abdominal wall to create a passageway into the stomach to provide long-term access for delivering nutrition), and adult failure to thrive. Record review 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 ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of one residents reviewed for Tracheotomy care (Resident #1) The facility failed to ensure LVN AA used sterile technique and checked oxygen saturation before and during tracheostomy suctioning for Resident #1 on 01/09/26. These failures placed residents with tracheostomy requiring suctioning at risk for respiratory infections, hospitalizations, and a decline in their quality of life. Findings included:Record review of Resident #1's face sheet revealed she was a [AGE] year-old female who was originally admitted on [DATE] and was readmitted [DATE]. Her medical diagnoses included tracheostomy status (a procedure to help air and oxygen reach the lungs by creating an opening…

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 medical records were kept in accordance with professional standards and practices and were complete and accurately documented for 1 of 5 residents (Resident #125) reviewed for accuracy of records. The facility failed to ensure Resident #125's bath or shower was documented as given on 1/1/26, 1/3/26 and 1/6/26 in her electronic chart.These failures could place residents at risk for improper care due to inaccurate records. Findings included: Record review of Resident #125's admission Record dated 1/9/26 revealed a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE]. Her diagnoses included encephalopathy (damage or disease that affects the brain), schizoaffective disorder depressive type (a mental health condition that is marked by a mix of schizophrenia symptoms such as hallucinations and delusions, and mood disorder symptoms), Alzheimer's disease with early onset, and morbid obesity.Record review of Resident #125's 5-day MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to 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 11 residents (Resident #12 and Resident #6) observed for infection control. 1.The facility failed to ensure C.NA AA and C.N A BB used the required PPE for Resident #12, who was on enhanced barrier precautions while performing incontinent/indwelling Foley catheter care on 01/07/26. 2. CNA E failed to perform hand hygiene with glove changes during perineal care on Resident #6. 3, CNA E donned gloves from out of her pocket during perineal care on Resident #6. These failures could place the residents at risk of cross-contamination and development of infection. Findings included: Record review of Resident #12's face sheet reflected a [AGE] year-old male originally admitted on [DATE] and re-admitted on [DATE] with medical…

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 an allegation of misappropriation of property was reported immediately but not later than 24 hours after the allegation was made to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 of 2 residents (CR #142 and Resident# 134) reviewed for reporting.The Prior administrator failed to report to the State Survey Agency the incident of missing money for Resident #134 on 7/22/2025 and CR #142 on 6-9-25.Facility staff did not immediately notify law enforcement of a suspicion of a crime when Resident #134 reported missing money on 7/22/2025 and when resident CR #142 reported missing money on 6-9-2025These failures could affect residents by placing them at risk of misappropriation of property if the reportable allegations are not reported timely…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure Residents receive adequate supervision and assistance devices to prevent accidents for Resident # 1. The facility failed to ensure CNA A properly transferred Resident # 1 on 07/16/2025. This failure could place Residents at risk of being injured. Findings include: Record review of Resident #1's face sheet retrieved on 08/12/2015 revealed, a [AGE] year-old female who was admitted to the facility on [DATE]. The resident's diagnoses included: Osteomyelitis, primary osteoarthritis-right hip, generalized muscle weakness, lack of coordination, communication deficit, Gastro-Esophageal Reflux, other seizures, bipolar, Dysphagia, anxiety, insomnia, profound intellectual disabilities, muscle wasting, pain, epilepsy, elevated white blood cell count, unspecified multiple injuries, hypermagnesemia, adrenocortical insufficiency, non-pressure chronic ulcer of the skin, hyperosmolality and hypernatremia, hypokalemia, soft tissue disorders, glaucoma. Currently…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of 3 of 8 residents (Residents #32, #70 and #60) and failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 2 of 5 medication carts (LEC MA cart and East Front Nurse cart) reviewed for pharmacy services.The facility failed to ensure the LEC medication aide's cart had accurate narcotic counts for Residents #32 and #70 on 8/14/25.MA W stored Resident #32's Lorazepam (a narcotic used to treat anxiety) on the medication cart incorrectly after not immediately wasting it with a nurse on 8/14/25. The facility failed to ensure the East Front Nurse's cart had accurate narcotic counts for Resident #60 on 8/14/25.These failures could place residents at risk for medication errors, drug diversion, and delay in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain and effective pest control program, so the facility was free of pest and rodents for 1 of 1 kitchen and 2 of 2 dining rooms reviewed for environment. - Flies were witnessed on residents dining plates, before food was placed on the plate.- Flies were sitting on residents' food, as they were eating.- A roach was identified in the dining area while residents were eating. These failures could place residents at risk of infection, skin irritation, allergies, which could result in unsanitary living conditions and decline in health and well-being. Findings include:In an observation on, 08/13/2025 at 11:48am, in kitchen 1 of 1, revealed flies on the plates that were prepped for serving resident's lunch. In an interview and observation with DM on 08/13/2025 at 11:49am, where the surveyor showed the DM flies that were on the plates. The DM removed 2 plates and took them to the kitchen. The DM stated that she removed the plates and did not…

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

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 the resident, consistent with the resident rights that include measurable objects and timeframes to meet the residents medical, nursing, and mental psychosocial needs that are identified in the comprehensive assessment for 1 of 9 residents (Resident #8) reviewed for comprehensive care plans. The facility failed to: - Update the comprehensive care plan to resident #8 having a 1/4 right rail on the right side of the bed.This failure could place the resident at risk for not obtaining/maintain their highest practicable wellbeing.Findings include:Record review of Resident #8's undated face sheet, revealed she was a [AGE] year-old female with an initial admission date of, 04/20/2024, with the most recent admission on , 06/10/2025. Resident #8 has diagnosis of, other lack of coordination, Alzheimer's disease with late onset, altered mental status, repeated falls, unspecified…

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 reviewed, the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #1) of 5 residents reviewed for quality of care. - Resident #1's Dialysis Hand Off Communication Report forms were not completed or incomplete for 22 out of 23 opportunities. This failure placed residents at risk of unrecognized dialysis complications. The findings included: Record review of Resident #1's admission Record, dated 07/11/25, revealed a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included type 2 diabetes mellitus (high levels of sugar in the blood) with diabetic neuropathy (nerve damage), cognitive communication deficit, acute on chronic systolic (congestive) heart failure, and unspecified atrial fibrillation (irregular heart rhythm). Record review of Resident #1's MDS Quarterly Assessment,…

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 one of two residents (Resident #2) reviewed for infection control and prevention, in that: The facility failed to ensure the Wound Care Nurse properly changed gloves during wound care for Resident # 2 on 04/09/2025. This failure placed residents with wounds at risk for infection, prolonged healing, worsening of existing pressure injury, new pressure injury formation and hospitalization. Findings included: Record review of Resident #2's admission Record, dated 04/09/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included chronic pain, cellulitis of buttock, muscle wasting and atrophy, cognitive communication deficit, and sepsis. Record review of Resident # 2'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 observation, interview, and record review, the facility failed to ensure residents had a safe, clean, comfortable, and homelike environment for 1 of 6 rooms reviewed for homelike environment. The facility failed on 02/20/2025 to ensure Residents #1 and Resident #2 windows on the secure unit (made of out of plexi glass- plastic glass replacement) were sealed, not broken and free from air entering the room through the window. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, uncomfortable, and unsafe. The findings included: Record review of Resident #1's face sheet dated 2/20/2025 reflected a [AGE] year-old female originally admitted on [DATE] and was last admitted on [DATE]. Resident #1 had the following diagnosis: Anemia (condition where there are not enough healthy red blood cells to carry oxygen to the body's tissues - symptoms include cold hands and feet), reduced mobility, and Alzheimer (a brain 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.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 secured unit reviewed for environmental concerns. The facility failed to ensure that floors were clean and devoid of dirt and debris. These failures could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment. The findings included: Observation on 9/26/24 from 11:45AM to 11:55AM in the secured unit revealed the following: The hallway floor was dirty with dust, dirt, and bits of debris. The floor was sticky and made noises as residents and staff walked down the hallway. A resident was observed walking out of her room barefoot and walking on the dirty hallway floor. The dining room floor was dirty with debris and spilled beverages. The activity room floor was dirty with cracker crumbs, bits of paper, and other trash on the floor. Residents were observed walking across floor with their shoes sticking to the floor and debris on the bottom of their shoes. In an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 3 of 9 residents (Residents #25, #46, and #437) reviewed for gastrostomy tube management. -The facility failed to ensure Resident's #25, #46, and #437 head of bed (HOB) was elevated at a minimum of 30-degree angle during enteral feeding (a way to deliver food directly to the stomach) via gastrostomy tube (G-tube) (A tube directly inserted through the skin to the stomach to deliver nutrition). -LVN J failed to check for residual before administering medication via G-tube to Resident #25. This failure could place residents who receive enteral feedings by G-tube at risk for injury, aspiration into the lungs (fluid or food enter the lungs accidently), decreased quality of life, hospitalization and decline in health). Findings included: Resident #25 Record review of Resident's #25 face sheet 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 provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of 3 of 10 residents (Resident #54, Resident #82 and Resident #98) and 2 of 5 medication Carts (West Front Nursing Cart and East Front Nursing Cart) reviewed for pharmaceutical services. - The facility failed to ensure Resident #98's Pre-Prandial Insulin (insulin taken before a meal) was scheduled and administered with regards to meals and in accordance with manufacturer instructions to administer 15 minutes before or right after a meal. - The facility failed to ensure the [NAME] Front Nursing Cart did not contain expired Lantus Insulin (Insulin Glargine) for Resident #82 with open date of 11/12/23 and expiration date of 12/10/2023, 28 days after opening per the manufacturer's instructions. - The facility failed to ensure the East Font Nursing Cart did not contain…

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 the medication error rate was not five percent or greater. The facility had a medication error rate of 25 % based on 7 errors out of 27 opportunities, which involved 2 of 4 residents (Resident #25 and Resident #93) reviewed for medication errors in that: - MA G failed to administer medication as ordered to Resident #93 by administering Sennoside 8.6 mg, a stool softener, instead of Sennoside 8.6 mg- Docusate 50 mg as ordered. - LVN J failed to administer medications as ordered to Resident #25 by administering plain Multivitamins instead of Multivitamins w/ Minerals as ordered. - LVN J failed to administer medications accurately to Resident #25 by administering Sucralfate, a medication that coats the stomach and reduces the absorption of other medication used to treat ulcers with, via G-tube ( a tube inserted through the belly that brings nutrition/medication directly into the stomach) immediately after a feed and with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to ensure a comprehensive care plan was developed for 1 of 22 residents (Resident #36) reviewed for care plans, in that: Resident #36 was not care planned for oxygen therapy. This failure could place residents at risk for not receiving adequate medical care. Findings included: Record review of Resident #36's face sheet, date1/09/2024, revealed a [AGE] year-old female who was admitted into the facility on [DATE] and diagnosed with chronic obstructive pulmonary disease. Record review of Resident #36's MDS, dated [DATE], reflected the resident was receiving oxygen therapy. Record review of Resident #36's physicians order revealed the resident was to be administered oxygen at 3L via nasal cannula every shift starting 03/25/2023. Record review of Resident #36's vital records, dated 12/0/2023 - 01/09/2024 documented O2% saturation reflected readings ranging from 95-99% from 12/08/2023 to 01/08/2023, with use of O2 nasal cannula, oxygen mask or 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 observations, interview and record review, the facility failed to ensure 1 of 2 residents (Resident #36) was assessed for accident supervision, in that: Resident #36 was observed with full size rails installed on her bed and did not have an assessment for bed rail entrapment risk. This failure could place residents who have bed rails installed at risk for entrapment. Findings included: Record review of Resident #36's face sheet, dated 01/09/2024, revealed a [AGE] year-old female who was admitted into the facility on [DATE] and diagnosed with chronic obstructive pulmonary disease. Record review of Resident #36's MDS , dated 11/04/2023, reflected the resident had a BIMS sore of 5, indicating the resident was severely cognitively impaired, and the resident needed touching assistance/supervision to go from lying to sitting on side of bed, but is dependent to go from sitting to standing. Record review of Resident #36's hospice physician orders, dated 01/10/2024 at 2:34PM, revealed in an order effective…

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 complete medical documentation was kept in accordance with professional standards for 1 of 3 residents (Resident #102) reviewed for weight loss in that: Resident #122 did not have weights documented after admission and for a span of nearly two months. This failure placed residents with nutrition-related risks at risk of not having their nutritional needs addressed in a timely manner. Findings included: Record review of Resident #122's face sheet, dated 01/10/2024, revealed a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with dementia, cerebral infarction, and hypertension. Record review of Resident #122's physicians orders, dated 01/10/2024, revealed the resident did not have any standing orders for weight monitoring. Record review of Resident #122's weight records revealed the resident's last documented weight was on 10/27/2023 and 11/03/2023 at 178lbs and there was no additional weights…

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 clean and serve in dishes that were in accordance with professional standards for food service safety for 1 of 1 Kitchen observed in that: 1. The facility failed to adequately clean drinking glasses that were used for serving drinks. 2. The facility served drinks in glasses that had dried, hard white residue around the rims and food debris inside of them. 3. The facility failed to adequately clean plates that were used to serve food to residents. These failures could place residents at risk for food contamination and food borne illness. Findings: Observation: On 10/17/2023 at 12:30 p.m., this Surveyor sampled a glass of lemonade from the kitchen. Surveyor observed white residue around the circling the inside of the rim of the glass. Surveyor observed food particles stuck on the inside of the glass. On 10/17/2023 at 4:05 p.m., this Surveyor observed the Kitchen Manager removing multiple plates that had dried food particles from a clean cart. On 10/17/2023 at 4:10 p.m., this Surveyor observed clean glasses in 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 did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 6 of 12 residents (Residents #1, #2, #3, #4, #5, #6) reviewed for infection control. -CNA A failed to change gloves from dirty to clean during incontinent care on Resident #1. -CNA B failed to distribute unpackaged cookies using gloved hands or paper towels to Residents #2, #3 and #4. -MA D failed to disinfect multiuse blood pressure cuff between 2 residents. These failures could place residents who require incontinent care and residents who are given unpackaged foods at risk of cross contamination and infection. Findings included: Record review of Resident #1's face sheet printed on 11/17/2023 at 2:00PM, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: dementia, hemiplegia (weakness of the left 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 interview and record review the facility failed to coordinate an assessment with the Preadmission Screening and Resident Review program (PASRR) under Medicaid to the maximum extent practicable to avoid duplicative testing and effort for 1 of 1 resident (Resident #7) reviewed for PASRR services. The facility failed to submit a NFSS request for nursing facility specialized services in the LTC Online Portal for Resident #7's physical therapy (PT) specialized services by a specific deadline of 06/10/23. This failure could place residents with a positive PASRR evaluation at risk of not receiving specialized PASRR services which could contribute to a decline in physical, mental, psychosocial well-being and quality of life. Findings included: Record review of Resident #7's face sheet dated 10/18/2023 revealed a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included cerebral palsy (a group of disorders that affect movement, muscle tone, balance, and posture), profound intellectual…

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 a clean, comfortable and home-like environment for 6 of 15 residents (Residents #3, #4, #5, #6, #7, and #8) reviewed for environment, in that: Resident #3 had brown crust on her wheelchair. Residents #4, #5, and #6 had wall plates for wiring disconnected and hanging off the wall. Resident #6 had dried blood stains on his curtains and an overhead lamp that did not work. Resident #7 had a clogged toilet with feces, urine and toilet paper filled nearly to the brim of the toilet and an approximately 6 inch hole in his wall. Resident #8 had a dirty curtain with brown stains on it and a vent covered with black dust. This failure can place residents at risk of experiencing a decrease in their quality of life. Findings included: Record review of Resident #3's face sheet revealed a [AGE] year-old female resident who was admitted into the facility on [DATE] and was diagnosed with hemiplegia and hemiparesis follow cerebral infarction…

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 for 5 of 15 residents (Residents #9 #6, #2, #10, and #7) reviewed for environment, in that: - Resident #9 was observed with a fly on her body - Residents #6, #2, #10, and #7 were observed to all have multiple live gnats in their rooms. This failure placed residents at risk of experiencing a decrease in their quality of life. Findings include: Record review of Resident #9's face sheet revealed a [AGE] year-old female residents who was admitted into the facility on [DATE] and was diagnosed with a stage 4 pressure ulcer, dementia and anxiety disorder. Observations on 08/01/2023 at 10:34 AM, revealed Resident #9 lying in bed with a fly crawling on her body and face. The resident was observed to flinch as the fly crawled on her face. An interview was attempted at this time, but the resident was nonverbal and unable to communicate with the surveyor at this time. Interview with the ADON on 08/01/2023 at…

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 activities of daily living to maintain good grooming and personal hygiene for 1 of 5 of residents (Resident #2) reviewed for ADL care, in that: - Resident #2 was observed in dirty clothes and emitting odors. This failure placed residents at risk of experiencing a decreased quality of life. Findings included: Record review of Resident #2's face sheet revealed a [AGE] year-old male resident who was admitted into the facility on [DATE] and was diagnosed with end stage renal disease and legal blindness. Record review of Resident #2's MDS, dated [DATE] revealed the resident had a BIMS score of 13, indicating the resident's cognition was slightly impaired. It also revealed the resident was in need of physical help in part of bathing activities. Record review of the shower schedule revealed that Resident #2 was supposed to receive a shower on Monday, Wednesday and Friday. Observation and interview with Resident #2 on 08/01/2023 at 11:48…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 4 residents (Resident #1) reviewed for gastrostomy tube management. The facility failed to ensure Resident #1's head of bed (HOB) was elevated at a minimum of 30-degree angle during enteral feeding ( a way to deliver food directly to the stomach) via gastrostomy tube (G-tube) (A tube directly inserted through the skin to the stomach to deliver nutrition). This failure could place residents who receive enteral feedings by G-tube at risk for injury, aspiration into the lungs (fluid or food enter the lungs accidently), decreased quality of life, hospitalization and decline in health). Findings include: Record review of Resident #1's face sheet undated revealed a 56- year-old-female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included hemiplegia and hemiparesis (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.